TRANSACTIONS 
OF THE 
International Medical Congress. 
NINTH SESSION. 
EDITED FOR THE EXECUTIVE COMMITTEE 
BY 
JOHN B. HAMILTON, M. I)., 
Secretary-general. 
VOLUME IV. 
WASHINGTON, I». C., U. S. A. 
1887. PUBLISHED BY AUTHORITY OF THE EXECUTIVE COMMITTEE. 
PUBLICATION COMMITTEE: 
JOHN B. HAMILTON, M. D., 
Secretary- General. 
A. Y. P. GARNETT, M. D., 
Chairman Local Committee of Arrangements. 
C. H. A. KLEINSCHMIDT, M.D., 
Librarian American Medical Association. 
WM. F. FELL & CO.. 
Electrotypers and Printers, 
PHILADELPHIA, PA. ERRATA-VOL. IV. 
Page kZ.-French title, for " Laryngiennes " read Laryngiens. 
Page 60.-French title, for " Perfections'' read. Perfectionnés. 
Page U5.-Tenth paragraph, for " cette " read cet. 
Page 170.-French title, for " Alimentation par rectum " read par le rectum. 
Page 225.-French title, for "Mercurials" read Mercuriels. SECTION XIII-LARYNGOLOGY. 
President: DR. W. H. DALY Pittsburgh, Pa. 
VICE-PRESIDENTS. 
Dr. J. Baratoux, Paris, France. 
Dr. Bouchut, Paris, France. 
Mr. Lennox Browne, London, England. 
Dr. J. Charazac, Toulouse, France. 
Dr. Carl Dehio, Dorpat, Russia. 
Dr. C. M. Desvernine, Havana, Cuba. 
Dr. J. J. Kirk Duncanson, Edinburg, Scotland. 
Dr. Joseph Gruber, Vienna, Austria. 
Dr. J. H. Hartman, Baltimore, Md. 
Dr. Prosser James, London, England. 
Dr. B. D. Moura, Paris, France. 
Dr. J. 0. Roe, Rochester, N. Y. 
Dr. O. Rosenbach, Breslau, Germany. 
Dr. A. Schnee, Nice, France. 
Dr. John Schnitzler, Vienna, Austria. 
Dr. E. L. Shurly, Detroit, Michigan. 
Dr. McNiel Whistler, London, England. 
Dr. F. Laborde de Winthuyssen, Sevilla, Spain. 
Dr. G. V. Woolen, Indianapolis, Ind. 
SECRETARIES. 
Wm. Porter, m. d., St. Louis, Mo. 
I D. N. Rankin, a. m. m. d., Allegheny, Pa, 
COUNCIL. 
Dr. J. Dennis Arnold, San Francisco, Cal. 
Dr. H. Blaikie, Edinburg, Scotland. 
Dr. S. N. Benham, Pittsburgh, Pa. 
Dr. W. E. Casselberry, Chicago, Ill. 
Dr. Lester Curtis, Chicago, Ill. 
Dr. H. H. Curtis, New York, N. Y. 
Dr. Andrew J. Coey, Chicago, Ill. 
Dr. Richard Ellis, Newcastle-on-Tyne, England. 
Dr. Herman E. Hayd, Buffalo, N. Y. 
Dr. E. Fletcher Ingals, Chicago, Ill. 
Dr. Geo. Mackern, Buenos Ayres, Argentine 
Republic. 
Dr. M. C. O'Toole, San Francisco, Cal. 
Dr. S. W. Pearson, Baltimore, Md. 
Vol. IV-1 
1 2 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
FIRST DAY. 
The Section was called to order promptly at 3 p.m. by the President, Dr. Daly. 
The President announced that he had been informed that Dr. Morell Mackenzie 
was about to receive the honor of knighthood, and hoped, this Section would 
promptly authorize an expression of pleasure and congratulation by cablegram. 
Mr. Lennox Browne, of London, moved a cablegram be sent at once. Motion 
seconded and carried unanimously. 
Dr. J. Solis-Cohen moved, and motion seconded, "that no paper be read, if the 
author is not present, until those present shall have been read. ' ' Carried. 
INAUGURAL ADDRESS OF THE PRESIDENT, W. H. DALY, M. D. 
Gentlemen-It is gratifying to see so many of my American confrères here to 
redeem the pledge made for them at Copenhagen, Denmark, in 1884, that an 
American welcome should be given the International Medical Congress, at this its 
ninth meeting. It is also a source of highest pleasure to meet those present from 
foreign lands, many of whose familiar names in the growing literature of laryngology 
remind us that we are not altogether new acquaintances. With many of us, our 
memories revert at this time with renewed freshness and pleasure to our last meet- 
ing in the capital city of the kingdom of Denmark, the home, not only of 
the sturdy Norseman, but of the most accomplished medical scholars; where both 
King and Nation gave up their country to the good of the Congress during its meet- 
ings, and where every one, from ruler to peasant, united in showing their nation's 
guests what the full meaning of the Norseman's hospitality was, so earnest, so quiet, 
so restful, so complete, that it comes back to us at the end of three years as though 
it was a quiet, happy dream of ours in a Norseman fairyland. 
We scarcely think that it is possible for us to be so successful; but if we can secure 
a degree of the happiness and profit realized by all of us in Denmark in 1884, then I 
think we shall have been successful indeed. 
To one and all, however, not only to personal friends from across the seas whose 
familiar faces I observe before me, and to whom I am so much indebted for early 
and valuable training in laryngology, but to all, I bid a heartfelt greeting and cordial 
welcome, and although we may not attain the perfection of the great meeting in 
Copenhagen in 1884, yet I beg all of you to feel that the broad bosom of this 
beautiful land is happy in being your resting place, and its people feel the high honor 
that is accorded them in being permitted to entertain the worthy representative 
medical men from foreign nations. We sincerely trust that none of you will leave 
this our nation's capital without inspecting its residential localities as well as its 
public buildings-The National Museum, the Museum of the Army, the Smithsonian 
and other institutions. None of these collections suffer by comparison with the 
famous collections of the old world. In fact, Washington City is placed in the front 
rank as a repository of scientific learning. SECTION XIII-LARYNGOLOGY. 
3 
We ought to congratulate ourselves as laryngologists in this our second meeting 
as an independent Section of the International Medical Congress, and endeavor to 
have the work of this branch of medicine placed in every large medical body as an 
independent Section, as the importance and growing excellence of its literature and 
valuable practical work deserves. 
When one looks back to the state of laryngology in 1876, and makes a comparison 
with the present status of it, it becomes a matter not only of the utmost interest, 
but of satisfaction and pride to those who have been engaged in its study and 
advancement, to note what, alone, its cognate branch, rhinology, has done for the 
successful and rational treatment of hay fever. Before the appearance of a 
paper which I read before the American Laryngological Association in 1881, 
calling the attention of the profession to some observations I made during a few 
previous years, upon the local predisposing intra-nasal causes of this disease, the 
sufferers therefrom had spent a rambling sort of life in seeking immunity from 
what they can now, in a large percentage of cases, easily get cured, permanently and 
surely, at home, by a proper rational treatment. 
I desire to say, however, that the lamented Hack, and some other able workers 
in the same field, claimed more for the plan of treatment I then advised than I ever 
did. What I then, in 1880, assumed to postulate, I still find, after seven years, 
strongly tenable, viz., "Whether we are warranted in believing any case of hay asthma 
purely a neurosis, without first eliminating the possible causation due to local, struc- 
tural or functional disease in the naso-pharynx. ' ' Therein clearly admitting that a 
proportion of cases were of the character of neuroses, but a far greater proportion 
still depended upon a chronic intra-nasal disease upon which the exciting cause, 
viz., pollen, and other agents, act with effect ; and second, without this intrinsic nasal 
disease the exciting cause is innocuous. 
I am firmly of the belief that the workers in our special branch will yet make the 
local treatment so complete that we will cure a still larger percentage, even to all the 
cases of hay asthma that present themselves. This is a hopeful and zealous view of 
the future of hay fever, but I nevertheless expect to see this realized. 
There are few laryngologists but have constant opportunity of observing the 
rapid development and growth of puny children, after having been under the treat- 
ment of the throat specialist, and their noses and throats put in proper order, so that 
the filthy catarrhal discharges are no longer swallowed, and the upper air passages 
are opened up, so that during sleep they can get a plentiful supply of air ; hence 
physical thrift and comfort quickly change the weakly constitution to a strong one. 
I think no working laryngologist can fail to note the growing importance of 
Rhinology, and I am free to say that the opinion I expressed in a paper before the 
Eighth International Medical Congress at Copenhagen, viz., ' ' That the laryngologist 
of the future must be more the rhinologist, and the rhinologist more the surgeon 
than the physician, ' ' has been fully borne out by the evidence afforded by our 
literature alone. 
There can be no question that a large proportion of the inflammatory diseases of 
the larynx are secondary to an initial disease of the intra-nasal cavities, of like inflam- 
matory character. This I have repeatedly verified by years of observation, and 
frequently publicly so stated in our deliberations, and I am pleased to say that the 
number of my colleagues who have since also verified this to their own satisfaction 
is an ever increasing one, comprising, as it does, some of the most successful and 
distinguished practitioners in this special branch of medicine. The aid modern 
rhinology has been in our successful prevention and treatment of internal and 4 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
middle-ear diseases alone is scarcely calculable. The fact is apparent that no aurist 
can be accomplished in his special work who ignores the facilities afforded him 
by a careful study of the concomitant, and too often initial, disease of the intra-nasal 
cavities. 
But, gentlemen, time passes, and I must not further dilate on the advancement 
of our beloved specialty and its cognate branches ; the bright minds who are now 
devotees of its service, and future workers, will place it higher and higher, till 
it reaches its zenith of excellence and usefulness to humanity. 
As you observe by the printed programme,.there is an abundance of papers, from 
able writers from many lands, upon most attractive subjects, and the valuable time 
of the Section must not be taken up, either by your President or any one else, to the 
exclusion of others. I will, therefore, set the example of brevity by making my address 
short. I feel I have your kind wishes, and that you will aid me in expediting 
the work of the Section from day to day, confining ourselves strictly to the time per- 
mitted to each member under the rules, viz., twenty minutes for the reading of a 
paper and ten minutes for each speaker engaging in the discussion thereof. I shall 
hope that each member will be promptly here at the hour to which we adjourn, so 
that we can begin our work and continue it without undue haste as the session 
advances. 
But, friends, we are solemnly reminded in these living moments, as we enjoy our 
happy greetings of old friends and new "from lands of sun to lands of snow," 
that there is an increasing number of the goodly names of our honored dead, who 
worked and won fame in the field we now cultivate ; while they are personally the 
silent members of this our Ninth International Medical Congress, yet through every 
one of you their names, and voices, and words of wisdom will be heard, as you speak 
from this, for the time being, the World's Medical Forum, to your absent colleagues 
in every7 land and clime. Their names are on the lips of every student of laryngology, 
and their words will always stand a part of its growing and valuable literature ; and 
while their fame is our pride, let if also be our aim to emulate the higher traits of 
character and the ability that won for our Elsberg, Krishaber, Foulis, Bruns, Walden- 
berg, Büro, Böcker and Hack, the distinction that made their teachings as beacon 
lights to guide their less gifted brethren in the fields of laryngological science. Oh 
honored dead, we in spirit strew flowers on your tombs, and join hand in hand while 
we bless the memory of your worthy lives and mourn the events of your too 
untimely deaths. A part of this number were young men, cut off in the growing beauty 
and strength of manhood, with all the zeal and enthusiasm of their scientific labors 
yet fresh upon them. May the earth rest lightly over them in the respective lands 
where their devoted bodies lie, the lamented, the honored, dead of our ranks. 
Prof. E. Fletcher Ingals, of Chicago, opened the discussion on Epistaxis, it 
being one of the subjects selected for special discussion. He remarked, this is an old 
subject, on which there is little to say, but we hope its discussion may call out some 
new thoughts from some of the many workers in this field. It is of much import- 
ance, because of the frequency of the affection, and therefore anything that may add 
to the general fund of our knowledge regarding it is valuable to the whole profession. 
DISCUSSION ON EPISTAXIS. SECTION XIII LARYNGOLOGY. 
5 
The ordinary cases of the disease occurring in children and young adults require 
no treatment whatever, as the bleeding is nature's attempt to relieve plethora, or it 
is so slight that any of the many popular methods will check it in a few minutes; 
but when bleeding is persistent, or when it occurs frequently in such amount as to 
debilitate the patient, it must receive our careful attention. 
In such cases constitutional remedies, such as ergot, gallic acid and iron, have 
been long recommended, and they may probably be tried, but I have little confidence 
in their efficiency. In most of these cases topical measures must be employed. Many 
times the bleeding may be checked by insufflations of cocaine, which is the most 
agreeable to the patient, or by tannin, gallic acid or matico, any of which may be 
used without causing great discomfort. If the insufflations do not succeed, plugging 
should be resorted to. The post-nasal tampon is efficient and is commonly employed, 
but it causes great discomfort, and is liable to set up inflammation of the middle 
ear, with serious consequences. A number of deaths have been reported from 
the inflammation which it has caused, therefore it should not be employed if it can 
be avoided, and in nearly every case equally good or better results can be obtained 
by tamponing the naris from in front. If the posterior plug is used, a short string 
should be left hanging down from it, behind the palate, to facilitate its removal. The 
method of tamponing which I have employed with most satisfaction is done with a 
strip of surgeon's gauze, about an inch in width and three or four feet in length, 
which has been saturated with a mixture of tannin rubbed up in water to the con- 
sistence of thin syrup. The nostril being distended, the end of this strip should be 
folded over a flat probe and carried quickly to the back of the nasal cavity, and sub- 
sequently fold after fold is pushed in more slowly until the whole cavity is filled. It 
is important to carry in the first fold quickly, otherwise the blood will cause it to 
adhere to the walls before it has reached its proper position. As this plug must be 
kept in situ sometimes for many hours, it is well to make a free insufflation of iodo- 
form just before its introduction. In some cases it will be found very advantageous 
to tie several threads of strong silk, about two inches apart, to the end of the strip of 
gauze which is just introduced. These are allowed to hang from the nostril; the end 
of gauze to which they are fastened is pushed into the naso-pharynx, and after the 
naris has been partially filled the threads are drawn upon, one after another, so as 
to thoroughly plug the posterior naris. After the immediate danger is over, a 
careful inspection of the naris will, in the great majority of cases, reveal a small erosion 
or ulcer from which the blood has escaped. When this has been thoroughly cauter- 
ized a cure may be expected. For cauterization nitrate of silver may be employed, 
but the galvano-cautery is far preferable. In some cases, viz., those depending on 
the hemorrhagic diathesis or extreme plethora, this may not effect a cure, but fortu- 
nately these cases are extremely rare. 
Dr. I. Bermann, of Washington, D.C., remarked-I have listened with great 
interest to the discussion on this interesting subject. I should like to say a few 
words on a remedy for epistaxis which has not been mentioned among the different 
cures to-day. They are, of course, all very valuable, but we sometimes meet cases 
where they all seem to fail. Such, at least, has been my experience in a number of 
cases, and in one case particularly, which I will describe shortly. I had a lady 
under treatment for acute otitis media, and had to make the paracentesis tympani, 
using also the nasal catheter to remove the pus from the tympanic cavity. I am sure 
I did not producé a lesion of the nasal membrane with the catheter, but on the 
evening of the following day I was called to the lady, who had been bleeding at the 6 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
nose for several hours. I found her indeed in quite an alarming condition, as she 
was already quite anaemic from having injudiciously nursed a fifteen months old 
baby, and this loss of blood was rather too much for her. I applied cocaine in sub- 
stance and in bulk without effect, also Morell Mackenzie's tannic and gallic acid 
mixture, as well as the anterior tampon; still the blood continued to flow in front as 
well as in the pharynx. Then I thought of a remedy I have sometimes used, and 
called for cracked ice, filled both nostrils with it, and put a small bag on the bridge 
of the nose. Then I made the anterior tamponade in both nostrils. This stopped 
the bleeding effectively, and another slight attack on the following day was also at 
once stopped by this application. I found also, on inquiry, that the bleeding of the 
nose was simultaneous with a flow of blood from the uterus. I have used this 
remedy for epistaxis before, on several occasions. I do not hesitate to commend it to 
the profession as a very superior and convenient remedy, where others fail. 
Dr. Walton Browne, of Belfast, Ireland, said-I believe in the treatment of 
epistaxis; we should trust to plugging from the anterior nares by a strip of 
lint impregnated with powered alum; remove it at the end of twenty-four hours 
by gentle syringing, and then plug with cotton wool saturated with hazaline. I 
would especially refer to the treatment of epistaxis by my friend Dr. Harkin, of 
Belfast, namely, counter-irritation over the region of the liver, with good results. 
Mr. Lennox Browne, of London, related a case to show that it was sometimes 
unwise to arrest a disposition to epistaxis in persons past middle age, even when 
appearing to proceed from purely local causes in the nostril. He also drew atten- 
tion to recent experiments which tended to prove that the astringent properties of 
tannin have been much exaggerated. 
Dr. IM. R. Coomes, of Louisville, Ky. related a case where a tampon had re- 
mained in the nostril by mistake for seven months; spoke of the plan of holding or 
compressing the nose, and the introduction of a piece of bacon in the nostril. 
Dr. John M. Foster, of Richmond, Ky., related a case of epistaxis due to heart 
disease relieved by the use of digitalis, and spoke of the influence of scrofula in 
bringing about the hemorrhagic diathesis. 
In closing the discussion, Prof. Ingals inquired of the other speakers as to 
whether ice or alum, as recommended by Dr. Browne, of Belfast, caused pain. 
He was answered in the negative, and therefore he thought well of both methods. 
He had no experience with bacon, recommended by one of the speakers. The method 
of compressing the nostrils until the blood had coagulated had been referred to as Dr. 
Roe's method; but he was sure that his friend from Rochester, if present, would not 
father a method which had been in common use for five thousand years-since 
according to one of the speakers of the session, rhinologists first began their practice. SECTION XIII-LARYNGOLOGY. 
7 
A CONTRIBUTION ON THE CAUSES AND TREATMENT OF SO- 
CALLED HAY FEVER, NASAL ASTHMA, AND ALLIED AFFEC- 
TIONS, CONSIDERED FROM A CLINICAL STANDPOINT. 
UN RAPPORT SUR LES CAUSES ET LE TRAITEMENT DE L'ASTHME DE FOIN 
ET DES AFFECTIONS SEMBLABLES CONSIDEREES AU POINT 
DE VUE CLINIQUE. 
EIN BEITRAG ZUR ÄTIOLOGIE UND BEHANDLUNG DES SOGENANNTEN HEU-ASTHMAS 
UND VERWANDTER AFFECTIONEN, VOM KLINISCHEN STANDPUNKT 
BETRACHTET. 
BY RICHARD HENRY THOMAS, M.D., 
Of Baltimore, Md. 
Mr. President and Gentlemen of the Section.-In asking you to consider 
with me the subject of the nasal neuroses, I do so with the object of relating chiefly my 
own experience, with a hope of thereby contributing to the solution of some of the 
vexed questions in regard to this class of diseases. ' 
There are those who claim that the occurrence of nasal reflexes depends chiefly upon 
a condition of neurasthenia, or some disturbance of the general nervous system ; others, 
that they are due to obstructive disease of the nasal passages, or to some well defined 
intra-nasal disorder. Again, it has been urged that there exist in the upper air pas- 
sages certain special areas, such as " the reflex sensitive area," and that if these areas 
become diseased, or irritated by the presence of a polyp, or an opposing hypertrophy, 
etc., they will give rise to reflex phenomena. Others consider that the underlying 
cause consists in a congenital peculiarity of structure, either in the nerve centres or end- 
ings, that render them liable to take on perverted or excessive action when exposed to 
certain exciting causes; that this condition, though obscure, is pathological, and is 
greatly affected by the general health of the individual, and by various diseases of the 
upper air passages. 
For reasons which I am about to submit, I incline to this last view, as opposed to 
the others I have mentioned.* 
1. Neurasthenia.-While it is true that many of those in whom we observe the pres- 
ence of nasal neuroses are either neurasthenics or show evidence of some disturbance 
of the general nervous system, and while this general condition, when present, undoubt- 
edly is a very important factor in maintaining and increasing the violence of the attacks, 
yet the frequency with which we meet with the reflex phenomena as the only evidence 
of nervous disorder, shows that neurasthenia, or any condition of the general nervous 
system, is not of itself the necessary predisposing cause. This proposition is further sup- 
ported by the fact that we not infrequently see neurasthenics suffering from various 
forms of nasal disease, who present no evidence of reflex phenomena referable to the 
upper air passages. 
2. Obstructive Diseases of the Nasal Passages.-These are undoubtedly very frequently 
associated with hay fever, nasal asthma, etc., but that this condition is not in itself a 
principal factor in producing the attack is shown by the following reasons:- 
(a) In the majority of cases where I have observed this condition (whether arising 
from polypi, hypertrophies, deflected septum, etc.,) there have been no reflex phe- 
nomena at all, even in neurasthenic individuals. While this condition usually aggra 
* In the list of theories I have not included that which considers that a specific action belongs 
to the pollen of certain plants, as this doctrine is held by but few, and they are decreasing in 
number. 8 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
vates the attacks, it cannot be said to do so invariably, for in one of my patients the 
symptoms are generally ameliorated when the nasal passages become occluded, either by 
swelling or secretion. 
(6) In typical cases of nasal asthma, I have observed patients in whom there was at 
no time nasal obstruction, though this condition is not so common as the opposite. 
(c) Cases have been reported, though I have not seen any, where reflex phenomena 
of nasal origin were associated with an atrophic condition of the nasal tissues. 
(d) It is generally possible in hay-fever patients to excite a temporary attack at any 
time, by touching the sensitive areas in the upper air passages with a probe, and this 
independently of the presence or not of nasal obstruction. 
3. The same remarks apply to nasal and pharyngeal diseases generally, that can be 
detected by the ordinary methods of rhinoscopic examination. They all may or may 
not be accompanied by reflex phenomena. We may, therefore, conclude that the pri- 
mary cause of the nasal neuroses is not to be looked for in any of them, while it is 
undoubtedly true, both in regard to neurasthenic and non-neurasthenic individuals, 
that their presence may greatly aggravate and prolong the attacks, and perhaps even 
develop a latent tendency thereto. 
4. The Existence of Sensitive Areas.-These have been variously defined by various 
observers. Some have been inclined to limit them to special places. Others have 
admitted that any part of the upper air passages may be sensitive, but claim that there 
are special areas which are most generally sensitive, and on this claim they base their 
own theories as to the aetiology of nasal neuroses. 
On this point I have instituted two series of observations. The first was to dis- 
cover the sensitive area, or areas, in those who were affected with some of the forms of 
nasal or pharyngeal reflex disturbance. The second was to discover any sensitive areas 
that might exist in cases where the upper air passages were normal, or, if pathological, 
not associated with reflex disturbance. Of course, I excluded all cases where there 
was any destructive disease. In carrying out these observations, I found that different 
individuals vary greatly, not only in the ease, but in the rapidity with which they 
respond to the touch of the probe. This makes it important to pause after touching 
one point before proceeding to another, for if this be not done, reflex phenomena really 
due to irritation of one part may be wrongly ascribed to another. 
In the first series of cases, that is, those where the reflex phenomena were present, 
I have found, as far as I have gone, that it is absolutely impossible to say positively 
that one part of the intra-nasal passages is more sensitive than another. In every case 
some area of special sensation was to be found, but this area would vary in every case, 
and in one or two instances could only be located in one nostril. In others, the sensi- 
tive area would be located in one nostril at one point, and in the other at another point 
not corresponding to the first. I find I have noted in different cases the floor of the 
nostrils, any portions of the turbinated bodies, the whole of the septum, parts of the 
pharynx. There is a slight predominance in favor of the middle and posterior 
portions of the nasal passages, and of any part of the septum, especially that 
portion supplied by the olfactory. In two cases almost every portion of the intra- 
nasal tissues appeared equally sensitive. These observations were all carried on during 
the intervals between the attacks, no observation taken during an attack or in the 
hay-fever season having been noted in the preparation of this paper. The reflex phe- 
nomena brought out in these cases were : besides the usual lachrymation, violent parox- 
ysmal sneezing, disturbances of respiration, such as temporary asthmatic dyspnoea, 
headache, etc. 
In the second series of cases, that is, in those where there were no reflex disturb- 
ances, I found, generally, that it was impossible by ordinary probing to produce any 
result beyond lachrymation, slight sneezing and, at times, a very slight expiratory effort. SECTION XIII-LARYNGOLOGY. 
9 
The second was very often the last, generally absent. There was in some individuals 
of this class a very high degree of ordinary hyperæsthesia in the nasal tissues, so that 
a slight touch of the probe would cause decided pain or great tickling. In these there 
was no reflex phenomena produced beyond lachrymation. In this class I have not been 
able to discover any area of special sensation, the slight phenomena produced being 
called forth about equally well from the various parts of the intra-nasal tissues. 
While my observations are still in progress, the results thus far incline me to 
adopt the opinions of those who maintain- 
(a) That, as a rule, there exists normally in the upper air passages no special ' ' reflex 
sensitive area. ' ' This view is strengthened by the occurrence of polypi, etc., where 
they can irritate the so-called sensitive areas without producing reflex phenomena. 
(&) When, under pathological conditions, such an area is present, it may exist in 
any part of the upper air passages. If this view be correct, we must accept the theory 
of Lublinski, that in the production of a paroxysm the olfactory, the trigeminus and 
the sympathetic may be involved. 
5. Congenital Peculiarity of Structure.-As the other theories I have mentioned are 
not sufficiently sustained, we seem driven to the theory that there is a peculiar condi- 
tion, in the nerve endings (or perhaps in the nerve centres), that renders them liable to 
take on excessive or perverted action when exposed to certain forms of irritation. 
Idiosyncrasy is, according to Jonathan Hutchinson, "to a large extent a diathesis 
brought to a point." I do not use the term as a means for hiding ignorance or dis- 
couraging research. But our knowledge is not yet sufficiently accurate to lay aside the 
expression. The existence of an idiosyncrasy always denotes a pathological condition 
which is still obscure. The pathological condition, however, occasions no disturbance 
until an exciting cause is present, and the readiness and violence with which it will 
respond to these excitants depends greatly upon the condition of the upper air passages 
and of the general nervous system. Why one irritant should produce an attack in one 
person and be harmless to another is, as far as our present knowledge goes, explicable 
only on the supposition of an idiosyncrasy. 
The exciting causes may be classed as follows : (1) Inert substances floating in the 
air, such as pollen, etc. (2) Psychical impressions. (3) Meteorological changes, and 
the effect of sunlight and wind. (4) Morbid changes and new growths in the upper air 
passages. (5) Irritation reflected from distant parts of the body. 
(1) Substances Floating in the Air.-In the class of cases affected by this variety of 
irritants, the periodicity depends upon the return of the irritant. Thus, in the case of 
a colored man who presented himself at my clinic, the man would be free from 
attacks all the year round, working on a farm in the country, but could not for a moment 
enter a room where oysters were being opened without having a decided attack. In a 
medical student the odor of a dissecting room was found to have a similar effect. 
Among the external irritants, other than those just mentioned, floating in the atmos- 
phere, which I have noted as producing a paroxysm in my patients, are the following : 
The pollen of rag-weed, luxuriant vegetation generally, Indian corn in tassel, the smell 
of flowers, dust, wheaten and other kinds of flour and meal, the odor of tobacco, the 
dust of a preparation called "soapine," the dust of a railway train, etc. 
(2) Psychical Impressions.-These are at times sufficient to act as an exciting 
cause in a sensitive person, as, e. g., the production of an attack by the sight of an arti- 
ficial rose, reported by Dr. I. N. Mackenzie. This interesting case has, as Dr. Bosworth 
points out, no bearing on the question as to the power of the odor of flowers to pro- 
duce an attack without psychical impressions, as it is not at all likely that the result 
would have been brought about had it not been for the former experiences of the 
patient with real roses. I have seen a patient become affected by the presence of 
flowers in a room before he knew they were there. In my own person I have noticed 10 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
the effect of another form of mental impression. Although not subject to hay fever, I 
frequently have an attack of something like it for about half an hour after treating a 
severe case. 
(3) Atmospheric Changes, etc.-The effect of these is so well known that I will merely 
refer to an interesting case that has lately presented itself to me. The patient suffers 
violently from asthma of naso-pharyngeal origin. The attacks only come on during 
the three summer months. The hotter the day the more comfortable she is, but the 
sudden cooling of the atmosphere by a thunder storm, either where she is or in the 
near vicinity, will bring on an attack. The peculiarity in her case is that if a thunder 
storm occur in May, after never so hot a day, it will not affect her. 
(4 and 5) New Growths and other Morbid Changes in the Upper Air Passages.-The 
influence of these has been so exhaustively discussed of late years, that it need only be 
referred to here. Neither will I take your time to dwell upon the power of irritation 
in other organs to produce reflex disturbance of the respiratory tract. Of the connec- 
tion between irritation of the genital apparatus and that of the nose, I have not had 
any experience as far as genuine hay fever cases are concerned. In a lady who suffered 
severely from migraine of nasal origin (which has since largely yielded to intra-nasal 
treatment) the first symptom would be occlusion of the nostrils and a simultaneous 
appearance of a leucorrhœal discharge from the vagina, which would abate with the 
abatement of the nasal symptoms. 
If the views advanced in this paper be correct, it follows that, in the history of a 
paroxysm, the hyperæmia and swelling are secondary phenomena, the underlying 
cause being the excitation of the nerve endings (or centres), which are in a condition to 
respond to the irritant acting upon them. 
I have noted, in common with others, the marked influence of heredity, but not to 
the same extent of race or station in life. While the majority of my patients have 
belonged to the more educated and intellectual classes, I have seen cases in every class 
of life, and not only in the Caucasian, but, in two instances, in the negro. 
Treatment.-This may be palliative or curative. The palliative consists in various 
applications and internal remedies used at the time of the attack. Of these there are 
many, and none of them are of much permanent value. Their constant use is not 
without risk to the parts. This can certainly be predicated of local applications, such 
as cocaine and other powerful drugs. 
Traveling is often a complete temporary relief. The precise cause for this is not 
always easy of explanation. A patient of mine, who for years was a sufferer, lived in a 
county in Maryland where the vegetation was luxuriant. One year he spent the season 
in another county where the conditions were the same, and where a number of the 
inhabitants are affected with hay fever. Yet he escaped entirely that year. The same 
individual would not be entirely free from attacks on a coasting vessel that kept within 
fifteen to fifty miles from shore, and this independently of the direction of the wind. 
The proper course to pursue is the one that looks to a radical cure. To accomplish 
this we must use, in the majority of cases, both constitutional and local treatment. If 
we take Jonathan Hutchinson's definition, above referred to, the presence of an idio- 
syncrasy should no more discourage treatment than a diathesis. The most important 
part of the treatment is the local, for the introduction of which we are indebted to our 
honorable President, Dr. W. H. Daly. This has two objects : 1st, to cure any coexisting 
disease in the nose or throat ; and, 2d, to search out carefully and locate the sensitive 
area or areas that may exist in the upper air passages and cauterize them, an operation 
rendered nearly painless since the introduction of cocaine. On the first indication it is 
needless to dwell. For the second I greatly prefer the galvano-cautery, although other 
caustics, such as glacial acetic acid, may be used instead. I have employed the galvano- 
cautery constantly for four years, and am more and more impressed with its adapt- SECTION XIII-LARYNGOLOGY. 
11 
ability and safety, when used with the proper precautions. After the applications, the 
nasal passages should be carefully cleansed with some mild antiseptic solution (as 
Dobell's), and the eschars removed as soon as possible, especially where the cauteri- 
zation has been made on a surface that nearly approaches the opposite wall of the naris. 
I frequently give iron and quinine internally after an application. 
The most important rule to be observed in carrying out the treatment is to be 
thorough. So long as any sensitive area remains, the patient is not cured. The main 
treatment must be carried out between the seasons for the attacks, and I prefer to begin 
as soon as the attack is over. It is important, also, to see the patient during the next 
season, as it is impossible to discover all the sensitive areas until the season arrives. 
The remaining sensitive spots are then to be cauterized. 
I have seen the most gratifying results by following this method, though I have one 
case on record where the patient was cured without the use of any cautery, but only by 
simple applications of astringents and general treatment. 
In cauterizing, my method is to destroy as little tissue as possible. The cavernous 
tissue is a normal one, and the process of engorgement and swelling which occurs in the 
varying states of the temperature and of the atmosphere is a normal one, and, in proper 
limits, preservative to the health. To attempt, then, anything like its entire extirpa- 
tion, even if that were possible, except where it is clearly required, is unwise. 
At the same time, constitutional measures, chiefly addressed to the nervous system, 
are generally, though not always, indicated. The drugs I most frequently use are the 
valerianates of iron, quinine and zinc, arsenic or hydrobromic acid (Gardner's syrup). 
In all cases of debility the general health must be built up by the usual tonics. Each 
case has to be made a separate study. If the treatment be properly carried out, the 
prognosis for a radical cure is decidedly good. Had time permitted, I should have 
illustrated this paper by more cases from my own practice, but, as it does not, I must 
be content to present these observations as a résumé of my work up to date. 
HAY FEVER. 
ASTHME DE FOIX. 
HEU-ASTHMA. 
BY ISRAEL P. KLINGENSMITH, M.D., 
Of Blairsville, Pa. 
At no time in the world's history, since the day Dr. John Bostock, in 1819, presented 
the first formal paper on this subject to the London Medico-Chirurgical Society, have 
more eager scientific workers been in the field in the pursuit of knowledge and its 
practical application to disease In no subject can you find a better proof of this fact, 
than in the disease now under consideration. I will not occupy your valuable time by 
giving a detailed history of the symptoms, course and duration of the disease, but will 
confine myself to submitting to your consideration the results of my investigations so 
far as they bear broadly and directly upon the method of treatment I propose to advo- 
cate. In very few diseases do we find such a diversity of opinion in regard to the cause, 
as in hay fever. Bostock attributed it to heat, while his contemporaries differed on 12 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
this point. Since that period many theories have been advanced, but considerable 
diversity of opinion exists even at the present time. Until within the last five or six 
years, inquiry has been directed to the investigation of the exciting cause of the attack, 
and the predisposing or more important causes of the disease have been overlooked. 
Most of the literature upon the subject of hay fever, hay asthma, autumnal catarrh, or 
by whatever name it may be designated, is devoted to the extraneous or exciting causes 
of the malady in question, and numerous remedies, which serve simply to divert the 
mind of the sufferer, without resulting in any practical benefit, are suggested. Each 
patient coming under our observation should be subjected to a thorough rhinoscopic 
examination, allowing all fine-spun theories and extrinsic causes to take care of them- 
selves. To Dr. W. H. Daly, of Pittsburgh, Pa., belongs the honor of first calling the 
attention of the profession to the important part which diseases of the naso-pharyngeal 
cavities play in the production of hay fever, who, in a paper read before the American 
Laryngological Association, in May, 1881, showed that the exciting causes of the disease 
are innocuous in those cases in which disease of the naso-pharyngeal cavities does not 
exist, and proved further, from clinical evidence, that the disease is a curable one, by 
removing the intrinsic local cause and restoring the parts to a normal condition. The 
succeeding year Dr. John O. Roe, of Rochester, N. Y., read a paper before the Medical 
Society of the State of New York, practically corroborating the investigations of Dr. 
Daly. In 1884, Dr. Hack, of Freiburg, Germany, a special laborer in this field, made 
known the result of his investigations, also holding the view that pathological con- 
ditions of the nasal mucous membrane play the most important part in the production 
of the disease. The investigations of other observers substantially affirm the same 
theory. In reference to my own personal experience, I will simply say, that of the 
thirteen cases that have come under my personal observation, in each one of them has 
disease of the nose or naso-pharynx existed. The numerous exciting and extrinsic 
causes which have been supposed to bring on attacks of hay fever would occupy several 
pages, and I will therefore simply refer to a few of the more prominent. In those cases 
where local irritability or any deviation from the normal condition of the nasal cavities 
exists, an attack may be brought on by almost any exciting agent, an odor or vapor, 
dust, light or heat, the pollen of flowers or grasses. In some cases I have known 
the attack to date from a severe cold. In support of the view that almost any agent 
may produce a paroxysm, I will mention the case of a patient who is so susceptible to 
the influence of ipecac and Dover's Powder as to be able to produce an attack at any 
time by their inhalation. More recently the case of a young man, a miller by profes- 
sion, has come under my observation, in 'whom the paroxysms are produced by the 
inhalation of small particles of flour while following his occupation. During the past 
few years great advances have been made in bringing the treatment of hay fever within 
the radius of a more scientific standpoint, based upon a nearer approach to a rational 
pathology of the disease. Based upon my own investigations, as already stated, I am 
compelled to adopt the view that in each case of hay fever does a condition of the nasal 
or naso-pharyngeal cavities exist varying from the normal. When we view these facts 
and theories with a view of carrying out a rational plan of treatment, we should in 
every case make a thorough anterior and posterior rhinoscopic examination. In a great 
majority of cases a chronic nasal catarrh exists, with sensitive areas not confined to any 
particular portion of the mucous membrane. In other cases I find a true hypertrophic 
condition either anterior or posterior, or both. Polypi or deflections of the nasal 
septum may also act as a prominent factor in the propagation of the disease. Fully 
believing that hay fever is due to local irritatives brought in contact with a diseased con - 
dition of the nasal mucous membrane, I am therefore compelled to call attention to the 
radical treatment as the chief mode of relieving or curing the disease. This plan in 
the hands of Daly, Roe and others, beside myself, has been followed by the most SECTION XIII-LARYNGOLOGY. 
13 
lasting and signal success. When nasal polypi exist I remove them by means of Alien's 
nasal polypus forceps or Jarvis' snare, always making sure to thoroughly cauterize the 
base with the galvano-cautery or glacial acetic acid. If large hypertrophies, either 
anterior or posterior, are found, they should be removed by means of the Jarvis snare. 
Smaller hypertrophies and sensitive areas I destroy by using the galvano-cautery, chromic 
acid or glacial acetic acid, giving preference in the order named. All surgeons have 
favorite instruments and appliances, giving preference to some, while discarding others. 
The battery in use by me now for several years was devised by Dr. Seiler, of Philadel- 
phia, and fulfills every indication required by the operator. The current can be controlled 
by the foot of the operator, thus giving him the use of both hands, and the temperature 
of the knife can be regulated to any degree of intensity. In using the galvano-cautery 
I introduce an Alien's hard-rubber nasal speculum, through which the electrode is 
placed on the spot to be cauterized, after which it is brought to a cherry-red heat; great 
care must be taken to have the electrode at the proper temperature when applied to the 
tissue about to be destroyed, as, when too hot, free hemorrhage may result, and when 
too cold great pain will be produced. As a certain amount of inflammation is necessa- 
rily produced, not too large an incision should be made at any one sitting. My prefer- 
ence is given to the galvano-cautery, since it can be brought more fully under the con- 
trol of the operator than chromic acid, and is less painful than glacial acetic acid. The 
pain produced, as a rule, is but momentary, except occasionally in persons of a highly 
nervous organization, when I apply a four per cent, solution of hydrochlorate of 
cocaine, either by means of the atomizer or an aluminium probe enveloped in cotton. 
The operation should be repeated about once a week, or as often as admissible, being 
governed by the degrees of inflammation produced, until all hypertrophies and sensitive 
spots are destroyed. During the intervals of the operations the patient is directed to 
use an insufflation, such as Dobell's, or some other alkaline solution. In the application 
of chromic or acetic acid I use the Bosworth's application. The treatment should be 
commenced about two months before the accession of the attack, and the nasal cavities 
should be restored to as nearly a normal condition as possible, relieving them of all 
hypertrophic conditions and sensitive areas. While I am of the opinion that treatment 
should be commenced several weeks prior to the expected attack, yet in no case do I 
desist from operating even when the disease is at its height. In several such cases have 
I known the intensity and duration of the paroxysms to be shortened. Of the thirteen 
cases upon which my observations are based, nine have been practically cured, and four, 
in whom the treatment could not be carried out perfectly, were greatly benefited. In 
conclusion, permit me to say, that I have tried to outline, in as brief a manner as pos- 
sible, the essential points of this method of treatment, but, as will be observed, much 
pertaining to the minor details has been necessarily omitted which is essential to a proper 
understanding of the subject. 
DISCUSSION. 
Mr. Lennox Browne, of London, Eng., expressed his general assent with the 
views expressed by the authors of the papers, and made a few remarks on details. 
He remarked the papers contained nothing new. He considered in some cases the 
pollen an exciting cause, in others the sole cause; the former generally held. He 
thought that often good might be done by gentle methods, as vaseline protection, 
etc. Cocaine, if long continued, might prove injurious. In using the galvano-cautery 
a dull-red heat is best, and least likely to produce hemorrhage. 
Prof. E. Pletcher Ingals, of Chicago, thought nothing more could be said 
upon the two papers than had already been said by Mr. Lennox Browne, but he was 
interested in what the last speaker had said regarding the heat of the electrode. He 
thought if the naris was first treated with vaseline or fluid cosmoline, it made little 14 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
difference whether a red heat or a white heat were employed, provided the electric 
currents were not cut off before the electrode was removed from the tissues, except- 
ing in cases of deep incisions, in which hemorrhage was very likely to follow the use 
of an electrode at a white heat. 
Prof. W. E. Casselberry, of Chicago, said- I am convinced that hay fever is 
primarily occasioned by local pathological lesions within the nose or naso-pharynx 
being acted upon by an irritant. It follows that thorough removal of the pathological 
condition will radically cure the disease, but it is essential that its cauterization be 
thorough, that all sensitive or diseased areas be removed. Many having been but 
partially treated and but partially or not at all relieved, speak adversely of the 
method, and unfairly so. Since the cautery cannot be applied oftener than once a 
week, to operate thoroughly requires not two months, the time mentioned, but often 
four, five, six or even more months; and it should be thoroughly understood with 
the patient, when treatment is commenced, that it is to be carried to a finish. 
Dr. Stucky, of Lexington, Ky., thinks the majority of cases require gen- 
eral treatment. He summarizes as follows : In thirty-four cases the majority were 
neurasthenic, and required constitutional treatment. He never uses the galvano- 
cautery at white heat; has better results from dull red. If the sensitive area is hyper- 
trophied tissue, he uses chromic acid. He usually prefers glacial acetic acid, applied 
every second or third day, and destroys every sensitive area, no matter how many or 
the location. His after treatment is soothing and protective, and consists of daily 
applications of vaseline. Three months was the longest time he had to treat 
a case. 
Dr. John N. Mackenzie, of Baltimore, Md., remarked, in regard to Dr. 
Thomas' reference to the sensitive area located by him some years ago, that he now 
maintained that the posterior end of the inferior or turbinated bones and septum 
were the sole spots from which pathological reflexes are obtained. Pathological 
reflexes may be gotten from any portion of the membrane, but the area indicated by 
him he believed to be the most sensitive. Dr. M. then related his experiments with 
artificial flowers, to counteract the criticism of Prof. Bosworth and Dr. Thomas. 
Gave a brief résumé of his theory of hay fever and allied affections and criticised 
the various theories hitherto advanced. 
Dr. J. Solis-Cohen, of Philadelphia, Pa., believed that much of the difficulty 
in understanding hay fever was due to too much specialism. In pre-rhinoscopic days 
the general physician knew nothing of the condition of the nose, and recent workers 
in rhinoscopic fields seem to know too little of general medicine. His own opinion 
closely coincided with that of the preceding speaker, but he would attribute the con- 
stitutional conditions of the sympathetic portion of the nervous system, and the 
resultant conditions of its vasomotor terminals in the vessels of the nasal mucous 
membrane to a lack of equilibrium in the nervous strength of the patient. This might 
be due to hereditary conditions or to acquired ones, whether from deprivations, from 
excesses or from overwork. Hence, given a patient in this condition, the action of an 
irritant to which he is very sensitive will precipitate the attack of hay fever. If 
neurasthenic, his nervous system requires tonic treatment. If neurasthenic, it requires 
sedatives. This condition of system must be treated for long periods after the subsi- 
dence of an attack in order to get the patient into such a condition of his nervous 
system as would render him less susceptible to the irritation when the period for his 
hay fever recurs. This might take a very long time, and require the hay fever sub- 
ject to be under the observation of his physician during the entire interval. SECTION XIII-LARYNGOLOGY. 
15 
Dr. Ridge, of Camden, New Jersey, believed, from his own experience, that hay 
fever was of sympathetic origin. 
Dr. Von Klein, of Dayton, Ohio, did not believe that the nose suffered from 
the constitution, but rather the constitution suffered from the nose. Hay fever is 
not a neurosis. 
Dr. Mason, of Bloomington, Ill., related his personal experience of having his 
hay fever renewed on a railway train, after a supposed cold of two years' duration. 
The cause appeared to be smoke from the locomotive. He cited two cases in which 
it was undoubtedly caused by mental impressions-one in which a child suffered 
by imitation of her father's symptoms during several years, to be relieved when her 
father was cured; in the other case, a physician had aggravated symptoms of hay 
fever after hearing a paper read on the subject. Coughs are often produced by 
hyperæsthenic areas in the naso-pharynx, which may be cured by using glacial acetic 
acid. 
Dr. Frank 0. Stockton, of Chicago, Ill., remarked-To my mind the causes 
of so-called hay fever are three; namely, constitutional, local and external; and the 
fault with gentlemen who follow this specialty is that they seek to find one cause 
alone for this disease. 
Dr. S. S. Koser, of Williamsport, Pa., objects to the theory of the neurotic 
origin of the disease, from the fact that many of these people are attacked on 
a given day of the month in every year, and to conclude it is entirely constitutional 
is, to my mind, illogical. I know a lake far up in the Alleghanies to which persons 
resorted with perfect immunity until this year, and during this season they have 
suffered, though always heretofore they escaped. 
Dr. R. II. Thomas, in closing the discussion, said that his object in preparing 
his paper had been largely to show that the theories which bring forward neurasthenia, 
or nasal obstruction, or the existence in the healthy upper air passages of areas of 
special sensation whose irritation would produce such reflex phenomena as asthma, 
etc., were not supported by clinical facts. He was surprised to hear it asserted that 
only two views existed as to the aetiology of hay fever; the view she had referred to 
were all held, and, in fact, the discussion which was now closing had of itself been 
sufficient to bring out a great variety of opinion on the subject. His assertion that 
the occurrence of an attack of hay fever in a patient who had previously suffered 
from the disease, by the sight of an artificial rose, had no bearing on the power of a 
real rose to produce an attack, had been called in question. He thought his posi- 
tion a sound one. The instance merely proved the power of imagination. He had 
read of cases where individuals supposed to be very ill of hydrophobia had recovered 
at once on being told the dog that had bitten them was not rabid. All the symp- 
toms in such cases were due to imagination, yet few doubted the existence of 
genuine hydrophobia. One of the gentlemen who had taken part in the discussion 
had spoken as if the results obtained by him (Dr. Thomas) in endeavoring to locate 
the sensitive areas had been carried out during the hay fever season, when all parts 
of the nasal passages were hypersensitive. 
The paper had distinctly said that the observations had been exclusively carried 
on between the seasons. The result of these observations, as far as they had gone, 
told against the theories that were based on the special sensitiveness of any particular 
parts of the naso-pharyngeal tract. 
In regard to the use of the term ' ' idiosyncrasy, ' ' he did not consider that the 16 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
present state of our knowledge rendered it possible for us to drop the term, or some 
equivalent of it. 
He strongly endorsed what had been said as to the importance of constitutional 
as well as local treatment, and the necessity for a prolonged and thorough course in 
order to accomplish satisfactory results. 
Dr. D. N. Rankin, of Allegheny, Pa., read a paper entitled- 
SOME REMARKS ON THE HISTORY OF RHINOLOGY. 
QUELQUES REMARQUES SUR L'HISTOIRE DE LA RHINOLOGIE. 
EINIGE BEMERKUNGEN ÜBER DIE GESCHICHTE DER RHINOLOGIE. 
BY D. N. RANKIN, A.M., M.D., 
Allegheny, Pa. 
Until a comparatively recent date the nasal cavities have been sadly neglected. 
This neglect is more surprising in face of the fact that the nares furnish the natural 
medium for respiration; that they are the organ of smell, thereby protecting the lungs 
from the inhalations of deleterious gases, and assisting the organ of taste in discrimi- 
nating the properties of food ; and as an adjunct to the vocal apparatus in making a 
pleasant voice, they are indispensable. 
It is certainly very desirable to have an acute sense of smell, though it is not so 
important as some of the other senses. 
Of its pleasures, let me here mention a few: Every hill, and vale, and shore is trib- 
utary to the sense of smell. There appears to be a scale in odors with respect to the 
pleasures which they excite in the organ of smell. The rose appears to be at the head 
of this scale, the shrub next, the pink, the jessamine, the tuberose, the honeysuckle, 
the sweetbriar, all gradually descend from it. The pleasure derived from odors is much 
increased by mixture. There can be little doubt that these odors are so related to each 
other as to produce from different mixtures greater or less degrees of harmony analo- 
gous to the vibrations of musical soun ds. 
The odor of flowers, certain vegetables, and meats in the process of cooking, is not 
only pleasant, but nutritious and medicinal, from the stimulus it imparts to the whole 
system through the medium of the sense of smelling. Country air owes one of its 
beneficial effects on invalids to this cause. 
The sense of smell is liable to be perverted, as we see in the artificial pleasure which 
some people derive from the fetor of the civet, musk, asafœtida, and even of the snuff 
of a candle. 
Who that never saw or experienced it, would believe that the odor of the rose 
could produce fainting, or that the heliotrope and the tuberose have made some persons 
asthmatical. The smell of musk, so grateful to many people, sickens some. 
It is well known that the sense of smell guides many of the lower animals to their 
food, or warns them of danger, as is exemplified in the hunting dog. The distance at 
which a dog tracks his master is scarcely credible. 
The acuteness of the sense of smelling in animals is such that in many instances 
our observations have been deemed fabulous. Birds of prey will scent the battle field SECTION XIII-LARYNGOLOGY. 
17 
at prodigious distances, and they are often seen hovering instinctively over the ground 
where the conflict is to supply their festival. 
Ancient historians assert that vultures have cleft the air one hundred and fifty 
leagues to arrive in time to feast upon a battle field. 
Whence comes it that the red-wing, that passes the summer in Norway, or the wild 
duck, that summers in the woods and lakes of Lapland, is able to track the pathless 
void of the atmosphere with the utmost nicety, and arrive on our own southern coasts 
uniformly in the beginning of October. 
It has been observed that animals which possess the most acute smell have the 
nasal organs the most extensively developed. The American Indians are remarkable 
for the acuteness of this sense, which accounts for their wonderful power of tracking 
their enemies. 
By a glance over the text-books, you will find in the chapter on nasal diseases that 
they do not receive that attention they deserve. It is an undeniable fact, that perhaps 
no department of medicine has been so much invaded by quacks. It is true they often 
acquire reputation and wealth, but this must be ascribed to the credulity of their 
patients, and to the zeal with which they exaggerate and advertise their cures, or 
palliate or deny their mistakes. 
It has been said, and well said, that quacks are the greatest liars in the world, except 
their patients. "Quacks and impostors," said Lord Bacon, "have always held a com- 
petition with physicians. ' ' 
Galen observed that patients placed more confidence in the oracles of Esculapius 
and their own idle dreams, than in the prescriptions of doctors. 
No science has been cultivated with more difficulty than that of this specialty. Sir 
Astley Cooper used to complain that a knowledge of the nasal cavities is by no means 
general in the profession, and still less are their diseases understood. 
Compare the armamentarium of thirty years ago with the outfit of the nasal special- 
ist of to day. What was it previous to thirty years ago ? Literally nothing ; no perfect 
rhinoscope, no insufflator, no inhalers, no galvano-cautery, no incandescent light, no 
sponge holders, no guillotine, no ecraseur, no snares. A single pair of polypus forceps and a 
cumbersome nose speculum constituted the set. While visiting the mountainous districts 
of western Pennsylvania, some years ago, I went into the office of the village doctor to 
pay my respects. He was a man of perhaps seventy years of age. In conversation I inquired 
if he had much nose and throat disease to treat. He said he had considerable of that 
class of disease to look after. He then exhibited his nose and throat instruments, which 
consisted of a tongue depressor and polypus forceps. He informed me that the tongue 
depressor was made by the village blacksmith. Our forefathers depended principally 
upon general treatment and snuffs, as then treatment locally was not thought of. If a 
person was unfortunate enough to have any of the many forms of disease of the nasal 
cavities, it was allowed to progress uninterruptedly, short of a constitutional treatment. 
It appears from historical accounts that the ancients, especially the Egyptians, made 
rhinoscopic examinations, but with what success is not stated. Since Prof. Czermak, 
of Pesth, conceived the idea of, and introduced to the attention of the profession, the 
rhinoscope, wonderful indeed has been its utility in diagnosing affections of the nares 
which previously had been very unsatisfactory and obscure. The usefulness of the 
rhinoscope, however, would have been greatly lessened had it not been for the ingenuity 
of other eminent rhinoscopists, who have devised many useful surgical instruments as 
well as means for making therapeutical and electrical applications to the nasal cavities, 
whereby local applications can as readily be made to the posterior nares as to the 
pharynx. Czermak has done for the nasal organs what the illustrious Laennec has 
done for the organs of respiration. 
The therapeutics of the nares have kept pace with the surgical and electrical pro- 
Vol. IV-2 18 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
cedures of that organ. Among the many excellent remedies that have been locally 
utilized, I would merely mention four-iodoform, bismuth, chromic acid and cocaine. 
The general practitioner, when summoned to see a case of nasal disease, is too often 
satisfied with a too superficial examination. Generally, he raises the point of the nose 
somewhat, and then the vague pronunciations are uttered : "high up in the nares," or 
"deep down in the nares," or, in the case of a child, "let it alone, it will grow out of 
it." Therefore, it cannot be wondered at that the diagnosis and treatment of nasal 
diseases have been in a mixed condition. 
We live, gentlemen, in a revolutionary age; our science has caught the spirit of the 
times, and more improvements have been made in this specialty within the past twenty- 
five years than had been made in a century before. From these events, so auspicious to 
our department, we may cherish a hope that advancement may draw nearer perfection. 
Great Britain is entitled to a large share of the influence in the advancement of this 
specialty. It has contributed much to this movement by careful clinical observations 
of diseases of the nose, and by numerous contributions to our anatomical and physio- 
logical knowledge of nasal diseases. The German spirit,, recognizing the importance of 
this new era, joined in, hand in hand. Austria, Denmark, Russia, France, Spain and 
Italy are all well represented by men eminent in this specialty. 
America, never behind in anything that conduces to the benefit of mankind, is rep- 
resented by men of marked ability as writers and teachers, as well as successful practi- 
tioners in this department. 
The American Laryngological Association and the American Rhinological Associa- 
tion are institutions we feel proud of. The former, with a fellowship of over fifty 
members, is composed of the very best talent in this country, who have already made 
their mark, and are still actively engaged in prosecuting their valuable labors. The 
American Rhinological Association, being of recent origin, is composed of excellent 
material and doing good work. It was my good fortune, during the last meeting of the 
International Medical Congress at Copenhagen, Denmark, to meet most of the gentle- 
men of the Laryngological Section, and without a single exception those I met were 
persons of the highest medical attainments, and gentlemen in every sense of the word. 
Here permit me to say a word in memory of the father of Rhinology and Laryn- 
gology in America. I refer to the late Lewis Elsberg, a man whose memory we should 
all revere, as not only a gentleman and scholar, but most eminent in Rhinology and 
Laryngology. He unquestionably did much to advance these specialties. 
To America is due the credit of bringing rhinology to its present status. Dr. Daly 
has doubtless done more to accomplish this end than any man in this country. 
The ample means we now possess of investigating diseases of the nares, and the 
facility with which the true nature of these diseases is arrived at, is certainly very 
encouraging. 
Comparing rhinology to a house, the different stories of which have been erected by 
different architects, Czermak, Elsberg, etc., have a large claim to our gratitude for 
having, by their arduous and successful labors, advanced the building to its present 
height. It belongs to the rhinologists of the present and future generations to place a 
roof upon it, and thereby complete the fabric of rhinology. 
DISCUSSION. 
Dr. M. F. Coomes, of Louisville, Ky., remarked: In 1859, Dr. Troupe Max- 
well, of Kentucky, had a mirror constructed, and obtained a view of the vocal cords, 
not the posterior nares. He was certainly the first American to use a mirror for 
looking at the vocal cords. SECTION XIII-LARYNGOLOGY. 
19 
SECOND DAY. 
The Section was called to order at 11 A. M., the President in the chair. 
Mr. Lennox Browne, of London, read a paper entitled- 
RECENT VIEWS ON THE PATHOLOGY AND TREATMENT OF TUBER- 
CULOSIS OF THE THROAT AND LARYNX. 
APERÇU RÉCENT SUR LA PATHOLOGIE ET TRAITEMENT DE LA TUBERCULOSE 
DE LA GORGE ET DU LARYNX. 
NEUE ANSICHTEN UBER DIE PATHOLOGIE UND BEHANDLUNG DER TUBERKULOSE DES 
SCHLUNDES UND KEHLKOPFES. 
BY MR. LENNOX BROWNE, F. R. 0. S., EDIN., 
London. 
At the present time it is almost universally accepted that the tuberculous process is 
initiated by the settlement of a specific bacillus on a suitable nidus, or, as it was form- 
erly called, at the spot of least resistance. This bacillus is of the nature of a fungus, 
and partakes of the special characteristic of all fungi, in that it requires for its growth a 
soil in which organic decay is taking place. Bacilli gain access to the lungs by means, 
primarily, of the main air passages; they may be deposited at a portion of the lung, 
for example, an apex, which is ill supplied with blood and especially with air, or in 
the altered pulmonary tissue which invariably exists after an acute lung disease ; of 
this we see an example in the case of tuberculosis following basal pneumonia. 
Like all parasites, bacilli are highly irritating, expression of which quality is evi- 
denced in the formation of the miliary tubercle, a tissue of very low vitality, prone to 
break down. As to whether the bacilli reach the tissue through a break of epithelial 
continuity, by diapedesis or otherwise, is a question which cannot now be entered on. 
What we do know is that the bacilli, having once established themselves, multiply in 
large numbers, and this circumstance leads not only to a local increase in the morbid 
process, but also to access of bacilli to the general circulation by the lymphatic system. 
When the tubercles are broken down so as to form cavities, bacilli are more or less 
abundant in the sputa. It is thus evident that bacilli may arrive at the region of the 
larynx by at least two routes. 
Taking into account the fact that tuberculous infiltration usually invades the deeper 
tissues of the larynx at an early period of the disease, and before any breach of con- 
tinuity of surface, I am inclined to the conclusion that when laryngeal phthisis follows 
a pulmonary disease of the same nature, the tubercles are transplanted through the 
systemic circulation. Without doubt, however, it occasionally happens that there is 
direct infection by the sputa through a breach of surface, the result of a coincident 
catarrhal laryngitis more or less acute. But, as a general rule, there must be in the 
larynx, as in the lungs, a condition of local receptivity. One factor, at least, of this 
predisponent is that of anaemia. This is manifested preferably at marginal and apical 20 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
regions of the larynx, as of the lungs, and we thus find that the general seats of earliest 
infiltration are the inter-arytenoid space, the coverings of one or both of the arytenoid 
cartilages, the ary-epiglottic folds and the epiglottis. On the other hand, in those 
cases in which functional abuse is an exciting cause of the local process, the tumefaction 
may first occur in the vocal cords and the ventricular bands. In this last class of cases, 
and in some few others not due to functional causes, the first condition is one of per- 
sistent hyperæmia instead of anaemia, and instances will occur to every practitioner 
illustrative, in its special application to the throat, of Trousseau's dictum, that a 
neglected catarrh is often a consumption commenced. There is, in fact, a condition of 
the larynx predisposing to tuberculous deposit very analogous to that of an unresolved 
pneumonia. 
Ulcerations of laryngeal phthisis are characterized by their small size, their mul- 
tiple character, and their tendency to coalesce and to extend laterally rather than to 
penetrate deeply. As before mentioned, erosions non-tuberculous in character may 
appear in the larynx of a tuberculous patient the subject of a fortuitous catarrh. Doubt- 
less, some of those that heal under treatment are of this nature. It remains to say a 
few words as to the mode of origin of tuberculous manifestations in the fauces. A 
long experience has assured me that disorders of absorption, assimilation, and digestion 
generally play a far more important part in the production of faucial, tonsillar and 
pharyngeal inflammations than any faults of atmosphere, climate or even exposure to 
cold and damp, these last preferably and mainly aflecting the respiratory tracts. When 
the pharynx is attacked in the case of an advanced pulmonary or laryngeal phthisis, 
we may not presuppose a breach of surface to be absolutely necessary for infection of 
this region by bacilli contained in the sputa and oral fluids, but we may postulate that 
the absorption of the liquid portions of the contaminated oral secretions must lower the 
vitality of the faucial and pharyngeal mucous membrane; in fact, a nidus is formed for 
the settlement of bacilli brought thither by the general circulation. When the fauces 
are primarily attacked we must admit the probability of a previous breach of continuity. 
I have reported a case in which the local irritation of diseased teeth, as evinced by 
marked improvement following their extraction, was the exciting cause of a tuberculous 
ulceration of the gums and mouth. 
In my experience, evidence of the tuberculous process is manifested later in the 
fauces than in the larynx, but, as I could show by relation of many cases, this region 
may be attacked at any stage of the disease; several circumstances, especially the now 
well known case of Demme*, have confirmed the opinion long entertained, though 
until recently unsubstantiated, that laryngeal phthisis may precede the pulmonary 
disease, f and it is quite possible that similar evidence will be afforded regarding the 
fauces and pharynx. At present we are not in a position to do more than assume its 
probability. 
Some six and a half years ago I reported, in conjunction with Dundas Grant, two 
cases-one arising, as just recorded, from direct irritation of decayed teeth, in which 
the first manifestation in the mouth and fauces had occurred between two and three 
years previously to any chest attack, or even- before the suspicion of pulmonary disease. 
Last December I exhibited a patient at the Medical Society of London, and I have 
* Demme's case is that of a boy aged four and a half years, who died of tubercular menin- 
gitis ; the necropsy showed the presence of laryngeal ulceration with tubercle bacilli ; the thoracic 
and abdominal organs being at the same time free from tubercular disease. 
f Ziehl has also related a very pertinent example, in which a woman was tracheotomized for 
laryngeal stenosis. The pulmonary secretions, which could thus be perfectly separated from those 
of the larynx, were free of bacilli, while those taken directly from the laryngeal ulceration con- 
tained them. SECTION XIII-LARYNGOLOGY. 
21 
reported it in full in the recently published second edition of my work, ' ' The Throat 
and its Diseases; " as far as clinical evidence could go, it clearly establishes the proba- 
bility of a primary tuberculous ulceration in the upper throat. 
The subject was a young woman, aged twenty, the mother of three children, the 
youngest of whom was fourteen months old. She applied for treatment on account of 
extreme pain in swallowing, not only food, but even saliva. There was no distress of 
breathing, no night sweats nor diarrhoea. Physically there was seen to be ulceration 
of the left tonsil and of the back wall of the pharynx along its whole length, with 
slight extension to the posterior border of the larynx. Beyond very moderate conges- 
tion of the coverings of the arytenoids, and hardly preceptible thickening of the inter- 
arytenoid fold, there was no other laryngeal disease, and the stethoscope revealed 
nothing beyond slight harshness of respiration and somewhat impaired resonance at the 
right apex. Tubercle bacilli were abundantly manifested in the sputa. Under treat- 
ment-by scraping and lactic acid-the patient lost all her symptoms, and beyond some 
adhesion of the left posterior faucial pillar there could be detected no signs of her former 
disease, but whenever the saliva was examined, as was done for many weeks after all 
functional and physical signs had disappeared, tubercle bacilli could be detected. It 
may be mentioned, en passant, that this circumstance well illustrates the limit of use- 
fulness of bacillary evidence. It is an important factor of diagnosis of the presence of 
tubercle, but of uncertain value in prognosis, since bacilli are often as abundant in mild 
and chronic cases as in those of an acute and advanced character. However, a very 
careful and thrice repeated search failed to detect any bacilli on the last occasion on 
which I saw her, namely, one week before I left England. The patient has gained weight 
and is really in fair health ; the lung symptoms have not in the least degree advanced 
since the first examination. 
Having thus indicated some of the more important of the local pathological circum- 
stances on which we are to base our treatment, and necessarily excluding from the 
present discussion pulmonary conditions, let us proceed to consider the means at our 
command for combating the tuberculous process in the pharynx and larynx, and, for the 
sake of still further confining my observations within available limits, I shall suppose 
that we have a case before us in which, though the morbid process is well established 
in some portion of the throat, the general system has not yet broken down, or the lung 
disease advanced so far as to preclude the hope of restoration to comparative health and 
a prolongation of comfortable and useful life. 
The basis of our treatment must be : First, by certain climatic, hygienic and general 
measures, to place the patient in the most favorable position for resisting the baneful 
influence of the bacilli, and, if we can, of rendering their life impossible. Under this 
head I have a preference for sea voyages and mountain air over residence in very hot 
climates, and especially at health resorts where the air is unduly moist, though, of 
course, such circumstances must be regulated by the particular character and stage of 
the case. The advantages of sea air and mountain elevation are generally allowed to 
arise from the greater rarity of morbific germs and the larger amount of oxygen and 
ozone present in such atmospheres. The only satisfactory case of actual cure of laryn- 
geal phthisis that I have seen has been the result of two sea voyages and a residence for 
two years in New Zealand. The subject, when first brought to my notice, was a lad 
of fifteen. The nature of the case undoubted, and was confirmed by others. Lung 
disease was hardly to be detected. The patient is now twenty-two years of age, and 
a hale farmer in the west of England. Hunter Mackenzie, in a recent article, has 
deprecated high altitudes as too irritating for patients suffering from throat consumption, 
but such an objection does not apply to the earlier stages or to cases in which the lungs 
are but slightly implicated. On the contrary, I have seen the happiest effects from 22 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
residence on mountainous plateaus. There are, of course, many circumstances not 
possible to at present consider, which may modify our advice on this head. 
Supplementary to these climatic measures may be considered those of inhalation, 
and I have only here to state that for some years I have ceased to advise those of 
medicated steam. I cannot agree with a recent author, Massei, that oro-nasal inhalers 
have at all fallen out of fashion. My daily experience convinces me more and more 
of their value. The particular mixture I employ for general use is one composed as 
follows : Oil of pine and oil of eucalyptus, of each a drachm ; alcohol and ozonic ether, 
of each eleven drachms. I have also found benefit from the inhalation of menthol, as 
advised by Rosenberg. This remedy is particularly valuable in the stage of anæmia 
and infiltration, i. e., before the occurrence of ulcerations. Under its use I have seen 
perceptible and increasing improvement in the shape of recovery of normal color of the 
mucous membrane and diminution of submucous infiltration. In the hyperæmic type 
I have witnessed resolution by means of the same remedy. The patients get to like 
the treatment so much that there is no necessity to encourage them, as is advisable, to 
wear the inhaler as long as possible, both waking and sleeping. I have found the cheap 
inhaler of Squire, devised by Burney Yeo, answer as well for general hospital purposes 
as any of the more elaborate apparatus. 
There is no doubt that the tuberculous process, when once thoroughly established, 
is one of septicæmia, and it is probable that the colliquative sweating and diarrhoea, 
the general asthenia and cardiac failure, often manifested by the phthisical patient in 
whom there is no actual cardiac disease, may all be explained as results of ptomaine 
poisoning. Many of these general symptoms are relieved by the oro-nasal inhaler ; but 
the particular alkaloid which seems antidotal to many of these evidences of ptomaine 
toxaemia is atropine. In any case, apart from theory, it is a symptomatic remedy of 
acknowledged value. 
Of further general measures I need only allude to the hypophosphites, but I may 
mention that while I often employ them in combination, as in Fellows' syrup, I have 
a preference for the salt of calcium as more likely to bring about a beneficent (calca- 
reous) degeneration of diseased tissues. I have also witnessed the excellent results to 
be obtained by administration of small doses of arseniate of soda or potash. Arsenic 
appears, indeed, to act on the tuberculous dyscrasia much in the same specific way- 
though perhaps less powerfully-as does mercury in syphilis. 
The second indication is to annihilate the bacilli by germicides. These remedies 
may be divided into two classes-those which, while acting as germ destroyers, may 
also powerfully affect the general system, and those of a more purely local character. 
Among the former are to be mentioned perchloride of mercury, aniline, and perhaps 
in a less degree sulphureted hydrogen and dioxide of carbon. 
Looking to the inj urious effects of mercurial combinations when internally admin- 
istered to a tuberculous patient, I cannot recommend either sprays or injections of cor- 
rosive sublimate. My own conviction is, that as germs are killed with more difficulty 
than are normal cells, especially in persons of tuberculous tendency, the remedy might 
but aggravate the disease. Nevertheless, Massei states that he has found the effect so 
satisfactory that he now employs it in daily practice to the strength of 1 in 2000. The 
aniline treatment by Kremianski has had but a short life and is generally condemned. 
The sulphureted hydrogen treatment, introduced by Bergeon and administered per 
rectum, is yet on its trial. Its special office seems to be to check bronchial secretion 
and to diminish night sweats, but it is doubtful if the process is in any sense truly 
microbicidal. I have no especial experience of this remedy at present beyond one case, 
in which the effect appeared at first to be very favorable-profuse bronchorrhoea and 
night sweats being both arrested almost as by a charm; but on the patient leaving his SECTION XIII-LARYNGOLOGY. 
23 
physician, Dr. Sinclair Coghill, whom I am happy to see present, and continuing the 
treatment himself without medical supervision, such alarming symptoms of dyspnoea 
occurred that I was summoned to perform tracheotomy. The operation was, unhappily, 
of no avail, although I made the opening as low as possible in the trachea, we having 
diagnosed, prior to operation, that there was, in addition to a mechanical laryngeal 
stenosis, a further considerable obstruction of the left bronchus near its bifurcation. 
After death, Dr. Montague Ball, of Hounslow, who was the practitioner in attendance, 
found that the vocal cords were greatly thickened and congested, the whole trachea and 
bronchi also very much congested and the left bronchus almost entirely blocked by a 
plug of thick, fibrous mucus. There was also great enlargement, with caseation of 
the glands surrounding the left bronchus to such an extent as to considerably diminish 
the diameter of the tube. In the light afforded by the autopsy, it would be unreason- 
able to say that the fatal result was due to the treatment; nevertheless, it should warn 
us, in cases favorable for its adoption, against allowing a patient to undertake it himself, 
as has been advised and countenanced by several writers on the subject. 
Of the germicides producing local effects may be mentioned- 
1. Galvano-cautery. 
2. Lactic acid. 
3. Menthol. 
4. Iodoform or iodol. 
The first I have employed with success in tuberculous ulceration of the tongue and 
tonsil, and I have reported cases in support of its adoption. 
The second has proved of great service in the practice of myself and my colleagues 
in pharyngeal and faucial manifestations. It is preceded by an application of a ten 
per cent, solution of cocaine and a scraping of the surface to which the acid is to be 
applied. Its effect is to stimulate healthy reaction, and, as Krause has said, pain is no 
contraindication to success ; for on recovering from inflammation, the parts generally 
cicatrize healthily. 
I have been so satisfied with this treatment that I have not employed the remedy 
by means of the syringe, as was first recommended by Hering, of Warsaw. Moreover, 
I have a distinct preference for a cotton-wool brush over the spray; for, as Roe, of 
Rochester, has shown, remedies introduced by the latter method do not penetrate to the 
ventricles and other chinks and crannies of the larynx so well as when the sphincter 
glottidis squeezes the fluid from a brush. This author believes that the continuous use 
of sprays is injurious to the cilia of the mucous membrane of the air passages, but that 
there is no such danger in soft brushes. In this respect the solution carrier made of 
absorbent wool possesses advantages over those of camel hair or sponge. Whatever 
form of applicator is employed, it is important to clear away the excess of frothy saliva 
and other tenacious secretion that always overloads a tuberculous throat. Neglect to 
take this precaution may account for many instances of failure of local treatment. The 
circumstance itself explains why fine sprays and insufflations are offen inert, whereas 
the slight friction inseparable from the use of the brush is really beneficial. 
As to the third method, our experience at the Central London Throat and Ear Hos- 
pital, of lactic acid in the larynx, has not been so favorable as in the upper throat, and 
we have frequently employed menthol, 20 per cent., as advised by Rosenberg. Although 
at first rather pungent, its application is quickly followed by a distinctly anæsthetic 
effect. I am not sure that ulcerations often or ever heal under this treatment, but I 
have no doubt that infiltration is frequently resolved, that in the case of anaemia the 
tissues gain color, while, when the condition is one of congestion, the hyperæmia is 
reduced. 
The fourth is that of iodoform or iodol, which it is recommended to apply in either 
ethereal or alcoholic solutions or as insufflations. These remedies have many warm 24 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
advocates among practitioners of repute, particularly of Lubinski, but have failed to 
give satisfaction in my own practice. It is to be noted that, according to recent inves- 
tigations, not only is the germicidal action of this drug doubted, but, as Watson Cheyne 
states, germs may even be cultivated in its presence. 
Although in no sense curative, insufflations and other remedies of a purely anodyne 
character demand at least passing consideration. For myself, I limit insufflations to 
cases in which it is desirable to apply sedatives and to keep them in contact with an 
elevated or otherwise painful.spot; but, as I have already said, I am not an advocate of 
insufflations as a general method of conveying topical remedies, for I have not unseldom 
seen them coughed away as a thick cake a second or two after their introduction, and 
if I wish to have a sedative retained I prefer a semi-fluid or emulsive medium of traga- 
canth. Cocaine has, of late years, taken preeminence as a pain destroyer, and is of 
undoubted value for allaying sensibility of the throat to the passage of food when adyn- 
phagia is a prominent symptom ; but morphia, whether in powder or in semi-fluid 
medium, and balsamic applications containing some preparation of opium or belladonna, 
are of more service in diminishing continuous pain and in allaying cough, since, the 
action of these drugs is far less transitory than in that of cocaine. Cocaine lozenges are 
useful in tuberculosis of the tongue and fauces. They are of no avail in laryngeal cases. 
Before the introduction of cocaine, I found great comfort was experienced from appli- 
cation of a mixture of compound tincture of benzoin and paragoric, each an ounce, and 
a drachm of tincture of belladonna mixed up with the yelk of one egg. Patients were 
allowed to apply it themselves before food taking and on occurrence of cough. I still 
employ this mixture, substituting cocaine in place of the belladonna, for allaying actual 
pain. 
Surgical Measures.-These are, for the most part, heroic, and are not pursued by me 
further than to the extent of scrapings prior to the application of lactic acid or menthol. 
It is hardly necessary to speak in detail of incision into the thickened laryngeal tissues, 
as advised seven years ago by Schmidt and also advocated by Hering. It is true that 
general periostitis has been treated successfully by stabbings and incisions ; neverthe- 
less, my experience of quite slight scarification of the larynx of a tuberculous patient, 
even where the swelling of the tissues seemed to be due to true œdema, has not 
encouraged me to further extend the practice. Such points rarely, if ever, heal, and 
are only too likely to become the seats of fresh infection. I doubt if there are many 
practitioners who have longer any faith in the treatment. Neither do I advise removal 
of the granulomata and other papillomatoid excrescences so frequently observed in the 
course of a tuberculous laryngitis, unless they are in such situation as to seriously 
interfere with respiration. Nor have I yet seen my way to the advocacy of tracheotomy, 
either as a prophylactic or as ameliorative of the distressing respiratory symptoms so 
often evidenced in laryngeal phthisis. My main objection is that the theoretical indi- 
cation on which the operation is based-namely, the giving functional rest to the larynx 
-is but very rarely attained in practice. On the contrary, a tracheotomy tube is almost 
always a source of extreme irritation and increased discomfort in the case of a tubercu- 
lous patient. Added to this, the physiological duties of the upper air passages are 
entirely abrogated, and the air is taken into the lungs impure, cold and dry. In this 
manner the operation is actually capable of inducing an aggravation or recrudescence 
of pulmonary disease, unless the patient is confined to a room and made to inhale an 
atmosphere charged with steam and antiseptics. 
Nor can I speak favorably of the prospects to be afforded by the recently revived 
procedure of intubation of the larynx, which has the additional objection of causing 
increased irritation by constant contact of a foreign body with tissues already ulcerated 
or highly prone to become so. The risk of blocking of the very small tubes used in 
these operations, by tenacious secretions and sputa, constitutes an adverse argument SECTION XIII-LARYNGOLOGY. 
25 
that must not be overlooked. For fear of bringing valuable surgical measures into 
disrepute, I go so far as to never remove even an elongated uvula in a tuberculous 
subject without most explicitly warning both the patient and his friends that the 
operation is but, at best, a palliative. Far less could I approve the suggestion to remove 
a portion of thickened epiglottis or arytenoid body. But to show the length to which 
surgical measures may be extended, I need only mention that Massei has recently 
suggested that ' ' the history of many successful cases of extirpation of glands, kidneys, 
ovaries and other organs for tubercular disease warrants us in entertaining the idea that, 
were early diagnosis of primary laryngeal phthisis possible, extirpation of the larynx 
in such instances would come within the pale as the most efficacious of all remedies." 
It is hardly necessary for me to say that I do not share such an opinion. 
After all is said and done, are we in a position to-day to claim that we can cure 
laryngeal phthisis ? I personally doubt it, and although I have alluded to two cases 
occurring in my own practice, in which there has been apparently complete arrest of 
all diseased processes, I am unable to report one in which I have seen what could fairly 
be called a cure, by either physic or surgery, of a case of well-established laryngeal 
phthisis. I could present you with a table of many carefully-watched observations, by 
which it could be shown that, under treatment such as has been indicated as that 
generally adopted in my practice, the following gratifying results have taken place :- 
1. Food taking has been rendered painless or less painful, and regurgitation of fluids 
has been especially obviated. As a consequence, weight has been gained. 
2. Expectoration and secretion have both been lessened. 
3. Erosions have healed, but rarely ulcerations, except in the fauces and pharynx. 
In this respect I am able to concur heartily with the dictum of Hunter Mackenzie, that 
success in treatment is in proportion to the accessibility of the seat of the lesion. When 
the vocal cords are implicated, I have but rarely witnessed material improvement in the 
vocal symptoms. 
4. The pulmonary condition has remained in some cases stationary, in others the 
morbid process has been retarded, and in a third class, although lung disease has been 
far advanced, and has continued active, improvement of throat symptoms, especially of 
pain and difficulty in food taking, has been really considerable. 
5. Hectic sweats have in many cases been diminished, even where the chart has not 
shown great variations of temperature. 
On the whole, I have to confess that evidence of local relief has been more satisfac- 
tory than that pointing to any real arrest of the disease, and we must still admit that 
faucial or laryngeal tuberculosis, being rarely primary, is but partially amenable to 
therapeutics, and that its existence in the throat as a complication of a pulmonary 
tuberculosis must always influence our prognosis most unfavorably, whether we calcu- 
late on the chances of an arrest of the disease or on the probable duration of a life. 
But while I am precluded from reporting such a happy experience as those of 
Schmidt, Hering, Bosworth and others, who claim to have quite a long list of cures, I 
am far from denying such a possibility. On the contrary, I feel sure that each year 
we are encouraged in the belief that there is at least equal hope that such a result may 
in time be attained, when the disease attacks the throat, as is at present held out 
regarding its manifestations in the chest. 
For this desirable end what is required is: First, earlier diagnosis and treatment of 
premonitory morbid conditions. 
Secondly, greater reticence in advertising the infallibility of new remedies, and 
adoption only of such as are based on sound pathological data. 
Thirdly, abstinence from "useless activity," as Paget has called it, especially in 
advanced cases, and a recognition of the fact that an attempt should be made to heal 
the nidus as well as to destroy the bacillus which is settled thereon. 26 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Lastly, and above all, to again quote the words of Sir James Paget, ' ' The chief need 
seems to be the collection of facts well observed by many persons. I say by many, not 
only because many facts are wanted, but because, in all difficult research it is well 
that apparent facts should be observed by many; for things are not what they may 
appear to each one's mind. In that which each man believes that he observes there is 
something of himself, and for certainty even on matters of fact we often need the 
agreement of many minds, that the personal element of each may be counteracted. ' ' 
DISCUSSION. 
Dr. J. Sinclair Coghill, of London, opened the discussion on this paper by say- 
ing-I have listened to Mr. Browne's communication with the same pleasure and 
instruction I always receive from that gentleman's contributions to the literature of 
that branch of medicine which he has cultivated so successfully. There is no form 
or complication of phthisis which causes so much distress to the patient and embar- 
rassment to the physician as tubercular laryngitis. It is of first importance to dis- 
tinguish between tubercular laryngitis as a primary and as a secondary lesion. 
This is more especially important as a basis of opinion in prognosis. As a secondary 
affection, the physician must content himself with relieving symptoms with a view to 
alleviate the evident and distressing sufferings of the patient. As a primary affec- 
tion we can hope to decrease, in the light of modern discoveries, the prognosis is 
vastly less grave, and at least we can regard a pause in the progress. It was long 
before I could convince myself that laryngeal phthisis was ever other than a lesion 
secondary to pulmonary tuberculosis. I have no doubt whatever, now, that it does 
occur as a primary disease from infection. It would indeed be strange if this were 
not to occur occasionally if the lungs are infected through the air passages, as they 
most undoubtedly are. One case recently under my care threw a most instructive 
light in this connection. A young lady contracted a tubercular ulceration of the 
left side of the pharynx, extending down to and involving the margin of the epi- 
glottis. Repeated examination of the chest revealed no pulmonary mischief. The 
disease was contracted while nursing a brother who died of chronic pulmonary 
phthisis involving both lungs. The patient in question had all the usual symptoms 
of tuberculosis. Iodoform applied locally, with extreme care, in association with 
apropriate general treatment, entirely cured the case. I know no remedy equal to 
iodoform, but it is a potent one, and must be used sparingly and cautiously. I have 
seen toxic effects repeatedly developed from comparatively small doses. I cannot tell 
what its mode of action may be ; it is possible, as Mr. Cheyne says, that ' ' the tubercle 
bacillus perishes in the purity of iodoform;" but there is no topical remedy I have 
employed with so much confidence and satisfaction in tuberculosis, nay, indeed, in any 
foul ulceration, as iodoform. I must confess I am not sound on the tubercle bacillus. 
My heterodoxy, however, only goes the length of referring the processes in which it 
may be recognized as more due to its nidus or environment, than to the bacillus itself. 
This is most important to bear in mind, as the importance of general treatment in 
such cases take this foreground in one regard. Tuberculosis is essentially a parasit- 
ical disease, and this fact must be continually borne in mind. I might illustrate this 
from what is so familiar to us in the vegetable world. When a tree has deficient air 
and light, its roots cramped in by barren soil, it gets sickly, looks ill, gets out of con- 
dition and speedily becomes the prey of every parasitic pest. Remove the unhealthy 
condition, let in air, light and sunshine, loosen the roots and furnish rich soil, and 
the change for the better begins, health is restored, and the parasites cease to flour- 
ish. This is seen in phthisis in states of arrest ; bacilli may be found, but the condi- SECTION XIII-LARYNGOLOGY. 
27 
tions for their development are absent. This question of raising and restoring the 
general health is not only true with respect to the recovery from disease, but also in 
resisting morbid influences. Note the different fate of twelve robust, well-fed and 
vigorous men, and a similar number of feeble and starved men, exposed to the infection 
of sewer gas. I must refer, before sitting down, to Bergeon's treatment. I believe it 
has no specific action in tuberculosis of lungs or larynx. It is only improving in the 
general health through the gastro-intestinal mucous membrane, improving action of 
liver, digestion and assimilation, just as sulphureted waters have been doing for 
ages, when taken by the stomach. The case Mr. Lennox Browne has referred to was 
one that improved marvelously under treatment. Indeed, it encouraged me vastly to 
believe in its efficacy. No case could have presented a greater consensus of unfavor- 
able conditions, both as regards the morbid history and the inherited cachexia, but that 
the patient seemed to revive miraculously, profoundly impressed me with the benefit 
he had derived. I think he confirms the treatment too energetically with the results 
stated. 
Dr. J. Solis-Cohen, of Philadelphia had frequent occasion to corroborate 
mostly the views of the reader of the paper, especially those of the last speaker, 
with whom he had seen much advantage from the topical use of iodoform, and with 
whom he thought the great elements in treatment are to improve the general con- 
dition of the tissues so as to disfavor the development of bacilli, and render them 
more innocuous, and to depend upon nutrition as the main resource in treatment. 
Prof. E. Fletcher Ingals, of Chicago, said-Like the preceding speakers, 
I fully agree with nearly all that has been said by the author of the paper, and I 
desire to call special notice to some of the points which have been made, with a view 
of emphasizing them. I was especially pleased to learn that the author had given 
up the use of steam inhalations, and I wish every one else would give them up, for 
I believe that in most cases they do more harm than good. Regarding climatic 
treatment, I am uncertain what cases of laryngeal tuberculosis are benefited by a 
high altitude. I now think that those in which the disease is recent may be bene- 
fited, but I am confident that many cases of advanced ulceration are greatly injured 
by it. I fully agree with the author that the salts of calcium seem most beneficial. 
I do not know that it matters materially what salt be used, but from several years' 
use I have come to like best the chloride, which is readily soluble and easily 
absorbed. Bergeon's treatment I have tried, and in one case of laryngeal phthisis 
found it beneficial for a few days, but afterward it caused such severe pain that the 
treatment had to be suspended. I have had little experience with the superficial 
application of lactic acid, and, fortunately, but little with the submucous injection. 
In only two cases have I tried the latter ; in both the effects were not good, and 
the patients went rapidly "to their reward." I have had very little satisfaction 
from the use of cocaine for the relief of pain, either when applied by myself or when 
used as an insufflation by the patient shortly before eating. I have had better 
results in these cases in relieving pain from the application of a pigment of morphine, 
carbolic acid and tannin in glycerine and water. I believe that the combination of the 
tannin with the glycerine hardens the tissues, and thus materially aids in preventing 
pain. As to the prognosis, I can now recall four cases, in two of which there 
were ulceration, and in the others erosions, in whom recovery had taken place. In 
these the diagnosis was not made by the aid of the microscope, but in all of them 
were pronounced pulmonary lesions. These cases are of from four to seven years' 
duration. The two of whose present condition I am certain have pulmonary scars. 
With the second speaker I fear I am not orthodox on the subject of bacilli, but 28 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
believe that the bacillus is not of so much importance as the soil upon which it 
thrives. This recalls the case of a brother physician suffering from laryngeal tuber- 
culosis in which the number of bacilli are greatly increased by the occurrence of cold. 
It seems as though in this case it must surely be the soil that causes the increase. 
Finally, as I said many years ago, I believe that constitutional treatment is of great- 
est importance, though I also believe that local treatment is of much value. If the 
condition of treatment can be improved, we may hope to benefit the larynx, but local 
treatment can hardly help other cases, excepting as they prevent pain and thus allow 
of proper nutrition. 
Dr. Coomes, of Louisville, Ky., said that a few years since he was in doubt as to 
the possibility of phthisis of the larynx occurring without involvement of the lungs, 
but at present he was satisfied that the larynx might be involved without the exist- 
ence of tubercle in other portions of the body. He reported four cases in which the 
disease of the larynx was arrested during the existence of the lung complication. In 
two cases the epiglottis was almost completely destroyed, but the open surface in 
each completely healed ; one of the patients is still living, the other died eighteen 
months after the throat lesion was cured, from pulmonary hemorrhage. He pre- 
ferred iodoform insufflations to all other local applications ; was careful to apply it in 
small quantities, two grains being quite sufficient. Had seen two cases of severe 
poisoning from its use in large doses. 
Dr. Max Thorner, of Cincinnati, Ohio, said-I think that tuberculous ulcer- 
ation in early stages may heal, even if only temporarily. The presence of bacterii 
tuberculosis seems not to be necessary, since other symptoms often will prove the 
presence of tuberculosis. Dr. Bryson Delavan, of N. Y., reported in the last meet- 
ing of the American Laryngological Association cases of tuberculous ulcers of the 
tonsils, where he did not find bacilli. I have seen two cases of laryngeal phthisis in 
which tuberculous ulceration was present, though I admit of not having found bacilli 
tuberculosis. One gentleman had ulcers on the vocal cords; he complained of pain 
radiating from the left side of larynx to the ear. The apices of the lungs showed 
acute bronchitis. After using iodoform and boric acid for about two months, the 
ulcers healed. Six months afterward the patient came with the same symptoms ; 
the same treatment had the same effect. 
In the second case, a young, emaciated man was exceedingly hoarse, complained 
of severe pain radiating from both sides of the larynx to the ears. The vocal cords 
were superficially ulcerated. The left arytenoid cartilage had the pathognomonic 
pyriform shape. There was no active process in the lungs ; both apices had a dull 
percussion sound. The ulcers healed twice, in intervals of about six months after, 
with the application of iodoform and lactic acid. When he appeared the third time 
with the same symptoms, I treated him alone, according to Bergeon's plan ; after six 
weeks there was no improvement at all in the laryngeal symptoms. I then again 
treated him with forty per cent, solution of lactic acid ; the ulcers healed in about 
eight weeks. These two cases seem to prove to me that laryngeal tuberculous ulcers 
may heal temporarily. 
Dr. McGeagh, of London, reported one case under observation at University 
Hospital, London, remarkable for the marked improvement during the exhibition of 
iodide of potassium, ten grains three times a day, with the local application of equal 
parts of iodoform, boric acid and starch by insufflation, after having the throat first 
of all thoroughly cleansed by a camel's-hair brush saturated with an antiseptic solu- 
tion. This case gained at the rate of five pounds a week for a period of several SECTION XIII-LARYNGOLOGY. 
29 
weeks; finally he left with his throat partially healed and his general condition mani- 
festly improved. 
Prof. Casselberry, of Chicago, remarked-There are formidable cases which 
tax our utmost resources. Lactic acid has been highly lauded, and as strongly con- 
demned. Rational selection of cases is necessary to obtain good results. The treat- 
ment is accompanied by considerable after pain and cough, which is badly borne by 
debilitated subjects. Comparatively sthenic subjects, with circumscribed laryngeal 
lesions, so treated, are the ones which recover. 
Thorough cleansing of the parts is an essential preliminary to all local applica- 
tions. An alkaline spray, to which a small percentage of thymol may be added, is 
useful for this purpose; iodol by insufflation is a useful substitute for iodoform. It 
is lighter, and consequently more diffusible. Ethereal solutions of iodoform are irri- 
tant, because of the irritant qualities of ether. Liquid vaseline probably is a better 
vehicle. Morphine is a better local sedative for continuous use than cocaine, the 
reaction from the latter maintaining congestion of the parts. I have observed spon- 
taneous recovery of the vocal laryngeal lesions during the progress of the pulmonary 
tuberculosis. 
Prof. Stockton, of Chicago, said-I am quite in accord with Mr. Browne, 
that mountain and ocean air are only applicable to recent cases. Lactic acid I have 
used, but found that the cases must be selected. Iodoform I consider the medica- 
tion par excellence; the ulcer must be carefully cleansed, and then only a small 
quantity of iodoform is necessary, as it should be localized to the ulcer. Cocaine is 
only useful for examinations, and must not be used for any length of time. I cannot 
see how iodide of potash can be of use in this disease, unless it is one of those com- 
plicated cases such as I have had the pleasure of seeing in Vienna, from one of the 
rare cases on the post-mortem table. 
Dr. John N. Mackenzie, of Baltimore, Md., shared the skepticism shown 
by some of his colleagues in regard to the bacillus theory of tuberculosis. If the 
bacilli be inhaled, why is it that tuberculosis of the nasal passages is not more fre- 
quently met with. While he believed that laryngeal ulcers tubercular in nature 
occasionally heal, the probability is not to be overlooked that the so-called tubercu- 
lar ulcer can be none other than the diphtheritic ulcers of the windpipe, so common 
in general tuberculosis. Dr. M. insisted on general treatment, commended the local 
use of iodoform and a weak spray of bichloride of mercury. The question of pri- 
mary laryngeal tuberculosis can only be settled by the scalpel; that had already been 
done by Orth. 
Dr. Lester Curtis, of Chicago, remarked that he had been listening to the dis- 
cussion in the hope of hearing mention of a line of treatment that he had followed 
in the case of a lady with a large cavity of one lung and extensive consolidation of 
the other. She had a temperature of 103° Fahrenheit or over, and the other usual 
symptoms of advanced phthisis. On the use of quinine in pretty full doses, the 
temperature fell to somewhat near normal, and all her symptoms improved to such an 
extent that she considered herself nearly well, and continued so for nearly a year. 
In regard to tuberculosis of the larynx, some eight or ten years ago, a case came 
to him with ulceration of the arytenoid cartilages, with great difficulty of swallow- 
ing. He was put upon a treatment of a spray of nitrate of silver. In a very short 
time the difficulty diminished greatly; he continued much better for a month or 
two, when he passed out of observation. In this case there was a considerable 30 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
consolidation of both apices. Another case of advanced phthisis, cavities in both 
apices, ulceration at the base of both arytenoids and great difficulty of swallowing; 
on treatment by nitrate of silver the dysphagia nearly disappeared, continued absent 
for three or four weeks, when he died by the natural progress of the lung lesion. 
Dr. Coghill, of London, closed the discussion by remarking-In view of the 
limited time at my disposal, and the very thorough manner this subject has been 
threshed out by the various speakers, I shall close the debate in a very few words. 
The number of speakers aud the very interesting views and experiences brought for- 
ward testify to the importance and value of Mr. Lennox Browne's paper. It is 
satisfactory to note how agreed all are with the correctness of the views enunciated 
and the principles for treatment, general and local, so precisely and fully laid down 
by Mr. Lennox Browne. I must conclude by expressing the great pleasure with 
which I have taken part in this extremely interesting and valuable discussion. 
Mr. Lennox Browne, of London, commenced his reply by thanking the 
Section for the generous reception of his communication, and by congratulating him- 
self on the discussion that had been raised. He expressed himself in entire agree- 
ment with those who had dwelt on the primary importance of climate, hygiene and 
general treatment, both medical and dietetic. In fact, he had discussed these 
subjects first in his paper. But he also urged that though, in many cases, a 
pharyngeal or laryngeal tuberculosis was but a complication of a similar lesion in the 
lungs, the pain and distress which it occasioned called for all our energies, and he 
expressed his belief that in no disease of the throat had the specialist done more 
serviceable work or more thoroughly justified his position than in the great advances 
that have been made in the palliation, and possibly even cure, of the evidences of 
this malady in the throat. This had been done, not by general therapeutic meas- 
ures, to improvement of which laryngologists have contributed little, but by remedies 
applied locally. It was therefore fit that local means of treatment should occupy 
the most prominent place in a discussion on this subject, in a Section devoted to 
laryngology. With regard to climate, he concurred with the speakers who con- 
sidered high altitudes most suited to early stages and deleterious in the later ; the 
criteria for judgment on this head were in no sense different from those regulating 
advice in general pulmonary disease. lie was forced to the conclusion that the 
result of the case treated successfully by iodide of potassium was one of syphilis, for, 
from his experience with the drug which had been so ardently advocated by Moretz 
Schmidt, of Milan, in 1880, its effects in a true tuberculosis were actually harmful. 
In response to the doubts expressed by many speakers as to the part played by 
bacilli as primary factors of tubercle, the author expressed himself as by no means 
indissolubly wedded to the view. He had given it as the most recent, and as one 
almost universally accepted in the present day. It certainly offered one of the best 
data for treatment that has yet been afforded. He thought it quite possible that 
many remedies, such as iodoform, so generally extolled by all who had spoken, might 
act, as suggested by Dr. Coghill, in such a way on the soil in which the bacteria were 
manifested as to hinder their growth and multiplication, even though the drug 
might not be germicidal; and doubtless the tendency of the day was to pay too much 
attention to the bacilli, to the neglect of the nidus. Against such neglect he had 
spoken in his paper. With regard to local treatment, as Prof. Casselberry had 
wisely drawn attention to the importance of selecting cases for particular remedies, his 
remarks were important as emphasizing a point only lightly attended to in the paper. SECTION XIII LARYNGOLOGY. 
31 
Lastly, as to cure of the ulcer, it was largely a question of opinion as to what was 
recognized as a truly tubercular ulcer. Without doubt such lesions were healed in 
the fauces and supra-glottic region. He personally doubted if the same happy result 
occurred, save as an exception, in the larynx, and he was pleased to find that Drs. 
Cohen and John N. Mackenzie agreed with him, that those that did best were, in the 
majority of instances, not truly tuberculosis. 
Dr. A. G. Hobbs, of Atlanta, Ga., read a paper on- 
THE NERVOUS PHENOMENA OBSERVED IN A CASE OF EXPO- 
SURE OF THE ANTERIOR COLUMN OF THE CORD 
FROM SYPHILITIC ULCERATION OF THE 
UPPER PHARYNX. 
LES PHÉNOMÈNES NERVEUX OBSERVÉS DANS UN CAS D'EXPOSITION DE LA 
COLONNE ANTERIEURE DE LA CORDE PAR SUITE D'ULCERATION 
SYPHILITIQUE DU PHARYNX SUPÉRIEUR. 
DIE NERVÖSEN PHÄNOMENE BEI EINEM FALL VON BLOSLEGUNG DER RÜCKENMARKS- 
VORDERSTRÄNGE DURCH SYPHILITISCHE EITERUNG DES 
OBEREN PHARYNX. 
BY A. G. HOBBS, M. D., 
Of Atlanta, Ga. 
In October last a young man was brought to my office to be treated for "ulcerated 
sore throat, " as his father expressed it. He had been a cowboy in Texas for two years, 
strong and robust, weighing 140 pounds. When he reached me he was thin, pale and 
anaemic, weighing only 104 pounds. 
He denied ever having had syphilis, nor had he any evidence of this disease other 
than the ulcer about to be described, and, according to his own history, there never had 
been any other symptom of syphilis. 
A posterior rhinoscopic examination revealed an ugly sloughing ulcer in the poste- 
rior and superior wall of the pharynx, about the size of a silver quarter. By the use 
of a soft palate retractor a direct view of a greater part of the ulcer could be obtained. 
A bent probe discovered necrosed and detached bone at the depth of about half an inch, 
a piece of which I succeeded in extracting at the first sitting. At each succeeding daily 
visit, for two weeks, small pieces of bone, from the size of a pin head to a small pea, 
were either washed out with the cleansing syringe or extracted with the probe or 
scoop. My index finger would now enter the cavity as far as the first joint, by which 
means I could discover either detached or jagged undetached bones. 
The treatment had from the beginning been based upon the assumption that it was 
a syphilitic ulcer, notwithstanding his repeated denials of ever having contracted the 
disease, and his father's assurance that he had been healthy from infancy and could 
not, therefore, have inherited the taint. 
He began on forty grains of iodide of potash, three times a day, in a menstruum 
of succus alterans ; this dose was afterward doubled. The ulcer was daily cleansed 
with cotton probes, syringes and sprays. Sprays were applied, not only directly, but 
through the nose, on account of the discharge being partly expelled through that 
channel. 32 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Listerine was used, for its disinfectant and cleansing properties, and nitrate of silver, 
full strength, was applied to the bottom of the cavity by a cotton probe, after which the 
cavity was packed with iodol. 
About this time, after four or five weeks of daily treatment, the nervous phenomena 
first occurred. 
For a week or ten days he had been complaining of constant pain in the back of his 
head and neck, which caused him to carry his head to one side, and rigidly. During 
this latter period-the fourth and fifth weeks-he had been unable to sleep, except for 
a few minutes at a time, and in a sitting posture. 
After the cavity had been thoroughly cleansed, at one of the treatments, I pressed 
the nitrate of silver probe to its bottom, when, as suddenly as if he had been shot, one- 
half of the patient's body became paralyzed ; his head fell to the right, his right arm 
dropped to his side, his right leg turned outward, and he would have fallen from the 
chair if I had not caught him. Without losing consciousness at any time, this hemi- 
plegic condition lasted about thirty seconds, when, as he expressed it, "he felt a tingling 
in the right half of his body," and in another half minute he slowly raised his right 
side into position. The next day the same phenomenon was repeated, but on the opposite 
side. The pupil on the side affected became slightly dilated, but the perspiratory glands 
did not seem to be affected during the paralysis. 
He was now so reduced in weight (to 96 pounds) and in strength, by the loss of 
sleep and constant pain, that he could not walk to my office. The extreme insomnia 
lasted about ten days, during which time his attendants thought he did not sleep one 
hour in twenty-four. But from this time healing began at the bottom of the ulcer, the 
discharge became less, and examinations with the finger did not discover any more 
rough bones ; he slept better, and complained less of the pain in the back of his head 
and neck. 
He naturally did not desire that a paralysis should be deliberately produced now, 
because he was not certain, nor could I with much confidence assure him, that it would 
only last one minute if repeated. A week passed on with all of his symptoms gradually 
improving, when I could no longer resist the temptation of making another pressure 
with the probe. 
Paralysis of the side pressed upon was again exhibited, but in a much milder degree 
than before, ending in the same tingling sensations as described before. 
As only the spray and powder blower were used from this time onward in dressing 
the cavity, no more pressures with the probe were made till healing had well progressed, 
probably ten days or two weeks after the last test. 
To my surprise, when the probe was now pressed into the cavity, a condition just 
the opposite of paralysis was exhibited ; the arm and leg jerked and jumped similar to 
a case of chorea. These choreic muscular contractions, unlike the paralysis, lasted only 
during the pressure of the probe. In repeating the probe pressures at intervals during 
the next few days, the same choreic symptoms were produced, always on the corre- 
sponding side of the pressure, but in a less and less degree, requiring a still firmer 
pressure to produce the effect. 
Finally, when the healing process had been thoroughly established, and cicatricial 
tissue had in a measure closed up the cavity, only a " tingling or pricking " sensation 
followed the probe pressure, a sensation similar to that which followed the hemiplegia 
in the first instance. After the cicatricial tissue had thoroughly hardened, no mani- 
festation followed the pressure of the probe. 
At the time of writing, ten months since I first saw the patient, he is entirely 
recovered, and presents a perfect picture of health. His weight is 37 to 40 pounds 
more than he weighed in November of last year. He was kept on a lessened dose of 
iodide of potash and succus alterans until last July. SECTION XIII-LARYNGOLOGY. 
33 
I cannot state accurately as to the total amount of dead bone taken from the cavity, 
but I should say that its area would about equal that of a medium-size almond. 
The sequel, it would seem, proved my diagnosis to be correct, since the ulcer had 
gradually increased in size and virulency for six months prior to the beginning of the 
anti-syphilitic treatment ; and though he did not improve at once, healing did begin as 
soon as the local treatment succeeded in cleansing the ulcer of necrosed bone. 
The case is of even greater interest to the neurologist than to the laryngologist, and 
had more systematic experiments been made, and closer observations been taken of the 
nervous phenomena, something of greater interest might have been gained. 
I will confess that I had not the temerity to risk many experiments at the time in 
the progress of the case when they would have been available. 
Some important points may be noted :- 
1. The necrosis must have occurred in the spinous process of the second cervical 
vertebra ; hence the spinal cord was exposed either between the first and second or the 
second and third vertebra. 
2. The probe pressure always produced its effect on the corresponding side of the 
body. 
3. The pressure that produced the paralysis must have wounded the anterior column 
by pressing a jagged piece of bone against the cord, and the pressure that produced the 
convulsions must have only irritated the anterior column, since it is well known, by 
experiments on the lower animals, that a wound of the anterior column produces 
immediate paralysis, and an irritation immediate convulsions. 
RHEUMATIC LARYNGITIS. 
LARYNGITE RHUMATISMALE 
ÜBER RHEUMATISCHE LARYNGITIS. 
BY E. FLETCHER INGALS, A.M., M.D., 
Of Chicago, Ill. 
Rheumatic laryngitis is a painful affection of the vocal organ, attended by more or 
less hoarseness and fatigue of the parts after talking, and sometimes by grave or even 
fatal obstruction of the glottis. The affection may be either acute or chronic. The 
acute disease, from having been associated with articular rheumatism, has been recog- 
nized for several years, but it has been but little studied, and the literature of the sub- 
ject is very meagre. Through the kindness of Dr. J. S. Billings, the library of the 
Surgeon-general's office has been searched for me, but we have succeeded in unearthing 
only two articles upon the subject. The first of these, from a thesis of Dr. E. J. R. E. 
Emery-Desbrousses,* 1861, relates to a case of acute febrile articular rheumatism, with 
laryngeal localization, which terminated fatally. The patient was a young woman, 
twenty-four years of age, suffering from acute articular rheumatism and pericarditis. On 
the fourth day the larynx became involved, causing aphonia and severe pain, with suf- 
focative attacks, which continued, with varying severity, until her death, from slow 
* " Rheumatisme articulaire aigu, febrile localisation laryngée péricardite et pneumonié 
mort." 4to. Strasburg, 1861-25. No. 544.-(Thèse.) 
Vol. IV-3 34 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
asphyxia, on the twentieth day. At the autopsy the arytenoids were found bare but not 
necrosed, and on the left side a reddish, serous fluid was found in the articulation, 
which demonstrated the rheumatic laryngeal arthritis. This seems to have been the 
first case placed on record, though brief references to the affection have been made by 
Besmer, Chomel, Lieberman, Dechamb and Prof. Jaccoud, and cases have also been 
recorded by Fauvel, Coupard and Joal. 
The second paper is a very complete article on the subject by R. Archambault. 
(Thésis, Paris, 1880.) He gives a careful history of the literature of the subject, and 
has collected five cases, one by Emery Desbrousses, just referred to, one by Fauvel and 
two by Coupard ; to these he adds the history of one which came under his own obser- 
vation. From these cases he draws the following conclusions - 
"1. Acute laryngeal manifestations of rheumatism are more common than is gener- 
ally supposed. 
"2. These manifestations may affect separately the various parts of the larynx, 
mucous membrane, articulations, muscles, nerves. 
"3. The congestions of mucous membranes are the most frequent as well as the most 
easily determined of the lesions. 
" 4. They may give rise to accidents of suffocation grave enough to necessitate sur- 
gical intervention. 
"5. The other manifestations are too uncommon and too little known to make a 
thorough and separate study of them. ' ' 
Treatment.-"Care should be taken to prevent the frequent occurrence of the laryn- 
geal congestion in individuals predisposed to it, by taking care to avoid exposure to cold 
and dampness. 
' ' The abnormal susceptibility of the larynx should be combated by fomentations of 
cold water upon the neck, and at the same time general bathing. 
"At the commencement of an attack absolute rest should be enjoined, the use of 
diaphoretics to keep up activity of the skin, and the use of emollient gargles and inha- 
lations of steam, with or without aromatics. 
' ' If the case is very severe, a more energetic medication is advisable. Hot fomenta- 
tions and application of tr. iodine externally. If necessary, the use of vesicants should 
be resorted to, applied in front, over the larynx. Leeches may often be applied to 
advantage. If pain is very severe, applications of solution of muriate of cocaine by 
means of a sponge carrier will give relief. The administration of salicylate of soda is 
at times beneficial, but not so much so as in simple rheumatism. When suffocation is 
imminent, tracheotomy must be performed as the only means of avoiding a fatal ter- 
mination." 
Of the chronic rheumatic laryngitis to which I would call your attention I can find 
no mention in medical literature. 
For many years past I have from time to time observed chronic painful affections of the 
larynx, attended by no erosions or ulcerations and by but little congestion and swelling 
of the part. At first I was inclined to consider these merely cases of neuralgia, but 
several years ago I became convinced that they were not all of neurotic origin, and 
during the past two years several similar cases have been under my care, which have 
confirmed me in the opinion that they are rheumatic in character. 
At the last meeting of the American Laryngological Association, in May of the pres- 
ent year, Dr. S. H. Chapman, of New Haven, Conn., read a paper on ' ' Myalgia of the 
Pharynx and Larynx," in which he described cases that seemed at first similar to those 
to which I refer. He thought them to have been caused by malaria. A careful perusal 
of his article will show that they were quite different from the cases I would term 
rheumatic. 
The affection to which I wish to direct attention usually occurs in persons of a SECTION XIII LARYNGOLOGY. 
35 
rheumatic diathesis, but often the larynx or the tissues about the hyoid bone present 
the only evidence of the constitutional disease. In this affection, as in the chronic 
rheumatism of a mild character, which often affects the joints, or as in muscular 
rhematism, the pain is not constant, but may frequently disappear for a few days, 
especially during fine weather, to return again on slight exposure or with changes in 
the temperature. Its course is erratic, but nearly always obstinate. The patients 
frequently have an inherited or acquired predisposition to rheumatism, and it is not 
unusual for them to complain of rheumatic pains in other parts of the body, but, singu- 
larly, they never suspect the true nature of the disease. 
Several of the cases I have seen have complained of hoarseness or aphonia. Most 
of them have been troubled with the pain for several months before coming to me, and 
I have usually found them filled with apprehensions of cancer. In no case has pain 
been very severe. In certain cases it has been most noticeable on using the voice, but 
it is often more troublesome when swallowing, and in some it is aggravated by every 
attempt at deglutition, even of saliva. However, it varies much in intensity from day 
to day or from week to week, being nearly always worse in damp or chilly weather. 
Patients commonly refer the pain to one side of the larynx when this organ alone 
is involved, but in some cases it is also referred to the trachea, the region of the greater 
cornu of the hyoid bone, to the base of the tongue, or to the lower part of the tonsil on 
the corresponding side. In similar cases we sometimes find the pain confined to these 
latter regions, there being little or no involvement of the larynx, but even in these the 
patient is liable to experience fatigue of the vocal organ after talking. Hoarseness or 
loss of voice are also frequent symptoms. Upon inspection of the parts, one or both 
arytenoids may be slightly congested, or the redness may be confined to one side of the 
fauces or to the pharynx. The vocal cords remain clear, and the inflammatory symp- 
toms seem altogether inadequate to account for the discomfort. In some cases the 
parts involved are slightly swollen, but in others no change of form is noticeable. 
The diagnosis of chronic rheumatic laryngitis must be based on the history and 
symptoms, and the exclusion of neuralgias and the various affections which cause 
organic change in the parts. Acute catarrhal inflammations, chronic syphilitic laryn- 
gitis and abnormal growths may be easily excluded. Tubercular laryngitis, in its 
inception, is often attended by fatigue of the larynx after talking, and sometimes by 
pain, even before there is ulceration or swelling ; but it has a different history from the 
rheumatic affections. In tubercular laryngitis the parts are usually paler than in 
health, while they are slightly congested in the rheumatic affection. In the tuber- 
cular disease the constitutional symptoms are marked ; not so in the rheumatic. 
Fully developed tubercular laryngitis cannot be mistaken for the affection under 
consideration. 
In malignant affections of the larynx pain is often present, but from my observa- 
tion I conclude that it does not often precede pronounced organic changes. Therefore, 
they are not likely to be confounded with the affection under consideration. Rheu- 
matic laryngitis is most likely to be confounded with neuralgia or paræsthesia of the 
organ. In distinguishing between these, the history must be carefully scrutinized, 
and rheumatic or neuralgic pains must be looked for in other parts of the body. In 
the rheumatic affection there is usually slight redness and swelling ; not so in neuralgia. 
For confirmation of the diagnosis, we must sometimes await the result of treatment. 
Rheumatic laryngitis usually runs a chronic course, extending over periods varying 
from two months to one or more years. In most cases, if not in all, there are periods 
of immunity from the soreness, but at other times there are quite severe exacerbations 
of pain. I recall one case which was troublesome at times for four or five years. 
Recovery may be expected ultimately, and the patient may and should be assured that 
the disease does not endanger life. 36 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
In the treatment of chronic rheumatic laryngitis, I have derived considerable bene- 
fit from the local application of stimulant and astringent sprays, or pigments, and in 
some cases galvano-cauterization of the congested surface seems to have aided much in 
recovery. However, I have relied mainly upon internal remedies suited to the 
diathesis. Iodide of potassium, salicylate of soda, guaiac, colchicum and cimicifuga 
have all been tried with more or less success. Extract of phytolacca has been given 
with apparent benefit, and oil of gaultheria, in doses of fifteen minims, three times a 
day, has at times given satisfaction. 
By way of illustration, I have selected from my note books records of a few cases 
that demonstrate the characteristics of this affection. 
Case I.-Mrs. W., aged thirty-two ; general health perfect. About four years ago 
this lady complained of almost constant pain in the larynx, which, however, varied 
greatly from time to time. Upon examination the whole throat as well as the 1 trynx 
was found congested ; but the pharynx was so exquisitively sensitive that she could 
scarcely tolerate inspection, and therefore declined any local treatment. This patient's 
father had been almost a cripple from rheumatism for many years ; other ancestors had 
suffered greatly from it, and the patient herself had frequently been subject to rheumatic 
pains, but at the time referred to there was no manifestation of the disease, excepting 
the pain in the larynx. She was not subject to neuralgia. Anti-rheumatic remedies 
were ordered and taken for a short time, but were not persisted in, as she had lost all 
faith in remedies for rheumatism, excepting the waters of a certain so-called magnetic 
spring, which had at times relieved her father. 
Whether or not she visited the spring I do not know, but the soreness continued at 
intervals for about two years, when it, with other rheumatic symptoms, gradually dis- 
appeared, and she has since been perfectly well. 
Case ii.-Mr. H. G., farmer, aged forty-seven ; general health good ; but he was 
morbid on the subject of cancer of the throat. He had been complaining for two 
months of pain and sense of fullness in the larynx, which he feared would choke him. 
The soreness was not constant, but would come on quite suddenly, last three or four 
days, and then gradually subside. 
The sensations, when I first saw him, were referred to the upper part of the left side 
of the thyroid cartilage. When the attacks were at their worst his voice was husky, 
and occasionally he had been aphonic for a short time. He had been frequently annoyed 
by muscular rheumatism, and he stated that he felt lame and tired all over his whole 
body when the exacerbations came on. 
Laryngoscopic examination revealed moderate congestion of the epiglottis and left 
wall of the larynx, with very slight swelling of the latter ; also very slight congestion 
of the vocal cord, but nothing more. On touching the parts with a probe he claimed 
that the sensitive spot was either on the inner surface of the left wall of the larynx, or 
else just external to the left wing of the thyroid cartilage, but he was not quite certain 
which. 
I placed the patient on twenty-grain doses of bromide of potassium, four times a 
day, and fifteen-minim doses of oil of gaultheria. I also applied a sixty-grain solution 
of nitrate of silver to the left side of the larynx. Eight days later it was noted that he 
was almost well, and was to have returned to his home, but the soreness had reappeared, 
lower down, at the upper portion of the trachea. During the next few days the pain 
shifted to the larynx again, and then to a point beneath the sternum. Sixteen days 
after I first saw him he returned to his home, free from pain, with directions to take 
iodide of potassium, grains vijss, and oil of gaultheria, rq, xv three times a day. I learn 
that the pain returned, subsequently, from time to time. 
Case hi.-Miss F. G., aged twenty-two ; general health good. Her voice had been 
weak for four years, whenever she attempted to shout, but this gave her no special dis- SECTION XIII LARYNGOLOGY. 
37 
comfort. For a month before consulting me she had been complaining of aching in the 
tonsils, larynx, trachea and sub-sternal region whenever she used the voice for a few 
minutes. The soreness was always worse in damp weather. Examination of the larynx 
showed paresis of the right vocal cord, which moved through only about one-third its 
normal excursion, but there was neither swelling nor redness. 
In this case there was no previous rheumatic history, and there were no signs in 
the larynx excepting those of paresis. 
Her principal symptoms were of only a month's duration, and I therefore concluded 
that the paresis was either of recent origin, or that it had nothing to do with the present 
attack. She complained of other pains which seemed rheumatic ; she had always been 
worse in damp weather, and under the influence of salicylate of soda, acetate of potas- 
sium, and oil of gaultheria she improved rapidly, so that I think the diagnosis was 
fairly established. 
Just as I was completing this paper the patient returned, after several months' 
absence, complaining of severe and constant pain in the same regions as before. She 
had been free from pain for several weeks during the interim, but it had recently 
returned with increased severity. No abnormal signs could be seen in the larynx, even 
the paresis having disappeared, and the evidences of rheumatism were more pronounced 
than ever before. 
Case iv.-Mr. J. C. E., aged thirty-nine. Patient complained of pains in the 
shoulders, chest and back of the head, and of aphonia of four months' duration. He 
had suffered several attacks of inflammatory rheumatism, and had been frequently 
troubled with slight attacks of sore throat. General health good. Weight, pulse and 
temperature were normal. 
On examining the larynx I found bilateral paralysis of the lateral crico-arytenoid 
muscles, with inability to close the glottis on attempted phonation, but there was no 
congestion or swelling. 
In this case the pains, and possibly the paralysis, seemed to be of rheumatic origin. 
I saw the patient only once, and have not heard the result of treatment. 
Case v.-Mr. C. F. M., aged twenty-nine. General health perfect. Had complained 
of soreness of the throat much of the time for four months, of occasional hoarseness, and 
of rheumatic pains in the back and chest, and in the regions of the trachea and hyoid 
bone. These pains were always aggravated by damp weather and by exposure to 
night air. 
Under the influence of stimulant applications to the throat and anti-rheumatic 
remedies internally he speedily improved, but every four to six weeks, with some 
renewed exposure, his symptoms have returned. He is at present well, but I expect 
renewed attacks. 
Besides these, several other such patients have been under my care, and I am confident 
that similar cases have presented themselves to other laryngologists, but we have been 
accustomed to class them with the cases of neuralgia or paræsthesia, with no very defi- 
nite idea of their etiology and but little hope of benefit from treatment. 
I am confident that, with more critical observation, we shall find many cases similar 
to those I have described, which are due to the same causes as muscular or articular 
rheumatism, and in which we will obtain far better results from treatment than we 
have been accustomed to if we bear this in mind, and prescribe constitutional remedies 
accordingly. 
DISCUSSION. 
Dr. J. A. Stucky, of Lexington, Ky., remarked-This Section is greatly 
indebted to Dr. Ingals for the timely, practical and valuable paper just read. I 
have no doubt but many of hs have had cases of rheumatic laryngeal trouble and 38 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
failed to recognize it. I remember of having only one case, and that of such interest 
and so instructive to me, I beg leave to report it. Patient was a lady æt. 26; had 
been bedfast for eleven days, I first saw her, with inflammatory articular rheumatism 
of violent form. I was called to see her on account of pain over the larynx, sensi- 
tive to the touch, and patient said her neck pained her as much as her joints. Deg- 
lutition and phonation were very painful. The laryngoscope revealed marked 
hyperæmia, with œdematous swelling of right arytenoid. Epiglottis slightly œdem- 
atous. A diagnosis of the rheumatic poison affecting the laryngeal muscles and 
articulation of the cartilages was made. And the dose of anti-rheumatic remedies 
was increased ; soothing applications, consisting of neutral oleate of cocaine in 
vaseline, were applied at short intervals, by means of the spray. The symptoms 
increased, with very little amelioration of the pain in the larynx, and by the four- 
teenth day the dyspnoea was so urgent that tracheotomy was advised. While on 
my way to my office for the instruments to perform the operation, the patient died, 
whether from suffocation or heart involvement I am not able to say. Since then, 
whenever a patient complains of pain in the laryngeal region, I look out for rheu- 
matic troubles. If these symptoms are detected, the line of treatment is easily 
decided upon. 
Dr. Stockton, of Chicago, Ill., said-I think Prof. Ingals' paper very timely, 
and I am very glad to hear it. I have met with a number of cases that I am confi- 
dent are rheumatic, being unwilling to class them as neuralgic. 
Paper by Dr. J. A. Stucky, of Lexington, Ky., owing to his paper being 
destroyed by fire, was read by title. " Clinical Report on the Treatment of Laryn- 
geal Phthisis. ' ' 
THE DIAGNOSTIC DIFFERENTIATION OF RECENT TUBERCULOUS, 
SPECIFIC AND RHEUMATIC.LARYNGEAL DISEASES. 
LA DIAGNOSTIQUE DIFFERENTIELLE DES MALADIES LARYNGIENNES RHUMA- 
TIQUES SPÉCIFIQUES, ET TUBERCULEUSES RECENTES. 
DIE DIFFERENTIALDIAGNOSE DER PRIMÄREN TUBERKULÖSEN, SPECIFISCHEN UND 
RHEUMATISCHEN KRANKHEITEN DES LARYNX. 
BY DR. E. S. SHÜRLY, 
Detroit, Mich. 
The differentiation of recent tuberculous, specific and rheumatic disease affecting the 
larynx, as we all know, is a topic of very wide range. I shall endeavor, however, to 
present the subject as concisely as possible, by confining myself rigidly to the laryngeal 
region. You will, therefore, notice the omission of many things which, were time and 
circumstances favorable, might be included. 
While there is much similarity in the symptomatology of the three diseases whose 
local expression we are about to consider, there is that variation, in even typical cases, 
which will allow very often of distinction. 
Without further generalization, I will call your attention, first, to the laryngoscopic 
appearances, second, to the objective symptoms, and third, to the systemic symptoms 
accompanying the three diseases. 
Hyperæmia, or congestion and inflammation of the laryngeal mucous membrane, is, SECTION XIII-LARYNGOLOGY. 
39 
of course, one of the earliest manifestations in each of the conditions under considera- 
tion, unless we may sometimes except phthisis. In recent syphilis, whether secondary 
or tertiary, it is apt to be diffuse and persistent, the color varying according to the 
individual. In phthisis, although a majority of cases present a paleness of the mucous 
membrane, yet this may soon be succeeded by congestion more or less diffused. In 
rheumatism, when the hyperæmia is general, it seems less intense and more disposed 
about the upper larynx-especially in the muscular variety-constituting so-called 
rheumatic laryngitis; while in the arthritic form the congestion seems to take place 
at first along the lateral wall up as far as the faucial pillars, either in streaks or quite 
diffused. The surface is not granular, as is the case sometimes with either of the other 
diseases. 
Anaemia, the opposite condition, rarely occurs in recent diseases of either affection, 
excepting phthisis, unless as an oedema, which may then accompany either syphilis or 
rheumatism, especially the latter, if an active inflammation be seated in one of the 
arytenoid joints. 
Tumefaction, or infiltration, either quickly or slowly, succeeds congestion in tuber- 
culous laryngeal phthisis, although not always. All of us have, I think, met with 
cases of tuberculosis where the tumefaction was quite diffuse, and beginning even in the 
lower larynx, which seemed more like real hyperplasia than mere infiltration. Of 
course, when the characteristic swelling of the arytenoid eminences and epiglottis-so 
common in this disease-is present, the diagnosis is about determined. In syphilis, 
either secondary or tertiary, when recent, the tumefaction comes slowly, while the 
thickening is not so great or regular. The surface may, and often does, show a papular 
character and very uneven surface, but when certain regions of the submucosa contain 
the principal exudation, a careless inspection might lead one to regard the nature of 
the case as tubercular. In some cases of rheumatism and gout-especially the latter- 
the tumefaction is not diffuse, but, on the contrary, distinctly localized at the posterior 
part of the larynx on either side, according to the arytenoid joint affected, and is of 
such consistence in subacute or chronic cases as to appear like an organized hyperplasia. 
Later on, if the joint undergoes organic change or perichondritis supervene, the thick- 
ening becomes firm and corrugated. In my opinion, it is very difficult, indeed, in such 
cases-early stages-to differentiate between a local manifestation of syphilis and 
rhuematic gout or gout. 
In the muscular variety of rheumatism the tumefaction is usually very slight, and 
disposed in lines or patches. 
Ulceration soon supervenes in recent tuberculous disease, and less rapidly, as a rule, 
in syphilitic, while never in rheumatic, excepting in advanced states of rheumatic 
perichondritis. 
Regarding syphilis, it is considered doubtful by many observers if condylomata or 
gummæ or ulceration ever occur in the larynx early or primarily ; while, on the other 
hand, there are cases reported in medical literature with descriptions of such appear- 
ances. When ulceration occurs, it comes on quickly and often symmetrically ; the 
ulcers are solitary, deep, with sharp-cut edges, irregularly round, surrounded by a bright 
areola of congestion and swelling, and having a predilection for the aryepiglottic folds 
and upper surface of the epiglottis. It is, however, very rare to find ulceration in recent 
syphilitic disease primarily occurring in the larynx. The ulceration of laryngeal 
phthisis or tuberculosis comes on slowly. It is more apt to occur primarily in the 
larynx than in the structures above. The ulcers are small, numerous, scattered, super- 
ficial, edges irregular, in some cases described as like worm tracks ; while in others they 
are smooth, oval excavations, generally seated on the under side of the epiglottis, ary- 
tenoid and aryepiglottic folds, ventricular bands, and less frequently on the vocal cords. 40 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
It has been said that tubercular deposit might be recognized in the edges of the ulcers 
of some cases. 
Of course there are many departures from the typical appearance, as, for instance, 
when the case is a mixed one ; then the ulceration may be rapid and serpiginous, or 
deep and confluent, even in the early stages. I remember a case of this sort in my own 
practice, with well-marked ulceration, confined to the larynx, and with a history of 
both tuberculosis and syphilis, which went on from congestion to extensive destruction 
of the laryngeal membrane in two weeks. 
Laryngeal hemorrhage is rarely a symptom of laryngeal phthisis or syphilis, 
excepting as a result of erosion, but it is sometimes an accompaniment of rheumatism. 
The mobility of the parts may very early suffer impairment in the course of these 
diseases, whether syphilitic, laryngeal or rheumatic. Immobility of one or both cords 
would be due either to tumefaction, hyperplasia or paralysis. The immobility due 
to rheumatism can be easily confounded with paralysis or immobility from totally 
different causes, as when a rheum-arthritis affects one of the arytenoid joints. The 
distinguishing feature, aside from the history, in cases where the articulations are 
involved, is the location of swelling or fullness toward the base of the cartilage and 
about the attached portion of the ventricular bands, together with the pain of larynx 
and neck muscles ; and when the laryngeal muscles are the seat of the trouble, the 
swelling may be insignificant and the mobility be incomplete, but the pain or soreness 
is excessive. 
The objective symptoms belonging to the early stages of these diseases may be 
mentioned as hoarseness, aphonia, dysphonia, odynphagia, dysphagia, pain in the throat 
and adjacent region, cough, secretion and expectoration, varying in degree according to 
the case. Hoarseness is generally present in laryngeal hyperaemia from any cause, 
unless confined to the upper part of the larynx, and is due either to functional disturb- 
ance or the different conditions of tumefaction affecting the mucosa or submucosa or 
the interarytenoid fold. Though generally present, it is not invariably in recent tuber- 
culous or syphilitic disease ; but dysphonia, especially accompanied by soreness of the 
neck, is a marked symptom of rheumatism. In gout, however, the pain and soreness 
is more limited and less fugitive than in the acute or subacute variety of rheumatism. 
Cough of peculiar character is almost always present in syphilis and laryngeal phthisis, 
but not so in rheumatic disease, except, perhaps, the occasional attempts at clearing the 
throat, which hardly amount to laryngeal cough. 
Waiving any remarks upon the secretions of the mucous membrane in syphilitic 
and tuberculous disease, with which all are familiar, I would state that in rheumatic 
it is usually a glairy mucus, excepting in gouty cases, associated with more or less 
bronchial catarrh, when it is muco-purulent. Microscopic examination of sputum never 
shows bacilli or elastic tissue, excepting in cases complicated with chronic bronchitis or 
phthisis. 
The shortness of breath, which I have seen mentioned as one of the signs of rheu- 
matic laryngitis, occurs only in those cases where there is mechanical obstruction from 
tumefaction, immobility of the glottis or concomitant bronchial catarrh, but occasion- 
ally it may depend upon implication of the muscles of respiration. In the other two 
affections it is, of course, due to structural changes. Odynphagia and dysphagia occur 
early in rheumatism, but later in syphilis and tuberculosis. 
Spasm of the glottis, while occurring at times in laryngeal phthisis and syphilis, is 
much more frequent in the early stages of rheumatic disease, but after a time, if the 
disease becomes general, this symptom disappears. Chorea of the vocal cords, or paræs- 
thesia, may also be the principal symptoms of rheumatic disease. 
The clinical history connected with these manifestations is certainly an important SECTION XIII-LARYNGOLOGY. 
41 
factor in the diagnosis, and oftentimes must be our main dependence in differentiation. 
As it would be a matter of supererogation as well as a waste of time to enumerate in 
detail the clinical history of laryngeal phthisis, syphilis and rheumatism, I will, of 
course, pass them with the mere mention. 
I am fully aware that the existence of rheumatoid disease of the larynx, as well as 
condylomata, gummata and primary tuberculous deposit, are denied by many competent 
observers ; hence great dissimilarity of ideas attach to the respective terms used in 
giving expression to these various local appearances. In some of the mixed cases, such 
as present a clinical history of all three of these diseases, differentiation in the earlier 
stages becomes almost impossible. 
Concerning the rheumatic affection, which is not as common as the others, I think 
we ought to recognize two varieties at least-the one a genuine arthritis, occurring in a 
gouty subject, perhaps with the local lesion confined to the neighborhood of the joint, 
mainly ; and the other, seated for the most part in the nervo-muscular apparatus of the 
larynx, and also affecting the neck or chest muscles more or less. In both forms the 
attending pain in the parts and neighborhood is apt to be severe. 
In conclusion, permit me to offer a summary in the form of a tabular statement of 
the marked signs of each of these diseases. 
TABLE SHOWING- PRINCIPAL SIGNS AND SYMPTOMS OF RECENT 
TUBERCULOUS, SYPHILITIC AND RHEUMATIC DISEASE 
OF THE LARYNX. 
Laryngeal. Phthisis. 
Syphilis. 
Rheumatism. 
Hyperœmia or congestion often 
not so marked. 
Hyperœmia and congestion al- 
ways persistent and extended. 
Hyperœmia and congestion 
always present but not intense, 
and often localized. 
Tumefaction or infiltration 
quite constant and peculiar, affect- 
ing epiglottis and arytenoids. 
Tumefaction not marked. 
Tumefaction rare, excepting in 
arthritic rheumatism, when it is 
local. 
None. 
Condylomata and g ummata 
sometimes. 
None. 
Ulceration, common, slow de- 
velopment, scattered, irregular, 
small, roundish or oval, commonly 
situated on under surface of epi- 
glottis and arytenoids. 
Ulceration may be rapid, but 
rare in larynx ; when occurring 
is rapid and apt to be solitary 
or symmetrical, surrounded by 
areola. 
No ulceration. 
Mobility of cords slightly 
affected. 
Mobility slightly affected. 
Mobility out of proportion to 
struct ural change, especially arth- 
ritic variety. 
Hemorrhage rare. 
Hemorrhage very rare. 
Hemorrhage common. 42 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
TABLE SHOWING PRINCIPAL SIGNS AND SYMPTOMS OF RECENT 
TUBERCULOUS, SYPHILITIC AND RHEUMATIC DISEASE 
OF THE LARYNX.-Continued. 
OBJECTIVE SYMPTOMS. 
Laryngeal Phthisis. 
Syphilis. 
Rheumatism. 
Hoarseness. 
Hoarseness, dysphonia, slight. 
aphonia, or hoarse- 
ness. 
Dysphagia and odynphagia only 
when epiglottis and arytenoid 
eminences are principally affected. 
Not marked, unless pharynx 
is involved. 
Quite persistent and constant. 
Pain in larynx absent. 
Pain in larynx absent. 
Pain in larynx, quite constant, 
and about neck. 
Expectoration of mucus contain- 
ing bacilli often. 
Expectoration of mucus, no 
bacilli. 
Little or no expectoration, no 
bacilli. 
Cervical glands not enlarged. 
Cervical glands enlarged. 
Cervical glands not enlarged. 
No spasm of laryngeal muscles, 
as a rule. 
No spasm oi laryngeal muscles. 
Spasm frequent, also chorea. 
Sensation not perverted. 
Sensation not perverted. 
Sensation often perverted, par- 
æsthesia. 
DISCUSSION. 
Dr. Ingals, of Chicago, Bl., had been much interested in the paper, especially 
because it contained much on rheumatic laryngitis, of which affection very little could 
be learned from medical literature. The author has mentioned some points which 
had not come under his observation, of which he could find no mention in medical 
literature. 
Dr. Shurly, in closing the discussion, remarked-I would like to call attention 
to rheumatic disease of the larynx because Dr. Ingals says the literature of the sub- 
ject is meagre, and because I believe cases of this sort are often passed as laryngeal 
phthisis or other diseases. 
THE TREATMENT OF LARYNGEAL PAPILLOMATA. 
LE TRAITEMENT DES PAPILLOMES LARYNGIENNES. 
ÜBER DIE BEHANDLUNG DER LARYNXPAPILLOME. 
BY PROF. W. E. CASSELBERRY, M.D., 
Of Chicago, Ill. 
A discussion of the treatment of laryngeal papillomata naturally resolves itself into 
a consideration of the best means of eradicating these growths. Their removal, by 
whatever method, has been much facilitated by the introduction of cocaine, and for the 
sake of brevity we will suppose that this local anaesthetic be applied in all cases, so as 
to permit of instrumental manipulation within the larynx. The laryngeal forceps are SECTION XIII-LARYNGOLOGY. 
43 
commonly employed to grasp the tumor or portions of it and cut or pull it from its 
base. A great variety of these have been devised, of which those of Mackenzie, 
Schrötter, Stoerk and Cusco are familiar examples. There are many cases in which 
one or other of these is unquestionably the simplest and best means at our disposal. 
This is true when the papilloma is single, with a narrow and circumscribed base, which 
is not too deeply inserted, and when it is in a position accessible to the forceps. 
There are other cases, however, in which I am convinced the forceps are not only 
slow, but ineffective, and perhaps even worse than useless. I have in mind two cases; 
in one the papilloma was sessile, flat, with a broad base covering the anterior two-thirds 
of the superior surface of the right vocal cord and spreading in half its extent around 
the free border of its cord on to its inferior surface. I tried forceps, but succeeded in 
detaching only small pieces at a time. Each operation was followed by inflammation, 
and by the time I could again operate the growth was as large as before. I despaired 
of effecting a cure in this way. It was like pulling pieces from a cutaneous seed wart - 
the more I pulled, the faster it grew. Moreover, a part of the tumor, being beneath the 
vocal cord, could not be reached by forceps. 
In the other case the entire larynx, at first sight, seemed filled with papillomatous 
growth. Forceps were used to clear away the grosser portions, when it was found that 
the warts sprang from the edges of both vocal cords along their entire extent and from 
the inter-arytenoid space. They had a seedy aspect, i. e., the appearance of a common 
seed wart as it grows on the hands. Again the same difficulty was encountered. I 
could not by means of forceps exterminate the roots, and stimulated apparently by 
the extraction of piece by piece, their growth was such that after a certain point no 
progress was made. 
This brings me to another method of removal-cauterization. But with what? 
Nitrate of silver is too superficial. Chromic acid is often uncontrollable. The galvano- 
cautery in the form of the apparatus which I here exhibit answers every indica- 
tion. The apparatus is Sajous' handle and laryngeal loop electrode, with its loop bent 
to one side. A perfect cure, with restoration of voice, was effected in one case. In the 
second case, restoration of voice has been produced, but the case is yet under treatment. 
A curette has been devised by Dr. Rossi, of Italy, cited by Ferreri, of Rome, the 
application of which is to be followed by scarification of its base and cauterization with 
a chemical caustic. I should be pleased to hear this method discussed. 
DISCUSSION. 
Dr. J. Solis-Cohen, of Philadelphia, referred to two methods of removing 
laryngeal growths not mentioned, one by employing the snare so successfully used by 
the Chairman, and the simple sponge probang by means of which white, soft growths 
can be rubbed off from the lower surface of the vocal bands. In many cases, how- 
ever, it is necessary to incise the crico-thyroid membrane in order to get direct access 
to growths in that position. He also called attention to a modification of the jaws 
of the forceps by which a broad surface is supplied, instead of the pointed end of the 
ordinary oval jaw, which facilitates catching hold of minute growths on the superior 
surface of the vocal bands. 
He likewise called attention to the importance of leaving the wires of the electric 
cautery as thick as is compatible with convenience in manipulation, in order the better 
to confine the heat in the platinum terminal, and avoid unnecessary heat in the 
handle. In cauterizing growths on the edge of the vocal bands, he recommended 
protection by layers of asbestos and ivory in the opposite side, so as to avoid injuring 
the sound tissues in the sphincter-like action following interference in the larynx. 44 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Prof. E. Fletcher Ingals, of Chicago, Ill.-Referring to the statement that 
chromic acid is uncontrollable, he thought there could be no difficulty whatever in 
controlling its action if it were fused on a probe in proper quantity. 
Dr. William Porter, pf St. Louis, Mo., uses chromic acid, and carefully applies 
it as a safe remedy. The curette has been efficacious in two cases, and the sponge 
method of Voltolini in one. He applies the chromic acid in cases of small growths 
where it is difficult to apply the forceps. He uses a probe, on which is fixed a small 
glass bulb with a depression upon one side, in which is placed a single crystal of 
chromic acid. 
Mr. Lennox Browne, of London, while expressing his interest in the cases 
considered by Prof. Casselberry, who had initiated the discussion, felt some regret 
that the field of debate had not been extended to consideration of the important 
question of recurrence. Without doubt, functional abuse of the voice, and a state of 
chronic and persistent hyperæmia, were main factors of the aetiology of papillomata ; 
and in certain instances in which the hyperæmic state persisted after removal of a 
neoplasm, there would be a liability to recurrence, not necessarily in the same situa- 
tion, but possibly so, or in some other part of the larynx. This fact constituted a 
serious element of consideration when forming a prognosis, and accounted for the 
disappointment often experienced by the operator, who, sometimes having cured his 
patient as he thought, heard of the case coming under the care of another confrère 
as uncured. In one such case .of obstinate recurrence in fresh situations, Mr. Lennox 
Browne had experienced a good result from enjoining absolute silence for two months, 
and the application during that period of continuous cold over the larynx, by means 
of a Leiter coil. 
Prof. W. E. Casselberry closed the discussion by remarking-All methods 
of treatment were not mentioned by me, as I expected they would be elicited by the 
discussion. The sponge method of Voltolini I have not tried. The snare would 
have been inapplicable in the two cases cited. That the galvano-cautery will burn 
but superficially is not my experience. I think it can be made to burn more deeply 
than other caustics. The electrode might be protected on one side, but the shield 
increases the bulk of the instrument, and in my hands has not been necessary. I 
have not searched the opposite side of the larynx, because I have carefully located 
the part to be cauterized, pressed the electrode into it and away from the opposite 
side before applying the current. With the parts thoroughly cocainized and in com- 
parative quietude, I can see no reason why the galvano-cautery should not be used as 
well below as above the epiglottis; although, as a matter of course, it must be by 
skillful hands. My galvano-cautery is not fickle, but quite reliable, if kept in proper 
repair. SECTION XIII-LARYNGOLOGY 
45 
RECURRENT HEMORRHAGE OF THE UPPER AIR PASSAGES 
L'HÉMORRHAGIE RÉCURRENTE DES VOIES RESPIRATOIRES SUPÉRIEURES. 
ÜBER RECURRENTE BLUTUNG DER OBEREN LUFTWEGE. 
WILLIAM PORTER, M. D., 
Of St. Louis, Mo. 
Mr. President.-You have asked me to speak upon a most interesting topic. I 
will not attempt to present it fully, but rather to make some suggestions along which 
the line of an argument may run. 
First let me limit the geographical boundaries of the term upper air passages. 
Epistaxis forms the subject of another discussion, and we will not include that at this 
time. Bronchial hemorrhage is rare except as a complication of pulmonary involve- 
ment, and when found is discovered by the use of the stethoscope rather than the laryn- 
goscope-by hearing rather than by sight. 
While many of us include diseases of the chest in our field of work, it is proper 
here that we should, as far as possible, confine our remarks to laryngological topics 
only. 
Excluding, then, for these reasons, epistaxis and hemorrhage from the bronchial 
tubes, let us turn our thought to recurrent hemorrhage of the larynx and pharynx. 
Again, I think we need consider those cases only in which the hemorrhage is of idio- 
pathic origin. Interesting essays have been written upon such themes as hemorrhage 
following uvulotomy (Morgan) and tonsillotomy (Lefferts), but such phenomena as these 
and other writers upon kindred subjects have mentioned can scarcely be called recurrent, 
but rather persistent and constant. 
Two cases may be used as illustrations of our subject. The first was recurrent hemor- 
rhage from the larynx. 
Miss K., about eighteen years of age, with good family history, consulted me 
because of frequent bleeding, which she feared originated in the lungs. She had had 
some hoarseness and at times soreness in the glottic region, but not constantly. A careful 
examination of the chest did not enable me to locate the lesion. At that time I could 
not discover any abnormal condition suggesting hemorrhage in the upper air passages, 
although there was a chronic laryngitis and pharyngitis. 
A few days later she again called. She had been bleeding slowly for some hours, 
and was still expectorating blood at intervals. This time the source of the hemorrhage 
was found. A small perforating ulcer, which had escaped my attention at first exami- 
nation, was seen on the right ventricular band, and, after removing all the exuded blood 
by absorbent cotton, the fresh blood could be observed coming from the ulcer. A solu- 
tion of iron and glycerine promptly controlled the hemorrhage. There was recurrence 
of the hemorrhage several times, and the ulcer healed slowly. Rest was enjoined, 
phonation restricted, and after two weeks there was no return of the bleeding. There 
has been entire absence of this symptom for two months, and the laryngitis under 
treatment has improved, though not entirely relieved. 
Where there is extravasation of blood into the submucous tissues of the larynx, 
serious complications may ensue and death may quickly occur from obstruction. One of 
the most interesting monographs upon this subject was published by Dr. Gleitsman in the 
American Journal of the Medical Sciences, April, 1885. After recording a typical case of 
his own, he mentions a number reported by others (Mandi, Fraenkel, Lewin, Hart- 
man, Wagner, Ingals, Knight, Morgan). Some of these gentlemen being present, will 
doubtless recall the cases to which I refer. 46 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Hemorrhage from the larynx is not a disease, it is but a symptom, and must be 
treated as such. Generally resulting from some form of laryngitis-simple tubercular 
or, in rare instances, syphilitic-yet a prominent factor in its production may be a 
faulty heart action. In one case, at least, topical applications were insufficient until the 
heart, unable to do its work through mitral lesion, was aided by rest of the body and 
digitalis. 
Hemorrhage from the pharynx may easily be mistaken for haemoptysis. In 1882 I 
reported two cases to the American Medical Association, in the Section on Laryngology. 
In each of these cases there was some slight pulmonary lesion, and when the hemor- 
rhage appeared, it was but natural to think that its origin should have been in the 
lungs, and in each the true site was in the pharynx. Since then I have seen several 
similar instances, the following case being typical :- 
Mr. N., a young attorney of St. Louis, having had during previous years several 
attacks of bronchitis, was oue day surprised by the rapid discharge of blood from the 
mouth. He was sure the hemorrhage came from the right middle lobe, where he had 
had some pain during the attacks of bronchitis mentioned. 
The bleeding had ceased when I saw him, and although there was evidence of a 
slight chronic bronchitis, the percussion note, vesicular murmur and rhythm were normal. 
Some days afterward, Mr. N. again came. He had had slight bleeding several times 
during the day. In my search for the source, I passed a bent cotton-covered probe into 
the upper pharynx, and was rewarded by the reappearance of the hemorrhage, the blood 
trickling down from behind the soft palate. 
Suffice it to say, that a small ulcer was found on the posterior wall of the velum, 
a little to the right of the median line, and I need scarcely add that, with this dis- 
covery, all fear of lung complication speedily passed from the patient's mind. There was 
no further hemorrhage, the ulcer rapidly disappearing under slight treatment. The 
thought which I would offer, in submitting these condensed histories, is that hemor- 
rhage from the upper air passages, is not infrequently a complication of chronic inflam- 
mation of the larynx or pharynx, and that it may be mistaken for haemoptysis or even 
hæmatemesis. This being admitted, in all cases of hemorrhage from the respiratory 
tract, of doubtful origin, there should be careful examination of the upper air passages. 
DISCUSSION. 
Prof. Stockton, of Chicago, Ill., remarked-I wish to add one more case to 
those already reported. A young lady, an opera singer, one day, in practicing, sud- 
denly lost her voice, and in a few minutes coughed up some bright, frothy blood. On 
examination I found the larynx coated with blood, and on wiping it away, I dis- 
covered a small pulsating vessel from which hemorrhage was taking place. I 
succeeded in controlling the flow of blood by the galvano-cautery. In two weeks' 
time the lady was able to sing. 
Dr. J. Solis-Cohen, of Philadelphia, does not think the occasional hemorrhages 
from rupture of vessels in chronic inflammations of the larynx and pharynx of much 
importance, and has never seen any extreme hemorrhage. In those instances in 
which the hemorrhage is submucous, there may be considerable trouble from stridor, 
especially in that of oedema of the larynx, termed hemorrhagic oedema. He does not 
approve of the term laryngitis hæmorrhagici, sometimes applied to these conditions, 
and does not use the term himself. 
Mr. Lennox Browne, of London, desired to bear testimony to the value of 
discussing the somewhat uncommon but important class of cases included in the 
interesting communication which had opened this debate. Personally, he doubted SECTION XIII LARYNGOLOGY. 
47 
the occurrence of laryngeal hemorrhage in the course of an uncomplicated laryngitis, 
and would always give a grave prognosis in any case presented to his notice. Laryn- 
geal hemorrhage was not a frequent complication of tuberculous laryngitis; it was 
more common in his experience in syphilis than was believed by Dr. Porter, and was 
one of the causes of death to be foretold in cases of laryngeal or rather pharyngo- 
laryngeal carcinoma. A very common but unrecognized cause of slight hemorrhages 
in the throat was varix of the vessels at the base of the tongue. This condition was 
often manifested to such an extent as to constitute a truly hemorrhoidal state of 
affairs. The ætiology was in many respects similar to that of rectal hemorrhoids; it 
was often associated with varix in other parts of the body, and required for successful 
treatment a local eradication by electric cautery of the diseased veins, and a careful 
search for and correction of all general and functional causes that might have 
led to the complaint. 
This subject was one which had been treated by the author and his deceased col- 
league, Llewelyn Thomas, at Milan, in 1880, but the communication, having been 
somewhat buried in the Comptes Rendus of that Congress, had not attracted much 
notice. It was fully discussed in Mr. Lennox Browne's recently published new 
edition of his work on ' ' The Throat and its Diseases, ' ' and the attention of the 
members present was invited. 48 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
THIRD DAY. 
Meeting called to order at 11 A.M. by the President. 
In the absence of Dr. H. H. Curtis, of New York, Dr. S. N. Benham was 
appointed by the President to read Dr. Curtis' paper, entitled- 
NASAL STENOSIS 
RÉTRÉCISSEMENT NASAL. 
ÜBER NASENSTENOSE. 
BY H. HOLBROOK CURTIS, M.D., 
Of New York. 
The exact function of the nose, from a physiological standpoint, has, as yet, not been 
definitely demonstrated, though great advances have been made in rhinology since 
the last meeting of the International Medical Congress. 
The important relationship between pathological conditions of the olfactory and 
respiratory nasal tracts and diseases affecting their continuity in the pharynx and 
larynx well deserves the amount of labor and research which has been devoted to 
rhinological laryngology during the past three years. 
The advent of intra-nasal surgery has not only compelled an entirely new classifi- 
cation of nasal diseases, but also admits of the elucidation of many previously obscure 
pathological problems. The surgery of rhinology had its origin and a greater part of 
its development in the United States, and the compliment paid by Mr. Lennox Browne 
to the American Laryngological Association, in his valuable work just issued, well 
shows the recognition American laryngology obtains abroad. 
The various deformities of the bony and cartilaginous framework of the nose, and 
their surgical relief, together with the altered structure or function of the turbinate 
bodies and their mode of treatment, will illustrate the purport of this thesis, and the 
title, Nasal Stenosis, will embrace all these conditions. 
NASAL STENOSIS MAY BE OF TRAUMATIC, HYPERTROPHIC OR REFLEX ORIGIN. 
1. Traumatic Stenosis comprises deviations of the septum, either bony, cartilaginous, 
or both, resulting from direct injury, improper mode of lying during sleep in infancy, 
congenital deformity or unequal cranial development. 
2. Hypertrophic Stenosis includes exostoses, enchondroses, thickened ridges along one 
or both sides of the septal articulations, hypertrophy of the turbinate bodies, erectile 
tumefactions, polypi, neoplasms, tumors, etc. 
3. Temporary or Reflex Stenosis includes the reflex neuroses and those conditions in 
which the erectile tissues are temporarily enlarged, either by increased nutrition, by 
vasomotor paresis or by irritation. 
The term Nasal Stenosis we employ in its generic sense. SECTION XIII-LARYNGOLOGY. 
49 
The descriptions of diseases under the names "Post-Nasal Catarrh," "Granular 
Pharyngitis," " Hypertrophic Lateral Pharyngitis, " etc., will soon be done away with, 
and the near future of pathological research, combined with better physiological knowl- 
edge, will cause a reflex impairment of function in these cases to be classified as such, 
rather than as diseases per se. 
Post-nasal catarrh is a symptom of nasal stenosis, so also is ethmoiditis, eustachian 
catarrh, otitis, adenoid growths, pharyngitis, laryngitis, hay asthma, spasmodic asthma, 
enlarged tonsils, bronchitis, etc. When we say bronchitis we do not include, neces- 
sarily, all bronchitis, any more than when we say otitis do we include every otitis; but 
nasal stenosis includes as symptoms some of the above conditions in a very large pro- 
portion of cases. Hence the relief of nasal stenosis becomes an essential factor in the 
treatment of these conditions, and at present has assumed an importance in laryngology 
not dreamed of in the past. 
Some of the best literature of to-day-the works of Mackenzie, Cohen, Lennox 
Browne, etc.-dismiss the subject of deviation of the septum with a page or two in five 
hundred, and, with the exception of Lennox Browne, make but passing reference to 
stenosis of the nostrils from so-called hypertrophies and catarrhs resulting therefrom, 
while to thoroughly cope with the seriousness of the trouble, and the magical effect of 
the restitution of the lower nasal air passages, would rightly deserve a quarter of the 
subject matter of their respective works. 
The study of stenosis is as important an attribute to laryngology as the consideration 
of stricture of the urethra is to genito-urinology. 
For several years the writer has been waiting to see a case of ' ' Post-Nasal Catarrh ' ' 
unaccompanied by enlarged turbinates or deviated septum. Writers on the subject 
maintain that the catarrh causes the erectile tumefactions. If this is so, why, then, 
do we never see a catarrh in its initial stage ? 
Rhinitis is a vasomotor phenomenon, with its stages of shock, dilatation and secre- 
tion. Catarrh may result from chronic rhinitis only when the dilatation has persisted 
long enough to produce oxygen starvation and changed secretion ; for by relief of the 
stenosis and reestablishment of free oxygenation the altered secretion of a catarrh will 
lose its tenacity and become normal. A catarrhal secretion is, then, the normal secretion 
of the nostril rendered viscid by want of oxygenation.* It is a matter of sincere regret 
that certain writers have made of late rather extraordinary claims for their ability to 
cure all conditions of catarrhal implication by the simple procedure of sawing off the 
angle of a septal deflection or the free use of chromic acid to the erectile tissues of the 
turbinate bodies, without taking into consideration possible ethmoidal complications ; 
for the writer has had the opportunity of seeing several cases of anterior ethmoidal 
catarrh, periostitis and caries which have presented themselves for treatment after 
having been positively assured entire freedom from their symptoms, following a relief 
of nasal stenosis. It seems proper to consider ethmoiditis to result either from con- 
tinued colds, causing chronic congestion of the inter-ethmoidal mucous membranes, or 
from stoppage of the orifice of ethmoidal secretions by pressure f from an enlarged 
turbinate body. There is no doubt that many so-described catarrhal conditions of the 
antrum are, in reality, but an anterior catarrhal ethmoiditis. The condition rarely 
occurs but on one side. It is frequently seen, but I do not find it described in any 
text-book. If the ethmoiditis has become carious, the slender probe introduced into 
* See paper by writer, read before Am. Soc. Sei. Ass., and published in American Social 
Science Journal. Report of meeting September 7th, 1886, at Saratoga. 
f See paper entitled "A Few Points Concerning Laryngological and Rhinological Work," read 
by Dr. H. Holbrook Curtis before the New York Academy of Medicine. (Weu? York Medical 
Record, April 30th, 1887.) 
Vnl TV-1 50 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
the anterior orifice of the ethmoid cells will at once give the bony touch. This is done 
with great facility as the result of a little practice. 
It is due to the apparent lack of appreciation of the existence of this interesting con- 
dition, that the differential diagnosis of nasal catarrhal diseases has been so hopelessly 
at fault, and though it does not directly concern the subject of nasal stenosis (except 
when it occurs from hypertrophy of the middle turbinate body causing pressure, and 
retention of ethmoidal secretions), it is important to understand the difference between 
an ethmoiditis and a simple nasal catarrh. 
Having outlined the principal causes of nasal stenosis, and touched upon the symp- 
toms, let us, for a moment, take up the consideration of the traumatic and hypertrophic 
subdivisions. 
1. Traumatic. This variety occurs as deviation of the nasal septum from the median 
line. These deviations have been classified by the writer as- 
(a) Vertical (V). 
(&) Horizontal (H). 
(c) Oblique, ascending and descending (OA) (OD). 
(d) Sigmoidal (S). 
(e) Pyramidal (P). 
The vertical deflection has an anterior and a posterior plane, with the line of the 
ridge or intersection perpendicular to the floor of the nasal cavity. 
The horizontal deflection consists of two planes or faces, with the ridge or intersection 
parallel with the floor of the nasal cavity. 
The oblique ascending consists of two planes, the ridge or intersection rising obliquely 
upward and backward, usually corresponding to the line made by the articulation of 
the vomer with the cartilage of the septum. 
The oblique descending ridge will make either an acute or right angle with this line. 
The sigmoidal is represented by a right (or left) horizontal deflection in the middle 
meatus, and a left (or right) horizontal deflection with the inferior meatus of the oppo- 
site side. Sigmoidal deflections may be horizontal or vertical. 
The pyramidal deflection presents three or more planes, w hose apex points either to 
the right or left. This method of classification has been adopted, to keep a record of 
operations with the saw or nasal trephine.* 
Thus, if an operation with the saw or trephine has been performed on a nasal deflec- 
tion of the septum, we write- 
R. H. D. I. M. f in. Trephine, or, 
L. P. D. M. M. Saw, or, 
R. V. D. total occlusion, Trephine No. 3. 
In other words, we have operated w ith the trephine on a right horizontal deflection, 
which caused stenosis of the inferior meatus, and extended for two-thirds of an inch. 
In the second case the letters express an operation with the nasal 
saw, on a left pyramidal deflection projecting into the middle 
meatus. 
In the third formula we read that a complete stenosis was over- 
pi come by making an artificial meatus with a T in. trephine. 
It will be seen that the deflections, except the sigmoidal and 
pyramidal, approximately correspond (considered geometrically) to 
the diameters of an octagon, and are most conveniently referred to 
in this manner. 
* See paper, " The Nasal Trephine and its Advantages," read by the writer before the Section 
of Laryngology, New York Academy of Medicine, March 23d, 1887.-New York Medical 
Journal, May 28th, 1887. SECTION XIII LARYNGOLOGY. 
51 
The deflections we are most frequently called upon to deal with are cartilaginous ; 
they usually present themselves as horizontal or oblique ascending in the anterior nasal 
chambers. 
Next in point of frequency occur the same deflections of greater extent, with bone 
in the posterior portion. Then follow in order of frequency of occurrence the vertical, 
pyramidal and sigmoidal. The oblique descending is most seldom encountered. 
Barely do we find a horizontal deflection which implicates the posterior border of the 
vomer ; and bony deflections without implication of the cartilage are infrequently met 
with. 
2. Hypertrophic.-The bony exostoses should be considered, though we do not find 
many cases of importance ; occasionally the middle or superior turbinated bone assumes 
an arborescent growth, causing pressure in the adjacent parts. The most frequent bony 
growth we encounter is a spinous process, which arises from the superior maxillary 
bone, and projects into and causes obstruction of the inferior meatus. This must not 
be confounded with the nasal maxillary spine, which is frequently seen on one side, 
with a dislocated cartilage in the other nostril. The septum immediately at its origin, 
at the anterior floor, often becomes thickened by cartilaginous proliferation, and may 
present prominences, the size of a large pea, on either or both sides. These processes 
are made up often of a union of osseous and cartilaginous material, of the same con- 
sistency as the ridges above alluded to, which form at the septal articulations. These 
ridges are found to exist most frequently in the noses of those of a rheumatic or gouty 
diathesis, and are generally associated with enlarged tonsils. There is always an 
enlarged turbinate body in the inferior meatus, obstructed by such a tumor, the direct 
result of the anterior stenosis. The tubercle of Zukerkandl must not be mistaken for a 
deflection or an exostosis, though it is often largely developed, and errors have arisen 
from its appearance. Far more often than the septal deflections and thickenings do 
we find nasal stenosis to result from enlargement of the turbinate bodies, and more 
especially the lower turbinate. This enlargement may be due to excitation of the 
erectile tissues for a considerable period, as we observe in workers in acid, wood sawing 
and metal filing, and also from exposure to certain dusts and pollens. This stimula- 
tion, as with snuff-takers, goes on until the contractile power of the tissues becomes 
lost, and we have a resulting enlarged turbinate body, either soft or hard, according to 
the amount of hyperplastic metamorphosis which has gone on. This condition, com- 
mencing with a dilatation, ends in true hypertrophy. These hypertrophic conditions 
are seen most frequently in middle life, and it is to be presumed that the decreased 
nutrition which supervenes on the development of true hypertrophy causes later a 
certain shrinkage, with consolidation of the material. Some nasal irritants, as acid 
fumes and pollens, tend to cause a primary excitation of the erectile tissues ; while 
others, such as snuff and menthol, cause contraction. But whether it be either con- 
tinued dilatation or contraction of the erectile tissues, the secondary effect will be an 
hypertrophy, as evidenced by the snuff-taker and the patient who has used cocaine for 
some time to counteract the disagreeable effects of a stenosis, as in hay fever. 
3. Reflex.-Various reflex conditions have been proved to be the direct result of 
hypertrophies and erectile tumefactions in the nostril ; and, on the other hand, we may 
find the nasal erectile mucous membrane to be acted upon and enlarged by an excita- 
tion or irritation of a co-related area. In the female the erectile tissues are distended 
during menstruation. By the irritation of the peripheral ends of the pneumogastric 
nerve in children suffering with worms, we also have a nasal excitation. These forms 
of nasal stenosis are not, however, origo malorum, and do not require our attention here. 
Symptoms.-Nasal stenosis causes first a diminished air current in normal respiration, 
and is widened by a general malaise in the individual, from want of proper blood 
•oxygenation. Sooner or later, to remedy the defect of improper oxygenation of the 52 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
pulmonary air tracts, the subject becomes a mouth-breather. From the moment a 
person becomes a mouth-breather, two diseases, as at present classified, announce 
themselves; viz., a subacute catarrhal rhinitis, and a subacute pharyngitis, afterward 
becoming glandular. These in course may be complicated witli subacute laryngitis, 
Eustachian catarrh, bronchitis, hypertrophy of the tonsils, adenoid growths, caseous 
degeneration of the tonsils, catarrhal pulmoualis, etc., etc. 
So many of the commonly encountered diseases of the ear, nose, throat and lungs 
have a symptomatic association with nasal stenosis, that it would be almost necessary 
to include an index of throat diseases. Why the profession at large do not and have 
not grasped this great truth is surprising. In many of the medical schools of this 
country the examination of the nasal passage is untaught, and among men with 
acknowledged ability in the practice of their profession, in New York City, many an 
error in diagnosis is corrected in the offices of our laryngologists. It seems a disgrace 
to scientific teaching, that patients suffering from a condition as apparent as nasal 
polypi, or almost complete stenosis from deflection of the septum, should be almost 
daily advised to go to Colorado or Florida to avoid phthisis. More good will be done 
to suffering humanity when the stethoscope is marie secondary to laryngo-rhinoscopy in 
the investigation of pulmonary affections. While briefly stating the symptoms of nasal 
stenosis, it is important to consider the fact that 50 per cent, of the cases which present 
themselves in our throat and ear hospitals are fit subjects for undergoing an operation 
for the relief of nasal stenosis. In looking over the reports of three of the large throat 
hospitals in Loudon, we find that among 20,000 patients treated during the year 1886, less 
than one patient in 1000 was operated upon for deviation of the septum, and with tae 
exception of one institution, viz., the London Throat Hospital, there was no attention 
directed to the use of escharotics to reduce enlarged turbinate bodies. At the London 
Central Throat Hospital, where Lennox Browne is making his name famous, the gal- 
vano-cautery takes the place of chromic acid, but the work accomplished is not as 
thorough. Woakes, though the first to recommend the free use of the nasal saw, 
seldom employs it in his clinic. It is easily comprehended, when one sees the thick- 
ness and clumsiness of the instrument, as compared with the saw of Bosworth, or the 
even more delicate saws manufactured for the writer, and known under his name. 
Notwithstanding the brilliant results obtained by the use of the nasal saw, in the cure 
of catarrhal symptoms from stenosis, nasal, pharyngeal and laryngeal, it requires some 
skill to properly manipulate the same in order to produce the best effects. Two distinct 
cuts are frequently necessary, and the angle of union must be carefully determined 
often in the presence of considerable hemorrhage. The saws which are most easily 
used, are the long, probe-pointed but very thin saws, with the bayonet handle parallel 
to the blade, the teeth on the upper or under side, as one wishes to cut either up or 
down; also the straight knitting-needle saw with double teeth. 
These three saws will enable one to do all the work necessary upon the nasal 
septum, the needle saw being useful in making crescentic cuts. A very large experi- 
ence with the saw has taught the writer that the region of the inferior meatus is the 
important seat of operations, and in many cases, the reestablishment of the lower 
channel will be enough to give relief from nasal, pharyngeal and aural troubles, with- 
out attempting to reconstruct the entire septal anatomy. For those whose opportuni- 
ties for operation are frequent, and time is an essential factor, an instrument which is 
vastly superior to the saw is the nasal trephine of the writer, operated by means of a 
flexible cable communicating ■with an electric motor, water motor, or revolving wheel 
worked by an assistant. This instrument has been employed by me for several months, 
to the exclusion of all revolving knives, burr drills, etc., and has proved extremely 
satisfactory7. By means of the nasal trephine, one is enabled to do many an excavation 
to relieve a stenosed inferior meatus, when the ridges appear as a thickening to which. SECTION XIII-LARYNGOLOGY. 
53 
eue would hardly apply the saw, on account of the difficulty of making a good opera- 
tion. The instrument has been thoroughly described by me in the New York Medical 
Journal of May 28th, 1887, and thus far, with a history of 75 operations, there is no 
modification which I can at present suggest. To any one who has had the continued 
disappointments with the stellate punch of Steele, and Adams' nasal forceps, that the 
writer has experienced in the operation of septal deviations, the trephine must be hailed 
with delight. With trephines of this kind, varying in size from one-sixteenth to one- 
fourth of an inch in diameter, one is enabled to do an operation in a few seconds, 
which by other methods would take a much longer time. The free use of cocaine 
renders the operation absolutely painless, bleeding never obscures the view of the 
operator, and the result is always better than when the saw is employed. The cut 
being circular, a concave surface results, which permits more space than when a straight 
cut is made with the saw. It is possible to make an artificial meatus in case of total 
occlusion of the nostril, where the saw cannot conveniently be introduced. When the 
perforation is complete, the core remains within the cylinder of the trephine, and is 
withdrawn with the instrument. In regard to the use of chromic acid for the treat- 
ment of those enlargements which occur, either as the result of a hypertrophy of the 
turbinate bodies, or as a dilatation of the same from a lack of vasomotor resiliency, 
I have no desire to retract the somewhat criticised assertion made by me in a paper 
read before the New York Academy of Medicine last April, in reference to nasal stenosis 
from turbinate hypertrophies or enlargements, in which I said that so great was the 
importance, in my estimation, of a reestablishment of the air current through the upper 
air passages, and particularly through the inferior meatus, in the treatment of all 
affections of the pharynx and larynx, non-specific or non-tubercular, that I would not 
exchange the flat probe and chromic acid, for the combined douches, sprays and 
therapy of the most complete laryngological establishment. There has been much 
comment upon the claims put forth for chromic acid, but those who are adverse to it are 
those who do not use it properly. The acid should be permitted to remain in an open- 
mouthed bottle and allowed to deliquesce; a drop of glycerine or a few drops of water 
arrests this. The partially deliquesced acid should be reduced to a pulpy consistency, 
containing fragments of the crystals, by rubbing up with a glass pestle. The thick mass 
is then spread upon one side of a flattened copper applicator and introduced. A good 
rule to observe, is to only apply the acid to the pendulous portion of the turbinate bodies, 
being careful not to touch the septum or floor of the nasal cavities; disagreeable symp- 
toms often follow if the soft palate is touched. 
Much more frequently are we called upon to treat in this manner erectile dilatations 
than true hypertrophies, our aim in these cases being to produce a cicatricial bandage 
for the dilated erectile structure. That the turbinate bodies possess a normal erectile 
function is conclusively proven, but the word hypertrophy, used to express an altered 
condition of this function without hyperplastic deposit, is, in my opinion, a misnomer 
The presence of a true hypertrophy is ascertained by the application of cocaine and 
chromic acid, neither of which contracts the hypertrophied turbinate body, but either 
drug causes the dilated plexus to contract at once. A true hypertrophy often needs 
the trephine for its removal ; it is hard and gristly to the probe touch, and is difficult 
of removal by chromic acid, and also with the galvano-cautery. Such a condition is of 
rare occurrence, though under the name of hypertrophies are generally described, in the 
current text-books, simple dilatations, which I have termed erectile tumefactions, in 
contradistinction to the true hypertrophies. An important point to be observed, also, 
in the use of chromic acid, is never apply enough to allow of its running. In my own 
practice I take a common copper wire, No. 14, about six inches in length, and flatten 
one end for about one inch. The acid is then smeared on one face of the flattened 
surface ; the application is introduced to about the middle portion of the lower turbinate 54 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
body, and applied, as it is withdrawn, with a gentle brush motion. If, now, the erectile 
tumefaction is well shrunken, and the surface is seen to be well " burned," we may 
again anoint the applicator, and if we have observed, by rhinoscopic examination, 
slight tumefactions on either side of the septum or posterior border of the turbinate 
bodies, they may be likewise " burned." Cocaine should be applied before we use the 
acid and the application becomes painless. Unlike the action of the galvano-cautery, 
there is severe pain often following the use of chromic acid, and ofttimes accompanied 
by a slight depression, which has been wrongly described as chromic acid poisoning. 
It must be remembered how frequently we witness such a depression following uvu- 
lotomy, more from an acute inflammation in the vicinity of ganglionic centres than 
from absorption of morbific products. After the chromic acid has remained in situ for 
some minutes, and before the patient has been allowed to blow the nose, it is desirable 
to spray the nostrils with a Dobell solution, and to keep this up two or three times a 
day until the sloughs detach from the turbinate bodies. The absolute relief of nasal 
stenosis occurs when under no condition there can be contact of the turbinate bodies 
with the septum. 
When the superior meatus is thoroughly free the middle meatus will in most cases 
follow suit, for it is principally by a deflection of the air current to the middle meatus 
which, a priori, has produced there the congested condition of the turbinate body and 
contact with the septum. There is no erectile tissue in the middle turbinate body, and 
enlargements of these are neoplasms or true hypertrophies. 
The tissues of the middle turbinate bodies never shrink up upon pressure from a 
probe, as one frequently sees even in young children upon making slight pressure on 
the anterior erectile structures of the inferior turbinate bodies. 
Chromic acid alone has been spoken of in the treatment of turbinate stenosis, 
because it has advantages over all other means. The galvano-cautery is not as certain 
of accomplishing as much, as the effect is over on the withdrawal of the electrode, and 
to do sufficient work we must of necessity greatly alarm our patient. I have tried both 
methods, and the patient's evidence is immensely in favor of chromic acid. Nasal 
surgeons have been accused of giving too little attention to therapeutics, and here I 
take occasion to give my evidence in favor of treating any stenosis of the third subdivi- 
sion, temporary or reflex, by doses of arseniate of strychnine, phosphide of zinc, aconi- 
tine, digitaline, etc. 
This class of cases, however, seldom reach the specialist until they have, by an 
enervation of the vasomotor centres, entered the class of permanent dilatation and 
demand local treatment. 
For patients to whom I have made applications for simple dilatation I always pre- 
scribe a course of tonic treatment against recurrence; otherwise, there will be a return 
of the trouble within the following six months, which will necessitate another applica- 
tion of the acid. To sum up: the relief afforded to the various pharyngeal and laryn- 
geal troubles by the simple operative procedures necessary to overcome a nasal stenosis 
would take a volume. I will, however, close my paper by citing, in as few words as 
possible, some illustrative cases :- 
Case I.-C. W. A.; November 6th; age eighteen; 121 pounds. 
History.-Nasal catarrh; dry throat in morning; insomnia; constant cough; deafness 
on left side; tinnitus, not constant. 
Examination.-Nasal stenosis, L. H. D.; glandular pharyngitis; bronchitis. Watch: 
R. 32 ins. ; L. 4 ins. 
Treatment.-Op. Saw. L. H. D. ; chromic acid R. I. T. and L. I. T. ; Politzer infla- 
tion and cleansing spray daily. (12 office visits.) 
Result.-January 3d, Watch: R. 42 ins., L. 22 ins.; cough and insomnia cured; no SECTION XIII-LARYNGOLOGY. 
55 
trouble from catarrh; glandular pharyngitis entirely disappeared; no longer a mouth 
breather; weight 124 lbs. 
Case II.-A. R. B. ; November 12th; clerk; age forty-five. 
History.-Catarrh; headaches; nightmares; nervousness; cannot read, on account of 
restlessness; vertigo during working hours. 
>aminafion.-Stenosis R. I. T. and L. I. T. ; erectile tumefactions; subacute pha- 
ryngitis. 
Treatment.-Chromic acid to R. and L. I. T., at weekly intervals ; hygiene; brom- 
hydrate of quinine; cleansing spray. 
Result.-January 12th, patient reported himself well and had gained eight pounds 
in weight. 
Case hi.-C. ; actor; age forty-one years; 182 pounds ; robust. 
History.-Had " been off" for a year; voice never lasted more than ten days; had 
been treated with strong astringents daily for several months; severe catarrh and ten- 
dency to clear throat after a few words. 
Examination.-Vocal resonance muffled; pitch lowered; could use low middle regis- 
ter, but broke on higher speaking tones; stenosis R. complete, L. slight; R. V. D. 
L. I. T. tumefaction; glandular pharyngitis; chronic laryngitis; rosy, fibrillated cords. 
Treatment.-Saw, R. V. D. ; chromic acid L. I. T. and R. I. T. 
Result.-One year has passed, and since restitution of nasal breathing has not been 
"off" a night, though playing constantly, 
Case iv.-A. P. ; actress; aged thirty; robust. 
History.-Singing voice becoming uncertain; constant sore throat; takes cold easily; 
throat a source of constant worry; cannot rest, as engagements made for season; oppres- 
sion on chest; travels continually. 
Examination.-L. P. D. almost complete stenosis; R. I. T. tumefaction; inflamed 
pharynx and larynx. 
Treatment.-Saw, L. P. D. ; chromic acid; R. and L. I. T. 
Result.-Seven months after operation: Voice has been in excellent condition; has 
not caught a cold nor had an attack of tonsillitis since the operation. 
Case v.-C. B. C. ; bank cashier; age forty-six. 
History.-Spasmodic asthma for eight years; never can go up stairs; obliged to use 
horse cars instead of elevated roads; always sleeps in an easychair; has not been in 
bed and slept lying down in five years; exhaustion on slight exertion; constant cough, 
with clear, gelatinous, starchy expectoration; frequently casts of smaller bronchi are 
expectorated; very emaciated. 
Examination.-Anaemia; total R. and L. stenosis; R. and L. H. D. polypi; R. and 
L. I. T. hypertrophied; pulse 120; respiration 42; temperature 98; weight 129 pounds. 
Treatment.-R. L. H. D. trephined; chromic acid R. and L. I. T. ; posterior fibroid 
tumor R. I. T. snared; polypi snared ; deep inhalations of iodoform in ether spray daily ; 
milk, three quarts daily, in addition to unrestricted diet; digitaline, quinine and 
strychnine; treatment persisted in for two months. 
Result.-Sleeps all night, with mouth closed; asthma, except slight symptoms on 
catching cold, cured ; pulse and respiration normal; after six months, weight 154 
pounds. 
The above patient presented himself in my office, supported by two attendants, 
under the impression that his lungs were the seat of his troubles, and had long been 
treated under that assumption. Notwithstanding some apprehensions of collapse, I 
immediately trephined both H. D. of the inferior meatus, and relieved him of some 
polypi, leaving two hard nasal catheters, 9 English, in situ for the day. Then followed 
a series of operations with the saw, trephine and snare, requiring several weeks of 
attendance once in every three days. 56 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
This case must be regarded as typical, in exhibiting a complete stenosis and the 
systemic derangement therefrom. There can be no artificial oxygenation from medi- 
cation that will so rapidly overcome an anæmia as the reestablishment of the nasal 
respiratory tracts. 
THE USE OF RESORCIN (C6H4(H2O)2) IN THE TREATMENT 
OF NASAL CATARRH. 
L'USAGE DE LA RESORCINE DANS LE TRAITEMENT DU CATARRHE NASAL. 
ÜBER DIE ANWENDUNG DES RESORCINS IN DER BEHANDLUNG DES NASENKATARRHS. 
A. B. THRASHER, M.A., M.D., 
Cincinnati, Ohio. 
The marked natural action of resorcin as a reducing agent has been pretty well 
demonstrated in diseases of the skin where there is infiltration of the corium. 
It causes a shrinking or contraction of the epithelium so as to produce a true corni- 
fication of this layer. The deeper tissues are affected by the contraction of the blood 
vessels and a consequent stoppage of the nutritive supply of these parts. The experi- 
ence of Professor Unna, of Hamburg, seems to indicate that this contractile effect lasts 
for a long time, and may be due to the absorption of oxygen from the histological ele- 
ments of the tissues and vessels. This active affinity for oxygen may also explain the 
very powerful anti-mycotic action of the drug. The brilliant results attained in the 
treatment of parasitic diseases of the skin, notably herpes tonsurans, by Ihle, of 
Leipsic, indicate that resorcin acts not only by reducing inflammatory conditions, but 
also that it is a powerful specific antiseptic. From Hile's report it appears that resorcin 
penetrates the skin deeply and destroyes the spores which have extended into the hair 
follicles. 
Having the physiological action of the drug thus pretty well demonstrated, it 
occurred to me to try its action in certain forms of nasal catarrh. 
There is a very obstinate rhinitis where the hypertrophy is not great and the oedema 
is considerable, where the acute stage has passed and the hypertrophy is not yet suffi- 
cient to occlude the lumen of the naris. The patient comes to the physician with the 
story that he ' ' takes cold " very easily, and his nose is stopped up at night. Sometimes 
but one side is occluded, and then both, or more frequently the stoppage alternates from 
one side to the other. Questioning will generally elicit the information that at night 
when the patient lies on the right side of the body the right side of the nose is stopped, 
and "vice versa." Examination of the nose usuallyreveals both nares more or less 
well open. If there is a closure of either or both sides a spray of two per cent, solution 
of hydrochlorate of cocaine will cause it to open in a fewT minutes. It is in this condi- 
tion that I have found resorcin of signal benefit. 
The use of acids or the galvano-cautery or the snare will quickly remove the 
hypertrophy and cause the most urgent symptoms to subside. But it leaves over a 
greater or less surface scar, tissue instead of the normal nasal mucous membrane. 
Resorcin accomplishes the same result as far as the subsidence of troublesome symptoms 
is concerned, and the nasal mucosa remains intact and is still capable of fulfilling its 
normal functions. 
Given a case as described above, and the daily application of a solution of resorcin SECTION XIII-LARYNGOLOGY. 
57 
will cause a whitening and shrinking of the swollen membrane, and a marked decrease 
in the action of the over-active mucous glands. The effect is somewhat similar to 
cocaine, with this difference, viz., whereas cocaine acts rapidly, and its action is over 
in a short time, resorcin acts more slowly, and its action extends over a very much 
greater length of time. 
The vehicle employed by me in its application has been either vaseline or olive oil, 
and the strength of the solution varying from two per cent, to ten per cent., in accord- 
ance with the amount of hypertrophy and the irritability of the membrane. 
I first cleanse the mucous membrane thoroughly by throwing a coarse spray of the 
following solution : R. acidi borici, sodii, biboratis, ââ drs. ij ; 01. gaultheriæ, gtt. ij ; 
Aquae, Oj. Misce. Then the mixture of resorcin is put in an atomizing tube having a 
large aperture, warmed, and the nasal mucous membrane drenched with the spray. 
The remedy is applied for the first week daily, to the cleansed mucous membrane. 
After the first week the nasal atomizer every second or third day, and on other 
days the patient uses an ointment (two to four per cent, of resorcin in vaseline), apply- 
ing it to the nasal mucous membrane by means of a small camel's-hair brush. 
My notes on forty cases treated in this way show that ten were dismissed cured in 
three weeks, fifteen in four weeks, seven in five weeks, four in six weeks, and three in 
two months. One obstinate case, where exacerbations were frequent, and which would 
tolerate only the weakest solution of the drug, seemed not to be entirely well at the end 
of twelve weeks' treatment. 
These cases were all essentially chronic, having had symptoms of stenosis and an 
excessive muco-purulent discharge from one to ten years. Some of these patients, since 
their discharge, have returned, with attacks of acute coryza, which, however, have 
readily yielded to the usual treatment given such cases. In summing up my experience 
with resorcin in the treatment of nasal catarrh, I would say :- 
1. It is most useful in chronic nasal catarrh accompanied by oedema of the mucous 
membrane without much hypertrophy. 
2. These cases are, as a rule, cured in from three to six weeks. 
3. Resorcin should be used daily in from two per cent, to five per cent, solution in 
vaseline or olive oil as a spray or in the form of an ointment. 
4. Resorcin allays the oedema of the turbinated bodies, checks the over-secretion of 
the mucous glands, and leaves the membrane in a normal condition. 
5. In acute coryza resorcin is not necessary ; in atrophic and in hypertrophic rhinitis 
it is not useful. 
6. Its good effects are due to its power of lessening the caliber of the hypersemie 
vessels, of reducing the cedematous and semi-hypertrophic mucous membrane, and of 
hardening (tanning) the epithelial cells, and to its remarkable anti-mycotic properties. 
DISCUSSION. 
Dr. J. A. Stucky, of Lexington, Ky., said-I desire to make only a few 
remarks on the very valuable and practical paper of Dr. Thrasher. Two years 
ago, I mentioned at the Kentucky State Medical Society my views as to the use of 
resorcin in atrophic rhinitis. Since then I have used the remedy in the manner men- 
tioned by the speaker, but in much stronger solution. A five to twenty per cent, of 
resorcin, in equal parts of glycerine and water, applied ten or fifteen times, two or 
three times a week, not only relieves the turgescence and tumefaction of the mucous 
membrane quickly, but in the large majority of cases permanently. 
In hypertrophy or hyperplasia, a saturated solution of resorcin in glycerine and 
water, with five grains of cocaine to the drachm, applied by means of the cotton- 
covered probe, affords a quick and satisfactory cure, if the hypertrophy is not too 58 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
large. The rapid oxygenation of the tissues caused by the remedy produces some 
pain, but lasts only a moment. After the application of resorcin, I think the parts 
should be covered with spray of an oleaginous, soothing substance, either vaseline or 
olive oil. 
In the absence of Dr. F. Semeleder, of Mexico, Dr. S. N. Benham, of Pitts- 
burgh, was appointed to read his paper, entitled- 
TWENTY YEARS OF LARYNGOSCOPICAL WORK IN MEXICO. 
VINGT ANS DE TRAVAUX LARYNGOSCOPIQUES AU MEXIQUE. 
ZWANZIG JAHRE LARYNGOSKOPISCHER THÀTIGKEIT IN MEXICO. 
BY DR. F. SEMELEDER, 
Of Mexico. 
When, in 1864,1 came with the Emperor Maximilian to this country, laryngoscopy 
was still unknown here, so it took that then new branch of medicine six years to cross 
the Atlantic. The physicians of the country had then no scientific intercourse with 
any other country but France. Whatever was done outside of France no notice w as 
taken of until it became known through the mediation of French books or papers. The 
United States was then, practically, far more distant than France or England ; railways 
did not exist here, nor direct steamship communication. It was a great deal easier to 
get anything from France than from New Orleans ; the English language was hardly 
appreciated or cultivated among the profession, and German was altogether neglected. 
I had then already published a monograph on rhinoscopy and the first manual of 
laryngoscopy,* both considered in one volume, and translated into the English language 
by the now deceased Dr. Edw. T. Caswell, of Providence, R. I. ; published by W. Wood 
& Co., New York, 1866. 
Since then I have occasionally practiced laryngology and rhinology, and propose, in 
the following, to give a brief account of my work. 
The only Mexican publications on the subject I am aware of, are : "La Laringo- 
scopia," etc., por Angel Iglesias, printed in Paris by Rosa & Bouret, 1868; and a 
translation into the Spanish language of my first two cases of " Extirpation of Laryn- 
geal Polypi through the Mouth ' f besides a verbal communication to the Academy of 
Medicine of "A Successful Extirpation of a Papilloma of the Vocal Cords per Vias 
Naturales." 
Taken as a specialty, laryngoscopy in this country was certainly a most ungrateful 
business, and would hardly pay one's house rent. 
Laryngeal affections are comparatively rare here, owing to the mildness and equa- 
bility of the climate. 
Acute and subacute laryngitis are common ; the chronic form is rare. (Edema of 
the larynx I only observed in one case, where laryngotomy was performed by a friend 
of mine, and with good results. 
* " Die Rhinoskopie," etc., Leipzig, W. Engelmann, 1862 ; and " Die Laryngoskopie," Wien, 
Wilh. Braumiiller, 1863. f ffaceta medica de Mexico, Vol. IV, No. 6, 1869. SECTION XIII-LARYNGOLOGY. 
59 
Tuberculous laryngitis I saw in five cases ; three of them were laryngotomized by 
me, with immediate good result ; two of them died later on ; one left the city for his 
home and, probably, must have died. In none of these cases the pulmonary affection 
was much advanced at the time when surgical interference was required, to prevent 
choking. 
Of syphilitic laryngitis, I have seen a number of cases in different stages. Laryn- 
gotomy performed in eleven cases, with good results. 
Diphtheria is happily rare here. The Mexicans pretend that it was altogether 
unknown here until about 1860 or 1862. We had two epidemics, pretty severe ; now 
for several years past we had only single cases. I have performed laryngo-tracheotomy 
for croup in two cases, both unfortunate as to the final result. 
Motor affections I observed in three cases of paralysis without appreciable causes, if 
not œdematous infiltration of the bands and the mucous membrane ; in a fourth case 
the paralysis was due to aneurism of the arteria anonyma. 
Benignant tumors ; only three cases belonging to Mexicans. I saw several more, 
but the patients were foreigners, and all but one only transient in the city of Mexico. 
On a young German I performed extirpation, per vias naturales, of a papilloma of the 
left vocal cord. Result good ; singing voice reestablished. 
Of people of the country, I only know of two cases of papillomata of the vocal bands. 
The first I saw in 1868 ; woman, thirty-eight years old ; papilloma, the size of a mul- 
berry, left vocal band ; extirpated per os. The second case, a man, presented himself 
in 1885 ; twenty-eight years old ; two papillomata, the size of a pea each, one in the 
anterior angle and the other on the lower surface of the left vocal band, about its 
middle ; both extirpated per os, the latter with some difficulty. The patient had 
repeatedly, before he came to me, when he had spells of coughing, expectorated small, 
fleshy particles of the tumors and a few drops of blood. 
In one case, a lady of about forty years, whom I saw only once, I observed on the 
left vocal band a flatfish tumor, size of a cherry stone, bluish, which I took for a varix. 
The lady did not like to have anything done to her tumor, and left town at once. 
In two cases, one a young man, and one a woman between thirty-five and forty 
years, I saw ulcers and scars in the pharynx and larynx, which I took for lupus. 
Malignant tumors, in different stages and varieties, cancer, epithelioma, encephaloid 
and scirrhus, epithelioma being the more frequent among my cases. The duration of 
the cases is extraordinary. I have seen patients lasting three years, with two and three 
epochs of so much improvement that I myself thought I had made a mistake in diag- 
nosis. I performed seven laryngotomies for cancer, all with temporary good results. 
All my cancer patients were of advanced age, and all men but two. 
Of remarkable rhinoscopical cases, I will only mention three cases oTretro-pharyngeal 
fibromatous polypi-one a young man, one a girl of eighteen years, and a woman of 
forty-two. For the girl, I extirpated the tumor through the nose, with good effect ; 
size like the first phalanx of index finger ; no reproduction in seventeen years. 60 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
In the absence of Dr. F. B. Eaton, of Portland, Oregon, Dr. Richard H. 
Thomas, of Baltimore, was appointed to read his paper, entitled- 
THE PRESENT STATUS OF THE GALVANO-CAUTERY IN THE 
TREATMENT OF DISEASES OF THE UPPER AIR PAS- 
SAGES. ILLUSTRATED BY IMPROVED FORMS OF 
ELECTRODES AND A DESCRIPTION 
OF CASES. 
LA CONDITION PRÉSENTE DU GALVANO-CAUTERE DANS LE TRAITEMENT DES 
MALADIES DES VOIS RESPIRATOIRES SUPÉRIEURES, ILLUSTRÉE 
PAR DES ESPECES D'ÉLECTRODES PERFECTIONÉS, ET 
UNE DESCRIPTION DE CAS. 
DER GEGENWÄRTIGE STAND DER GALVANOKAUSTIK IN DER BEHANDLUNG DER KRANK- 
HEITEN DER OBEREN LUFTWEGE, ERLÄUTERT DURCH ELEKTRODEN 
VERBESSERTER FORM, UND BESCHREIBUNG VON 
FÄLLEN. 
BY FRANK B. EATON, M.D., 
Of Portland, Oregon. 
The surgical is now the most popular if not the prevailing method of treatment in 
chronic diseases of the upper air passages. This is due, in a great measure, to the oppor- 
tunity offered by cocaine, and also to the brilliant results obtained in many cases. At all 
events, the inventive faculty of many surgeons is now stimulated to such an extent in 
the field of nasal surgery, that if all the assertions made in our journals are to be relied 
upon, the air passages can be cleared in one sitting with little or no p;fin. 
There is, nevertheless, a want of unanimity among specialists as to what is the best 
general plan of removing hypertrophic tissue in the anterior and posterior nares, and 
evidence of such difference of opinion is not wanting in the reports of medical acade- 
mies and societies, each writer appearing to narrow himself as much as possible to bis 
own method instead of utilizing the good features of all. As far as can be gathered 
from such reports and from the various articles published during the last two or three 
years, the prevailing tendency is to adopt more and more radical methods, so that now 
we have progressed on from the mild treatment by bougies to the use of snares, the gal- 
vano-cautery, and, finally, to that by revolving drills actuated by an electric motor. 
Owing to the extreme prevalence of chronic nasal catarrh in America, the popular- 
ity of all these methods is assured. That they have been, and will, one and all, be 
abused and overdone, and that a reaction must necessarily follow excessive zeal in 
clearing the upper air passages, goes without saying. Indeed, something of a reaction 
against indiscriminate surgical interference with these parts has already set in ; a sort 
of therapeutic skepticism, if I may employ the term, as to the value of topical medi- 
cation of the nasal and post-nasal mucous membrane, being one of the resultant evils 
against which Dr. J. M. W. Kitchen, of New York, has protested in an exceedingly 
fair, able and temperate communication (Medical Record, May 14th, 1887). Nor can it 
be denied that this excessive trust in surgical methods has called away due attention 
from hygienic prophylaxis and treatment, which are of such paramount importance in 
nasal diseases. in our art should be viewed more as an unfortunate but 
unavoidable necessity, resulting from the fact that 
" Art is long and time is fleeting," 
than as a mercenary choice, and the aim of the specialist should not be, as it seems to be, 
to effect complicated apparatus and to arrogate it to himself, but to simplify and to SECTION XIII LARYNGOLOGY. 
61 
make known to the profession at large his operative methods as much as possible, that 
they may be rendered available to the general practitioner, and thus the field of use- 
fulness enlarged. 
The principal aim of this paper is to claim again for the galvano-cautery (see Medi- 
cal Record, August 28th, 1886) that in the form I here present it to you, it is one of the 
best and most available surgical instruments for the removal of nasal and post-nasal obstruc- 
tions now at the disposal of the majority of surgeons at present practicing in our cities. I 
hasten, however, to state emphatically that I do not claim for the cautery an exclusive 
value in comparison with other operative methods, some of which are clearly more radi- 
cal for the removal of certain obstructions, though more complicated, severe, and less 
easily managed; and I shall honestly enumerate, with its advantages, its objectionable 
features. 
I submit this testimony to the value of the galvano-cautery in nasal diseases partly 
as a vindication, in answer to what I must designate as an unjust attack upon it by 
those who seem to favor the exclusive use of chromic acid, saws, snares, etc. And I 
am prepared to take issue with and prove the unfairness of one well-known specialist, 
who, not long ago, made the sweeping assertion that " a crystal of chromic acid accom- 
plishes all that the platinum wire can possibly accomplish, ... it can be applied with 
far more accuracy, its action controlled with far more delicacy, and it also creates a 
more efficient slough. While the galvano-cautery, on the other hand, is a cumbersome, 
expensive, disappointing, troublesome device, and, also, is not unattended with danger." 
[F. H. Bosworth, M.D., New York Academy of Medicine, April 21st, 1887.] 
Now, I believe that such unqualified assertions and such fulsome laudations of a 
particular method of treatment are precisely what injure it in particular and surgery 
in general, and while endeavoring in this paper to present fairly the true value of the 
galvano-cautery, and the improvements I and others have introduced in the apparatus, 
I repeat again that I do not wish to convey the idea that it is facile princeps, but, that 
in respect to general availability to the operator of average skill and adaptability to the 
greatest variety of conditions, it is, in my opinion, preeminent. 
Let me consider some of the above-quoted objections to the galvano-cautery:- 
1. That it is cumbersome. Compared with the chromic acid crystal, no doubt it is, 
but only relatively. The battery I here show you is that devised by Dr. Seiler; it 
occupies a space only 18 by 13 by 11 inches, permitting it, as in my office, to be placed, 
when being used, out of the way, under a bracketed operating table ; it is indeed far 
from cumbersome. 
2. That it is expensive. This objection is also a relative one, battery and electrodes 
costing only $70.00; certainly no great expense in view of the fact that both are lasting 
and durable, for the first expense is practically the only one. 
3. That it is disappointing. I can aver that, on the contrary, it has, in the form used 
by me, surpassed all my expectations, which were very sanguine. I can best refute the 
objection that the cautery is disappointing, by giving the results of treatment, as I will 
further on. 
Finally, to the assertion that the galvano-cautery is a troublesome device, I repeat 
that in its most recent improved forms it is far less so than chromic acid, if I can judge 
by the complaints made to me, and the published experiences of other surgeons. 
It is difficult to understand how the action of chromic acid, as has been asserted, 
' ' can be controlled with far more delicacy than the platinum wire. ' ' This may be 
true in respect to some forms of batteries and electrodes, but the characteristic and 
most valuable features of the apparatus I present to you, are the perfect control which 
the operator has over the current in respect to its quantity and duration, the delicacy 
of the electrodes and their adaptability to different conditions. It is useful to view the 
electrodes contrasted with the application of chromic acid, as probes variously bent, by 62 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
means of which caustic heat is so supplied as to cauterize or destroy only the part 
touched by the incandescent platinum, and in proportion to its size, temperature and 
the extent to which this platinum is pressed into the tissue by the hand of the opera- 
tor, is the effect produced. Will it be claimed that chromic acid can be thus con- 
trolled ? I think not. 
As to the positive advantages of the galvano-cautery, they are not to be despised. 
1. There is nothing in the appearance of the apparatus to alarm timid patients, so 
many of whom are intimidated by the snare, saws, knives and drills, so as to abso- 
lutely refuse, in some cases, to submit to an operation. The very brief duration o f the 
application of the incandescent burner is another admirable feature. I have applied 
my "scythe " burner to a posterior inferior hypertrophy, immediately following it up 
with a "lateral " burner and destroying all the remains of hypertrophied tissue on the 
same inferior turbinated bone within the short space of a minute, and that without 
giving any pain, or causing the slightest hemorrhage. Pain continuing during its 
necessarily protracted application to a posterior hypertrophy is inseparable from the 
use of the snare, with or without cocaine, in order to prevent hemorrhage; whereas, 
when a 20 per cent, solution of cocaine is used there is none caused by the cautery, except 
sometimes when deeply burning, and then it is never severe. Hemorrhage beyond 
slight and brief oozing is rare in my experience. Cautery operations, with proper tem- 
perature of platinum, are essentially clean ones. 
Again, all forms of hypertrophic obstruction of the upper air passages can be 
removed by means of the cautery, save large exostoses. 
Every operative method has limitations and objectionable features ; so with the 
galvano-cautery. While thin, shelf-like exostoses of the septum can readily be cut 
through and destroyed by a spatula burner kept at a high temperature, of course the 
larger ones cannot, and require the use of a drill or saw. 
Large enchondromas I find can in most cases be readily destroyed either by cutting 
them off with a knife-like burner, or causing their absorption by puncturing them with 
a pointed burner. On several occasions, however, I found such punctures only stimu- 
lated the larger growths, and even caused the peculiar cystic or fatty degeneration to 
which they are liable, and a general increase of the tumor. Naturally, large hyper- 
trophied pharyngeal tonsils can best be removed by cutting forceps, such as Loewen- 
berg's; and although in one case I operated by way of the mouth upon the enlarged 
pharyngeal tonsil of a child of twelve years successfully with my "S" burner, I 
believe the operation par excellence for this form of hypertrophy in children is to 
scrape it out with the finger nail. In adults this tonsil, when sessile, can best be 
removed by the cautery. 
In what way is the beneficial effect of the cautery accomplished ? It was at one 
time the practice of certain operators to produce only a very superficial slough, and 
lately it has been claimed that " the object tobe accomplished by the use of the cautery 
is not the destruction of tissue. . . . A caustic applied on the superficial layer of the 
mucous membrane reduces the amount of blood supply to the part, arrests hyperæmia, 
diminishes nutrition, and in this way restores healthy action." [F. H. Bosworth, 
Ibid.~\ While this may be sound reasoning, as regards the proper local therapeutics 
of simple chronic rhinitis, it needs qualifying as regards chronic hypertrophic rhinitis in 
which the nares have become the seat of permanently hypertrophied mucous tissue. 
Thus Schaeffer (" Chirurgische Erfahrungen in der Rhinologie und Laryngologie," pages 
16 and 17), in describing the treatment of chronic hyperplastic rhinitis, says, " I have 
used chromic acid in mild cases always with the object of removing chronic hyperplastic 
rhinitis. . . . In describing my operative method (by galvano-cautery) I may state at 
the outset that I, as well as Bresgen, from the first aimed at making a furrow ; I antici- 
pating that the resulting cicatrix should become bound down to the concha by the SECTION XIII-LARYNGOLOGY. 
63 
inflammation produced and bring about free ventilation of the nose. . . . Hack 
laid the most weight on his so-called puncturing method {Stichel Methode), but later 
adopted the same view as the rest of us, that above all things a radical destruction of 
the hyperplasias is necessary to accomplish a permanent result." 
The plan introduced by Dr. Schweig, of making one puncture in anterior hyper- 
trophies {Medical Record, Vol. 29, p. 206) with a galvano-cautery point, thus permanently 
collapsing them while preserving the overlying mucous membrane with its glands, is 
the only modification of the above quoted views that I believe advisable in the treat- 
ment of turbinated hypertrophies, so called, although it is only useful where there is 
merely erection of the turbinated body, and not in true hypertrophy. 
I described in detail the burners I now show you in the Medical Record of Aug. 28th, 
1886, so I will now only briefly refer to their forms and uses. All the burners are com- 
plete in themselves, being only attached directly to conducting cords from Dr. Carl 
Seiler's cautery battery, and the circuit is closed with the foot, thus raising the cups. 
The heavy handle, so long in vogue, is therefore not used, and delicacy of touch and 
case and correctness of manipulation are secured. 
The most generally useful are the "scy/Äe" and "lateral" burners (No. 4, A and 
B, and No. 3, A and B), which have the same length and are bent at the same angle as 
the long spatula burner (No. 1, A). The scythe burner is most useful for the destruction 
of posterior hypertrophies of the middle and inferior turbinated bones. I have also 
used them to destroy the wing-like hypertrophies so often seen on each side of the 
posterior extremity of the vomer. The lateral burners are used mainly for the destruc- 
tion of the hypertrophied or erected tissue along the length of the middle and inferior 
turbinated bones, the lateral position of the platinum wire permitting it to be passed 
along a very narrow nostril and rendering a protecting plate unnecessary. The long 
and short spatula burners I employ mainly to cut off shelf-like enchondroses and exos- 
toses of the septum, using them as knives. Although simply sinking them deeply here 
and there in these tumors is suflicient often to bring about their speedy absorption, I 
tried in one case of enchondrosis Dr. Jarvis's plan of freezing the enchondroma with 
a rhigolene spray, and used a sharp spatula with which to shave off the growth, but 
the resulting bleeding, though not very profuse, was not easily checked, and I have 
since preferred the burner. 
For exostoses too bulky to be burned off I have employed Dr. Bosworth's saws. 
The pointed burner, No. 6, I have reserved entirely for cases of persistent erection of the 
anterior portions of the inferior turbinated body, puncturing them and freely removing 
the glowing point about beneath the mucous membrane. It is useless in true anterior 
hypertrophy. 
The post-nasal scythe burners (No. 5, A and No. 5, B), designed by Schalle for the 
destruction of adenoid vegetations and the pharyngeal tonsil in the post-nasal space in 
children, I rarely use, believing the finger nail to be the best instrument for the pur- 
pose. 
For sessile hypertrophies of the pharyngeal tonsil in adults, I use the " S" burner 
(No. 2, B), with which, by bending it appropriately, I can reach all parts of the pharyn- 
geal roof. 
In operating I use a 20 per cent, solution of cocaine, by means of a cotton carrier, or 
by spray, and pain is rarely complained of. By properly controlling the burner, keep- 
ing it always aglow and always moving, hemorrhage, save a little oozing, is rare. 
I have kept a sufficiently exact record from which to draw conclusions in the last 
forty cases of nasal and post-nasal obstructions treated by me in private practice with 
my burners, and will present a brief analysis of them. 
While the number of cases is comparatively limited, my record of them is so com- 
plete in all the details of history, objective symptoms, operations and results, that I feel 64 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
DK. F. B. EATON'S NASO-PHARYNGEAL CAUTERY ELECTRODES. 
1, A. Long Spatula Burner, for hypertrophy of turbinated bones. 
1, B. Short Spatula Burner, for anterior hypertrophy of turbinated bones. 
2, A. Lateral "S" Burner, for growths on'post-nasal walls. 
2, B. " S " Burner, for growths on post-nasal roof. 
3, A. Lateral Burner, for right nostril, for hypertrophy of turbinated bones. 
3, B. The same, for left nostril. 
4, A. Scythe Burner, for right nostril, for posterior hypertrophies of turbinated bones. 
4, B. The same, for left nostril. 
5, A. Post-nasal Scythe Burner, for growths, in post-nasal space. 
5, B. The same, of smaller size for children. 
6, Pointed Burner, for puncturing anterior hypertrophies. SECTION XIII-LARYNGOLOGY. 
65 
justified in offering this analysis as a contribution to our knowledge of the value of 
the cautery in rhinology. The cases are not selected, being the last forty consecutive 
cases recorded in my case-book up to July 1st, 1887. 
Number of cases, 40. Male, 30. Female, 10. 
Subjective Symptoms.-Loss of night rest from obstructed breathing, 2. Snoring, 7. 
Habitual mouth breathing, 10. Deafness, 20. Tinnitus aurium, 18. Asthma, 2. 
Headache, 3. Dropping of mucus from above palate, 17. Pharyngitis, 6. Epiphora, 
2. Epistaxis, 3 cases. Obstructed nasal respiration (often not complained of, although 
existing), 23. Anosmia, 1. 
Objective Symptoms.-Polypi, 4; 3 E, 1 L. Hypertrophy of middle turbinated 
body, 12; 11 E, 9 L. Persistent erection of inferior turbinated body, 13; 13 E, 13 L. 
Hypertrophy of inferior turbinated body, 25; 20 E, 24 L. Posterior inferior hyper- 
trophy, 13; 13 E, 13 L. Enchondrosis of septum, 19; 9 E, 15 L. Simple chronic post- 
nasal catarrh, 6. Chronic hypertrophic post-nasal catarrh, 23. Hypertrophy of pharyn- 
geal tonsil, 6. Deflection of septum (marked), 9; 1 to E, 8 to L. Exostosis of septum, 
5. Pharyngitis, 11. Atrophic nasal catarrh, 1. Changes in membrana tympani 
(marked), 27. 
Operations.-Middle turbinated bodies, 9 operations on 4 patients; E 5, L 4. Pos- 
terior inferior hypertrophies, 21 operations on 13 patients; 10 E, 11 L. Anterior and 
middle portions of inferior turbinated bodies, 51 operations on 32 patients; 25 E, 26 L. 
Posterior middle hypertrophies, 7 operations on 4 patients; 3 E, 4 L. Hypertrophies 
of posterior extremity of vomer, 5 operations on 4 patients; 3 E, 2 L. 
Enchondroses, 32 operations on 22 patients; 9 E, 23 L. Exostoses .of small vomer, 
9 operations on 4 patients, all on left side. Pharyngeal tonsil, 13 operations on 4 
patients. Polypi, 3 operations on two patients; 2 E, 2 L. Punctured anterior inferior 
hypertrophies about six times on 5 patients. 
RESULTS. 
(1) Cured (excluding aural symptoms) 2 5 per cent. 
(2) Relatively cured, i. e., of all subjective symptoms (ex- 
cluding ear.) 15 = 37.5 per cent. 
(3) Subjective and objective symptoms greatly improved 
(including ear.)*' 30 75 percent. 
(4) Subjective and objective symptoms slightly improved 
(including ear) 6 15 " 
(5) Lost sight of 2 5 " 
40 100 per cent. 
As regards the very small number of cures recorded, I may state that I consider no 
case cured unless all the subjective and objective symptoms are removed, a result 
which, as is well known, is almost impossible in chronic nasal and post-nasal catarrh. 
The principal subjective symptoms entirely relieved and recorded above as relatively 
cured (37.5 per cent.) were obstructed nasal respiration, and excessive discharge. 
REMARKS. 
It is not within the scope of this paper to present the complete record of my cases. 
I may, however, mention a few points of treatment, which, as far as I know, have not 
yet been referred to as regards the cautery. 
Of late, in several cases, I have with my spatula burners at a white heat cut through 
medium-sized shelf-like exostoses of the septum of considerable length. In one case, 
where the left naris was so occluded that the patient could barely, with considerable 
effort, force air through it, I found the septum moderately deflected to the left, and a 
Vol. IV-5 
® (3) necessarily includes (2). 66 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
large shelf-like tumor extending half way back and touching the opposite inferior tur- 
binated body. With my spatula burners I cut off, at one sitting, the whole growth 
close to the septum, and found, on examining the piece, that instead of being cartila- 
ginous, it was mainly composed of bone covered with cartilage. For large exostoses, I 
use Dr. Bosworth's saws, which I find accomplish the end very successfully. In a few 
cases of polypus, too, where I have found it difficult or impossible to apply the snare, I 
have succeeded easily in removing them with the scythe burner, by passing this behind 
the pedicle and cutting it off. 
As to topical applications, I nearly always follow up the removal of obstructing 
hyperplasias with Dr. Leffert's solution in the form of a spray, and sometimes, in marked 
general hypertrophic thickening of the mucous membrane of the post-nasal space, I 
apply silver nitrate, two drachms to the ounce, to the entire surface. 
I have had no experience with the galvano-cautery snare, nor have I any intention 
of employing it since reading the following passage in Hack's famous brochure concern- 
ing his experiences with it for the removal of turbinated hypertrophies: . In 
spite of all foresight, I uniformly met with profuse hemorrhage from the opened caver- 
nous spaces, which could with difficulty be checked even by exact tamponading, an 
accident which entails quite a loss of time." (Dr. Wilhelm Hack, "Ueber eine operative 
Had ical-Behandlung bestimmter Formen von Migräne, Asthma, Heufieber, etc.," 1884.) 
In conclusion, I submit the following propositions :- 
1. The galvano-cautery in its improved forms is the most generally useful and 
available means now at the disposal of the majority of practitioners for the surgical 
treatment of diseases of the upper-air passages. 
2. For the treatment of turbinated hypertrophies the cautery possesses the advan- 
tage over the cold snare of causing little or no pain, of being more easily and quickly 
applied, and of being less intimidating to the patient. In the same class of cases the 
cautery has the advantage over chromic acid of being safer, more easily controlled, more 
effective and of being adapted to a greater variety of conditions. 
3. While small exostoses and medium-sized enchondroses of the septum may be 
removed by the cautery, the larger growths are not suitable for such treatment. 
4. For the removal of the large and projecting pharyngeal tonsil in adults, other 
means are to be preferred to the cautery, and the latter is relatively less suitable for the 
removal of such growths occurring in children. For the sessile growths in adults the 
cautery is to be preferred. 
5. The above described burners in general possess great advantage in dispensing with 
the use of the heavy handle, thus insuring delicacy and exact manipulation; and in 
particular, their varied forms permit every part of the anterior and posterior nares to be 
reached. 
6. Topical applications should, in the majority of cases, supplement or follow the 
treatment of nasal diseases by the cautery. 
DISCUSSION. 
Dr. B ermann, of Washington, D. C., agrees with the writer on the use of the 
galvano-cautery, but wishes to state that the application of chromic acid has proven 
in a number of cases very useful. The following method he has seen used very 
successfully, first by Dr. Moritz Schmidt, of Frankfort-on-the-Main, by which an 
excessive application of the acid is prevented. A small number of crystals of chromic 
acid are spread on a thin layer of cotton, about one by two inches, and then this cotton 
is carefully and firmly wrapped around a thin silver probe. By pressing this probe 
firmly against the place to be cauterized we get the full effect of the acid. Has seen 
it applied himself in this way after drawing a line with the galvano-cautery knife SECTION XIII-LARYNGOLOGY. 
67 
through the hypertrophied membrane of the lower turbinated bone, and then used 
the probe containing the acid on the same place. It is always to be neutralized with 
bicarbonate of soda in solution. 
Dr. Richard II. Thomas, of Baltimore, said he could strongly endorse what 
Dr. Eaton had said in regard to the general applicability of the galvano-cautery to 
hypertrophies, etc. In regard to new growths and large posterior hypertrophies he 
preferred the cold snare. He doubted the advisability of dispensing with the use of 
the handle and regulating the current with the foot. He had found that the motion 
of the foot in depressing the lever in order to raise the fluid caused sufficient unsteadi- 
ness of the operating hand to interfere with the absolute accuracy of the operation. 
He also deprecated the indiscriminate use of such strong solutions of cocaine as twenty 
per cent. He had seen solutions of much less strength, applied to the intra-nasal 
passages, produce very unpleasant, and in one case alarming, symptoms. A five per 
cent, solution is often sufficient to produce the necessary anaesthesia. 
Dr. Ephraim Cutter, of New York, said-I am called up by the President's 
kind reference to me. I wish to say that I have a battery which I have used, 
a galvano-cautery battery, for ten years at least. It cost about ten dollars. It is 
made of carbon and zinc plates, each one inch by ten inches; carbons, half inch thick; 
zincs, one-eighth inch thick, connected by couplings of my invention. They go into 
a single cell made of paraffine, black walnut covered with sheet lead on the outside. 
This requires the ordinary bichromate of sodium-acid solution ; one pint of this 
solution is enough to run the battery fifteen minutes for galvano-caustic use. A 
new solution is to be used each time, to be sure of results. I tested this battery 
lately, when the zincs were almost worn out by use, yet it registered the same as my 
largest battery of thirteen square feet of surface. I think the Main Storage battery 
is the coming storage battery, though it weighs about as much as the Mailer battery 
I have referred to. 
In the absence of Professor F. Massei, of Naples, Italy, his paper was read, by 
request of the President, by Dr. Max Toeplitz, of New York. 
ON PRIMARY ERYSIPELAS OF THE LARYNX. 
SUR L'ÉRYSIPÈLE PRIMAIRE DU LARYNX. 
ÜBER DAS PRIMÄRE ERYSIPEL DES LARYNX. 
A CLINICAL NOTE BY F. MASSET, 
Erysipelas of the larynx is a morbid process of which we find notice in several 
authors, and even the primary one has been admitted, although considered as very rare. 
Old and modern writers have hinted at its possibility, among whom me may refer 
to the names of Boyle (1816), Porter and Ryland (1837), Sestier (1852), Lendel (1859). 
But it appears that Semeleder and Turk were the first who observed erysipelas of the 
larynx on living subjects. 
Naples, Italy. 68 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
This notwithstanding, we can confirm that in the present laryngoscopical period it 
has been less noted than in the pre-laryngoscopic time ; and if we find in Ziemssen and 
Mackenzie's books more exact details, it is not without wonder that we find in Ryland 
(1837) a very exact description. Among the moderns, I quote the names of Cuire 
(1864), Radcliffe (1865), Campenon (1872), Bryson, Delavan, Semon (1885), Charazac. 
Strdmpel, etc., who relate cases of the kind, and all admit an erysipelas of the larynx. 
If we make, however, a minute analysis of all the reported cases, we find either a 
simple affirmation, or the confirmation of the erysipelas of the larynx in a post-mortem, 
examination. 
The clinical and laryngoscopical characters for recognizing, on living subjects, the 
primary erysipelas of the larynx, are not described in any of these pamphlets or books, 
and in those who are acquainted with the laryngoscope the opinion prevails that it is 
an excessively rare disease. He who has the more insisted is Ryland,* but from the 
seven quoted observations, it is to be deduced :- 
1. That for the greater part the erysipelas was secondary to a similar affection on the 
surface of the body (Cases I, II and in) and appeared in patients affected with violent 
lesions. 
2. That it developed in hospitals and in patients who lived near other patients 
affected by erysipelas on the surface of the body, or in hospitals where erysipelas was 
dominant (Case iv). The erysipelas was seen, not only in the larynx, but also, in the 
meantime, over the tonsils and pharynx. 
3. That once (Case Vll) the erysipelas began from the tonsils and appeared after- 
ward on the skin. 
4. In a case (vi) in which recovery took place, and in which there was erysipelas of 
the skin, it was highly questionable if it had been present as a laryngeal erysipelas. 
In the year 1885 I called attention of the profession to an affection of the larynx, 
which has all the clinical features of erysipelas ; which appears primarily, i.e., without 
appearance of erysipelas of the face, of the throat, or of the body, in private houses, 
and which is not rare to be seen. 
A diligent study of the relative symptoms has convinced me that many of those mor- 
bid forms I described as phlegmonous laryngitis (primary oedema of the larynx) were to 
be considered, vice versa, as erysipelas of the larynx, and that in a general manner we 
can admit two forms ; the one in which the local symptoms and fever prevail, the 
other in which collapse is prevalent. The process can also, in a later period, extend to 
the lungs or reach the fauces without the least appearance of erysipelas on the outer 
surface of the body. 
I have not described in this way a new disease, but I have well considered some 
symptoms, diligently followed with the thermometer and the laryngoscope the course 
of the disease, and so I have recorded many observations of the primary erysipelas of 
the larynx, subtracting them from the chapter of phlegmonous laryngitis, in which they 
were placed by mistake. 
At present they are only clinical arguments which support my views ; in order to 
prove that I am right, it would have been necessary to establish the bacteriological 
experiments ; to recognize the streptococcus of Fehlisen, to cultivate and inoculate it ; 
but I must freely declare that, on a living person, in which the symptoms of a narrow- 
ing of the larynx are present, it is not easy to obtain the products in which these 
inquiries are to be made. Besides this, I have, happily, to record many recoveries ; 
and autopsy was never permitted me, in the cases which ended fatally, as they belonged 
to private families. Nobody has had better opportunities than I ; and I have not seen 
any recorded observations on this subject by cotemporaneous investigators. 
* Larynx and Trachea, 18.37, Chapter vu. SECTION XIII-LARYNGOLOGY. 
69 
But it is also well known that the erysipelatous nature of many other diseases has not 
been discussed, although based upon evident clinical features. I do not see why we 
should be so skeptical as to the primary erysipelas of the larynx. 
The considerations I have urged on this important subject seem to me to have been 
appreciated by only a few. It has been brought to my notice by competent observers 
that epidemic forms of a laryngeal disease have ended fatally with symptoms of an 
acute narrowing which could be referred to erysipelas. Other writers believe that I 
have denied the existence of a phlegmonous laryngitis, and ascribed to me a fault which 
I have not committed. The phlegmonous laryngitis remains the same, as do also 
the acute epiglottitis, in consequence of burnings, the primary oedema of the larynx 
for nephritis, the laryngitis angioneurotica of Strübling, etc. 
The primary erysipelas of the larynx has a well characterized feature, and, in order 
to eliminate every doubt, I decided to present you, dear fellows, the argument, and in 
the following short propositions all that clinical observation teaches us:- 
1. The initial symptoms are of two orders : local and general. The first compre- 
hends a difficulty in swallowing, in consequence of severe pain, with changed resonance 
of the voice, like that which happens in a common angina ; the second are those 
referred to the fever. 
2. The inspection of the fauces gives a negative result ; all that is met with is con- 
gestion of the posterior wall of the pharynx ; on the contrary, either with the laryngeal 
mirror, or by strongly depressing the tongue, the epiglottis appears intensely swollen. 
3. Temperature is very high-about 40°, more or less. 
4. The local symptoms rapidly increase. Dysphagia goes as far as complete aphagia, 
and soon is connected with difficulty of breathing by narrowing of the larynx. 
A diligent inspection with the laryngoscope shows a contraction which, from the 
back of the tongue, reaches the epiglottis, the ary-epiglottic bands, the arytenoid carti- 
lages. If the contraction is a moderate one, and bound to the orifice of the vestibule, 
the narrowing is supportable with life ; but, on the contrary, if it is considerable, the 
patient is menaced with suffocation or, in fact, dies suffocated. 
This severe danger is often lessened by the fact of a great interest for the diagnosis, 
i. e., the contraction migrates; the parts which were first attacked quickly sink, and 
those which were healthy become tumefied with equal rapidity. 
When it is possible to see the internal cavity it can be easily observed that the 
swelling is preceded by an intensive congestion (very marked, for instance, in the 
inter-arytenoid space). Again, with the tumefaction is associated the eruption of 
blisters full of serum, which burst, and then the exudation, mixed with blood, forms a 
■crust on the surface. It is also possible that the morbid process constitutes a purulent 
infiltration, or a true abscess. 
5. Fever is relapsing, of anomalous type. A high temperature is soon followed by 
defervescence. From 40°, the temperature goes down to 38°, but this notwithstand- 
ing, the local symptoms do not improve. In a short time, however, without any regular 
period, temperature again increases. In this instance, surely the local lesion is in- 
creased, or extended in the neighborhood, or below, to the lungs. 
6. The lymphatic system (groups of pre-tracheo-laryngeal glands and pre-laryngeal 
ganglia) is something distinctly felt with the palpation, which causes pain. 
7. After several such oscillations, the disease tends to three different character- 
istic issues : first, recovery, in consequence of a gradual resolution ; second, death by 
suffocation, if tracheotomy is not performed in time ; third, death by collapse, with 
or without signs of pulmonitis, which can be considered, with reason, of the same 
nature. 
8. Primary erysipelas of the larynx can assume an epidemic character. It is most 70 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
probable that many cases of severe sore throat ending fatally with suffocation could 
have been recorded in this chapter. The appearance of erysipelas in the face, in the 
throat or elsewhere, at the same time with the laryngitis, or after, renders the diagnosis 
easier. 
9. We can admit two forms of the disease : the one in which the danger is repre- 
sented by the laryngeal affection itself ; the second, in which is present collapse, or 
extension to the lungs takes place. In old people, the last, and death in consequence, 
is the most common issue of the disease. 
10. In the first form we can do much ; it is only necessary to recognize in time 
the affection. In such a case, ice, internally and externally, is a portentous remedy ; 
surely preferable to the application of leeches. Ice can be supplied with the adminis- 
tration of calomel, quinine and stimulants. Spray with sublimate solution (1 to 2000) 
is a good remedy. It may be necessary, if the dysphagia is severe, to feed the patient 
with Dujardin-Beaumetz' apparatus. 
11. If, in spite of all this, the narrowing increases, scarification may be approved, 
and after tracheotomy ; but, as the migration is a common phase, it is not advisable 
to try it in an earlier stage. The patient, for this reason, ought to be overlooked 
with rigor. 
12. In the adynamic form, every effort is useless. The disease very quickly ends 
fatally, or before the remedy has time to act, or in spite of its good effects, as for the 
local symptoms. 
DISCUSSION. 
Prof. Stockton, of Chicago, remarked-It has been my good fortune to meet 
with one of these cases. The patient was a strong, healthy man, who caught a severe 
cold, as he supposed, and was nearly suffocated. When I was hastily summoned, 
I found the patient lying back in bed, breathing heavily, the temperature 103j°, pulse 
140. I found that the patient had severe rigors that morning. The pharynx was 
normal, the larynx intensely congested, and there were several blebs on the epiglottis 
and on both arytenoids. The ventricular bands were so swollen that they covered 
both vocal cords, and I saw that something must be done at once. I did not have any 
tracheotomy tube, and went to my office to get one, when I thought of a large 
O'Dywer tube that I had, and resolved to try it, which I did, with great success. 
The disease gradually extended through the whole upper-air tract and over the upper 
part of the face. In two weeks the patient made a perfect recovery. 
Dr. Toeplitz, of New York, advocates the use of pilocarpine (1 per cent.) sub- 
cutaneously applied. He has not seen the effect of this remedy in cases of erysipelas 
of the larynx, but in those of œdema ; he would treat erysipelas of the larynx on 
general principles, and warns against the use of O'Dywer's tubes in such cases as 
dangerous, by the possible production of gangrene through pressure. 
Dr. W. H. Daly stated that the early use of a most extensive mustard plaster 
would by its revulsive action tend to change a laryngeal erysipelas into a superficial 
one, and suddenly rescue a patient from imminent danger of suffocation from œdema 
of the glottis. Many cases of erysipelas of the larynx are really treated not only by 
the specialist, but by the general practitioner, and their erysipelatous nature 
unrecognized. 
Dr. L. N. Benham, of Pittsburgh, Pa., said-I was greatly pleased with the 
subject matter of the paper just read, as with the remarks made thereon by Dr. SECTION XIII-LARYNGOLOGY. 
71 
Stockton. Laryngeal erysipelas, with pharyngeal, for they practically may be con- 
sidered one and the same, is, according to my observation, seldom recognized, and 
not sufficiently appreciated by the profession. It has been my good fortune to see 
eight caseswell marked and confined simply to the pharyngo-laryngeal space; they all 
yielded to general treatment, combined with douches of hot water, and without enter- 
ing into detail of symptoms, I wish to call attention to the suddenness with which 
relief would come to patients without having any discharge of blood, pus or mucus, 
commensurable to the gravity of the symptoms present. 72 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
FOURTH DAY. 
Meeting convened at 3 P. M., the President in the chair. 
Prof. W. E. Casselberry, of Chicago, read a paper entitled- 
NASAL FIBROMATA. 
FIBRÔMES NASALS. 
ÜBER NASENFIBROME. 
BY W. E. CASSELBERRY, M.D., 
Of Chicago, Ill. 
Under this title it is proper to include only neoplasms of a purely fibrous or pre- 
dominating fibrous structure which originate in the nasal fossæ anterior to the naso- 
pharynx. Tumors in this situation are prone to assume a compound type. Multiple 
nasal polypi, for instance, may be found purely myxomatous in the anterior nares, but 
fibro-myxomatous in the median nasal region and as the naso-pharynx is approached. 
The fibro-sarcoma is another combination occurring in varying proportions of fibrous 
or sarcomatous elements. The scope of this paper will not permit of consideration of 
these compound types, notwithstanding their intimate relationship to the fibromata. 
Likewise of fibromata which originate in the neighboring sinuses, and which involve 
the nose only secondarily, must such meagre mention suffice as is essential to the eluci- 
dation of the nasal growths proper. 
Current literature of the last decade has teemed with reports of cases of naso-pharyn- 
geal fibromata, recounting the various operative and preliminary operative procedures 
for their removal, including Langenbeck's resection of the superior maxilla, Fergusson's 
resection of the same, Nélaton's operation, Gussenbauer's subperiosteal resection of the 
hard palate, Rouge's operation and the recent method of Furneaux Jordan.1 Nor have 
rhinologists failed to emphasize the advantages of the intra-nasal or intra-naso-pharyu- 
geal galvano-cautery method. I will urge in nasal cases the use of similar means in 
preference to the other graver, disfiguring and sometimes fatal operations. 
Fibromata originating primarily in the nose anterior to the naso-pharynx are com- 
paratively rare. The Internationales Centralblatt für Laryngologie, Rhinologie und Ver- 
wandte Wissenschaften, a journal of abstracts of all current literature pertaining to these 
subjects, does not contain the report of a single case during the past three years. One 
case of fibro-sarcoma which may have originated as a fibroma is reported therein. In 
the Annales des Maladies de V Oreille, du Larynx, du Nez, et du Pharynx, from 1875 to 
date, is found but one other case which can possibly be included in this category. 
Hopman,2 of Cologne (248 cases), and Schmiegelow, of Copenhagen (17 cases), have, 
together, reported 265 cases of nasal neoplasm, of which there were 121 myxomata, 63 
1 Internationales Centralblatt für Laryngologie, Rhinologie, etc. Jahrgang n, S. 207. 
a Internationales Centralblatt für Laryngologie, Rhinologie, Vol. n, 429, etc. SECTION XIII-LARYNGOLOGY. 
73 
polypoid hypertrophy of the turbinated bodies, 24 papillomata, one lupus and one 
sarcoma, the series containing no cases of fibromata. Yet their occasional occurrence 
has been recognized probably from the time of Hippocrates, who had a large experience 
in connection with nasal polypi. 
In the case of hard polypi, Hippocrates,1 cited by Mackenzie, directed that the 
nostril should be slit open in order that the tumor might be thoroughly extirpated, and 
the roots afterward destroyed by the hot iron." 
Celsus2 treated polypi in various ways, but he strongly disapproved of meddling 
with the harder tumors, which he considered malignant. 
Recent works on the throat and nose treat briefly of the subject. Stoerk 8 mentions 
fibromata as originating from the submucous structures. Cohen4 briefly, but lucidly, 
describes the neoplasm, and mentions its comparative infrequency. Sajous,6 mentions 
the roof as its favorite site in the nose, but remarks that cases have been reported in 
which fibrous polypi sprang from the septum, the inferior turbinated.bones, and even 
the floor of the nose. He further remarks upon the rarity of its primary occurrence. 
Wagner6 writes : "Fibromata may develop in any portion of the nasal cavity, the 
floor of the fossæ, the turbinated bones, or lateral walls," etc., and he reports two cases. 
Robinson7 thinks it so unusual in the nose and so usual in the naso-pharynx that 
,he considers the difference in location a point in diagnosis between fibroma and 
myxoma. 
Morell Mackenzie8 has reported a single case of his own, and two others probably 
fibromata, and remarks, in this connection: "Though fibrous polypus of the naso- 
pharynx is not unfrequently met with, this form of tumor extremely seldom originates 
in the nose itself, the only case, so far as I am aware, in which such a growth has been 
proved to exist being one of my own." " There are, however, two other instances in 
which there is every reason to believe the tumors were fibromatous." 
It seems probable that nasal fibromata are in reality more numerous than the few 
cases recently reported would indicate, and this probability should tend to enhance our 
interest in the subject. 
Growths in the nose and naso-pharynx, in a measure, correspond in type to the struc- 
tural elements of the tissue from which they originate. The nasal mucous membrane 
consists of two layers, a superficial mucous stratum, which is covered by epithelium, 
and a deep fibrous layer, which has the position and functions of periosteum and peri- 
chondrium. In the upper or olfactory tract these two strata are closely adherent, 
while in the lower or respiratory tract they are separated by variable quantities of con- 
nective tissue.9 
The fibrous layer has been shown by Pauas,10 cited by Mackenzie, to be especially 
abundant, and more densely fibrous at the upper and posterior part of the septum and 
in the immediately adjoining space on the base of the skull, and hence the frequency 
of naso-pharyngeal fibromata, while in the anterior nares it is least abundant, the super- 
1"Morbis," lib. n, Lettré's Ed., Paris, 1851, Vol. n, p. 51. Mackenzie, "Diseases of the 
Throat and Nose." Wood's Ed., Vol. n, p. 245. 
2 " De Comp. Pharm. See. Locos.," Lib. m ; Cap. in. Mackenzie, loc. cit. 
3 " Klinik der Krankheiten des Kehlkopfs, der Nase und des Rachens," S. 90. 
4 " Diseases of the Throat and Nasal Passages," 1880, p. 392. 
5" Diseases of the Nose and Throat, 1885," p. 146. 
6 "Diseases of the Nose," 1884, p, 134. 
7 "Nasal Catarrh and Allied Diseases," 1885, p. 256. 
8 " Diseases of the Throat and Nose." American Ed., Vol. n, p. 275. 
8 Mackenzie. Am. Ed., Vol. n, page 238. 
de la Soe. de Chir., 1873. Mackenzie, "Diseases of the Throat and Nose." Wood's 
Ed., Vol. ii, page 386. NINTH INTERNATIONAL MEDICAL CONGRESS. 
74 
ficial mucous layer predominating, and hence the more common occurrence in this 
location of the myxomata. 
Further, between these sites, around the posterior nares, the membrane presents a 
kind of transitional form, and growths in this situation are likely to present a corres- 
ponding fibro-mucous type. 
This observation, in connection with the assertion of Stoerk,1 that polypi arising 
from the mucosa (superficial layer) are of mucous structure, while those arising from 
the sub-mucosa or periosteum are fibrous, affords a reasonable explanation of the com- 
parative infrequency of true nasal fibromata. 
True, the attachments of ordinary myxomata are sometimes traceable to the perios- 
teum or to the bone,2 but it is probable that they have first originated in the superficial 
mucosa and only subsequently penetrated to the deeper structures. 
Nélaton, cited by P. Koch,3 has advanced the opinion that fibrous polyps of the 
nose are never of a primary nature, but that they always proceed from neighboring sin- 
uses, e. g., the antrum of Highmore, etc. Apractical refutation of this theory is fur- 
nished by a case reported by Gerdy,4 in which, on post-mortem examination, a fibroma 
was found to be attached to the posterior part of the vault of the left nasal fossa. 
This tumor was not examined microscopically, but from its macroscopic appearance 
there is every reason to believe that it was a fibroma, and it is so classed by Mackenzie.5 
Fibromata may arise from any part of the nasal cavities. The vault, especially its 
posterior portion, is the favorite site, as here is found in greater abundance the fibrous 
stratum from which they primarily originate, but the turbinated bodies, the cribriform 
plate of the ethmoid bone, the septum and the floor of the nose,6 may furnish points of 
origin. 
More or less extensive secondary adhesions may form in the course of the expansion 
of the growth, as the result of friction and pressure, so that it is sometimes difficult to 
determine the original point of attachment. 
Of the accessory cavities the antrum of Highmore is a favorite site of origin, the 
fibromata of which become very large, and encroach secondarily upon the cavities of the 
nose and orbit, and next in order are the frontal sinuses, tumors from which extend 
into the same cavities. 
The ætiological factors in the development of nasal fibromata are not definitely 
known, but a local irritation from traumatism may serve to excite a hyperplasia of the 
fibrous elements, as in one case of fibroma of the septum, which was directly attribut- 
able to a blow on the nose. In other instances a localized perversion of the chronic 
hypertrophic inflammatory process may act as the exciting cause by stimulating the 
fibrous elements to unusual proliferation. 
Both sexes and all ages seem equally liable. In this respect the disease differs from 
naso-pharyngeal fibroma, of which Lincoln7 collates 38 genuine cases, all of them males 
under twenty-five years of age, Nélaton,8 cited by Mackenzie, knew of no example 
of naso-pharyngeal fibroma becoming developed in a female of any age or in a male 
over thirty-five. 
1 "Die Krankheiten der Nase," 1880, S. 90. 
2 Zuckerkandl, cited by Mackenzie, "Diseases of the Throat and Nose," American Ed., Vol. 
<i, page 362. 
8 P. Koch (Luxemburg) Int. Centralb. f. Laryn. und Rhinol., il, page 256. 
4 " Des Polypes et de leur Traitement," Paris, 1833, page 19. 
6 " Diseases of the Throat and Nose," Wood's Ed., Vol. n, page 264. 
6 Sajous, " Diseases of the Nose and Throat," page 146. 7 Loc. cit. 
8 " Rapport sur le Progrès de la Chirurgie," Paris, 1867, p. 325. Mackenzie, " Diseases of 
the Throat and Nose," Vol. II, p. 497, Am. Ed. SECTION XIII-LARYNGOLOGY. 
75 
Of six cases of pure nasal fibroma collected in this paper, three were females, one of 
thirty-five years, one of thirty-eight years, and one of fifty years of age. 
The rapidity of growth, as indicated by the duration of the symptoms up to the 
time of operation, averages about two years. 
The early symptoms are those of a catarrhal nature, followed by obstruction and dis- 
tention of the fossa. Its development continues, to the detriment of bones and cartil- 
ages that may be in the way. These are absorbed, enveloped and rent asunder, the 
neoplasm penetrating into fissures, accessory sinuses, and neighboring cavities. 
The bridge of the nose becomes flattened, the eyes bulged forward and the cheek 
swollen, the whole constituting the hideous deformity known as ' ' frog-face. ' ' Fre- 
quent and dangerous attacks of epistaxis may proceed from surface ulceration. Exten- 
sion upward may open the cranial cavity. 
A probable diagnosis is not difficult. Its appearance in situ differs much from that 
of the mucous polyp. It is not multiple, but may be lobulated. The base is broad, 
the color is dark red, there is no translucency, and it is firm and resistant to pressure 
by a probe. It is more difficult to distinguish it thus from fibro-sarcoma and sarcoma. 
The microscope is the only means of positive diagnosis. 
Fibrous tumors in this situation present the ordinary pathological characters of fibro- 
mata in general. In consistence they vary, being sometimes very firm and dense, and 
at other times softer and more succulent. The fibres which constitute the chief part 
of the growth are grouped in bundles of various sizes, or are simply closely interlaced 
and devoid of definite arrangement. A very few minute cells, either round or spindle- 
shaped, may be present among the fibres, or in larger numbers around the blood ves- 
sels. The vessels are not usually numerous, but it is probable that the tumors or por- 
tions of them may partake at times of the erectile structure of the turbinated bodies. 
A smooth, fibrous capsule usually envelops the whole. 
Concerning the prognosis, nasal fibroma tends to degenerate into sarcoma when it is 
incompletely removed, or even without any interference. There is a tendency to recur- 
rence after removal, although, if thoroughly extirpated and the base cauterized to the 
bone, the prognosis should be good. 
I have tabulated and appended the records of eight cases, including one of my own, 
which is published for the first time, and which I will relate in detail. 
Case.-Mrs. R., native of Canada, aged about thirty-eight years, first had a nasal 
polypus, described as an ordinary myxoma, removed from the left nasal fossa, about ten 
years ago. She remained well for five years, and then again noticed gradually increas- 
ing obstruction, and later a dark, reddish mass presenting itself at the left anterior nasal 
aperture. 
Four years ago she submitted to operation under chloroform. The operation was a 
failure, only a few small pieces being removed by means of forceps and without the aid 
of artificial illumination. Severe hemorrhage was occasioned at the time and continued 
intermittingly for weeks. No relief was afforded. 
She declined further interference until February, 1886, at which time she came under 
the observation of Dr. W. F. Coleman and Dr. A. P. Gilmore, of Chicago, through 
whose kindness I have a portion of the record. The left nostril was much distended, 
showing evidence of commencing frog-face, and the fossa anteriorly was thoroughly 
filled in all directions by a firm, elastic tumor which projected slightly from the anterior 
aperture. There was no undue prominence over the antrum of Highmore, nor encroach- 
ment upon the orbit. 
These gentlemen operated skillfully by means of the galvano-cautery. Efforts to 
include the neoplasm in a snare failed, on account of its large size, tight fit and 
numerous adhesions, so its lower portion was slit up by the knife electrode, some 
adhesions separated in like manner and a large section, perhaps one-half of the 76 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
tumor, extracted by means of forceps. The operation was necessarily prolonged, 
painful and bloody. 
Through the courtesy of Dr. Coleman, the case was now referred to me. 
Status Præsens.-Examination, about ten days subsequent to the operation just 
described, March 4th, 1886. The left half of the external nose is decidedly more promi- 
nent than the right. The left nasal fossa above the line of the inferior turbinated body 
is completely filled by a firm, elastic, irregularly-lobulated neoplasm. No middle tur- 
binated body is discernible, its position being occupied by tumor. The inferior meatus 
is free, corresponding to the portion of the growth already removed. 
The anterior two-thirds of the septum narium has been pressed far over to the right, 
narrowing the right fossa and enormously increasing the capacity of the left chamber. 
Rhinoscopic inspection posteriorly shows the naso-pharynx to be approximately 
normal. Only a faint outline of the tumor, located well forward, can be seen through 
the left choana. The posterior portion of the septum is in the median line. 
First Operation, March 10th, 1886.-The affected nostril was first thoroughly cleansed 
by cotton swabbing and by means of a condensed air spray of Dobell's solution. The 
parts were illuminated by the ordinary method of reflected gas rays projected through 
the anterior aperture, which was widely dilated by a bivalve speculum. Complete local 
anæsthesia of the entire nostril was induced by hydrochlorate of cocaine, applied in 
the form of a spray of a five per cent, solution, repeated three or four times at intervals 
of three minutes, followed by a ten per cent, solution on cotton, introduced and allowed 
to remain in contact with the fibroma for three minutes. 
I employed Flemming's galvano-cautery écraseur, as devised by Seiler and which I 
exhibit, which consists of a universal handle into which is inserted a pair of parallel 
tubes threaded with wire. The ends of the wire pass through eyelets, one on each side 
of the wheel, in the axle bar of the windlass, which is inserted into a slot in the handle, 
so located that while holding the handle the loop can be wound in on the windlass by 
means of the thumb. 
I substituted steel or tempered iron wire (piano wire) for the platinum usually 
employed. Platinum is devoid of resiliency, a property which enables the écraseur 
loop of steel wire to retain or regain its contour after contact, when one of platinum 
would remain permanently indented. The steel loop offers some resistance to tissue 
against which it is pressed, thus facilitating envelopment of the part. The steel wire 
is sufficiently tenacious and takes the glow from the battery as well as platinum, but a 
fresh piece must be used at each application. Before threading the parallel tubes it is 
well to withdraw the temper from the ends of the wire by heating them to redness, as 
the portion thus rendered ductile will wind more easily around the windlass. 
I would catch in the écraseur the most easily enveloped lobule or corner of the 
growth, then connect the battery by running down the treadle with my foot and at the 
same time wind in the loop, thus severing without pain and with little or no hemor- 
rhage a cubic centimetre or more of the growth. By a repetition of the process, three 
or four such pieces would be removed in a sitting. 
Occasionally it became necessary to make a preliminary incision into the substance 
of the tumor with the knife electrode, in order to prepare a place for the wire, or, by 
the same means, to detach an adhesion, that the écraseur might take hold. 
The operations were repeated weekly, the patient using a cleansing spray in the 
interval. They might have been performed more frequently, every day or every alter- 
nate day, for a time, thus shortening the duration of the treatment, but the slower 
method sufficed, and, for good reasons, was preferable in this case. During the course 
of some weeks the growth was thus followed up to its primary attachments, which 
extended along the horizontal plate of the ethmoid bone backward to the anterior 
surface of the body of the sphenoid. SECTION XIII-LARYNGOLOGY. 
77 
I regard the posterior portion of the vault-i. e., vault of nose, not of pharynx, 
including the anterior perpendicular surface of the sphenoid hone-as the point of 
origin of the tumor, the base of which extended thence anteriorly along the cribriform 
plate of the ethmoid bone, becoming adherent, at the same time, to portions of the 
superior turbinated body and the walls of the ethmoid cells. 
The absence of the middle turbinated body, which had been reduced to a rudiment 
by absorption from pressure, permitted a more brilliant illumination of the parts above, 
and not only facilitated operation, but enabled me, with certainty, to follow the tumor 
to its base. After the removal of all portions which could be included in the snare, I 
cauterized the base by means either of the galvano-cautery point, knife or moxa elec- 
trode, causing the instrument to penetrate each time to the bone. This, also, I did 
a small part at a time, fearing to produce much inflammatory action, on account of 
the immediate proximity to the cerebral meninges through the cribriform plate of 
the ethmoid bone. I cauterized everything which had any appearance of fibroma, 
preferring to touch that which was not fibroma rather than to leave untouched that 
which was. 
At the end of six months the tumor seemed thoroughly eradicated. The fossa 
above the inferior turbinated body was unoccupied by anything but rudiments of the 
middle and superior turbinated bodies, the view of the vault in all directions being 
uninterrupted. She still remained under observation. 
At the end of nine months a recurrent tumor, the size of a small bean, was discov- 
ered attached to the lateral wall just above the anterior end of the inferior turbinated 
body. I think a point of secondary attachment here had escaped cauterization and 
re-developed, for, on account of the recession of the lateral wall, it was at a point diffi- 
cult of illumination and access, being just within the anterior aperture, but around the 
corner as it were. This tumor was removed by the same means. 
At the end of seventeen months there is no appearance of any further recurrence, 
although, in view of the known tendency to relapse in such cases, she cannot even yet 
be considered wholly free from liability to re-development. 
I am indebted to Dr. Elbert Wing, Demonstrater of Pathology in the Chicago Medical 
College and Pathologist to Cook County Hospital, for the microscopic examination which 
demonstrated the tumor to be a typical fibroma. This result was also confirmed by my 
own examination. The pieces removed, in the aggregate, would about equal in size a 
small hen's egg. 
Treatment in General.-Of the seven other cases appended, in No. 1 attempts at 
removal by ligature and forceps failed, and were followed by an attempt to cut through 
the base of the polypus with a bistoury, which resulted in death from hemorrhage. The 
treatment in Case No. 2, is not stated. In Case No. 3 the tumor projected posteriorly 
and was removed by forceps introduced through the naso-pharynx. In three cases, Nos. 
4, 5 and 7, external operations were performed to give access to the tumor ; in No. 4, a 
crucial incision was made over the left side of the nose and the nasal bones lifted out ; 
in No. 5, the nasal columns and septum were divided and the nose turned up ; in No. 
7 ( fibro-sarcoma), a median incision was made through the bridge of the nose. All of these 
operations must have been disfiguring and somewhat dangerous. In Case No. 6 (possibly 
fibro-myxoma) the tumor was successfully removed piecemeal, in fifteen sittings, by a 
cold-wire snare. The advantages of the intra-nasal galvano-cautery method, as detailed 
in my own case, are sufficiently obvious. 
General anæsthesia is unnecessary, and the consequent shock and dread of operation 
are avoided. There is no external disfigurement, no dangerous hemorrhage, and, under 
cocaine, no pain. My patient would sit in the operating chair and have piece after 
piece removed without manifesting even discomfort. No. 
Date. 
Operator. 
Reference. 
Sex. 
Age. 
Previous 
Duration 
of 
Symptoms. 
Situation and Extent. 
Point of Attach- 
ment. 
Pathological 
Nature. 
Treatment. 
Result. 
Subsequent 
History. 
1 
1833 
Gerdy, " Des Poly- 
pes et de leur Traite 
ment," Paris, 1883, 
page 19. Mackenzie, 
" Diseases of Throat 
and Nose," Am. Ed., 
II, 375. 
Male. 
13 
18 mos. 
Left nostril. 
Posterior part of 
vault of left nasal 
fossa ; demonstrated 
by an autopsy. 
Fibroma. Substance 
firm and elastic ; on sec- 
tion seen tobe of purely 
fibrous structure. No mi- 
croscopic examination. 
Failure of attempts at 
removal by ligature and 
evulsion, followed by an 
attempt to cut through 
the base of the polypus 
with a bistoury, result- 
ing in death from hem- 
orrhage. 
Death from hemor- 
rhage. 
2 
1872 
Lichtenberg, Lan- 
cet, 1872, Vol. n,page 
773. Mackenzie, 
"Diseases of Throat 
and Nose," Am. Ed., 
Vol. ii, page 375. 
Not 
stated. 
Not 
stated. 
Not 
stated. 
Not stated. 
Superior turbinated 
body and cribriform 
plate of ethmoid bone. 
Fibroma. No micro- 
scopic examination. 
Not stated. 
Not stated. 
3 
1877 
Mackenzie, "Dis- 
eases of Throat and 
Nose," II, 376, Am. 
Ed. 
Female. 
35 
2 years. 
Pedunculated, solid tu- 
mor, size of pigeon's egg, 
obstructing and project- 
ing through the left choa- 
na into the naso-pharynx. 
Roof of nasal fossa 
well within the nasal 
cavity. 
Fibroma. On section, 
hard, dense and pale : 
microscopically, closely 
interlaced whitishfibres, 
with a few minute cells. 
Evulsion with forceps 
through naso-pharynx. 
Recovery. No subse- 
quent history given. 
4 
1879 
Kempf, Louisville 
Medical News, Vol. II, 
page G5. Wagner, 
"Diseases of Nose," 
1884, page 207. 
Female. 
50 
1 year or 
more. 
Left nostril entirely 
blocked up; frog face ap- 
pearance; left eye bulged 
forward. After removal, 
size of goose egg, contain- 
ing in its centre bones of 
nasal septum. 
Not stated. 
Fibroma. 
Unsuccessful attempts 
at removal by forceps; 
hemorrhage severe. Fi- 
nally, chloroform, post- 
nares plugged, crucial 
incision over left side of 
the bridge of the nose, 
and bones lifted and tu- 
mor pulled out by fin- 
ger. 
Recovery. No re- 
currence six months 
later. 
5 
1882 
George Buchanan, 
Glasgow Medical Jour- 
nal, xvil, 211. Wag- 
ner, "Diseases of 
Nose," 1884, page 216. 
Male. 
21 
2 mos. 
• 
A firm, reddish, elastic 
tumor, growing from the 
cartilaginous septum on 
each side,projectingdown- 
ward, so as to appear out- 
side the alæ nasi. After 
removal, size two inches 
long and one inch broad. 
Septum nasi. 
Fibroma. Microscopi- 
cally, well-defined fib- 
rous tissue Here and 
there clumps of round 
cells close to blood ves- 
sels, probably inflamma- 
tory. 
Columns divided at 
its base and turned up; 
septum divided above 
and below; tumor 
grasped by vulsellum 
forceps and twisted from 
posterior attachments. 
Recovery. Immedi- 
ate union. No subse- 
quent history. Excit- 
ing cause, a blow on 
nose. 
TABLE OF CASES. 
78 6 
1883 
J acquemart, A nnales 
des Maladies de 1'0- 
reüle, du Larynx, du 
Nez, et du Pharynx, 
Mai, 1883, page 69. 
Male. 
29 
Several• 
years. 
Multilobular tumor on 
each side; nose flattened, 
dilated and enlarged; 
masses of firm consistence 
protruding anteriorly 
from each side, having an 
aspect more fibrous than 
mucous; quite vascular 
and resistant. 
Superior turbinated 
body and ant. part of 
sup. meatus. 
Fibro-myxoma. With 
greatly predominating 
fibrous structure. No 
microscopic examina- 
tion. Also some smaller 
myxomatous growths. 
Removal in 50 pieces 
by cold wire écraseur in 
15 sittings. Previous 
attempts by forceps had 
failed. 
Recovery. No sub- 
sequent history. 
7 
1884 
Jeanselme, Annales 
des Maladies de 1'0- 
reille, du Larynx, du 
Nez, et du Pharynx, 
etc., Nov., 1884. Ini. 
Centlb. für Laryngolo- 
gue, Ilhinologie, etc., II, 
12. 
Not 
stated. 
Not 
stated. 
2 years. 
Occupied the left nasal 
fossa, occasioning deform- 
ity of the nose ; peduncu- 
lated. 
Posterior part of the 
septum. 
Fibro-sarcoma. (Mi- 
croscope.) Included in 
this table because the 
fibrous elements seemed 
to predominate, and be- 
cause of the likelihood 
that it originated as a 
fibroma. 
Exposed and removed 
by a median incision 
through the bridge of 
the nose. 
Recovery to be in- 
ferred. No s u b s e- 
quent history. 
8 
1886 
Casselberry, "Nasal 
Fibromata," Interna- 
tional Medical Con- 
gress, 1887. 
Female. 
38 
5 years. 
Left nostril distended 
and fossa anteriorly filled 
in all directions by a firm 
elastic tumor, which pro- 
jected slightly from the 
anterior aperture. Tumor 
size of small hen's egg. 
Posterior part of the 
vault, including the 
anterior perpendicu- 
lar surface of the sphe- 
noid bone, with exten- 
sion along the cribri- 
form plate of ethmoid 
bone. 
Fibroma. (Micro- 
scope.) 
Removal, piecemeal, 
during repeated sittings, 
by the galvano-cautery 
écraseur and knife, and 
other electrodes. 
Recovery. Small 
recurrence at end of 
9 months. Removed. 
No further recur- 
rence at end of 17 
months. 
79 80 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
It is certainly a more brilliant operation, when possible, to encircle the entire tumor 
and remove it in toto at one sitting, but in case of the larger fibromata this will usually 
be impracticable, on account of the impaction of the mass into the inequalities of the 
nasal fossa, and the formation of adhesions. Moreover, the slower method of removal 
piece by piece offers the advantage of greater deliberation, implying also, as it does, 
greater precision, for, when sufficient oozing occurs to interfere with the view, further 
action is postponed until the next time, and by repeated sittings the patient grows 
accustomed to manipulation, and learns to assist the surgeon by holding correctly. 
The surgeon, also, in turn, by repeated opportunities to study the parts, becomes 
so familiar with the area over which he is working, that he can readily trace out all the 
ramifications of the growth. 
No undue inflammatory reaction follows the operations, and sepsis can be avoided 
by thorough cleansing of the nostril by means of an antiseptic spray. 
In the case of Mrs. R., a lady of refinement, to whom any facial disfigurement 
would have been exceedingly abhorrent, the galvano-cautery used in this manner was 
the one means which rendered a formidable external operation avoidable. The nature 
of the case would have precluded an effective intra-nasal use of the cold wire snare, 
ligature, forceps, or chemical caustics. 
An agent capable of effecting such brilliant results naturally engenders an enthu- 
siam which is liable to lead to its abuse, and a word of caution is not unnecessary 
in this respect. Accurate diagnosis, precise indications for its use, and a certain 
amount of skill on the part of the operator, are essentials to the judicious employment 
of the galvano-cautery. And it must not be supposed that all cases will be susceptible 
of this means of cure. Enormous size and penetration into accessory cavities may 
render it ineffective. 
Electrolysis has been successfully employed in naso-pharyngeal fibroma, and it may 
prove serviceable in nasal fibroma of enormous growth, at least to reduce the size to 
such a point that the galvano-cautery can cope with it, thus again avoiding an external 
operation. 
DISCUSSION. 
Mr. Lennox Browne, of London, congratulated the author of the paper on the 
success of his case, and conceived that in the present state of knowledge no surgeon, 
certainly no specialist, would think of any but intra-nasal treatment, and probably 
the electro-cautery would be the most generally serviceable method for these as for 
other neoplasms of firm structure. Mr. Browne mentioned that the instrument em- 
ployed by the author was in no respect different from that used by him nearly twelve 
years ago. 
Dr. M. F. Coomes, of Louisville, Ky., said that he desired to thank Dr. Cassel- 
berry for the excellent paper, and further said that he had seen such a case some eight 
years since, in the person of a stout laborer. The tumor protruded at the anterior 
naris, the characteristic frog-face rapidly developing. The tear passages were occluded, 
the tears flowing over the cheek. He had suffered from severe epistaxis. He refused 
to be operated on until he had almost lost his life by epistaxis. He was chloroformed 
and the ala of the nose raised by cutting through the soft tissues, carrying the incision 
up to the hard tissues (to the bones). An attempt to remove the growth by grasp- 
ing it with a pair of strong forceps and making strong traction failed. The pedicle 
of the growth was finally severed by the use of the scissors, when it was seized with 
the forceps and by strong traction was removed. The tumor weighed nearly one 
ounce when cleansed. There was severe hemorrhage following the removal of the 
tumor, which was attached to the upper part of the middle and the inferior portion SECTION XIII-LARYNGOLOGY. 
81 
of the upper turbinated bones. The patient made a good and rapid recovery. I do 
not think there was a return of the disease, as the patient passed from under my 
observation. 
Prof. E. Fletcher Ingals, of Chicago, said he had never seen a pure and 
simple nasal fibroma, but had seen two cases in which the tumor was attached both 
in the naso-pharynx and the naris, and he apprehended that their removal would not 
be materially different from the nasal fibroma. He thought that his friend had been 
fortunate in having a case in which he could operate without pain, for in the cases 
in which he had removed the fibrous mass from the naris he had found it impossible 
to anæsthetize the part so that the patient would not suffer considerable pain, and 
this although he was thoroughly familiar with the application of cocaine, and had 
used it very often. He thought, also, that the absence of hemorrhage in the case re- 
ported was the author's good fortune, and not a rule that would apply to all cases. 
He wished to inquire about the steel wire used by the author with the galvano-cau- 
tery. He had the same kind of écraseur, but he had always found that the steel 
wire heated with much greater difficulty than the platinum. 
Dr. Stockton, of Chicago, said-I simply rise to make a suggestion, namely, 
that the platinum and iridium wire be used instead of pure platinum, because the 
platinum and iridium is much stiffer and has more spring, also offers more resistance, 
consequently heats more rapidly. 
Prof. W. E. Casselberry closed the discussion by remarking-I feel grateful 
for the very friendly manner in which this paper has been received. In reply to Mr. 
Lennox Browne, I would say that galvano-cautery snares are constructed much on the 
same principle, and when a foreign instrument is modified in this country, an enter- 
prising instrument maker is sure to advertise it as the device of its modifier. In 
reference to the painlessness of cauterization in the nose, people differ in suscepti- 
bility both to cocaine and pain, but in the case reported the cocaine was applied in 
strong solution, both by spray of five to ten per cent., and repeated applications on 
cotton of twenty to twenty-five per cent., allowing the cotton applicator to remain 
within the naris, in contact with the parts, for from three to five minutes. Other 
cases, perhaps, when less thoroughly cocainized, feel the cautery more. To avoid 
any possible toxic effect, strong applications of cocaine should never be used until 
the susceptibility of the patient has been tested. I have no means of measur- 
ing minutely the comparative ease of glow of the steel and platinum wire. To me, 
for all practical purposes, they take the glow the same. I have even had to exer- 
cise more care in order to prevent my steel loop from burning up than in using the 
platinum wire. Hemorrhage is liable to succeed the cautery, but less so than 
after other methods of operating. The iridium and platinum wire is a useful 
suggestion. 
Vol. IV-6 82 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Paper read by Dr. John 0. Roe, of Rochester, N. Y., entitled- 
LARYNGEAL CHOREA (CHOREA LARYNGIS). 
CHOREE DU LARYNX. 
CHOREA LARYNGIS. 
JOHN O. ROE, M.D., 
Rochester, N. Y. 
In pre-laryngoscopic literature we find records of many cases of peculiar spasmodic 
conditions of the larynx attended by a cough of a barking, howling, bellowing, crow- 
ing or musical character, which were considered due to hysterical or psychical dis- 
turbance, but which were unquestionably in many instances simply cases of chorea of 
the larynx. The first to apply the term laryngeal chorea to a peculiar manifestation 
in the larynx was Lac de Bosredon, of Bordeaux, in 1857.1 He reported the case of a 
boy attacked, during inspiration, by a peculiar crowing cough like that of a cock, 
which followed an attack of bronchitis. The cough ceased during sleep but began at 
once on waking, and was entirely uncontrollable. All remedies failed to relieve him 
until they were directed to the nervous system. The administration of valerianic 
acid and atropia (evidently valerianate of atropia) in large doses caused the barking 
to cease almost immediately. In this case Bosredon applied to the affection the term 
"Chorée laryngienne," although he at the same time considered it allied to the affection 
termed " délire des aboyeurs," the delirium of the barkers, which was first observed 
in the sixteenth century by Wiesus, among several of the religious enthusiasts in the 
Convent of Sainte Brigette, and later in the large number of barking women near Dox, 
in 1613, and in the " Mewing Orphans " at Amsterdam. 
During the past ten years cases have been reported by Wheeler,2 Langmaid,8 Lef- 
ferts,4 Schrotter,5 Schreiber,6 Geissler,7 Massei,8 Revillout,9 Holland,10 Blanchez,11 
Knight,12 Major,18 Holden,14 Keimer,16 Ledbetter, 16 in which this manifestation in the 
larynx was recognized as a distinct affection. 
The following four cases of this affection have commanded my observation:- 
Case I.-Miss S , age seventeen, was brought to me in May, 1885, on account 
of a cough of a peculiar barking character, which she had had about two months. She 
was of a somewhat delicate constitution and nervous temperament, but had always 
enjoyed very good health. The cough followed an attack of quinsy, the result of expo- 
sure from wet feet. She recovered promptly from the quinsy, but soon after was sud- 
1 Jour, de Méd. de Bordeaux, 1857, 2d series, p. 208. 
Med. and S. Jour., 1878, Vol. xcix, page 503. 3Id., page 505. 
4 Transactions, Am. Laryng. Assn., 1879, page 234. 
6 Allg. Wien. Med. Ztg., 1879, xxiv, page 67. 
6 Wien. Med. Bl'dt., 1879, II, 350. 
7 Jahresb. d. Gesellsch. f. Nat. u. Heilkunde in Dresden, Leipzig, 1879, 63. 
8 "Gior internaz. d. Sc. Med.," Napoli, 1879, I, 662. 
8 Gaz. d H6p., Paris, 1880, lui, 746. 
10 Louisville Med. News, 1881, XI, 232. 
11 Gaz. hebd. de Med., Paris, 1883, 2 S. xx, 692. 
12 Transactions Am. Laryng. Assn., 1883, page 23. 
13 Canada Med. & Surg. Journ., Montreal, 1885-6, xiv, 337. 
14 New York Med. Jour., 1885, xli, 37. 
16 Deutsch. Med. Wochenschr., No. 40, 687. 
16 Alabama Med. & Surg. Jour., Birmingham, 1886, I, 387. SECTION XIII-LARYNGOLOGY. 
83 
denly seized with an uncontrollable cough of extreme violence and of a loud barking 
character, much resembling the peculiar shrill bark of some dogs. It was so loud that 
it could be heard one-quarter of a mile, and excited so much curiosity that boys would 
congregate near by to hear the girl bark. She would cough thirty or forty times in 
rapid succession, then there would be a rest for about one minute and then a repetition 
of the paroxysm. The cough ceased entirely at night during sleep, which was natural 
and calm. If she slept during the day the cough would also cease, but would return 
instantly upon waking. 
On laryngoscopic examination the larynx was found congested, particularly about 
the vocal cords and posterior commissure, which condition was attributed to the vio- 
lent concussion of the cords. Between the intervals of coughing there was a restless- 
ness of the larynx and a peculiar twitching of the cords, which increased until the 
next paroxysm. Various local applications were made to the larynx in the form of 
sprays of astringent, anodyne or sedative character. Internally, bromides in large doses 
and sedative cough mixtures were given. Galvanism was used, but, also, without 
apparent benefit. The only way in which the cough could be controlled was by the hypo- 
dermic injection of morphia and atropia over the inferior laryngeal nerves, and this 
only arrested the cough while the efiect of the drugs continued. She was seen by a 
large number of physicians, and was given a great variety of medicines, but without 
apparent benefit, and the cough, which commenced in March, gradually increased in 
intensity and continued uninterruptedly until October, when it ceased as suddenly as 
it came. The patient has had no manifestation of the trouble since. 
The diagnosis was generally concurred in that it was hysteria, although there was 
no other evidence of that affection, as her menstruation was perfectly regular and there 
was no evidence of any uterine, derangements. At the time I was unable to classify 
the affection, but subsequent study of such cases has convinced me that it was clearly a 
case of chorea of the larynx. 
Case ii.-A robust, well-developed girl, thirteen years old, living in Brockport, 
N. Y., was referred to me on account of a peculiar barking cough which she had had for 
about two months. This cough came on without assignable cause and was gradually 
increasing in severity. The cough was quite loud and resembled that of a small poodle 
dog. She would cough fifteen or twenty times in rapid succession, when there would 
be a rest for two or three minutes and then a repetition of the paroxysm. On laryn- 
goscopic examination the arytenoid cartilages and ary-epiglottic folds were found 
markedly congested, but between the paroxysms of cough the larynx remained com- 
paratively quiet, and little or no twitching and restlessness found in the former case was 
manifest, except just before and during the paroxysm of coughing. Physical examina- 
tion of the chest?revealed emphysema of the middle lobe of the right lung, which was 
evidently caused by the expiratory pressure. Local applications were made to the 
larynx of a solution of sulpho-carbolate of zinc and tincture iodine on cotton. Gal- 
vanism was applied to the larynx externally and a hydrocyanic acid and morphia cough 
mixture was given. The cough at once began to subside, and in about five days the 
barking character of the cough entirely disappeared. The treatment to the larynx was 
continued a short time longer until all the local trouble in the larynx had disappeared. 
A member of her family, a short time ago, told me that she had remained entirely 
well since. 
The cough in this case was at first ascribed to enlarged tonsils. These were excised 
before I saw her, and when no benefit to the cough resulted it was ascribed to hysteria, 
although she did not have a nervous temperament ; and, as in the first case, there was 
no other suspicion of such influence, except that it slightly preceded her first menstrua- 
tion. 
Case hi.-A boy, seventeen years old, of a highly nervous temperament, who had 84 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
had general good health, was, two months before I saw him, attacked with a violent 
cough of a peculiar, shrill, short, barking character. This cough followed an attack of 
sore throat (a pharyngitis or acute catarrhal tonsillitis), the result of cold from wet 
feet. The cough was at first moderate in intensity, but gradually increased both in 
severity and frequency until, at the time I saw him, he would cough ten or fifteen 
times in rapid succession, and after an interval of two or three minutes the attack would 
be repeated. This would continue without interruption, even at meals, and also to 
some extent during sleep without awakening the patient. 
On examination there was a well-marked congestion of the whole larynx, but more 
pronounced over the arytenoid cartilages. The vocal bands were reddened along the 
inner border, where they came in collision with each other during the laryngeal spasm. 
The action of the larynx during the act of coughing, as observed in the laryngeal mir- 
ror, was as follows :- 
Immediately following each act of coughing there was a momentary rest, then an 
incoherent action and twitching of the larynx. The cords were then violently approx- 
imated and held there for an instant, when they were abruptly forced apart and the 
cough took place. 
The diagnosis of this case as laryngeal chorea should not, it seemed, be questioned, 
although this condition of the larynx and the cough were the only manifestations of a 
choreic condition. There was also a so-called neurotic condition in the family. The 
mother was hysterical, anoIder sister had had general chorea when nine years old, but 
recovered from it, and the person under treatment had had convulsions during his first 
dentition. » 
In the treatment of this case, local applications to the larynx of astringent and ano- 
dyne preparations would arrest the paroxysms at once and as long as the effect of the 
remedies continued. Application of cocaine to the larynx afforded no relief, but, on 
the contrary, increased the laryngeal distress. He was also placed on a grain 
of arsenious acid every four hours; valerianate of zinc and dyalised iron were also given. 
Under this combined plan of treatment, together with galvanism of the pneumogastric 
nerve, he gradually improved in strength, the cough slowly subsided, and at the end of 
six weeks had entirely disappeared. A year and a half has elapsed, with no evidence 
of a recurrence of the affection. 
Case iv.-Miss M., aged sixteen, of Hornellsville, N. Y., was referred to me by her 
family physician, May 25th, 1887, on account of a distressing cough which she had had 
for about three months. During the latter part of last February she took a severe 
cold, mainly in her head, and two or three days afterward she began to have this peculiar 
cough. She would cough from four to ten times in rapid succession, then there would 
be a respite of from three to five minutes, when the paroxysm would 4»e repeated. The 
cough was loud but deep-toned, a combination of a bark and a bellow, resembling 
somewhat the bark or bellow of a sea-lion. In the intervals between the paroxysms 
she would, in addition, often cough a natural cough of a short, irritable nature-an 
ordinary cough from laryngeal irritation. Sometimes these two coughs would alternate, 
or occasionally the natural cough -would take the place of the bark. During each 
paroxysm of coughing there would be a marked swelling in the left front part of the 
neck, which she would instinctively grasp with her right hand to prevent its hurting 
her. Three years before she had had a similar cough, following a cold, although not so 
loud or deep toned, which was promptly cured by applications made to the pharynx. 
The same treatment had been persistently pursued this time, by the same physician, but 
without the slightest benefit. Bromide of potassium and other nerve sedatives had also 
been given in large doses, but without effect on the cough. 
Her general health had always been delicate. Eight years ago she had scarlet fever, 
with an abscess in the left ear. A perforation of the membrana tympani resulted, and SECTION XIII-LARYNGOLOGY. 
85 
there has been more or less discharge from that ear since. During the past three years she 
has had much pain j ust back of the eyes, which glasses had failed to relieve. She has 
now amaurosis in the left eye, with almost complete loss of sight in that eye. 
The cough in this case was so particularly distressing to hear, that it was with great 
difficulty she could find a boarding-place while under treatment. At hotels she attracted 
so much attention that she would not remain, and at private boarding houses they were 
not willing to entertain her. 
As in the preceding case, cocaine applied to the throat and larynx not only did not 
check the cough, but actually increased it, and caused a distressed feeling in the larynx, 
due, undoubtedly, to its contracting effect. The cough did not cease at night during 
sleep, but would continue all night without awakening her. She experienced no pain 
about her throat at any time, only this sensation of pressure from the swelling which 
took place each time that she coughed. There was no evidence of any uterine trouble, 
and her menstruation had always been regular. 
On examination, the larynx appeared pale and anaemic, although the vessels were 
distended, giving the larynx a streaked appearance. The mucous membrane had a 
pale, puffy appearance, particularly over the arytenoid cartilages and along the ventri- 
cular bands. After each paroxysm the larynx would remain for a short time perfectly 
quiet, excepting the respiratory movements ; but before the onset of the paroxysm, the 
action of the larynx would become restless, the arytenoid and vocal cords would begin 
to twitch and then come into violent contact, when an explosive separation would take 
place and the cough follow. The swelling of the neck I at first thought to be a tracheal 
hernia or tracheocele, but it would only occur during the peculiar cough, and as she 
could not produce it at will by holding her breath during a forcible expiration, or during 
the ordinary cough, it was evidently due to the forcible contraction of the thyro-hyoid 
muscles. Pressure over the cricoid cartilage externally would at once start the bark- 
ing, and keep it going so long as the pressure was applied. Application of the Faradic 
current to the neck would also aggravate the cough. 
The treatment of this case was both local and general, and resulted in complete relief, 
although the ordinary slight laryngeal cough persisted to some extent. Since the cessa- 
tion of this peculiar bark she cannot reproduce or even imitate it. The treatment con- 
sisted in the application to the interior of the larynx, on cotton, of a solution of sulpho- 
carbolate of zinc, extract of krameria and eucalyptus. This was also applied to the 
fauces. Internally, arsenic and iron and bark. 
It is a curious fact to note that the first application of the preparation to the interior 
of the larynx arrested the peculiar cough for three or four hours, or during the con- 
tinuance of the effect of the remedy, while the application of ten per cent, solution of 
cocaine aggravated rather than decreased it. To me, the only satisfactory explanation 
of this is the following : While the cocaine benumbed the terminal filaments of the 
nerves in the larynx, where nearly all the primary disease was located (as shown in the 
arrest of the cough by the local medication which had no anodyne effect whatever), the 
contraction of the tissues caused by the cocaine exerted a pressure on the deeper por- 
tions of the recurrent nerve which had become sensitive, and thus produced an irrita- 
tion which was reflected to the nerve centres. 
An interesting and peculiar symptom in these last two cases was the continuance of 
so violent a bark during sleep, without wakening the patients. I have found no other 
cases reported in which this symptom was present. Its cause was certainly the same as 
that of the day bark, for they corresponded to each other and both ceased together. 
Regarding the pathology of chorea, a different view is held by nearly every writer 
on the subject. Thus, Hughlings-Jackson tells us that it is due to capillary emboli in 
the corpus striatum and optic thalamus. Dickenson tells us that it is due to a general 
dilatation of the smaller arterial vessels throughout the substance of the brain and cord, 86 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
attended with exudation into the surrounding tissues. Legros and Onimus tell us that 
the site of chorea is either in the nerve cells of the posterior horns, or in the fibres 
which connect them with the motor cells. While Brown-Sequard ascribes it to a 
"softening of the cord." 
The diversity of opinion held by the few authorities that I have cited regarding the 
pathology of this affection, simply reflects the lack of definite knowledge concerning it. 
Therefore, in the absence of a known positive pathology, we must rely wholly on its 
symptomatic manifestations. 
It is true, as Massei says, laryngeal chorea describes a manifestation and not a dis- 
ease. But such is the case with chorea in every form, and also with many other affec- 
tions ; and it should not for this reason go unnamed until we can establish for it a posi- 
tive pathology. If the term is without pathological significance, it cannot be less satis- 
factory than hysteria, which is the ' ' diagnostic refuge ' ' for all forms of uncertain mani- 
festations of a neurotic character. As Knight1 and Major2 remark, whenever the 
movements of the larynx are choreic we are j ustified in using the term ; the evidence 
of a general chorea should confirm and fortify rather than weaken or detract from the 
diagnosis. That there is not necessarily a direct connection between choreic symptoms 
of local origin and a general neurosis is becoming more and more generally recognized. 
The local origin of many choreas is very clearly pointed out in the recent article by 
Jacobi.3 In alluding to the frequency of convulsive movements of the face and upper 
portion of the trunk due to irritation in the naso-pharyngeal region, he says : "If gen- 
eral nervousness were the cause, its effects would be apt to be general. For the local 
effect, there is a local cause ; even in the usual form of generalized chorea the involun- 
tary, spasmodic, reflex movements are occasioned by local irritation." 
Krishaber4 calls attention to "vocal asynergy," a term which is used to imply a 
want of command over the laryngeal muscles, generally occurring during some form of 
laryngitis, but sometimes arising idiopathically. 
Von Ziemssen 5 describes a condition of the laryngeal muscles accompanying general 
chorea, in which there is a restlessness and twitching contraction of the closers and 
openers and tensors of the vocal cords. " It is characterized, ' ' he says, ' ' by insufficient 
force and duration of the tension of the vocal cords in phonation, owing to a want of 
coordination and persistence in the muscular act." 
Our eminent London friend, Mr. Lennox Browne, who is present, states, in the last 
edition of his excellent work,6 which has just been issued, and which I had the pleasure, 
by his kindness, of perusing last evening, that this form of neurosis of the larynx occurs 
in the course of a general chorea. He also states that "Inasmuch as it represents 
fatigue and spasm of one set of muscles, through wrong use and over-use of another, 
this ' psellismus laryngis ' bears some analogy to the conditions comprised under the 
designation of ' writer's cramp.' " 
The neurotic character of inany coughs due to irritation in the larynx, reflected from 
disease in the nasal passage, is very frequently observed by laryngologists. Not only 
do we first look for a local cause in all forms of localized choreic manifestations, but we 
often find, on careful examination, a general chorea, due to a localized cause. Thus, 
M. Boretti7 reports the case of a boy, thirteen years old, who had had a violent chorea 
1 Op.'XHt. 3 Op. Cit., page 338. 
3 " Partial, and sometimes general, chorea minor from naso-pharyngeal reflex." American 
Journal Medical Sciences, Vol. xci, 1886, page 517. 
* " Diet, de Sc. Med.," page 681. Mackenzie, " Dis. of the Throat and Nose." London, 1880. 
Vol. I, page 495. 6 " Cyclopæd. Prac. Med.," Vol. xiv, page 436. 
6 " The Throat and its Diseases." London, 1887, page 480. 
7 Bulletin de la Société de Chirurg., 1852, page 252. SECTION XIII-LARYNGOLOGY. 
87 
for thirteen months that had resisted all forms of treatment. On the removal of a neu- 
romatous tumor that was discovered on the bottom of one of his feet, the choreic symp- 
toms immediately disappeared. 
A case is reported by Fischer1 of unilateral chorea caused by the stump of a tooth. 
On removal of the roots of the tooth, the choreic movements entirely disappeared. 
As local choreas are most often the manifestation of an irritation of some portion of 
the nerve which supplies that region, we would therefore expect to find in chorea of the 
larynx an abnormal excitation of the pneumogastric nerve or some of its branches. This 
was unquestionably the case in three of the cases that I have reported, and confined 
almost entirely to the nerves supplying the larynx. In the other patient the cause was 
doubtless central or due to the irritation of the nerve centre from which the pneumo- 
gastric is derived. 
The diagnosis of chorea laryngis can only be made by a laryngoscopic examination. 
The peculiar cough usually attending this affection is not significant. In nearly all 
cases of laryngeal chorea the respiratory as well as the laryngeal branches of the 
pneumogastric are involved, giving expression in peculiar and involuntary coughs. 
Two cases have been reported by Knight2 in which the choreic movements were 
confined entirely to the larynx and unattended by cough. 
Hysteria of the larynx is the only affection with which chorea laryngis is liable to 
be confounded. The characteristic manifestations of hysteria of the larynx are those 
of aphonia, spasm, anæsthesia and hyperæsthesia; while chorea laryngis is characterized 
only by a peculiar choreic, incoherent action or incoordination, or, as Watson would 
term it, an ' ' insanity ' ' of the laryngeal muscles. It may not be impossible for a 
laryngeal chorea to be of an hysterical origin ; that is, due to an irritation reflected from 
the uterus. It is not the cause or direction from which the irritation comes that is 
significant, but it is the peculiar choreic manifestations of the larynx that are diagnostic. 
From a study of the cases that I have reported, and of those reported by others, I 
am led to the following conclusions :- 
1. That chorea laryngis is a term applicable to all forms of movements of the larynx 
that are choreic. 
"2. That this phenomenon may be excited by a local disease of the larynx, or by 
a disease of the central nerve centres. In the former it is of a reflex character, involv- 
ing the sympathetic ; in the latter it is direct, involving the centres from which the 
nerve supply to the larynx is derived. 
3. That anæmia or a depressed condition of the system is present in every case, 
favoring in one instance a ready transmission of the local irritation to the nerve ganglia, 
and back again to the larynx; and in another instance a ready transmission of the irri- 
tation from the diseased nerve centres to the periphery. 
4. That choreic conditions of the larynx are usually attended with spasmodic 
actions of the respiratory muscles, manifested in a peculiar bark or cough, but not 
necessarily so, for two cases of chorea of the larynx unattended by cough have been 
reported. 
5. That in some cases coughs or barks choreic in character are hysterical. In these 
cases they are attended by other hysterical symptoms and sometimes spasms of the 
larynx, but there is an absence of the incoherent actions of the larynx which are diag- 
nostic of this affection. 
6. That the prognosis in these cases is favorable. In some, the affection ceases 
spontaneously. 
1 Zeitschrift für Wundärzte, 1853, Bd. v, page 89. 
2 Case I, ArcÄwe« of Laryngology, Vol. I, 1879, page 254. Case II, Transactions American 
Laryngological Ass., 1883, page 26. 88 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
7. That in the treatment of this affection, when the exciting cause is localized in 
the larynx, as it was in three of the cases which I have reported, the larynx must of 
neccessity receive appropriate treatment. But in those cases where the disease is cen- 
tral, the plan to be pursued is that which should govern the treatment of chorea in 
general. 
DISCUSSION. 
Dr. Max Thorner, of Cincinnati, 0., said he saw two cases of so-called chorea 
laryngis, where the chorea was one of the frequent nervous complications of preg- 
nancy. The first was that of a girl, æt. 15, who appeared in Prof. Schnitzler's 
clinic in Vienna, with a frequent, barking cough; laryngoscopically only frequent 
adduction and abduction of the vocal cords could be seen. Gynaecological examination 
showed the girl to be in the fourth month of pregnancy. The second case was that 
of a married lady, æt 24. She consulted me for a loud, hacking cough in the seventh 
month of pregnancy. No signs of disease in the larynx could be detected, except 
twitching of the vocal cords. The lady was of exceedingly nervous temperament. 
The cough ceased spontaneously a short time before the delivery, just as had been 
the case in her first pregnancy. 
Dr. E. Cutter, of New York, asked Dr. Roe to say where he would place a case 
of a voluntary barking cough in a young lady of 18 years, which she could cause at 
will, but which attracted the attention of all observers. On laryngoscopy the larynx 
and throat were found normal, save that both false or ventricular bands were thick- 
ened to thrice their normal size. This appeared to me to explain the cough, especi- 
ally as I found a case of so-called spasmodic cough, in which this same pathological 
condition was found. The Doctor said it was probably not chorea. 
Mr. Lennox Browne had seen occasionally cases presenting choreii laryngeal 
symptoms without cough, but he had seen many of nervous laryngeal cough. They 
were generally of a reflex nature, and when the cause of the reflex was not readily 
ascertainable, the benefit of a sea voyage was very marked and generally permanent. 
Dr. Roe, in closing the discussion, said-The last speaker, Dr. Ingals, has called 
attention to the special diagnostic feature of this affection, which I emphasized in 
my paper, but which the other speakers have overlooked in their remarks, namely, 
the peculiar and characteristic incoherent action or choreic condition of the laryngeal 
muscles, which can only be diagnosticated by the aid of the laryngeal mirror. 
We also have very frequently reflex coughs of a peculiar character caused by 
irritation in the nose, pharynx, larynx, or the fauces, as in the cases of cough excited 
by enlarged tonsils, cited by Mr. Browne. Such cases, however, are not cases of 
chorea laryngis, unless the larynx presents the peculiar and characteristic choreic 
manifestations. 
The peculiar coughs, moreover, that frequently attend pregnancy, of which Mr. 
Browne and Dr. Thorner have spoken, are doubtless due to irritation reflected from 
the enlarged uterus to the pneumogastric nerve, as evinced by the cessation of the 
cough after parturition. It is not impossible that there may be in some of these 
cases temporary chorea of the respiratory and laryngeal muscles, but in the absence 
of a laryngoscopic examination we are not warranted in classifying any such coughs 
as chorea laryngis. SECTION XIII LARYNGOLOGY. 
89 
Dr. Max. J. Stern, of Philadelphia, read a paper entitled- 
INTUBATION OR TRACHEOTOMY.* 
INTUBATION OU TRACHEOTOMIE. 
INTUBATION ODER TRACHEOTOMIE. 
BY DR. MAX. J. STERN, 
Of Philadelphia, Pa. 
The following paper considers tracheotomy and intubation only in their relation to 
diphtheria and croup ; for intubation has as yet been so rarely practiced for the relief 
of other affections, that it would be unjust to draw any comparisons between the two 
procedures, in any other than the diseases named. Until within a recent period, there 
was but one method which could be employed for the prolongation of life when 
asphyxia confronted us. It remained for Dr. O'Dwyer to place in our hands an instru- 
ment, the importance of which, in a little more than two years, already rivals that 
method for the promulgation of which Bretonneau, Trousseau, and many others have 
so faithfully labored. 
When but one line of conduct can be employed for the relief of a particular affection, 
there ought to be no doubt as to the manner of interference. With two methods, where 
the position of one is not yet determined, the particular applicability of the one or the 
other is the point upon which elucidation is needed. My earnest hope, therefore, is 
that in the discussion which may ensue some light may be thrown upon this particular 
point. 
Tracheotomy was proposed for the relief of serious cases of angina in remote anti- 
quity ; Cœlius Aurelianus and Galen accrediting Asclepiades with it, in the time of 
Cicero. Antyllus is the first who described a manner of operating, and is cited by 
Paulus Ægineta. Fabricius ab Acquapendente advised the use of a cannula with wings. 
Casserio argued in favor of the operation, and gave a complete description of it. Rhazes, 
Mesne and Avicenna spoke of bronchotomy as a supreme resource in suffocative tonsil- 
litis. Avenzoar performed tracheotomy successfully on a goat. The operation then 
fell into disuse until, in 1546, Antonio Musa Brassavalo, physician to the Duke of Fer- 
rara, performed a successful one for suffocative angina. Laryngocentesis was first per- 
formed by Santonio, about 1600, and again by Garengeot, in 1748. In 1730 Dr. George 
Martine (27) performed the first successful and recorded tracheotomy for croup, but 
cited earlier successes by Mr. Baxter and Dr. Oliphant. About 1750 Heister recom- 
mended a mode of operating similar to that now practiced. Decker, Bouchut, Barbeau- 
Dubourg and Richter invented special bronchotomes. Tracheotomy was also recom- 
mended by Habicot, Severinus, Rene Moreau and DeVeiga. Home, about 1765, recom- 
mended it as a dernier ressort in croup. D'Azyr, in 1776, published a work on Laryn- 
gotomy. Stoll, in 1786,1 strongly advocated the operation, although he had never seen 
it. 
The next credited success was that of John Andre, in London, in 1782, and recorded 
by Borsieri.2 This was followed by Thos. Chevalier,3 of London, in 1814, and Breton- 
neau after two, and according to Guersant six, unsuccessful operations, achieved his 
first, and the fourth recorded, success, in 1825. After the report of M. Royer-Collard 
on the Concours of 1807,4 the Académie de Médecine strenuously opposed tracheotomy. 
This was evidently to check the enthusiasm of Caron, who was its staunchest advocate, 
* References and bibliography will be found at end of the paper. 90 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
and who offered a prize of one thousand francs to any one who would cure a case of 
croup by opening the windpipe. 
It was Bretonneau's task to demonstrate the feasibility of the operation to the 
French. He and his student Trousseau remained its strongest exponents throughout 
their lives, and it is due mainly to the efforts of these men that the operation was per- 
fected. Bretonneau5 in his first operation used a goose quill for the passageway of air 
to the lungs, in the second a piece of wax catheter, in the third a curved silver 
cannula, which, for practical purposes, is almost identical with the single tubes until 
recently in use. 
After Bretonneau's success the operation steadily gained in favor, and in 1835 Trous- 
seau6 reported sixty cases of tracheotomy for croup, with eighteen authenticated recov- 
eries. They were divided among the following operators :- 
Bretonneau 17 operations and 5 recoveries. 
Trousseau 36 " " 9 " 
Scouttetten 1 " " 1 " 
Senu, of Geneva 1 " " 1 " 
Gerdy 1 " " 1 « 
Andre 1 " " 1 " 
Velpeau 1 " " Failure. 
Guersant, Jr 1 " " " 
Sanson, the elder 1 " " " 
Blandin .... 1 " " " 
It will thus be seen that thirty per cent, of the earlier cases were saved. After 
1835 the operation became general, and the reported cases rapidly multiplied, and it 
was not long ere the operation was performed in all parts of the world. 
It is almost impossible to gather any reliable statistics in the earlier years of the 
operation, as there is so much difference in the reports of various authors, who yet 
seem to have gained their information at the same sources. The most trustworthy 
which I have been able to find are those given in Cohen's book on "Croup and its 
Relation to Tracheotomy." He has discarded all those looked upon as being doubtful. 
It is from this magnificent work that I have in part taken the statistics which I shall 
shortly give. Many excellent works have recently been brought forward, but none 
that materially change the ultimate ratio of successes. It would, indeed, seem that 
with all our approved appliances the total percentage of recoveries has not increased, 
although occasionally we find single reports where fifty per cent, of recoveries will be 
noted, which is over twenty per cent, more than the gross relation. It would be unjust 
to take any single group of statistics, and we must deduce results from the experience of 
the world. 
Tracheotomy in the United States, until recently, has not given very encouraging 
results; indeed, in certain parts of the country, the mortality has been so high that the 
mass of the profession refuse to sanction the operation, and it is often as difficult to 
gain the consent of the attendant as that of the parents. 
The feasibility of tubage of the larynx was accidentally demonstrated in 1801, by 
Desault, who passed an oesophageal catheter into the trachea, where it remained for some 
hours without causing inconvenience, but the patient succumbed when the bronchi were 
filled with food intended for the stomach. Bichat, profiting by this lesson, placed a 
catheter in the larynx of a patient suffering from acute oedema of the glottis. It 
remained in situ for twenty-four hours, the patient recovering. Green, Chapman and 
Loiseau recommended a like procedure. In 1835 Guersant7 reported Dupuytren's 
method of cleansing the trachea in croup by means of a small sponge attached to a 
whalebone probang, which the latter had first practiced on a child of Bonaparte's 
Mameluke. Dieffenbach employed the same method as early as 1839. In 1854 Horace 
Green injected tuberculous cavities (?) by means of a flexible tube passed into either SECTION XIII-LARYNGOLOGY. 
91 
bronchus. In a case of oedema of the glottis, Hack used a Schroetter bougie for intu- 
bating the larynx. Monti, of Vienna, has for a long time employed a hard rubber tube, 
one end passing into the larynx, the other protruding from the mouth, as a temporary 
substitute for tracheotomy. McEwen has employed catheters passed through the mouth 
to relieve dyspnoea. Reichert, Landgraf, Weinlechner and others have resorted to 
the same expedient. 
Intubation of the larynx, as we now understand it, was first practiced for the relief 
of croup by Bouchut in 1857, and he reported in 1858, to the Académie de Médecine of 
Paris, seven cases thus treated, two of which recovered after subsequent tracheotomy. 
Although the ultimate result was bad, he claimed an immediate relief of the distressing 
dyspnoea. 
Through the efforts of Trousseau, one of the commission appointed to investigate its 
merits, the procedure was ridiculed and condemned, and in consequence fell into oblivion. 
It should be borne in mind, at this time Trousseau was tracheotomy's staunchest 
champion. 
In 1880 Dr. Jos. O'Dwyer, of New York, ignorant of former efforts, began experi- 
mentation in the footsteps of Bouchut, and in 1885 published the results of his labors. 
His method is that of his predecessor, his instruments radically different, and are now 
so familiar that they need no description. 
Bretonneau said, "a large increase in the fatality of tracheotomy must be set to the 
negligence or ignorance of surgeons who imagine with the performance of the operation 
all has been done that is required." I know from my own experience that this can be 
applied to intubation, the operator not having had the wit to discern that he had but 
eliminated one factor to be combated in these dread diseases. While this, of course, is 
applicable to but few, it nevertheless lowers the ratio of success. 
The reports various operators have recently published in reference to intubation 
have sufficed to enable me to present a reasonable number of cases, which we will pro- 
ceed to dissect and compare with the results of tracheotomy. I will omit references, but 
they are appended to the paper and will be published. 
The number of tracheotomies derived from French sources were in part gleaned 
from Cohen's "Croup"8 and in part from Sanne's "Diphtheria,"9 the latter having 
personally examined the hospital registers. We can then gather from France 5151 trache- 
otomies ; of these there were 1306 recoveries, or a ratio of 24T per cent. From Por- 
tuguese sources 10 we get 59 operations with 21 recoveries, or 35T5jy per cent. From 
Belgium,11 reported by Henriet and Warlomont, we have 43 cases and 12 recoveries, 
or 27t% per cent. From Germanic12 sources we gather 1837 cases showing 558 recov- 
eries, or 30r4(j per cent. In Switzerland Dr. D'Espine13 reports 148 operations and 
57 recoveries, or 38 r% per cent. From England 14 we can obtain 333 tracheotomies 
showing 97 successful cases, or a ratio of 29t2<j per cent. Wm. M. Masten 15 has col- 
lected from American sources 860 operations showing 195 cures, or 22/5- per cent, of 
recoveries. This would give in all 8380 cases with 2225 recoveries, or 26T%- per cent. 
Certainly not an enviable showing, and yet the percentage in individual reports occa- 
sionally runs very high ; thus the statistics of the Annen-Kinderspital in 1884 showed 
over 50 per cent, of recoveries. 
In 1878, Agnew16 reported ll,696cases, ofwhich 26}percent.recovered. Monti,17 of 
Vienna, in 1884 published 12,736 operations showing 3409 recoveries, or 26T% per cent. 
Lovette and Monroe18 have published, in July of this year, 21,853 operations 
showing 6135 recoveries, or 28 per cent. 
Although our number of intubations is still comparatively limited, I have yet 
been enabled to collect 957 cases 19 showing 252 recoveries, or 26| per cent, of those 
operated upon. This, in all probability, judging from a comparison of tracheotomy in 
its earlier days, with the result in the present time, will remain about the established 92 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
ratio. Among certain individual operators the proportion of recoveries is very much 
higher, among others it is far below the mean percentage. Taking into consideration 
the liability to recovery in certain epidemics, and vice versa in others, I do not think 
even with improved instruments, such as are already being experimented with, the 
ultimate ratio of recovery to operation will be greatly altered. This is subject to the 
proviso that the constitutional treatment of the disease remains unchanged. Intubation 
and tracheotomy are not practiced to cure the disease, but simply that air may be con- 
veyed to the lungs. This O'Dwyer's tubes now accomplish, and this the various 
tracheotomy cannulæ have always performed. Accidents in either procedure-the word 
is advisedly used-are responsible for a comparatively small number of deaths. 
Tracheotomy gives us 261 per cent, of recoveries. Intubation shows 26f per cent., 
not an appreciable difference, yet marked variances are found on analysis. Owing to 
incompletely reported cases, only a part of them were available for classification. Sex 
would seem to have a decided bearing upon the results ; thus of 448 cases in which I 
could ascertain the gender, 236 were boys and 212 girls. Of the boys 78 recovered, 
of the girls 51, showing the ratio of recovery in males to be 33 per cent., in females 
241. This may be a mere coincidence, although the excess of recoveries in favor of 
males was even more marked in the earlier cases. Why this difference should exist I 
do not know, although it may be a point for further consideration. Fisher and Briche- 
tau 2 0 reported 396 tracheotomies, of which 225 were in males, of whom 38 recovered, 
and 171 in females, of whom 29 recovered, showing 17 per cent, of recoveries in both 
sexes. Bourdillat's 21 analysis of 1300 cases also showed no difference in favor of either 
sex. Yet at various times statistics have shown a marked preponderance of recoveries 
in either gender. 
I have been able to analyze 519 cases of intubation with reference to age and 
result, and will compare them with Bourdillat's 22 statistics of tracheotomy. The 143 
intubation cases which recovered show a slight increase of lj per cent, over the gross 
result. These may be divided as follows :- 
Intubations. 
Recoveries. 
Per Cent. 
Per Cent, of 
Tracheotomy 
Recoveries. 
Under 2 years 
110 
17 
1'4 
3% (6%) 
Between 2 and 2| years 
53 
13 
241 
12% 
Between 21, and 3| years 
135 
39 
28t% 
17% 
Between 3Î and 41 years 
86 
29 
30% 
Between 41 and 5| years 
60 
17 
2«™ 
35% 
Over 5| years 
75 
28 
37Ä 
391% 
Bourdillat's ratio for recoveries under two years seems much lower than those of 
other statisticians; an average of most of them would bring it to about 6%, and this I 
have taken for those years. 
We find, then, that intubation practiced on children- 
Under 2 years gives a gain of 9 J per cent. 
Between 2 and 2| gives a gain of 12| per cent. 
" 2i and 3| " " 11A " 
" 3Î and 4J " " 3Ä " 
" 4£ and " a loss of 6Ä " 
Over " 2A " 
The youngest recovery in intubation was six months old. In tracheotomy, Scout- 
teten23 reports the case of his own child at six weeks, but the correctness of his diag- 
nosis has been so invariably questioned, that it might be eliminated. The next youngest 
tracheotomies that recovered were those of Croft24 at five months, Fisher25 at six SECTION XIII-LARYNGOLOGY. 
93 
months ; Tait26 and Bell 27 each had one at seven months. The oldest intubations to 
recover were those of Van Fleet28 and Langmann29 at eleven years and Austin G. 
Cases 80 at ten and a half years. A child of fourteen years was the oldest intubation 
recorded. Recovery in tracheotomy has, at rare times, been reported in adults. 
Among the difficulties to be surmounted in the performance of tracheotomy in 
children is obtaining the parents' consent ; this is also experienced in intubation, 
although rarely to so marked an extent. The difficulty of obtaining an attendant who 
is familiar with and skilled in the after treatment of a tracheotomized patient is one 
of the greatest objections to this interference. Many of the writers upon intubation 
tell us that after its performance no skilled attendance is necessary. I think any one 
who will closely study the reported cases will see the fallacy of this statement. In one 
of the cases which I have reported, the attendant left the house for a few minutes to 
mail a letter ; upon his return he was horrified to find the child suffocating. It died 
during attempted removal of the tube, which had become choked with membrane. But 
there is less danger in the after treatment of intubation than of tracheotomy ; infinitely 
less, I think. We hear much of the ease and facility with which intubation is prac- 
ticed ; this is misleading ; to one familiar with laryngeal work it is no great task. 
I had a gentleman try to intubate my own larynx, and now I appreciate the difficulty 
of intubation when the obturator is not in a laryngologist's hands. Inquiry among 
many who practiced intubation substantiates these views. If the introduction of the 
tube is difficult, the removal is infinitely more so, and not a few patients have been 
killed in the latter attempts. 
Tracheotomy is an exceedingly difficult operation in young children, becoming less 
so as the patients advance in age, but always remaining an extremely delicate one. 
Much has been written about shock. Now, patients do not die of shock after trache- 
otomy. They do die immediately after or sometimes during the operation, but it is 
never of shock. It is of the effects of the disease itself or the result of accidents during 
the operation. Tracheotomy requires ordinarily at least one skilled assistant, intuba- 
tion none. In tracheotomy the foods most readily assimilated may be given, in intuba- 
tion only solids or semi-solids may be ingested. In intubation the dangers of erysipelas 
and emphysema, local and general, and the consequently bad results, are not incurred. 
In no case of intubation has the tube been worn over twenty-one 31 days, and even that 
was exceptionally long, the majority retaining them from the fourth to the ninth day* 
In tracheotomy it is not at all unusual for a child to wear a tube fifty days, and Steiner 
reports one in which the tube was retained one year and three months. An unfortunate 
circumstance in connection with tubage is the dying of the patient upon the introduc- 
tion of the instrument, through the crowding down of membrane or the plugging of 
the tube. One of the greatest advantages of intubation is that a patient can be intu- 
bated much earlier than tracheotomized ; consent can more readily be gained and the 
attendant, I think, will be more likely to perform it ; with tracheotomy he is apt to 
postpone the performance a little more and more, hoping for a favorable turn and urged 
thereto by the enormous labor entailed in the after treatment. One of intubation's best 
features undoubtedly is that it does not preclude a subsequent tracheotomy. Another 
feature of inestimable value is that the air reaches the lungs in the normal manner. 
The grave question now remains, When shall tubage be done and when tracheotomy 
performed ? 
1. All things being equal, I would always intubate when the patient is under three 
and one-half years of age. 
2. Between the ages of three and one-half and five years I would be regulated, of 
course, by individual circumstances, with a preference for tracheotomy. 
3. Over five years of age I should perform tracheotomy. 
4. In adults I would never tracheotomize, but willingly test intubation. 94 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
5. Among poor people, irrespective of age, I would always intubate. While it may 
sound harsh to draw such class distinction, good reasons are forthcoming. The general 
results of intubation are about equal to those of tracheotomy. Skilled attendance, 
such as is always required after tracheotomy, can only be procured for considerable 
purchasing power, and is, in consequence, only available where people have means. 
While the operator himself may be willing to give his own valuable time, he may owe 
to other patients attendance that may be of as much value to them as to the child 
operated upon. 
6. Intubation should never be performed at any age when there is a strong probas 
bility that the trachea is crowded with membrane. 
7. Where skilled assistants cannot be obtained, intubation should always be practiced. 
I should not like to close the paper without a slight tribute to the labors of Dr. 
O'Dwyer, who, through his perseverance and patient period of experimentation, has 
placed in our hands a procedure that will probably save many, many lives. Had he, 
upon the incipiency of the experiments, followed Bouchut's plan of immediately pub- 
lishing his results, would it not again have shared a like fate ? Which of us may not 
yet have personal cause for a debt of gratitude to this modest inventor ? 
Operator. 
No. OF 
Cases. 
No. of Re- 
coveries. 
Operator. 
No. OF 
Cases. 
No. of Re- 
coveries. 
Jos. O'Dwyer, 
137 
27 
L. U. Dunning, 
7 
2 
E. E. Waxham, 
131 
34 
J. Eichberg, 
6 
2 
Dillon Brown, 
87 
18 
H. H. Mudd, 
6 
2 
F. Huber, 
47 
20 
I. H. Hance, 
6 
1 
J. N. Bleyer, 
42 
11 
J. E. Winters, 
6 
0 
D. O'Shea, 
37 
14 
J. Salinger,* 
6 
3 
W. P. Northrup, 
32 
6 
Hopkins, 
6 
6 
A. B. Strong, 
31 
1 
H. O. Bates, 
6 
3 
C. E. Denhard, 
24 
10 
W. H. Preston, 
6) 
F. Van Fleet, 
22 
7 
W. P. Boles, 
2 r 
2 
D. C. Cocks, 
21 
6 
H. L. Smith, 
2 J 
T. H. Meyers, 
21 
4 
Carl Beck, 
5 
4 
E. E. Montgomery,* 
21 
11 
James McManus, 
5 
2 
A. Caille, 
15 
5 
F. K. Priest, 
5 
0 
W. Cheatham, 
15 
1 
Forscheimer, 
5 
2 
G. H. Cocks, 
14 
4 
G. W. Gay, 
4 
0 
E. F. Ingals, 
12 
3 
F. C. Shaffer, 
4 
0 
J. Tasher 
11 
4 
Geo. Thilo. 
4 
3 
W. K. Simpson, 
10 
0 
H. D. Ingraham, 
3 
0 
J. A. Anderson, 
10 
1 
A. S. Hunter, 
3 
0 
E. L. Cocks, 
10 
3 
G. W. Mason, 
3 
1 
J. J. Reid, 
10 
4 
F. W. Merriam, 
3 
2 
Geo. McNaughton, 
10 
2 
S. A. McWilliams, 
3 • 
0 
C. G. Jennings, 
10 
0 
H. Boenning, 
3 
1 
A. E. Hoadley, 
9 
0 
M. J. Stern,* 
3 
1 
F. Henrotin, 
9 
3 
Rehfuss,* 
3 
2 
H. W. Berg, 
8 
2 
N. S. Roberts, 
2 
1 
David Prince, 
2 
2 
W. E. Shaw, 
2 
0 
W. L. Carr, 
2 
0 
J. L. Mullfinger, 
2 
1 
Hailes, 
2 
2 
S. Solis-Cohen,* 
2 
0 
J. W. Niles, 
1 
0 
E. C. Morgan, 
1 
0 
B. T. Shimwell,* 
4 
2 
J. B. Wheeler, 
1 
0 
L. L. Palmer, 
1 
0 
H. F. Ivins, 
1 
0 
A. G. Case, 
1 
1 
F. Donaldson, Jr., 
1 
0 
Frank Tipton, 
1 
1 
Charles Dennison, 
1 
1 
Langmann, 
1 
1 
E. D. Furgueson, 
1 
0 
Rihl, 
1 
0 
James Collins, 
1 
0 
T. G. Morton, 
1 
0 
No. of Operators, 75. 
No. of Cases, 
957. No. of 
Recoveries 
, 252. 
* Personally communicated to writer from notes. 
OPERATORS, NUMBER OF CASES OPERATED UPON AND NUMBER OF RECOVERIES. SECTION XIII-LARYNGOLOGY. 
95 
REFERENCES AND BIBLIOGRAPHY OF INTUBATION. 
Medical Record, New York. 1885, Feb. 21st. 
" " " " 1886, xxix, 410. 
" " " " 1886, xxix,'641. 
" " " " 1886, xxx, 437. 
" " " " 1886, xxx, 645. 
" " " " 1886, xxx, 683. 
" « " " 1887, xxxi, 26. 
" " " " 1887, xxxi, 108. 
" " " " 1887, xxxi, 324. 
" " " " 1887, xxxi, 677 to 687. 
" " " " 1887, xxxi, 608. 
" " " " 1887, xxxi, 705 to 707. 
" " " " 1887, July 2d, xxxn. 
" " " " 1887, July 9th, xxxn. 
" " " " 1887, xxxii, 99, 106. 
New York Medical Journal. 1885, xlii, 145. 
" " " " 1886, xliii, 384. 
" " " " 1886, xliv, 373. 
" " " " 1886, XLiv, 322. 
" " " " 1887, xlv, 238. 
" " « » 1887, xlv, 273. 
" " " " 1887, xlv, 624. 
" " " " 1887, xlv, 640. 
" " " " 1887, XLVi, 11. 
" " " " 1887, XLVi, No. 5. 
Journal American Medical Association. 1886, VI, 147. 
" " " " 1886, vi, 186. 
" " " " 1886, vi, 426. 
" « " " 1886, vu, 35. 
" " " " 1887, vin, 199. 
" " " " 1887, vin, 342. 
" " " " 1887, vin, 337. 
" " " " 1887, vin, 359. 
" " " " 1887, vin, 291. 
" " " " 1887, vin, 701. 
" " ' " 1887, ix, 135. 
Letter to E. Fletcher Ingals. Reprint from the New York Medical Journal, July 2d and 
9th, 1887. 
Statistical Records of Intubation, Medical Record, July 23d, 1887. 
New York Medical Journal, August 8th, 1885. 
Transactions of the American Laryngological Association, 1887. 
Chicago Medical Journal and Examiner. 1885, l, 475. 
« " " " « 1885, Li, 511. 
" " " " " 1886, Lin, 132. 
" " " " " 1886, in, 214. 
" " " " " 1885, Li, 401. 
Medical and Surgical Reporter. 1886, lv, 586. 
New Yorker Med. Presse. 1887, in, 259. 
" " " " 1887, June. 
Medical Register. 1887, I, 174. 
" " 1887, i, 146. 
Medical Neics. 1887, L, 341. 
" " 1887, l, 630. 
Maryland Medical Journal. 1886, xvi, 67. 
" " " 1886, xvi, 168. 96 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Medical Review, Pittsburgh. 1887, i, 114. 
Weekly Medical Review, St. Louis. 1887, xv, 57. 
Pacific Medical and Surgical Journal. 1887, xxx, 129. 
Chicago Medical Times. 1887- 8, xix, 53. 
Cincinnati Lancet and Clinic. 1887, N.S., xvn, 97. 
" " " " 1887, n.s., xviii, 321. 
Hahnemannian Monthly, June, 1886. 
American Practitioner and News. 1886, N.s., II, 321. 
St. Louis Medical and Surgical Journal. 1887, LII, 115. 
American Lancet, Detroit. 1886, N.s., X, 401. 
Canadian Practitioner, Toronto. 1887, XII, 1. 
Archives of Pediatrics, 1885, n, 657. 
" " " 1886, in, 215. 
" " " 1887, iv, 154. 
Medical Age, Detroit. 1886, iv, 313. 
Mississippi Valley Medical Monthly. 1886, vi, 345. 
Albany Medical and Surgical Journal. 1887, II, 331. 
Boston Medical and Surgical Journal. 1887, CLVI, 518. 
American Journal of Obstetrics. 1886, June 17th. 
1 Si omnibus his non, sero, vel frustra tentatis, morbus sit maxime recens et strangulans 
statum post acerbam prognosim instituenda exit bronchotome. Stoll, aphorism, page 32, bind 
ob 1786. 
2 Guersant Dictionnaire de Médecine, 1835. 
3 Med.-Chir. Transactions, vi, 1816, p. 151. 
•»Trousseau, "Trachéotomie Dictionnaire de Médecine," 1835. 
» Communication to French Academy, July, 1825. 
6 Trousseau, op. cit. 
i "Dictionnaire de Médecine," Paris, 1835. 
"NTo nr 
Operators. Cases Recoveries. < 
Operators. 
Serdy, 
Roux, 
Trousseau, 
V elpeau, 
No. of 
Cases. 
6 
4 
80 
6 
Recoveries. 
4 
0 
20 
0 
8 Amussat, 6 
Baudelocque, 15 
Blandin, 5 
Bretonneau, 18 
0 
0 
0 
4 
(a) Bull. de I'Acad, de Med., 
1839, 1858-9. 
Cohen's "Croup," Philadelphia, 1874. 
Operators. 
No. of Cases. 
Recoveries. 
Gosselin, 
23 
0 
Michon, 
20 
2 
Langier, 
8 
1 
TSTfîlntnn f Before 1848, 23 1 
f Before 1848, 0 | 
Q 
Nelaton, j After 1848 13 1 36 
( After 1848 
, 13 J 
Ö 
Monod, Jr., (About) 
40 
0 
Sheirry (in Children), 
37 
3 
" (in Adults), 
3 
0 
Malgaigne, 
8 (or ten) 
1 
Bardinet (and Confrères at Limoges), 57 
17 
Sausier (Troges), 
6 
3 
Bey lard (Paris), 
13 
4 
Moynier " 
17 
8 
Archambault (Paris), 
21 
8 
Perrochand (Boulogne), 
3 
2 
Delarne (Paris), 
3 
1 
Salvis (Belleville) 
6 
3 
Viard (Montbard), 
2 
1 
Petel (Gateau), 
9 
5 
Baudin (Nautua), 
4 
3 
Dubarry (Condom), 
5 
2 (6) Bull, de l'Acad. Mêd., xxiv, page 231. 
Gaz. Hel>d., Dec. 3d, 1858, page 844.-Cohen's " Croup." 
Recoveries. 
OB' 
Operators. Cases Recoveries. Operators. 
NO. OF 
Cases. 
Richet, 9 5 Richard, 
5 
2 
Rollin, 7 2 Demarquay, 
6 
2 
Broca, 12 6 
(c) Bull, de I'Acad. Méd., xxiv, page 233. 
Cohen's "Croup." 
Operators. No. of Cases. Recoveries. 
Rousseau (1851-4, private practice), 
24 
14 
Isnard, 
4 
2 
Baizeau (Paris), 
12 
2 
Brockel (Strasbourg), 
33 
12 
Schoolhammer (Haut Rhin), 
7 
6 
Other Operators, 
43 
16 
Calvet (Catred), 
23 
13 
Hennette (Brussels), 
8 
4 
' Gill's-Sanne's " Diphtheria," St. Louis, 1887, page 467, 
8, 
Operators. No. of Tracheotomies. Recoveries. 
10 Antonio Maria Babbosa, 23 
9 
Theotonio da Silva, 21 
8 
Other Operators, 15 
4 
59 
21 
(a) Gill's-Sanne's, op. cit., page 470. 
- 
Operators. 
Cases. 
Recoveries. 
11 Henriet, 
8 
4 
Warlomont (St. Peter's Hospital at Brussels), 
35 
8 
43 
12 
(a) Gill's-Sanne's, op. cit., page 471. 
Operators and Country. 
No. 
of Cases. 
Recoveries. 
12 Passawant, Frankfort, from 1851 to 1882, 
229 
67 
Baum, Svettingen, 
31 
12 
Fock and others, Magdeburg, 
43 
18 
Roser, Marbourg, 
42 
19 
Midé and others, Braunschweig, 
Simon, Rostvik (one in an adult terminated 
81 
21 
fatally), 
22 
6 
Borow, Koenigsburg, 
59 
7 
Schmidt, 
15 
2 
Leipzig, City Hospital from 1878 to 1883. 
310 
67 
Peltzer, Brennen, from Oct., 1883 to March, 1884, 
88 
12 
Bartels, Kiel, 
Man Bartels, Berlin, statistics of the operations 
61 
17 
performed in the service of Prof. Wilms, at the 
Batheanien Hospital, from 1861 to 1872, and 
comprise the 100 published by Siiterboch in 
1867, 
335 
103 
Eberth, Berlin, 1857 to 1865, 
13 
6 
Busch, Berlin, 
72 
10 
Von Kopl, 
17 
11 
Morath, 
1 
1 
Stelzner, Dresden, 
12 
4 
Muller, Cologne, 1862, 1869, 
45 
15 
Molard Ziniski, Lemberg (one an adult), 
2 
0 
Oelschlaeger, Danzioy, 1856 to 1869, 
12 
1 
Reiffer, Frauenfeld, 
18 
8 
Heuter, Rostock, 
29 
7 
Birnbaum, Darmstadt, 1873 to 1883, 
140 
47 
Van Arsdale, Annals of Surgery, Vol. i, No. 2,1885, 
88 
76 
Harmer, Munich, 
Fifty-eighth Congress of German Nat. and Physi- 
cians, Strassburg, Sept. 18th to 23d, 1885. 
(Med. Record, Nov. 14th, 1885), Rauke, 
of Munich, Tracheotomy, 7| years, 
17 
2 
45 
19 
1837 
558 
SECTION XIII-LARYNGOLOGY. 
97 
Vol. IV-7 98 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Gill's-Sanne's, op. cit., page 472-3. 
Operators and Country. 
No. of Cases. 
Recoveries. 
13 Billroth, Zurich. 
12 
1 
Revilliod, Geneva, 
87 
38 
D'Espine, Geneva, 
15 
6 
Picot, Geneva, 
4 
3 
Papin, Geneva, 
30 
9 
148 
57 
(a) Gill's-Sanne's, op. cit., page 473. 
Operators and Country. 
No. of Cases. 
Recoveries. 
14 Spence, Edinburgh, 
87 
28 
Buchanan, Glasgow, 
39 
13 
Comchoshank, 
11 
8 
H. W. Fuller, Statistics 
of, 7 
3 
Conway Evans, 
5 
1 
Henry Smith, London, 
3 
0 
Ronson, Nottingham, 
3 
0 
West, London, 
30 
7 
(a) Cohen's, op. cit. 
(&) Gill's-Sanne's, op. cit., page 474. 
Operators. Recoveries. 
Operators. 
No. OF 
Cases. 
Recoveries. 
Dickinson, 18 6 
Gee from 1853 to 1878, 34 
3 
Fagge, 43 7 
R. W. Parker, 
32 
17 
127 
33 
Dickinson, Transactions of the Royal Med.-Chirurg. Society (1879). 
Hospitals. 
No. of Cases. 
Recoveries. 
St. George's (one of the fatal cases was 16 years old), 
6 
3 
Dreadnought Hospital Ship, 
1 
0 
Metropolitan Free Hospital, 
1 
0 
Hospital for Sick Children, 
King's College Hospital, 
3 
0 
1 
0 
Middlesex Hospital, 
6 
0 
St. Mary's Hospital, 
1 
0 
Addenbrooke's Hospital, Cambridge, 
1 
1 
20 
4 
(c) Same, op. cit. 
15 " Annals of Anatomy and Surgery," 1881. 
16 Agnew, "System of Surgery," Vol. in, 1878. 
17 " Annals of Anatomy and Surgery," Vol. i, page 581. 
18 Lovett & Monroe, Amer. Jour. Med. Sciences, July, 1887. 
19 Appended Statistics. 
20 " Traitement du Croup ou Angine laryngée diphthéritique," seconde édition, Paris, 1863. 
21 Bourdillat, Bull. Soc. Med. Ho., Paris, 1887, page 39. Cohen, op. cit. 
22 Bourdillat, op. cit. 
23 Am. Jour. Med. Sciences, 1844, April, page 466. 
21 Lancet, Nov., 1880, page 849. 
25 Deutsche Medizinische Wochenschrift, No. 45, 1887. 
26 British Med. Journal, April 15th, 1877, page 391. 
27 Syme Ed. Med. Journal, 1861, page 956. Philosophical Transactions, Vol. vu, No. 414, 
page 448, 1719, 1733. Cohen, in Ashhurst's Encyl. of Surg., Vol. v, page 704. 
28 2V. Y. Med. Journal, 1887, Vol. xxxit, page 103. 
29 N. y. Medizinische Presse, 1887, B. in, Seite 259. 
30 Med. Reviere, Pittsburgh, 1887, Vol. I, page 114. 
31 Montgomery, personal communication. SECTION XIII LARYNGOLOGY. 
99 
DISCUSSION. 
Dr. C. Dennison, of Denver, Col., spoke of the influence of the unwillingness of 
the surgeon to operate, as well as the liberty granted by parents to operate as a der- 
nier ressort, as militating against what would otherwise be the favorable standing of 
intubation as compared with tracheotomy. That is, the more unfavorable cases 
operated on by intubation (as the surgeon can delay so long) unduly lessens the per- 
centage of success with this method. The great variety of cases entering into the 
calculations (whether œdema glottidis, true croup, or genuine diphtheria), and some 
uncertainty perhaps as to the question of diagnosis, were mentioned as elements of 
uncertainty in deciding between tracheotomy and intubation. 
Dr. Dennison referred to his own experience with the operation of intubation, 
which comprised three cases, two of membranous croup, which recovered, and one 
of diphtheria, which terminated fatally. The latter case was very instructive in 
showing the unsuitableness of the gag which goes with the O'Dwyer set of tubes. 
The patient, a girl about eight years old, in struggling, hit the long descending 
handles of the gag with the shoulder and the gag was thrown out, when the jaws 
closed on the operator's finger, and the teeth penetrated nearly to the bone. The 
operation was completed, and then, when the Doctor had turned to put his finger into 
an antiseptic solution, the child caught hold of the silk thread connected with the 
tube and pulled the tube out. The tube was immediately re-introduced, but the 
awkwardness of the gag led the operator to devise another, which is shown in the 
accompanying cut. The features which are new about this instrument are the par- 
tially swivel motion of the troughs to receive the jaws, and the new device to force 
the jaws open, the cross bar between the handles having attached to it a spring to 
free the teeth against a stop on the lower bar. 
Messrs. Tiemann & Co., of New York, will make the instrument with the needed 
corrections stated. 
Prof. W. E. Casselberry, of Chicago, said-In performing the operation it is 
better to use the arytenoid'cartilages as a guide for the finger. In this position the 
finger is practically in the oesophagus, and if the finger is there the tube will not go 
there, and is more easily introduced in the larynx. Practice on the cadaver, I 
regard as essential ; a foetus anywhere near term will answer for this, and there is 
little excuse for an attempt without such preliminary practice. A finger stall should 
be worn. A physician of Chicago lost his life by diphtheria, through having his 
finger bitten. In closing, I would quote Prof. Fenger's remarks: "I would per- 
form intubation and have the tracheotomy instruments on the table." 100 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Dr. Coomes, of Louisville, Ky., said that the handle of a small teaspoon passed 
back and forced between the jaws at the angle, will always result in causing the child 
to open its mouth. He advised masking the nose and mouth while examining diph- 
theritic throats and noses. He said that Brandies, of Louisville, Ky., had saved a 
patient's life, some twenty years ago, by introducing an ordinary catheter and per- 
mitting it to remain twenty-four hours. 
Dr. Waxham, of Chicago-I have been interested in this very valuable paper, 
doubly so as the conclusions of the author coincide so closely with my own. 
It has been my privilege to report one thousand and seven cases in another 
Section (the Section on Diseases of Children). Of this number there were two 
hundred and sixty-six recoveries, or 26.54 per cent. The ages were recorded in six 
hundred and sixty-one cases ; the average age being three years and three months. 
I cannot agree with the author in the statement that we should perform intubation 
upon the younger patients and tracheotomy upon the older ones, for these statistics 
show that the operation is not only more successful in the young children, but in the 
older ones as well. In the cases reported by myself the percentage of recoveries 
among children five years old was 33.92; among those seven years old 50.1, while 
among those of nine and ten years it was also 50. 
It seems hardly fair to compare tracheotomy as performed by European operators 
with intubation as performed by American surgeons. In America operative proced- 
ures are seldom allowed excepting as a last resort, while in Europe tracheotomy is 
performed earlier, especially by the most successful operators; some, as Herr 
Ranke, of Munich, operate as soon as there is the first symptom of laryngeal 
invasion, admitting that the operation is sometimes performed upon those who 
might recover without it. Tracheotomy in America is not a brilliant success, because 
the operation is seldom performed early. It therefore seems more fair to compare 
intubation, not with tracheotomy as performed in Europe, but with tracheotomy as 
performed here. 
The feeding of a patient after intubation is highly important, and the physician 
should personally superintend it. We should endeavor to find what the child will 
swallow best. Not long since I had a little patient that was extravagantly fond of 
bananas, which she would eat without the least difficulty, while she would refuse 
almost entirely all other food. Bananas and cracked ice formed the diet for several 
days together, with a very small amount of semi-solid food. Not a very nourishing 
diet, to be sure, but sufficient to support life. Some patients swallow with very little 
difficulty, indeed, while others swallow poorly. If the head of the tube fits too 
tightly in the larynx there will be greater difficulty. The artificial epiglottis is of 
great assistance in swallowing. In using the rubber attachment, however, one must 
first see that it is properly attached to the tube, and that it does not become dis- 
arranged during its introduction. 
It appears to me that the proper method of comparing the value of intubation 
and tracheotomy is not by comparing the number of cases operated upon alone, 
but also by comparing the proportion of recoveries in each case with the total num- 
ber requiring an operation. For example, taking one thousand cases of croup, how 
many will be saved by tracheotomy. We may safely say that the operation will not 
be allowed in more than one-fourth of the cases, or two hundred and fifty. If we 
save twenty-five per cent, of this number, which I believe is above the average, we 
will thus save sixty-three of the one thousand. On the other hand, out of the one 
thousand cases we would be allowed to perform intubation upon every one, and if we 
save twenty-five per cent., which is below the average, it will give a total of two 
hundred and fifty saved in contrast to the sixty-three by tracheotomy. SECTION XIII-LARYNGOLOGY. 
101 
Intubatlon has become a thoroughly established operation, and its future no 
doubt will be more brilliant than its past. 
Dr. M. J. Stern, of Philadelphia, in closing the discussion, remarked-I have 
seen one case of chorea of the cords. A young female, who had just recovered from 
post-diphtheritic paralysis, presented herself for a slight catarrhal affection, at the 
office of Dr. J. Solis-Cohen, whom I was assisting. She was extremely hysterical, 
and after the younger Dr. Cohen and myself discoursed, in her presence, of some rare 
affection, she always presented herself some few days later with characteristic symp- 
toms of the disease described. On the day mentioned, I examined her larynx, found 
it normal, and turned to the medicine chest to obtain some non-irritating application. 
On my return I was horrified to find her suffocating. I was sure she had no foreign 
body in her mouth, and hurriedly got a tracheotomy knife, laid her on the floor, and 
then emptied a pitcher of ice water over her face. To my relief she drew a deep in- 
spiration, and was soon able to be carried home. A laryngoscopic examination could 
not be obtained for four or five days, and when it was obtained, the bands showed a 
peculiar wavy motion, and quick jerks toward each other, and she was again seized 
with a paroxysm. It was accompanied by a peculiar bark-like cough. She was 
unable or unwilling to talk. Spontaneous cure in about three or four weeks. 
Dr. M. F. Coomes, of Louisville, Ky., read a paper entitled- 
DELETERIOUS EFFECTS OF TOBACCO ON THE AIR PASSAGES. 
EFFETS DÉLÉTÈRES DU TABAC SUR LES VOIES RESPIRATOIRES. 
DIE SCHÄDLICHEN WIRKUNGEN DES TABAKS AUF DIE LUFTWEGE. 
BY M. F. COOMES, A.M., M.D., 
Of Louisville, Ky. 
For a period of sixteen years I have observed carefully the effects of tobacco on the 
air passages. These observations have been made upon persons in all the walks of life, 
of all ages-from twelve or fourteen years to the centenarian. 
The consumption of tobacco in the United States is mainly by chewing, and espe- 
cially is this true of the population of the rural districts. The cigar smoker comes 
second in the order of a consumer, as regards quantity, then the pipe smoker, then the 
cigarette smoker, then the class that take snuff by the nose-the ordinary snuffer, who 
is met with all over the world-and lastly, what is known in the southwestern part of 
the United States-for I believe that it is confined to that locality in the main-the 
snuff dipper, or commonly called a "dipper." 
This latter mode of using tobacco is confined almost exclusively to women in the 
lower and medium walks of life. Many of them become absolute slaves to it, using 
enormous quantities of the snuff which in the market is known as Scotch snuff, and is 
manufactured from tobacco stems and cigar stumps. It is used by dipping a mop into 
the snuff, and then introducing the mop into the mouth. Many of them keep con- 102 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
stantly rubbing their gums and teeth with the mop, while others simply suck the mop 
or chew it. In individuals who use tobacco in the above manner the gums are usually 
very red and, as a rule, they are pushed well down on the teeth. The buccal surface 
of the cheeks, and in many of them the entire buccal, pharyngeal and laryngeal mucous 
surfaces are in a state of congestion similar to that which is met with in persons who 
are habitual cigar or pipe smokers. I think that there can be no doubt that many of 
the " dippers "of snuff induce a chronic inflammatory state of the larynx, trachea and 
larger bronchial tubes by inhaling the tobacco in this finely comminuted state. A sim- 
ilar condition is met with in persons who handle tobacco in the leaf or comparatively 
dry state. Within the past year I saw a case of phthisis pulmonalis which I am satis- 
fied was hastened to a fatal termination by constantly inhaling the dust from tobacco, 
which kept the air passages and lungs in a perpetual state of irritation. 
Before leaving the subject of snuff dipping, I will state that one of the worst cases 
of tobacco amblyopia that I ever saw resulted from dipping snuff. So far as local 
effects of tobacco are concerned, I believe that the least amount of harm results from 
chewing. A chronic pharyngitis is one of the most common results from its use in 
this way, and in this connection I may say that I believe that many a clergyman's sore 
throat is nothing more nor less than a tobacco throat, which may result from either chew- 
ing or smoking. 
I have seen two well marked cases of buccal inflammation resulting from chewing 
tobacco. The first occurred in the person of a young mechanic who had been chewing 
fora number of years. The entire buccal cavity and pharynx were acutely inflamed, 
the mucous membrane being as red as scarlet. After making diligent inquiry into 
the history of his case, I could find nothing to account for the trouble, unless it was 
the tobacco. I advised him to quit the tobacco, and gave him a soothing mouth 
wash. 
In the course of eight days he was well, and asked my advice about using tobacco 
again. I told him to try it. He did so, with the result of having a very sore mouth 
and pharynx for several days, which got well under the plan of treatment pursued in the 
former instance. He made numerous efforts to indulge in his old habit, but always 
with the same unpleasant results. The second case was similar to the first, but much 
less severe. 
The greatest injury to the air passages from the use of tobacco results from smoking. 
The habit that many persons have of carrying the smoke into their lungs often develops 
irritation of the mucous membrane lining the trachea and larger bronchial tubes, which 
finally results in chronic inflammation of the parts thus irritated. 
It is not an uncommon thing to find the nasal mucous membrane of those who exhale 
smoke through their noses in a hypertrophic and hemorrhagic condition. In such cases 
the hemorrhage is not profuse, but the handkerchief is often soiled with blood as the 
result of an ordinary effort at ' ' blowing the nose. ' ' Such membranes bleed upon the 
slightest provocation. In many persons thus affected the sense of smell is impaired ; 
in some instances it is almost destroyed. 
In numerous instances I have seen the entire anterior portion of the nasal mucous 
membrane in a condition which resulted in the formation of a bloody crust or scab, the 
removal of which was often followed by considerable hemorrhage. 
In such cases the cessation of the tobacco was usually followed by marked improve- 
ment in the course of a few days. A snuff composed of powdered borax £ ss, and 
powdered camphor gr. x, affords great relief in such cases, by inducing increased 
activity in the glands of the nasal membrane. 
The question very naturally suggests itself, why is it that the throats of smokers 
are, as a rule, in a worse condition than those of chewers. There are two reasons 
why smokers suffer more than chewers, the chief one being, I think, the fact that an SECTION XIII-LARYNGOLOGY. 
103 
inferior grade of tobacco is used by the smoker ; secondly, the smoke is carried into the 
mouth hot, and were it not for the constant secretion which goes on, the walls of the 
mouth would soon become covered with nicotine, but instead, a portion of it is absorbed, 
and the remainder expectorated with the saliva or swallowed. It is possible that all of 
this irritation is not due to the presence of nicotine, but to the burning of potash salts, 
which is present in large quantities in all grades of strong tobacco-indeed, it may be 
seen in the pure crystalline state on the stems. How much is due to the one or the 
other is a matter which I have not attempted to investigate, but it is certain that one 
or both of these agents play a very important part in the production of the diseased con- 
ditions met with in the noses and throats of smokers. I am fully satisfied that the throats 
and noses of more than 95 per cent, of smokers will be found in a diseased condition, 
i.e., not in a normal physiological condition. The entire mucous surfaces of the 
pharynx and larynx are in a chronically hypersemie state, or in a state of chronic 
inflammation. 
I have seen great numbers of smokers with the epiglottis and true vocal cords in a 
highly congested state. Many of those with congested cords suffer greatly from a per- 
sistent hacking cough. Their efforts to remove the tenacious mucus which accumulates 
in the pharynx and larynx makes their presence disagreeable, to say the least of it. 
Throats in this condition are always aggravated by exercise, and particularly by 
prolonged speaking, as in ministers and lawyers, and other public speakers. 
Persons who are suffering with tobacco throats always experience much more diffi- 
culty in recovering from acute inflammatory diseases of the air passages than other per- 
sons thus affected. 
DISCUSSION. 
Dr. Stockton, of Chicago, remarked, I cannot agree with the author on this 
subject, for I have found that chewers suffer more than smokers do. If the injuri- 
ous effects are due to the salts of potash and the alkaloid nicotism, why do our laryn- 
gologists use chlorate of potash in solution as a cleansing gargle. Potash is prescribed 
to allay congestion of mucous membrane, yet the worst case of atrophic rhinitis I 
ever saw was caused by the use of potas. chlorate. The cigar smoker does not get 
very much nicotine, because he only holds the smoke in his mouth for a short time, 
then he lets it escape, and the nicotine is driven off by the heat of the burning leaf, 
to some extent. The cigarette smoker inhales the smoke, so that it is taken into the 
system. The chewers, on the contrary, get the soluble alkaloids, the saliva being 
a very good solvent; in my experience the chewer is the most severely affected of the 
tobacco users. 
Mr. Lennox Browne, of London, bore testimony to the frequency of injurious 
effects on the throat from the use of tobacco, and was in the habit of interdicting it 
in all cases of obstinate pharyngitis occurring in smokers. He was of the opinion 
that chewing was more likely to be harmful than smoking, and there was some evi- 
dence to show that the cigarette, if smoked through a mouth piece, and if not inhaled 
into the lungs, was the most innocent form. The experience of the speaker led him 
to believe that snuff taking was, considering the proportion of snuff takers, a frequent 
factor in the production of nasal polypi. 
Dr. Coomes, in closing the debate, said that he thought Dr. Stockton's remarks 
concerning the effects of the chloride of sodium were at variance with the expe- 
rience of every one who used that agent for cleansing the throat and nose. He 
considered it one of the best that could be used. He had ceased to use all of the 104 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
potash salts, save the bromide, which he used frequently as a gargle. He said that 
the mouth, pharynx and nose of a smoker virtually became a pipe stem, inasmuch as 
the smoke came in contact with the walls of these structures, and were it not for 
the moisture of the parts they would certainly become covered with the same black 
mass that is found in the stem of the pipe, thus affording a full opportunity for the 
absorption of the nicotine. SECTION XIII-LARYNGOLOGY. 
105 
FIFTH DAY. 
Meeting convened at 11 A. M. In the absence of the President, Mr. Lennox 
Browne presided. 
On motion of Dr. Wm. Porter, the following resolution was passed :- 
Resolved : That the President and Secretaries, with such members of the Council 
as have attended the Congress, be empowered to decide upon the publication of all 
papers presented at the Section. 
On motion of Prof. Ingals, the following resolution was passed :- 
Resolved : That all papers on our programme which have been passed for future 
consideration be read by title and referred to the President, Secretaries and members 
of the Council, as provided by resolution, excepting such as may be called up by the 
Section to be read at this meeting. 
Prof. Ingals also moved, and motion seconded, that proof of all papers read, 
as well as of all remarks made by gentlemen attending the Section on Laryngology be 
furnished to the authors for correction, and that the authors be given a reasonable 
time for such corrections before the Transactions are published. 
Prof. Ingals moved, motion seconded and passed, that the Secretaries be 
directed to publish with our proceedings, if possible, a list of the members who have 
been in attendance. 
THE RELATIONS OF PHONATION TO CANTATION, WITH SOME 
PRACTICAL DEDUCTIONS. 
LES RAPPORTS DE LA PHONATION AVEC LA CANTATION ET QUELQUES 
DEDUCTIONS PRATIQUES. 
DAS VERHÄLTNISS ZWISCHEN STIMMBILDUNG UND GESANG, MIT EINIGEN PRAKTISCHEN 
SCHLUSSFOLGERUNGEN. 
BY EPHRAIM CUTTER, M. D., LL. D., 
New York City. 
The object of this paper is to note some of the principles that obtain in phonation 
and cantation, and to suggest what may be of interest to laryngologists and voice teach- 
ers in particular and the public in general, to wit : that as there is but little physical 
difference between the voice in speaking and the voice in singing, there is a pertinence 
in proposing that the rules of song may, in some measure, be applied to speech, and 
that speech may be more like music ; agreeable to hearer, easier to speaker, more intel- 
ligible and more effective. 
This matter I have already brought to the attention of the Music Teachers' National 106 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Association at Indianapolis this season, but I feel that the presentation should also be 
made to the specialists who treat the vocal organs and who have the best mastery of 
their pathology, and because the voice teachers naturally look to throat specialists for 
support in acting on suggestions based on the physics of song and speech. 
I. NO VOICE WITHOUT A LARYNX. 
Hence the terms "head," "chest" and "abdominal" tones are misnomers. If it 
can be shown that there are no chest or abdominal tones, when the larynx is disabled, 
this proposition is enforced. 
Case, to Illustrate.-In April, 1866, I removed, by " thyrotomy modified" by dispens- 
ing with the usual tracheotomy tube, the voluminous growth I have in my possession. 
Previous to this the patient suffered with complete and continuous aphonia, for about 
two years or more. After the operation she spake and sung, and continues to do so, for 
a period of over twenty-one years. Now, so long as the larynx was occupied by the 
tumor, she had no voice, no head, no chest and no abdominal tones. If the head, chest 
and abdomen were competent to produce voice or tone, why did they not do it while the 
larynx was held by the tumor ? The fact is that these names were given when the 
state of knowledge was not as complete as at present. They satisfied, but had no good 
foundation in the actual facts in the case. 
This is not peculiar to this department of human knowledge. The nomenclatures 
of disease suffer terribly from the want of correspondence with facts in the case. Names 
have been conferred on things that did not exist; things thought to be integral, palpable 
and essential parts of the subject. 
As new light is shed on the hidden parts and they are displayed in the bright sun- 
light, as in laryngology, erroneous conceptions are dissipated and new nomenclatures 
must result. 
But what shall be said when the teachers of the voice cling to the state of knowl- 
edge that existed before laryngology ? as is done by some to-day. As well might the 
electrician consider the state of knowledge complete before the year 1840, and ignore 
the great advances since made. It is humiliating to see people of the present day using 
the lines and plummets of past times, that have been superseded. Indeed, there is, I 
think, more trouble in the advancement of the human race, from this very idea of try- 
ing to measure our present knowledge with the lines and plummets of a past and out- 
grown age. 
So, to repeat: There is no voice without a larynx. As well might one speak of the 
head tones, chest tones, or bellows tone of a church organ. To be sure the chest, the 
abdomen and the head have much to do with the production of the voice, and modify 
it when diseased, but there is no sense in telling a person to produce a head tone, a 
chest tone, or an abdominal tone, when it has been shown that without the larynx there is 
no voice of any kind. 
Why not say laryngeal tone ? 
II. OFFICE OF THE CHEST AND THE VOICE. 
The chest may be considered as simply a part of the bellows apparatus of the human 
organ of voice. For good service it should be in good condition. Broken ribs or spine, 
pleurisy, pneumonitis, dropsy, empyema, consumption, asthma, all interfere with good 
voice. 
So that the environments that dressmakers embarrass the chest with are bad for the 
voice. It is wonderful what vocal results a prima donna will produce on the stage 
while the chest is encompassed by a cuirass that fixes the ribs so that the inspiration 
heaves the upper and most immobile part of the thorax. It must be torture; one can- 
not but wonder what could be done in the same circumstances with the corset left out. SECTION XIII-LARYNGOLOGY. 
107 
Professional people, like doctors, may pride themselves as to their position and influ- 
ence in the world, but let a dressmaker assert herself, and she will undo the dicta of 
us all, though we were kings or presidents. 
If it were the fashion for vocalists to use the plaster jackets of Sayre it would be 
better, as he fixes them on during a full inspiration and puts a big pad over the stomach, 
to make room for food eaten. 
HI. THE ABDOMEN 
should be expansible and its muscles in good condition. Peritonitis, gastritis, enteritis, 
diarrhoea, dysentery, kidney, liver or pancreatic disease, etc., are bad for the voice. 
The chest and the abdomen may be considered as the complete human bellows, which 
must be under control of the will, to avoid too lavish use of the breath and to keep up 
a given pressure-just as the bellows in a church organ is weighted, to give the desired 
power of tone varying with the will of the organ builder. As a large bellows is better 
than a small one, so a large chest and abdomen are desirable things for a song or speech. 
IV. THE HEAD. 
The head is that part of the human body above the neck. While it does not, of 
itself, make a tone in phonation or cantation, as has been supposed, still it is indis- 
pensable. 
Without the mouth, the pharynx, the nose, the ears and cerebral nerve centres, 
normal speech and singing would not occur. From what has been said, it is clear that 
oripulations modify the laryngeal sounds into song or speech. 
The pharynx must be clear and normal, as shown by the disastrous effects on the 
voice when it is diseased or when the palate is cleft. 
These results are direct and indirect. I have seen cases where adenoid hypertrophies 
of the pharynx caused inability to sing properly, by sympathy alone, as far as I could 
judge. 
Patients with tumors of the pharynx cannot be good singers or speakers, according 
to my experience. 
The nose, too, must be in good condition for normal voice. If it is occluded by 
growths, by deviations of the turbinated bones, if the maxillary antra and the frontal 
sinuses are closed and diseased, there cannot be normal voice, chiefly, I think, because 
the conformation is so altered that the natural over-tones of the voice are altered or 
removed, and thus the timbre is interfered with. This subject alone is worth a paper 
by itself. 
Mme. Luisa Cappiani, of New York (7%e Voice, August, 1887, page 126), takes 
the ground that the vomer, ethmoid and turbinated bones, with the superior maxilla, 
form a sounding-board, "without which the tone will be vulgar and rough, bare 
of sympathy and devoid of æsthetic expression." This is a fine idea, and tallies 
with the position taken here. The same writer takes the ground that the tonsils never 
should be removed by the knife. She insists that " only a portion of the tonsils should 
be removed by galvano-caustic or astringent applications." 
A strict diet of beef has reduced the tonsils, in my experience. I never saw any 
surgeon cut out the whole tonsil. I agree with the lady, if she would not make her 
dictum universal, but partial. 
The ears are necessary; for the congenitally deaf are dumb, as a rule. Again, as 
we have color blindness, so we have sound or tone deafness, which teachers of the voice 
find out to their sorrow sometimes. 
The ear must regulate the larynx, else how can one sing in time or tune ? 
The cerebral nerve centres join in the work of phonation and cantation with their 
inner consciousness, to indicate what the soul wants to communicate, express or engage 
in, by means of the organs of voice. 108 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
In no more marked manner are emotions made manifest than through the voice and 
in the universal language of music. To show that the writer is not alone in this posi- 
tion, he would refer to a meeting of the London Musical Association, held in 1879, 
when Herr Emil Behnke gave a lecture on the mechanism of the voice, and Mrs. Jenny 
Lind Goldschmidt and her husband, among others, were present. Mr. Behnke main- 
tained that the vocal tone came from the larynx only, and ridiculed the terms " chest, " 
"head" and "falsetto," as applied to the registers. Mr. Lennox Browne compli- 
mented Herr Behnke on his successful demonstration. 
The writer gave these views to the world in January, 1873, six years before.* 
V. THE LARYNX. 
What musical instrument, or part of what musical instrument, is the larynx like ? 
It is unique and unlike any musical instrument, or part of a musical instrument. 
It is a pipe to the human musical instrument, where the air enters and leaves by the 
same lumen. The Jewsharp and penny whistle have this feature, but they are in- 
capable of the high musical effects that come from the human larynx. 
Again, the vocal cords themselves are attached in front to the angle of the thyroid 
cartilage, so that they do not separate anteriorly, while posteriorly they separate widely 
during respiration, like the letter V, when the angle of the V represents the front 
insertion of the vocal edges and the free ends of the V represent the arytenoid carti- 
lages. Close up the legs of the V, and thus the vocal platform is made, while the vibra- 
ting chink is almost exactly what forms the tone in a cornet by the use of both lips. 
In a cornet the edges of the lips vibrate as the cords do, but here the parallel ceases. 
The vocal cords at their hinder parts (i. e., the free ends of the V) are stiffened and 
stretched over projecting horn-like points called the arytenoid cartilages, which by 
coming together, and stretching backward, through muscular action controlled by the 
will, approximate the posterior ends of the vocal cords and give the required tension to 
produce a given note, automatically. 
In these details of anterior insertion in one point, posterior insertion of the right 
vocal cord in the base of the right arytenoid cartilage and the left vocal cord in the 
base of the left arytenoid cartilage, is the uniqueness of the human larynx. There are 
other particulars touched on here. 
The technical descriptions of the larynx are so familiar that there is no need here to 
lay them down again. 
WHAT IS SEEN IN THE LARYNGOSCOPE DURING PHONATION. 
Take "ah," in the writer's case. Note that the arytenoid carti- 
lages come within half an inch of each other, and are a little stretched to the front of 
the mirror. In place of the cavity of the larynx, is seen a platform of pearly white 
sheen, stretching across the larynx. In the median line, antero-posteriorly (the mirror 
reverses this), is a chink running nearly the whole length of the vocal cords, resembling 
the opening of the lips when a cornet is played-narrow. 
The action is quick as a flash, the length of the tone being governed by the time 
taken to say "Ah." The termination of the sound is caused by the sudden withdrawal 
of the arytenoid cartilages to the gate recesses outward and the resumption of the open 
windpipe by the sudden withdrawal of the vocal cords' platform aforesaid. 
and the same phenomenon occurs, only the 
Now, phonate "Ah" 
* Boston Journal of Chemistry. SECTION XIII-LARYNGOLOGY. 
109 
length of the longitudinal slit in the vocal cords platform is half the length of the 
" Ah." 
The most striking points to be seen are: the movements of the arytenoid cartilages, 
the building of the vocal cord platform, its sudden removal, and the amount of chink 
between the vocal cords. 
No matter what the pitch of the phonation, the same phenomena are seen, varied 
only as follows : The higher the voice, the smaller the chink, and the lower the voice, 
the larger the chink. So that the larger the larynx, the heavier and lower the voice. 
This corresponds with what is observed daily: Men have lower voices than women 
and children. 
Phonation, then, in its laryngeal aspect, is essentially a matter of short vibration of the 
true vocal cords. 
But I have given only the word "Ah." Let me give the sentence : "Ah, few shall 
part where many meet," with the observer's eye on the laryngoscope, as follows: "Ah 
ew al at ar en ey e "-an unintelligible melange of phonation. 
Now, I remove the laryngoscope and say the same, and we have the result, of which 
the following is a brief analysis:- 
The breath is inhaled. 
"Ah "-Vocal cords sound "Ah," and the sound is cut off by the opening of the 
vocal cords. 
' ' Few ' '-Lower lip closed against upper teeth, sibilant sound with expiration ; 
ew sound from the vocal cords, closure of the sound by withdrawal of the vocal cords. 
"Shall"-" Sh " through lips partially opened; a sound from vocal cords, with 
descent of tongue tip to behind the lower incisors; "11," elevation of the tongue tip to 
front hard palate; mouth opened and vocal bands cease to vibrate at the same instant. 
"Part"-Lips closed; short expiration; "a" sound with vocal cords; closure of 
lower jaw, so as to bring the anterior third of tongue against the hard palate in front 
of mouth; sound of t by mouth alone, the tip of the tongue suddenly leaving the 
hard palate and mouth opening with forced expiration. 
"Many"-Vocal cords sound m with mouth closed; lips open suddenly; tip of 
tongue rises to behind the incisors, and a sudden opening of the mouth, with a cessa- 
tion of the vocal-cord sound, forms the ny. 
"Meet."-Lips being closed, the vocal cords sound me with sudden opening of the 
lips; t is formed by a sudden closing of the lips, while the tongue tip remains behind 
the front lower incisors, and the anterior third of tongue touches the hard palate in 
front, followed by a sudden opening of the mouth with an explosive delivery of the 
breath. 
SINGING OK CANTATION. 
The following are the phenomena occurring while the same sentence is sung on F, 
fourth line, bass clef :- 
Breath inhaled. 
"Ah !"-Expiration. Vocal cords form "Ah", which, when the time is up, is 
ended by opening the vocal cords. 
"Few."-Lower lip against the upper teeth, released with aspiration sound; ew-sound 
continues during the half note, and ceases with the withdrawal of the vocal cords. 
" Shall."-Sibilance with closed teeth; vocal cords sound sha, at expiration of the 
time the mouth closes with the tongue tip applied to the hard palate in front. 
"Part."-Lips closed; released with expiration while the vocal cords sound abas 110 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
the lips open. At the expiration of the time the tongue tip touches the hard palate in 
front, and immediately falls between the lower incisor teeth. 
"Where."-Aspiration through open lips and vocal cords sound at the same instant; 
at the expiration of the time the vocal cords withdraw. 
" Many."-Lips closed and vocal cords sounding, the lips open and the vowel sound 
is formed till the expiration of the time of the note, when ny is formed by the tongue tip 
against the hard palate in front, its release and sound of the vocal cords. The tone 
ended at the expiration of the time by the vocal cords ceasing to act. 
"Meet."-Lips closed and vocal cords sound; lips open; vocal cords hold on to 
the sound e till the time is up, when the note is finished by the tongue tip touching the 
hard palate, and suddenly dropping, while the vocal cords stop. 
This description might be carried to other sentences, but it is enough to show the 
relation of phonation to cantation. In both acts the vocal cords are the basic source of 
sound. In both this basic sound is modified by the action of the mouth, ' ' oripula- 
tions." in very much the same way. The great distinction between them is that the 
vocal cords in singing vibrate for a longer time than speech. To prove this let the 
same example be sung staccato. If sung very fast and very short, the effect is almost 
the same as in reading. In this view the matter of the prolongation of the singing 
voice, may be considered a harmonious prolongation of the vowel sounds of the words, 
while the oripulations are about the same. It must not be said that oripulations are 
not sufficient to render speech visible, for it is now a common thing to see deaf-mutes 
read correctly from the lips and mouth what is said by persons in ordinary conversa- 
tion. The speakers use their vocal cords, but as the deaf-mutes cannot hear them, it 
must be inferred that they get their ideas of what is said from the lips and mouth, 
because I have noticed that the utterances were made with the mouth wider open than 
usual, so that the mutes almost see the uvula. 
IS PHONATIOX SUBJECT TO THE SAME LAWS OR LIKE LAWS AS CAPTATION ? 
I think so. Singing differs, as has been seen, mainly in the prolongation of the 
basic laryngeal vowel sounds. Otherwise they are alike in pitch or key, in timbre or 
overtones, in atmospheric air, in the working of the chest and abdominal bellows appa- 
ratus, to say no more. Why then should there not be an application of some of the 
rules of harmony to speaking as is done to singing ? This question has come to me 
during the preparation of this paper and I cannot but ask it here. Aware that the late 
Professor L. B. Monroe, of Boston, tried to work this up, I do not feel that I can decide 
as to the application, still there can be no harm in suggestions made in the hope that 
those who are especially conversant and interested in this important subject may, per- 
haps, catch a hint which may lead to positive results. Surely there is a need. I have 
followed public speakers with a view of ascertaining the pitch of their phonation, and 
have been surprised at the variations of tone running through an octave at least, with 
none of the symmetry, order and harmony of musical progression. The effectiveness 
of such speakers as compared with those who kept their voice within two or three tones 
was very much less. The glides, or the inflections, major and minor, seemed used with- 
out any reason. In the responsive readings in church, for example, nearly every gamut 
is heard, but the effect is not harmonious, of course. The voices speak together but do 
not blend. 
Suggestion 1.-For responses or reading in unison, find the key note of the audito- 
rium. Then have the congregation read on the pitches 1-3-5-8. The men might take 
one, the boys three, the girls five, and the women eight ; or in any other way, pro- 
vided the chord is maintained. 
Suggestion 2.-As speaking in a monotone is more easy to be heard, let the speaker 
find out the key note of the auditorium, and if his own voice accords let him adhere to SECTION XIII-LARYNGOLOGY. 
111 
the pitch ; if not, take a third, or fifth, or eighth, and stick to it, only varying three or 
more notes as may be necessary. For example, take F, fourth line, bass clef, as the 
pitch. In quotations use G, fourth space, bass clef. In reading in a dialogue or paper 
where three persons are represented, use A, G, F, employing a different tone for each 
person. Thus the individuality would be readily preserved and could be clearly dis- 
tinguished by the hearer with pleasing effect. 
I have other suggestions to make, but these are enough to show the drift of thought, 
to show that the union of phonation with the rules of hearing is not impossible, and is 
likely to be fraught with the best results by avoiding reckless waste of conflict of 
voice and waves of sound in useless changes of pitch; by making unison responses really 
so in fact ; by better distinction of character in a composite production; by better hear- 
ing of the auditor. 
SYLLABUS OF THE LARYNGOSCOPICAL DEMONSTRATION OF WHICH THIS PAPER IS 
A PART. 
1. Appearance of my larynx during respiration only. 
2. Appearance during the act of laughing, showing both the false and true vocal 
cords. 
3. Appearance during the holding of the breath, and showing the false vocal cords 
forming a closed platform, which shuts the larynx tight enough to stop and hold the 
breath. 
4. Playing on the vocal cords as on an instrument. 
5. Phonation and cantation of a, e, i, o and u. 
APPEARANCES OF LARYNX WHEN " AH " IS PHONATED AND SUNG ON THE FOL- 
LOWING NOTES. 
1. F, first space below the staff, bass clef. 
2. F, fourth line, bass clef. 
3. F, first space, treble clef. 
4. F, fifth line, treble clef. 
In the absence of Dr. Camalt Jones, of London, Dr. Stockton, of Chicago, 
read his paper, entitled- 
THE ACTION OF THE EPIGLOTTIS IN SWALLOWING. 
L'ACTION DE L'ÊPIGLOTTE DANS L'AVALEMENT. 
ÜBER DIE THEILNAHME DER EPIGLOTTIS AM SCHLINGEN. 
BY DR. CAMALT JONES. 
It used to be taught .that the epiglottis had an action like a lid, and that one of its 
functions was, in the act of swallowing, to shut down over the larynx, as if it were 
hinged on at the base of the tongue, and thus to prevent food, etc., from passing into 
the larynx ; and that, in addition, the epiglottis being thus tilted backward and down- 
ward acted as a sort of guide or shute for the food, and directed it, to some extent, 
toward the upper end of the oesophagus, when pushed backward by the base of the 
tongue. 
" It (the Epiglottis) is placed in front of the superior opening of the larynx, project- 
ing, in the ordinary condition, upward, immediately behind the base of the tongue, but 112 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
during the act of swallowing it is carried downward and backward over the entrance 
into the larynx, which it covers and protects." (Swain's " Anatomy," 1876, page 283.) 
"The root of the tongue being retracted and the larynx being raised with the 
pharynx and carried forward under the tongue, the epiglottis is pressed over the upper 
opening of the larynx and the morsel glides past it, the closure of the glottis being 
additionally secured by the simultaneous contraction of its own muscles, so that even 
when the epiglottis is destroyed, there is little danger of food or drink passing into the 
larynx so long as the muscles can act freely." (Kirke's " Handbook of Physiology," 
edited by Morrant Baker, 1872, page 264.) 
These two quotations are sufficient to prove what the old teaching has been, and I 
have never read or heard of any doubt being cast on the lid-like action of the epi- 
glottis. 
For my own part I do not believe that the epiglottis has any such action. 
Occasionally, with the laryngoscope, an epiglottis may be seen hanging backward 
over the glottis instead of " projecting upward behind the base of the tongue," and so 
far covering the larynx that it is impossible to get a view of its interior, and thus sug- 
gesting that it would only have to go a little further back or to shut down a little more 
to form a complete protection to the larynx against the entrance of any foreign body on 
its passage from the mouth to the oesophagus, but when seen in this position it also 
suggests the idea that in vomiting it would be just in the very position to intercept 
material in its passage upward and forward, and to direct it with considerable force 
into the larynx. Are we to suppose that the epiglottis goes with the tide, and when 
the stream flows backward the epiglottis flaps in the same direction, and that when the 
stream flows forward the epiglottis projects toward the tongue? In any case, it must 
be remembered that a pendulous epiglottis is not a normal one, and that when such 
cases come under observation it is generally on account of some throat trouble. 
I have many times noticed, when using a brush to make an intra-laryngeal appli- 
cation, that the epiglottis has the power of closing the sides together ; that is to say, 
that the lateral borders approximate in the middle line over the glottis, and the front 
of the epiglottis remaining erect it folds its two sides together, leaving only a small 
round or oval opening immediately behind the tip of the epiglottis. The epiglottis at 
this time presents an appearance not unlike an infant's tongue when sucking the breast, 
and it is necessary to wait until the patient allows the epiglottis to unfold itself, if au 
application is to be made to the vocal cords, or the brush will pass over the larynx into 
the oesophagus. 
There are also cases where the epiglottis stands up very prominently behind the base 
of the tongue, and can be seen without the mirror by drawing the tongue forward, or 
even only slightly depressing it. In some of these cases the epiglottis can be seen to 
diminish its breadth by folding the sides together, but I have never seen it flap 
backward. 
One simple experiment, which can be tried by any one, also goes to show that the 
backward movement of the base of the tongue necessary to allow the flapping backward 
of the epiglottis is more theoretical than practical. 
Take a little water in the mouth, protrude the tongue as far as possible, then either 
close the teeth firmly on it or grasp the tip with the fingers. Swallow, and it will be 
found that the water passes down the oesophagus in gulps, with perfect ease, and does 
not enter the larynx or cause any discomfort there. It can also be noticed at the same 
time, if the tongue is held in the fingers, that the tongue makes only a very slight effort 
at retraction, but the action of the constrictors of the pharynx is very forcibly brought 
into notice. 
Taking the results of this experiment, Kirkes' statement that even when the epi- 
glottis is destroyed there is little danger of food passing into the larynx so long as its SECTION XIII-LARYNGOLOGY. 
113 
muscles can act freely, and the practical knowledge that in many cases, when the 
epiglottis has been seen to be largely eroded, and yet the patients have been able to 
swallow freely both solids and fluids without any signs of choking, the epiglottis 
can, in some cases, be seen to fold itself together, and that it is not seen to move back- 
ward, I submit that the action of the epiglottis in swallowing is that of closing its 
sides together above the glottis, and not that of shutting down like a lid. 
DISCUSSION. 
Dr. Ingals, of Chicago, wished it not to be forgotten that although there were 
numerous instances in which the epiglottis had been in part or wholly removed, and 
the patients had subsequently been able to swallow without difficulty, yet this fact 
proved nothing as to the function of the epiglottis. Nature has great resources; if 
We lose one hand we get along with the other; and that a hundred people can swallow 
without an epiglottis in no sense proves that in the remaining millions it does not 
close the larynx during deglutition. It was readily apparent that when the epiglottis 
had been lost, with the depression of the base of the tongue and the raising of the 
larynx nature might readily close the larynx, even without the presence of the 
epiglottis. 
Dr. C. Slover Allen, of New York, mentioned a case where syphilis had 
caused destruction of the centre of the epiglottis down to the base of the tongue, 
leaving the sides of the epiglottis with muscular attachments intact. A spasm of 
the pharynx caused by instruments produced an approximation and slight rotation 
of these thin projecting sides of the epiglottis. 
Dr. A. B. Thrasher, of Cincinnati, 0., remarked-These interesting observa- 
tions appear to me to indicate the probable movement of the epiglottis during the 
act of spasmodic contraction of the glottis induced by the local irritation. It does 
not indicate the condition of the epiglottis during the act of deglutition, when the 
action of the larynx is very different, and we may not conclude that there is no differ- 
ence in the movement of the epiglottis during these very different conditions, viz., 
spasmodic closure of the glottis from irritation and the physiological act of deglu- 
tition. 
Dr. Stockton, of Chicago, said-I think that the epiglottis has different action 
at different ages, as in the child I found that the epiglottis closed down closely. We 
all know that the epiglottis can be caused to move backward and forward, as we see 
in examining the larynx and base of the tongue. 
Vol. IV-8 114 
NINTH INTERNATIONAL MEDICAL CONGRESS 
Dr. Wm. Porter, of St. Louis, Mo., read a paper, entitled- 
L THREE SUPRA-EPIGLOTTIC BENIGN NEOPLASMS. IL A NEW 
PROCEDURE IN THE TREATMENT OF CYSTIC GOITRE. 
I. TROIS NEOPLASMES SUPRA-ÉPIGLOTTIQUES BENINS. II. UN PROCEDE 
NOUVEAU DANS LE TRAITEMENT DU GOITRE CYSTIQUE. 
I. DREI OBERHALB DER EPIGLOTTIS BEFINDLICHE GUTARTIGE NEUBILDUNGEN. II. EIN 
NEUES VERFAHREN IN DER BEHANDLUNG DER STRUMA CYSTICA. 
BY WM. PORTER, M.D., 
I. THREE SUPRA-EPIGLOTTIC BENIGN NEOPLASMS. 
(a) Cyst of the Posterior Pharyngeal Wall. 
This was the case of a poor woman whom I saw at my clinic. Her only symptoms 
were dysphagia and the constant irritation of " something sticking in her throat." 
A direct examination revealed a cyst of the mucous membrane, about eight lines in 
diameter and projecting about six lines from the posterior pharyngeal wall, a little 
below the level of the centre of the tonsils. 
With a curved-pointed bistoury the sae was freely laid open by cutting from below 
upward. To the inner surface tr. ferri hydrochlor, was applied and the patient made 
a quick recovery ; though until she ceased her visits there was some thickening at the 
site of the cyst. 
A mucous cyst projecting from the back of the epiglottis and partly covering the 
glottis, is recorded by Mr. Durham (Medico-Chir. Transactions, XLVll), also retro- 
tracheal gland cysts are described by Prof. Gruber, which opened into the trachea. 
(&) PqpiZZoma of the Pharynx. 
A young married lady, of good physique, but very nervous, was recently brought to 
me on account of an incessant cough and some difficulty of swallowing. 
A papillary growth was found, having its origin j ust below the left tonsil but entirely 
distinct from it. The papilloma encroached upon and hung over the left wing of the 
epiglottis. It was as large as an ordinary Malaga grape, and had a thick, strong pedicle. 
The patient declined operative interference, but I succeeded in getting her to con- 
sent to the application of a destructive agent. Chromic acid was repeatedly applied to 
the pedicle, and in a fortnight the nutrition of the tumor was evidently impeded, and 
in another week it sloughed so nearly off that it was easily detached. 
The troublesome cough is almost gone, though the patient has some irritation about 
the original site of the tumor, but this is fast disappearing. 
Luschka ( FïrcAoic's ArcArue«, Vol. l) and Sommerbrodt (Ibid., Vol. Li), have each 
described cases of pharyngeal papilloma, and Mackenzie ("Diseases of the Throat," 
Vol. l), refers to several cases varying in size from a pea to a small grape. This author 
also refers to two preparations of pedunculated tumors removed during life, now in 
the Museum of the Royal College of Surgeons. 
(c) Chondroma of Epiglottis. 
I will merely refer to this case, as a full account of it, with the bibliography to date, 
was published in the American Journal of the Medical Sciences, April, 1879. 
The patient was a stock raiser, age forty-four. A tumor was found occupying the 
left margin of the epiglottis, extending about three lines into the normal tissue. It 
caused difficulty in swallowing and some pain in articulation. It was easily removed 
by rectangular cutting forceps and the margin of the epiglottis rapidly healed. 
The growth was a chondroma directly connected with the epiglottidean cartilage. 
Of St. Louis, Mo. SECTION XIII-LARYNGOLOGY. 
115 
II. A NEW PROCEDURE IN THE TREATMENT OF CYSTIC GOITRE. 
I believe the method of treating cystic goitre herein described will be found as effi- 
cient and less objectionable than the usual one of injecting the sac, after evacuation, by 
a solution of iodine or iron. 
I have but one case to report since adopting this plan. A gentleman, having a large 
cyst of the thyroid gland, consulted me early last spring. The growth greatly inter- 
fered with his comfort, the trachea being pushed far to the left of the median line. 
He objected to the usual treatment by injections of irritating fluids, as I told him it 
would probably necessitate his being confined to his room for some days. 
The fluid was drawn off by means of a trocar and cannula, and six inches of catgut 
steeped in tr. iodine introduced through the cannula. The instrument was then 
removed, leaving a little of the foreign body projecting. As soon as there were symp- 
toms of local inflammation the catgut was removed and a compress placed over the 
region of the cyst. There was very little annoyance and there has been no return of the 
cyst. 
DISCUSSION. 
Dr. E. Fletcher Ingals, of Chicago, thought the treatment new and believed 
it would be found of great value. 
Dr. Stockton, of Chicago, said : In my clinic in Chicago, pure carbolic acid has 
been used to inject the cysts with, and in one or two cases very successfully. The 
quantity of acid used was only about five minims. 
Dr. C. M. Desvernine, of Havana, Cuba, read a paper entitled :- 
A CRITICAL AND EXPERIMENTAL ESSAY ON THE TENSION V 
OF THE VOCAL BANDS. 
UN ESSAI CRITIQUE ET EXPÉRIMENTAL SUR LA TENSION DES CORDES 
VOCALES. 
KRITISCHE UND EXPERIMENTELLE STUDIEN ÜBER DIE SPANNUNG DER STIMMBÄNDER. 
BY DR. C. M. DESVERNINE, 
Havana, Cuba. 
The earlier investigators on the mechanism subserving the longitudinal tension of 
the so-called vocal cords, once acquainted with the distal attachments or their longi- 
tudinal elements, naturally located the active force regulating their distention in the 
muscular apparatus having under its control such displacements of the thyroid and 
arytenoid insertions which directly influence their length, and, as a matter of course, 
the solution of a problem was sought in the study of the anatomy and physiology of 
the thyroid and cricoid cartilages, the crico-thyroid articulations and the set of muscles 
connected therewith. The relative simplicity of this group of anatomical elements 
soon afforded a most accurate morphological description, and their superficial situation 
rendered it exceedingly easy to investigate experimentally the effects of the muscular 
action on the cartilaginous organs between which the vocal ligaments are stretched. 
But there must be some fundamental factor that eludes experimental control, since the 
results arrived at by equally competent observers are no more concordant, even now-a- 
days, than they were more than two centuries ago, in the times of Dodart and de Halle. 116 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
There are, indeed, but few points on which the uniformity of opinion is absolute. 
It is unanimously said and believed that the crico-thyroid muscles distend the 
bands ; but contrasting with this accord as to their functional significance, we have on 
the explanation of the accomplished act a sum of information made up of the most 
conflicting theories, the difficulties residing in the precise determination of the excur- 
sions of the cartilages best adapted to bring on and control the adequate attitudes 
requisite for distinct sonorous tensions. 
The current theories thereon may be classed in two main groups. 
1. Those who affirm that the condition sine qua non of the elongation of the bands 
is the approximation anteriorly of the cricoid and thyroid cartilages, with a corresponding 
depression of the arytenoid region. 
2. Those who assert, on the contrary, that the cartilages are separated or kept apart 
by the crico-thyroid muscles. 
The second group has only a historical interest, the greatest weight of evidence being 
in favor of the first opinion, and their supporters dissenting solely as to which is the 
disturbed cartilage in the accomplishment of the act. 
They are subdivided thus :- 
(a) The cricoid is the fixed point and the thyroid rotates forward and downward. 
This is the classical, widespread theory, and to it are attached the names of Galen, Cas- 
serius, Meckel, Müller, Turk, Henle, Hyrtl, Cruveilhier, Quain, Gray, Sappey, Car- 
penter, Huxley, Todd, Bowman, Schrotter, Heath, Kuss et Duval, Beaunis, Morel et 
Duval, Mackenzie, Wagner, Jaccoud, Hermann, Dieulafoy, de Meyer, etc. 
(&) The cricoid is moved on to the thyroid : Magendie, Longet, Cuvier, Lauth, 
Battaille, Fournié, Jeleffy, Schech, Schmidt, Edwards, Elsberg, Cohen, Stillman, 
Hooper, etc. 
(c) Both cartilages are brought together ; Vesalius, Merkel, Blache and Beclard. 
The crico-thyroid muscle is the active element that has furnished such diverging 
results through vivisections and experiments on the cadaver ; but all these theories are 
necessarily more or less defective, inasmuch as they only give us the detached and 
independent action of a muscular apparatus without full attention to incidental circum- 
stances which modify greatly the ultimate static effects of its contractions. In fact, 
since Winslow's protest against the Galenic theory and Duchenne's (de Boulogne) 
brilliant demonstrations, it is a well established principle in muscular dynamics that, 
physiologically, no muscle ever exerts its mechanical influence independent of other 
forces, either passive or actively awakened in associated automatic centres by the initial 
purposive impulse. The effects of these forces on their respective subordinate organs 
are in the aggregate, and functionally considered as to the end aimed at, co-relative to 
each other ; but if mechanically studied, they are found to be very often antagonistic. 
Their ultimate function, then, is the resultant of their combined action entirely opposed 
at times to the immediate and direct manifestation of the activities of its constituent 
elements. 
In our present case, in no instance do I see that the whole vocal apparatus has been 
placed in conditions natural enough to bring upon its solid frame certain extrinsic 
forces, active and passive, of great moment, and which, through the intricate solidarity 
of the laryngeal structural arrangement, are decomposed and utilized so as to be brought 
to bear on the cartilaginous support of the vocal bands in the best possible manner to 
render the kinetic energy of the crico-thyroids most effective on the length and resists 
ance of the bands. 
The crico-thyroid muscles will approximate the thyroid to the cricoid, or the cricoid 
to the thyroid, or both to each other, according to the relative fixity afforded to its 
insertions ; but neither of these results can be in harmony with the demonstrations of SECTION XIII-LARYNGOLOGY. 
117 
the laryngeal mirror and clinical observation, because the experimental basis has not 
been as exact as it should be. 
Ferrein, the first experimenter on the human cadaver, detaching the larynx with a 
portion of the trachea, studied thereon the effects of a current of air. 
J. Müller solidly fixed the human larynx to a board, nailing down the arytenoid 
and cricoid cartilages, and he succeeded in elevating the pitch of the sound produced 
by a current of air passing through the glottis, by tilting forward the thyroid through 
a weight and pulley. 
Longet, after sectioning the superior laryngeal nerves in dogs, provoked a hoarseness 
readily overcome by approximating anteriorly both cartilages. 
Hooper, in thoroughly etherized dogs, well secured to a dog-holder, stimulated elec- 
trically the exposed superior laryngeal nerves without disturbing any muscular 
attachments. Through a system of levers stuck into the centre of the thyroid and 
cricoid cartilages, and on proper stimulation, before and after section of the medulla 
oblongata, he obtained tracings on a smoked revolving cylinder showing that the cricoid 
was drawn up to the thyroid. 
These are the leading data upon which is based our present knowledge of the physio- 
logical rôle of the crico-thyroid muscles. They teach us that the rotation forward of 
the thyroid alters the tension of the bands, and also the simultaneous approximation 
of both cartilages to each other. They tell us likewise, that the direct stimulation of 
the crico-thyroids displaces the cricoid because it is less solidly fixed than the thyroid, 
and that, on certain conditions the least resistance is in the line of its rotation upward. 
No other evidence do these experiments convey, and by no means do they contain the 
proofs that either of these results is exclusively the constant effect of the muscular 
power under consideration, when associated with the variable and complex circumstances 
attending normal phonation. In fact, during normal vocalization, the increasing 
demand of tension of the vocal bands for a series of ascending prime tones, coincides 
invariably with the progressive ascent of the whole larynx, carried up from its respira- 
tory position, by the powerful supra-hyoid muscles. Consequently, the trachea being 
put upon the stretch, the tension muscle is called upon to act with its insertions under 
the influence of two antagonistic forces unequally distributed on the antero-posterior 
diameter of the cricoid, against its anterior segment through the greatest resistance of 
the anterior portion of the trachea and the unyielding tracheo-cricoid ligament on the 
one side, in contrast with the elasticity of the posterior tracheal ligament on the other. 
The immediate result of these factors is a more or less effective separation of the 
cricoid and thyroid cartilages anteriorly, limited solely in this tendency by the energy 
of the traction force and the elasticity of the anterior inter-cartilaginous ligament. 
Now then, the obliquity of the fibres of the muscle in question is a very unfavor- 
able mechanical disposition for it to overcome resistances thus distributed, and the worst 
possible conditions, hindering such an evolution of the muscular power, are created by 
the unsteadiness of the fulcrum as represented by the crico-thyroid articulations. Under 
these conditions, the significance of the end points of the cricroid, as to motility and 
resistance, are necessarily reversed, and the form changes consequent to the active force, 
being inversely proportional to the resistances acting in opposition to the movement, 
the effective traction force has to resolve itself, in this case, in the direction of the crico- 
thyroid articulations, as representing the initial absolute motility, and not in the line 
tangential to the arc of rotation of the cartilage. As opposed to these interpretations, 
there is the general assertion that the movement allowed by the crico-thyroid joints is 
of a rotatory description, the articular surfaces revolving on their transverse axis. But 
this limitation is not correct, since the articular surfaces are susceptible of a general 
gliding motion impressed upon them and directed by the powers acting on their levers. 
The geometric sections of the opposed surfaces and the lax capsular ligaments, with their 118 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
reinforced antero-inferior fasciculi, permitting and limiting, respectively, the displace- 
ment, but not determining it. 
My own investigations to determine how the tension of the bands is regulated, rest 
exclusively on clinical observation, dissections and experiments on the cadaver. Vivi- 
section led me previously to certain misinterpretations. 
The narrow compass assigned to us on this occasion compels me to omit all technical 
description. 
My leading object has been to determine how the bands are influenced by different 
positions of the cricoid and thyroid cartilages in distinct positions of the larynx, and 
to ascertain under which circumstances the maximum distensive effect is obtained. 
I proceeded thus:- 
Fixing the thyroid solidly in its cadaveric position and acting on the cricoid so as to 
approach it to the thyroid, it was found difficult to execute the required rotation with- 
out a concomitant slipping movement upward and backward. To succeed in the 
attempt the traction had to be directed forward and upward, and then certain results 
originated utterly incompatible with the possibility of such a rotation ever presiding 
by itself over the longitudinal tension of the bands-above all, in the respiratory posi- 
tion of the larynx. 
Thus, the length of the glottis from its extreme anterior point to the inter-arytenoid 
region measured twenty-five m. before and after the experiment; the width of the 
glottis was not reduced and the bands assumed a thick, lax appearance. The aryte- 
noids were invariably depressed three m. at least. 
The cricoid being properly fixed, the uncomplicated rotation of the thyroid downward 
yielded similar results. Repeating the previous experiment, but allowing the cartilages 
to glide over as it is their natural tendency-forward in the case of the thyroid and 
backward with the cricoid. Then a certain extension of the bands takes place, but 
they remain comparatively lax even after previous coaptation of the arytenoids. 
Now, then, by the gradual elevation of the thyroid to its full capacity, the crico- 
thyroid space gains five m. in height over the six and a half that it has when undisturbed; 
the upper surfaces of the bands are depressed four m., and they become somewhat 
resilient. The cricoid is less movable. Thus prepared, if we proceed to study the 
problem under discussion, we learn certain facts of great interest. The cricoid being 
firmly secured, if we tilt the thyroid forward and downward, an actual distention of 
the bands takes place, of one and a half m. as an average ; but their free border is yet 
lax, they are easily turned over and they remain so. 
Reversing the basis of the experiment, if we maintain the thyroid absolutely 
immovable, and we act on the cricoid, three things may happen:- 
1. The cricoid being rotated strictly upward as far as possible, then we have depres- 
sion of the arytenoid region, slight elongation of the bands, slight diminution of the 
width of the glottis, vocal bands thick and lax at their free border. 
2. The cricoid is elevated and allowed to slide backward, then we obtain elevation of 
the arytenoid region, elongation of the bands from twenty-five to twenty-six and a half 
m., the width of the glottis is greatly reduced, the bands less thick and lax than in 
any of the previous cases. 
3. The cricoid being acted upon in the direction of the fibres of the crico-thyroid 
muscles, then it is readily and energetically displaced backward and upward, the 
glottis is reduced to a mere chink, the length of the bands increased to 28 m., the ary- 
tenoids are elevated, the vocal bands become narrow and resilient, their free border is 
held in place and the crico-thyroid space is not lessened in height. 
From this inquiry, we may conclude, I think, that the excursions of the cricoid 
cartilage are the most effective in results on the modification of the bands, and that they 
are not invariably the same under all circumstances. That it influences in a twofold SECTION XIII-LARYNGOLOGY. 
119 
and contrasting manner the physical properties of the vocal reed, according to the 
position of the organ, regulating thus and controlling in association with other factors 
the oscillative phonetic antagonism of their two dimensions. 
The crico-thyroid muscle, then, is the direct longitudinal tensor when in favorable 
conditions to retract the cricoid, and it is also a direct factor in the transverse distention. 
Its participation in the width of the bands is in direct relation to the capability allowed 
to it in elevating the cricoid by the greater or less depression of the whole larynx, the 
thyro-arytenoidei contracting and swelling proportionately to furnish the bands with the 
sonorous tension that they progressively lose as the organ descends, and thus, by the two 
sets of muscles, a continual process of compensation is kept up. 
This intimate solidarity between the cricoid and the vocal bands is to be explained 
by the presence of a fibro-elastic structural arrangement incompletely described by 
anatomists and not duly appreciated functionally by physiologists and laryngologists. 
I refer to the inferior thyro-arytenoid ligament. The best reputed authors give us dis- 
similar descriptions of it. 
Fournaié, Béclard, Huxley and de Meyer describe it as constituted by the general 
sub-mucous fibrous investment of the larynx, adherent to the thyroid anteriorly, to the 
arytenoid posteriorly, and below, to the inferior border of the cricoid (Fournié, Béclard). 
Quain, Sappey, Gray, Heath, Boekel, Morel et .Duval, speak of it being the upper 
free border of the lateral crico-thyroid membrane springing from the upper border of 
the cricoid according to Sappey, Gray and Mackenzie, and from the inner edge of the 
upper border according to Quain. 
Based upon numerous dissections and transverse sections of the larynx, we come to 
the conclusion that the ligament in question is not a mere membranous structure. It 
is a large, thick, fibro-elastic pyramidal body, as shown in the direct photographs which 
I present, bounded internally by the sub-mucous fibrous investment of the larynx, 
externally, by a membranous expansion attached to the outer surface of the cricoid 
cartilage, and below, by the cricoid cartilage itself. The base measures no less than 
five m. half way from its anterior to its posterior extremities, and from it spring elegant 
and strong offshoots of fibro-elastic tissue, filling up the space included between the 
lateral walls, to ascend to the apex of the pyramid, where they terminate intermingled 
with and capped by the longitudinal thyro-arytenoid fibres. 
This substruction is both anatomically and physiologically a most integral part of 
the vowel apparatus, and it represents in man, together with the cricoid cartilage and 
crico-thyroid muscles the highest evolutive adaptation of the elementary disposition 
existing in certain lower vertebrates endowed with modulated voice. 
In the tracheo-bronchial syrinx of song birds, for instance, we have in its bare sim- 
plicity the scheme of what is essentially phonogenous in the human larynx. The thy- 
roid and cricoid are represented by the ossified inferior segment of the trachea and 
upper portion of the bronchi. The vocal bands are constituted by a thick and loose 
segment of the general fibro-mucous lining membrane, adherent to trachea and 
bronchi, anteriorly and posteriorly. During phonation two sets of distinct perpendicular 
and oblique tracheo-bronchial muscles, double in the mucous membrane and stretch it, 
elevating the bronchial ring and shifting it backward under the steady tracheal 
extremity. 
This is fundamentally the mechanism of the human larynx, where the vocal bands 
being furnished with a direct transverse tensor, the kinetic energy of the crico-thyroids 
is brought to effect distinct form changes by the interchange of the points of absolute 
motility and resistance through extrinsic forces, regulating the general position of the 
vocal organ. 
From the adduced facts and considerations I am led to attribute to the crico-thyroid 
muscles an active intervention in both the longitudinal and transverse dimensions of 120 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
the vocal bands. If the larynx is in the respiratory position, then it draws up the ante- 
rior segment of the cricoid, the arytenoid segment is depressed, the free border of the 
bands relaxed, and thus, indirectly, it cooperates with the thyro-arytenoideus to their 
transverse distention. If, on the contrary, the larynx is more or less suspended, then 
its contraction is resolved in a displacement backward and upward of the cricoid, the 
bands are powerfully elongated, the transverse diameter reduced and it opposes at the 
free border of the bands, through the thyro-arytenoid ligament, the required resistance 
to the impinging blast of air. 
With regard then to the vocal bands, I think that Ludwig's nomenclature of the 
laryngeal cartilages could be advantageously modified. Retaining for the arytenoids 
the designation of the " cartilages of position," the thyroid would be the "cartilage 
of suspension" and the cricoid the "cartilage of distention." 
These interpretations find also a solid support in clinical observations. 
Elsewhere, I have described under the head of " Laryngo-hyoid " paralysis, 
a hysteroid paralytic dysphonia dependent on insufficient action of the elevators of the 
larynx. The vocal organs remain more or less in the respiratory position, and the 
contractions of the crico-thyroids invariably approximating the cricoid up on to the 
thyroid, the distention of the bands is too limited to pitch properly the note sounded. 
Under a general phonetic effort, intended for a high prime-tone, the arytenoids are 
depressed and the free border of the bands give way under the powerful expiratory 
current of air, the thyro-artenoid ligament being relaxed. 
The traction of the tongue improves the voice, and in some instances it persisted 
normal for some time afterward. This phenomenon would be ascribed to a psychical 
impression modifying favorably the laryngeal disturbed motility and brought on by the 
technique necessary for the examination. It is very possible, but the clinical fact is 
also susceptible of another interpretation. Having restored the voice on one occasion 
by the mere traction of the tongue, I thought of a reflex contraction of the paralytic 
muscles, due to the elongation of the antagonistic infra-hyoid muscles, analogous to 
Westphal's paradoxical contraction, as seen in other regions of the body, and well 
studied by Charcot and Richer. 
This is not the only instance in which the alluded phenomenon can be observed. 
In cases of functional paralysis of the adductors, O. K. Oliver says that to restore 
motility it only seems necessary "to start the machinery," and he advocates, as giving 
excellent results, phonation during inspiration and while the thyroid is being com- 
pressed bi-laterally. This procedure is based on Wylie's investigations demonstrating 
that during inspiration in these conditions the cords are forcibly adducted. According 
to us, the arytenoids being violently rotated inward by the inspired current of air, the 
abductors are distended and reflexedly the motility of the adductors is restored. 
In conclusion : The recorded cases of inter-crico-thyroid laryngotomy with a per- 
manent rigid cannula in the crico-thyroid space and persistence of modulated voice are 
absolutely contradictory to the current theories on the elongation of the bands. 
Réélus, of Paris, reports a case of this instance published in the Gazette Hebdomadaire, 
of 1880. He quotes thus on the condition of the patient's voice : " Thanks to a val- 
vular cannula, he speaks with a pitched and powerful voice to such a measure that the 
existence of an apparatus in the wind tract might be ignored." I myself performed 
Vicq d'Azyr's laryngotomy on a man for a supra-glottic syphilitic production menacing 
life. He recovered ad integrum, and the emission of voice was not interfered with in 
the least during high conversation or singing. Vocalization below the fundamental 
laryngeal sound was impossible. 
BIBLIOGRAPHY. 
Ferrein, "Mem. Acad, de Sc.," 1741. 
Meckel, J. F., " Traité Général d'Anatomie Comparée," Paris, 1828. T. S I N CLAIR ». S 0 N, LI TW. PH I LA. 
Transverse section of the right vocal cord, x 35 diameters. 
a b. Ascending fibers of the thyro arytenoid ligament. d. Antero posterior elements of the 
vocal bands, e.Papilla at the free border of the bands.a'.b'. Submucous glands. 
Desvernine. Fig.I 
Transverse serial section of the left human vocal band, x 40 diameters. 
a. Cricoid cartilage. b.Thyro -arytenoid ligament. c.Inner portion formed by tbe submucous 
fibrous tissue . c'. Outer wall formed by fibers springing from the cricoid cartilage. d. Antero-posterior 
fibers of the vocal bund intermingled with ascending fibers, e.Papilla at the free border of the band. 
f.f' Crico-arytenoid lateralis and thyro - arytenoid muscles, g. Ventricle, h. Ventricular band . 
Desvemine . Fig. I. A 
Transverse section lateral wall of the human larynx 
halfway between the thyroid and arytenoid insertions of the bands. x '1-0 diameters. 
a. Cricoid cartilage.b.Thyroid cartilage.c.Lateral crico-arytenoid muscle.d. Ihyro-arytenoid muscle . 
e. Fibro-vascular septum separating the two muscles. £ Base of the thyro-arytenoid ligament. iS. Ascending 
fibres of cricoid origin of the same ligament .h. Antero-posterior fibers of the vocal band .doubled . 
Desvernine. Fig. II 
Transverse serial section of the left lateral wall of the human larynx, x 40 diameters. 
a.b.c. Large submucous glands - showing; that Coyne's description of the same is 
not correct. For the rest, the same demonstration as of the previous photograph. (Fig I.) 
Desvernine . Fig. II. A 
Transverse section of the eight lateral wall of the human larynx x 40 dianiel eis. 
The same seclion as the previous one, fl'io.H.) the muscles being removed. 
a.Cricoid cartilage.b.Thyroid cartilage, c.d.Cavities occupied by the lateral crico-arytenoid. and thyro 
arytenoid muscles which have been removed to bring out the thyro arytenoid ligament and its connect 
ions with the cricoid. e.Thyro arytenoid ligament, e'. Offshoots springing from the cricoid.f Ascending fibers of 
the same structure.g.Antero posterior fibers of the vocal bands,doubled. h.Fibro vascular intermuscular septum 
Desvernine. Fié III 
Transverse serial section of the left lateral wall ofthe human larynx, x 50 diameters, 
a . Outer boundry of the thyro - arytenoid ligament. 
Desvernine Fig. IV. 
Transverse serial section of the left lateral wall of the human larynx. x 50diameters. 
Same demonstration as the previous one . (Fig-III.) 
Dftsvcrnine. Fig.V 
Transverse serial section of the left lateral wall of the human larynx. x 40 diameters. 
a. b. Outer and inner boundaries of the thyro arytenoid ligament. c .Longitudinal 
elements of the vocal hands near the processus vocalis of the arytenoid. 
Desvcrnine. Fig. VI 
Transverse serial section of the left lateral wall of the human larynx, x 40 diameters, 
a. Processus vo calls of the arytenoid. 
Desvernine. Eig. Vil. 
Transverse serial section of the leftlateral wall ofthe human larynx. x 40 diameters. 
a.Processus vocalis ofthe arytenoid.h.The thyro-arytenoid ligament springing on this level 
from the inner surface ofthe cricoid cartilage . 
Desvernine. SECTION XIII-LARYNGOLOGY. 
121 
Blache, Art. "Larynx," Vol. xvn, Diet. Méd. in 30, Paris, 1838. 
Millier, J., " Manuel de Physiologie," Paris, 1851. 
Czermak, " du Laryngoscope," etc., Paris, 1860. 
Longet, "Traité de Physiologie," Vol. n, Paris, 1861. 
Moure, " Laryngoscopie," etc., Paris, 1865. 
Fournié, " Physiologie de la Voix," etc., Paris, 1866. 
Du Chenne, '"Physiologie des mouvements," Paris, 1867. 
Gray, "Anatomy," Fifth edition, Philadelphia, 1870. 
Bakel, Art. "Larynx," Vol. xx, Diet. Jaccoud, Paris, 1875. 
Sappey, "Anatomie," Paris, 1876. 
Brain, part 31, October, 1885. 
Wylie, J., The Edinb. Med. Jour., Vol. xn, 1876. 
Quain, "Elements of Anatomy," Eighth edition, New York, 1877. 
Jaccoud, "Pathologie int.," Paris, 1877. 
Hermann, "Elements of Human Physiology," Second edition, London, 1878 
Huxley, "The Anatomy of Vertebrated Animals," London, 1880. 
Dieulafoy, "Man. Pathol. Ynt.," Paris, 1880. 
Heath, " Practical Anatomy," Philadelphia, 1881. 
Reclus, " Clinique et critique chirurgicales," Paris, 1884. 
Klein, et Vairot, "Histologie," Paris, 1885. 
Am. Journal of Med. Ses., New series, 1885. 
Desvernine, " De contraccion paradojica de Westphal in laryngo dinamica," Cronico-Medico- 
Quirurgica de la Habana, 1886. 
See an abstract of this paper published in the January number of the Journal of Laryngology, 
edited by Mackenzie and Wolfenden. 
De Meyer, " Les organes de la Parole." Biblio. Sc. international, 1885. 
INTUBATION OF THE LARYNX. 
INTUBATION DU LARYNX. 
ÜBER INTUBATION DES LARYNX. 
BY DR. JOSEPH O'DWYER. 
New York. 
Had intubation of the larynx proved a complete failure in the treatment of croup, 
I should still feel amply repaid for the time and expense consumed in developing it, 
for I believe that it offers the most rational and practical method yet devised for the 
relief of chronic stricture of the glottis. 
I have records of five such cases treated by intubation, three of them by myself and 
two by other physicians. 
Of the first case I will give only an abstract, as it has already been published in the 
Medical Record of June 5th, 1886. This patient was a woman forty years of age, who 
came under my treatment December 5th, 1885. Twelve years previous to this time she 
had contracted syphilis, which manifested itself chiefly by ulcerations in the pharynx, 
and for the last two years had also involved the larynx, but without producing any 
serious interference with respiration until within two months. The immediate per- 
formance of tracheotomy had been recommended by a leading laryngologist a short 
time before I saw her. The soft palate was adherent to the posterior wall of the 
pharynx on both sides, and a small ulcer still existed on the left side. A cicatricial 
band encircled the left half of the larynx and crossed to the right over the posterior 122 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
portion of the chink, leaving only a small breathing space between it and the right 
cord. The epiglottis was also deformed on its posterior surface by cicatricial contrac- 
tion. 
On the date above given I attempted to insert the smallest tube I then had for adult 
cases, but failed after several attempts, and was obliged to fall back on the largest of 
the croup tubes, that intended for children from eight to twelve years of age, which 
I succeeded in passing by using a great deal of force. She could breathe through 
this small tube with perfect comfort in a state of rest, and with it obtained her 
first night's comfortable sleep in the recumbent posture in two months. Tubes of 
larger size were used in rapid succession, as the smaller ones were coughed out, and she 
returned home at the end of eighteen days with ample breathing room in the larynx. 
During this time the tubes were inserted nine times and retained an aggregate of 173 
hours. She reported occasionally for observation, and while there was no return of the 
cicatricial band, which had disappeared apparently by ulceration, and there was ample 
breathing room in the chink of the glottis, there was a gradual return of the dyspnoea, 
due, undoubtedly, to sub-glottic obstruction. Almost from the beginning I was con- 
vinced that there was considerable thickening on the right side below the cords, from 
the fact that the lower extremity of the tube was deflected sharply to the patient's left 
as it passed below the rima, and also because the force required to overcome the resist- 
ance was greater than could be offered by the cicatricial tissue in the glottis. 
After an interval of about two and a half months I was obliged to resort to dilata- 
tion again, and found it necessary to begin with the smallest tube and use almost as 
much force as on the first occasion, although there was very 1 ittle recontraction in the 
glottis. 
This time the patient was under treatment twenty-seven days, and I used still 
larger tubes, which were inserted thirteen times and retained 204 hours. 
I was now thoroughly convinced that the only means of preventing a return of the 
stricture was continuing dilatation by the occasional introduction of a tube. I, there- 
fore, began by using it once a week, leaving it in the larynx from twelve to twenty-four 
hours at a time. The interval was gradually lengthened until it amounted to six 
weeks, but I found that this was too long, and was obliged to reduce it to one month 
and sometimes five weeks. I still continue to insert this hard rubber tube, which is 
the largest I have used, once a month, and leave it in from two to three days. 
It is now one year and nine months since I began the dilatation of this patient's 
larynx, and there is scarcely any doubt that it will be necessary to continue it during 
the rest of her life. I am, therefore, beginning to teach her to insert the tube herself, 
which I do not think will be very difficult, as she possesses an unusual amount of 
pluck. 
If this patient omits her iodide, of which she was taking sixty grains daily when 
she came to me and which I increased to ninety, for any length of time, points of ulcer- 
ation appear in the larynx and on the posterior wall of the pharynx. The metal tube 
always produced some ulceration where it exerted the most pressure, especially on the 
anterior surface of the arytenoids, but this has not occurred to any extent with the light 
vulcanite tube. I have used the latter several times in this case, and while the patient 
doos not swallow nearly as well with it as with the metallic tube, she is convinced that 
it causes less irritation, and that expectoration of the tenacious mucus is much easier. 
Although swallowing of both solids and liquids was very imperfect, this patient found 
no difficulty in taking an ample supply of nourishment. Liquids were swallowed 
better while she was lying on the back. 
Notwithstanding the free use of cocaine, very sharp pain was complained of just 
after the introduction of the tube, which usually required a hypodermic injection of mor- 
phia for its relief. Tolerance was soon established and a repetition of the dose was SECTION XIII-LARYNGOLOGY. 
123 
seldom required unless the tube was allowed to remain in the larynx for about a week, 
when the pain would again become severe. 
In order to render possible the introduction of the small tubes used in the early 
treatment of this case it was necessary to reduce the retaining swell to almost nothing, 
which rendered their rejection certain as soon as the stricture became somewhat relaxed. 
They were consequently often expelled in less than twelve hours. To avoid the pain 
and irritation necessarily produced by the frequent forcing of a tube through the larynx, 
I would, in another case, if reasonably certain that the stricture were confined to the 
chink of the glottis, produce sufficient divulsion under ether to admit a large or 
medium-sized tube that would be retained as long as desired-a week, a month, or 
longer, according to the pain and irritation excited. It would be a much more rapid 
and less painful method. In this case it would have accomplished nothing, as no 
amount of divulsion short of rupturing the cricoid cartilage could effect the sub-glottic 
stenosis. 
I have here a set of ten laryngeal stricture tubes made by Tiemann & Co., of New 
York. The retaining swell is left greater on the smaller sizes than it was on those used 
in the case just reported, because I believe the force required to pass the tubes was 
necessitated in great measure by the fact that the sub-glottic thickening was confined 
principally to one side, thus rendering the canal tortuous. 
The larger of these tubes is constructed of hard rubber, the medium sizes of metal, 
brass, gold-plated, with vulcanite heads to diminish the weight, and the smaller of metal 
only. The heads of the latter are left comparatively small, so that they can also be 
used in acute stenosis of the larynx in the years immediately following puberty, for which 
no provision has been made in the set of croup instruments. 
The largest of them, in which the transverse diameter of the head is seven-eighths 
of an inch, can be used in any form of acute stenosis in the large adult male and the 
medium sizes in the female and small adult male. 
In the largest larynx that I have yet measured, the antero-posterior diameter of the 
chink, which is the same as that of the trachea, was only seven-eighths of an inch, and 
the transverse a little more than five-eighths. 
The diameter of the sub-glottic division of the larynx varies from one-eighth to 
three-sixteenths of an inch less than that of the trachea. 
Case II.-Louise M., aged thirty-five, married, was sent to me in April, 1886, by Dr. 
J. J. Reid, from the throat wards of Charity Hospital, where she had remained since 
the performance of tracheotomy two years before. For seven months of this time she 
was under the care of the late Dr. Elsberg, and came to me with the diagnosis of incur- 
able bilateral paralysis of the abductor muscles of the cords. Electricity and other 
methods of treatment had been tried in vain and her case was regarded as hopeless as 
far as the functions of the larynx were concerned. 
The history that I obtained as to the beginning of her ailment, and which I do not 
consider reliable, is as follows :- 
During one of her periodical sprees with a number of boon companions who were 
trying to make as much noise as possible by singing or screaming, in a desperate effort 
to outdo the rest, she suddenly lost her voice. Her throat swelled, and she soon began 
to suffer from dyspnoea and was ordered to hospital by a physician who was called to 
attend her. She had no recollection of reaching the hospital or of the tracheotomy that 
followed, and I could form no estimate of the time intervening between the first symp- 
toms and the operation ; she placed it at a few days. 
The introduction of a laryngeal tube with the vocal bands lying in apposition and 
their abductor muscles incurably paralyzed I regarded as useless, and did not contem- 
plate it for a moment. My intention was first to remove the vocal cords or a portion 124 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
of them, and make a cylindrical opening where before there was none, and then insert 
a tube until the healing process was accomplished. 
When I came to investigate the case I found there was not the least power to 
whisper. She was obliged to communicate her thoughts altogether in writing. I 
already knew from my experience with intubation in children, that with a very small 
column of air passing through the larynx the ability to whisper distinctly is retained. 
I found further, that no air could be driven through the larynx by stopping the 
tracheal cannula and directing the patient to make a forced expiration, and was led to 
the only conclusion that could be drawn from these facts, viz. : that the larynx was 
completely occluded, or that if any opening existed it was a mere pin-hole. 
In the mirror the vocal cords could be seen closely approximated but normal in 
appearance. No adhesions were visible, and during all attempts at phonation or inspi- 
ration the arytenoids remained motionless. I now interpreted the case differently. This 
patient had undoubted symptoms of syphilis when I first saw her, which soon disap- 
peared under the influence of the iodide. I believed that the first trouble was an acute 
laryngitis aggravated by the constitutional disease and attended with marked swelling 
of the mucous membrane and submucous tissues, which brought the under surfaces of 
the vocal cords in contact. 
This would be still further increased by the cessation of all attempts at abduction 
by the admission of air through the tracheal cannula, and all that was required to seal 
the opposing surfaces was a little ulceration followed by healing. 
This view of the case rendered the prognosis much more favorable. All that appeared 
to be necessary was to break up the adhesions and insert a tube to prevent reunion. 
For this purpose I had her removed to the New York Foundling Asylum, and on 
April 29th, 1886, assisted by Dr. Dillon Brown, the resident physician, Drs. J. J. Reid, 
W. K. Simpson, J. J. Griffiths and F. S. Sellew, I placed her under ether and attempted 
to pass a small tube through the larynx, but failed after using a great deal of force. I 
then enlarged the external opening and realized for the first time that the cannula had 
been inserted, not, as I supposed, in the trachea, but in the crico-thyroid space. No 
opening could be felt by pressing the finger upward in the wound, nor could any be 
made out in the chink of the glottis, which was easily reached by pushing the larynx 
up on the outside at the same time that the finger was inserted through the mouth. All 
the force that could be exerted in this manner made no impression on the adhesions. I 
therefore passed a uterine sound, with proper curve, guided by the finger, between the 
cords, and forced it down and out through the wound, working it backward and for- 
ward, then passed it in the same way from below upward, and again tried the finger in 
both directions, but failed as before. A strong pair of forceps was now introduced, 
closed, from below, opened widely and withdrawn in this condition. This gave room 
to admit the tip of the index finger, and by using much force, the adhesions suddenly 
gave way, allowing the finger to pass up into the pharynx. 
I now inserted a tube two and one-half inches in length, the longest I had at the 
time, but here encountered a difficulty which I had not anticipated. The lower end of 
the tube came out through the wound and no means that I could devise would keep it 
in place. I was therefore obliged to reinsert the tracheal cannula until a tube three 
inches long could be made. 
Nine days later it was necessary to etherize the patient again in order to break up 
the adhesions, which had re-formed, before I could pass the long tube. While doing 
this, an assistant drew forward the inferior angle of the wound with a blunt hook and 
pressed the lower end of the tube backward as it passed the opening, by means of a lead 
pencil, notched at the end to prevent it from slipping. 
The increase of half an inch to the length of the tube removed the difficulty experi- SECTION XIII-LARYNGOLOGY. 
125 
enced with the shorter one. A cork was now placed in the external opening and 
retained by a tape passed through it and tied around the neck, which the patient could 
remove quickly if necessary. 
To provide against the danger of the lower end of the tube still engaging in the 
wound and thus obstructing both openings, the string was left attached to it and was 
passed behind the ear. 
The fact that this patient could again breathe through the natural passages and com- 
municate her thoughts in a very distinct whisper did not surprise her nearly as much 
as the ability to expectorate through the mouth, which was a great source of pleasure 
and amusement to her. 
The tube was coughed out on the second day, notwithstanding its weight of one 
ounce and three-quarters. The patient choked immediately and was obliged to remove 
the cork and have the nurse re-insert the tracheal cannula. I replaced the tube in the 
larynx four hours later, without difficulty, and a week later removed it to see if she 
could get any air at all through the larynx, but, to all appearances, not a particle 
entered, and the tracheal cannula again had to be used. A laryngoscopic examination 
showed the vocal cords in the old position of close adduction. I was now forced to the 
conclusion that the original diagnosis of paralysis was correct, and that adhesion 
resulted from ulceration produced by the tracheal cannula, which subsequently healed 
under anti-syphilitic treatment. 
Ether was again administered May 20th, 1886, and an operation was undertaken for 
the purpose of removing a portion of the vocal cords as originally intended. I enlarged 
the wound downward in order to make room to keep the cannula in position during the 
operation, and at the same time to keep it out of the way, and tamponed the trachea 
around it to prevent any blood gaining admission to the bronchi. The incision was 
then carried up to, but not interfering with, the thyroid cartilage. On separating the 
edges of the wound with retractors, I missed the cricoid cartilage, or at least the ante- 
rior part of it. From the first ring of the trachea to the thyroid cartilage there was no 
support for the soft, yielding tissues, and when the flaps were allowed to drop back into 
position the anterior and posterior walls approximated in the same manner as those of 
the oesophagus or vagina. I hesitated now about proceeding further with the operation, 
as I regarded the case as next to hopeless, but believing that the cricoid cartilage might 
have been cut in the original operation, and only displaced by the cannula, which was of 
hard rubber and very large size, I decided to complete the operation by hooking a 
tenaculum into each cord, guided by the finger, and cutting on the outside of this with 
a blunt-pointed bistoury. I found this much more difficult than I anticipated, for the 
cords, although not far above the external wound, were not visible. In doing this 
operation again, I would lay open the thyroid cartilage, which would make it a very 
simple matter. 
The wound was brought together, with the exception of the opening for the tracheal 
cannula, in which a cork was placed, as before, and the same tube was passed into the 
larynx. At the end of eight days I removed it, and found that she could breathe, for 
the first time, through the larynx, with the external wound closed by adhesive plaster. 
A laryngoscopic examination showed that only a small portion of each cord had been 
removed, and from the seat of the incisions granulations were already springing which 
promised soon .to supply the place of the tissue removed. I therefore re-inserted the 
tube in the larynx one day and a half after its removal, during which respiration was 
carried on comfortably through the natural passages. 
More lateral pressure appeared to me to be the thing required to prevent the further 
growth of granulation tissue, and this could not be obtained with the ordinary oval 
tube, which was designed specially to avoid undue pressure on the vocal cords. I 
therefore had one made almost cylindrical in form, and passed it into the larynx June 126 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
15th, where I allowed it to remain until the 26th, eleven days. I then removed it, not 
because it was giving rise to pain or inconvenience in any way, but because my experi- 
ence with the first case was against leaving the tube in the larynx continuously for 
much longer than a week. On laryngoscopic examination, more breathing room was 
found than at any previous time, but granulations were still present. During the 
following three days she continued to breathe comfortably through the larynx, with 
moderate exercise, and could even ascend one flight of stairs without producing much 
dyspnoea. 
On examining the external opening on June 29th, I noticed a marked sinking in of 
the tissues both above and below it, where the cartilaginous support was defective, and 
I anticipated some difficulty in replacing the tube. So great was the contraction in this 
short space of time that on using a great deal of force I failed to pass the tube beyond 
this point until a slight incision was made downward. 
The almost certain recurrence of this difficulty every time the tube was allowed to 
remain out for a few days convinced me of the necessity of leaving it in for a much 
longer time. 
I therefore sent her back to Charity Hospital, with the tube in the larynx, and told 
her to return in a month, when I would remove it, or sooner, in case it gave rise to 
much pain or any interference with respiration occurred. 
Dr. Reid, in whose service she was, reported from time to time that she was doing 
well, and at the end of the month reminded her that it was time to have the tube 
removed. She left the hospital, but did not report to me, and months passed without 
hearing anything from her. Knowing that she was much given to dissipation, I 
believed that in all probability she was dead; but she surprised me very much by 
coming to my office on May 3d last, looking and feeling remarkably well, with the 
exception of a cold recently contracted, which gave rise to a good deal of cough. She 
was still wearing the tube, which had remained in the larynx ten months and four 
days. Her reason for not returning sooner was that she felt comfortable and happy 
and did not wish to run the risk of having to wear the outside tube again. 
It required some force to remove the tube, which was black, from coating of the 
sulphides, and closely dotted over with coarse granules of calcareous matter. When 
these were scraped off, the surface of the metal was left quite uneven, and the tube is, 
consequently, somewhat smaller now than it was originally. The thin gold plating 
had probably disappeared before the tube was in the larynx a month. 
For a moment after the tube was removed inspiration was seriously obstructed, and 
I was about to insert another one, which I had ready, when the breathing became per- 
fectly free. On using the mirror I found that the obstruction was due to masses of 
granulation tissue growing from the sides of the larynx above the ventricular bands, 
which must have partially overlapped the head of the tube, and which -were drawn 
together by the forced inspiration immediately following the removal of the tube. 
During quiet respiration this did not occur. A good view of the larynx could not be 
obtained, and if ulceration existed, which is more than probable, it was covered by the 
granulation tissue. 
She complained for some days of a void in her throat, as if an important part of it 
were missing. 
The granulations, which I believed at first would have to be removed, in some 
manner grad ually decreased in size, and at the last examination, about July 1st, a 
better view of the larynx was obtained. A large cylindrical opening existed where 
the chink should be, and no trace of the vocal cords was visible. There was undoubted 
motion of the arytenoids during inspiration. In the seat of the external wound was a 
deep sulcus extending down between the unapproximated edges of the cricoid cartilage. 
The cough was toneless, and the voice, as before, a distinct whisper. SECTION XIII-LARYNGOLOGY. 
127 
I have not seen this patient since, but Dr. Reid informed me that she returned to 
Charity Hospital in the early part of last August, suffering from alcoholism, and left in 
about a week. He examined the larynx and found the same condition as described 
above. The breathing was perfectly free. 
Had I the least suspicion that the larynx would tolerate a tube continuously for so 
long a time I would not have interfered with the vocal cords, as the tube, if it did not 
cause their destruction by ulceration, would in all probability have fixed them perma- 
nently in the abducted position. I felt that I was assuming a serious responsibility 
when I concluded to leave the tube in the larynx for even the space of one month. 
These two cases afford a remarkable illustration of the difference in sensibility dis- 
played by the larynx in different persons. One could not retain a gold-plated or finely 
polished vulcanite tube longer than a week at a time without its producing undue irrita- 
tion, while the other practically wore a hollow file and not a very fine one either, in 
her larynx for many months, and was happy in consequence. 
I had previously noticed the same difference in children suffering from croup, and 
at first attributed it to the protection afforded to the living sensitive tissues by a greater 
or less deposit of pseudo-membrane, but was soon convinced that this was not the 
explanation. 
Case hi.-Mrs. L., aged 40, the mother of eight children, in the early part of 
December, 1886, began to suffer from hoarseness and a feeling as though something 
loose existed in the upper part of the windpipe, which she could not get rid of by 
coughing. She consulted Dr. J. W. Lyman who found bronchitis and albuminuria and 
these together with the hoarseness were believed to be due to cold. Later the voice 
was lost and dyspnoea developed. The latter became so urgent on the night of January 
14th, 1887, that everything was made ready for tracheotomy, when it occurred to Dr. 
H. Griswold, who was called in consultation, that it would be a good case for intubation. 
When I saw her, at 9 p.m., there was very little cyanosis but the breathing was very 
laborious, but almost noiseless. She was unable to assume the recumbent posture. Dr. 
Griswold had made a satisfactory laryngoscopic examination and found nothing abnor- 
mal in or above the chink except hyperæmia, but below the cords he could see what 
appeared to be œdematous folds of the mucous membrane crowding in toward the 
centre and more marked on the left side. 
The diagnosis was therefore sub-glottic oedema. But the fact that she was also 
suffering from bronchitis and albuminuria rendered it doubtful as to whether the dysp- 
noea was not, in part at least, pulmonary. On listening to the chest no air could be 
heard entering the lower posterior portion of the lungs, and a very marked up and down 
movement of the larynx could be detected by placing the fingers over it. The latter 
symptom alone was sufficient to locate the obstruction in the glottis. 
I first attempted to insert a tube two and a half inches long, but owing to the short 
curve on the introducer it was necessary to detach it before the lower end of the tube 
had passed through the obstruction, and the probe point being thus lost the tube 
caught on the swollen tissues and was arrested. A three inch tube which extended 
below the stricture before the obturator was removed passed without difficulty and 
with complete relief to the dyspnoea. There were present Dr. J. W. Lyman, H. Gris- 
wold, G. G. Van Schaick and Adolph Rupp. 
On inquiring more closely into the history of this patient it was found that she had 
contracted syphilis from her husband some years before, and since that time had had 
several miscarriages. 
After the tube was inserted, she refused to swallow anything, either in the solid or 
fluid form, and was fed, at first by the rectum and later by the stomach tube. 
The iodide was given mixed with the food in small doses, as the stomach would not 
tolerate large ones, and mercury was administered by inunction. 128 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
The tube was removed in five days but had to be replaced in twenty minutes, owing 
to the rapid return of the dyspnoea. It was again removed two days later and was left 
out for half an hour, while Dr. Geo. M. Lefferts, who was called in consultation, made 
a careful laryngoscopic examination. Dr. Lefferts' diagnosis was sub-glottic laryngitis. 
It was removed for the third time January 24th, ten days after first insertion. This 
time it was left out twenty-one hours, when the dyspnoea became so urgent that I was 
obliged to replace it, and Dr. Griswold removed it February 4th, twenty-one days from 
first insertion. 
It produced no ulceration nor pain, but caused excessive coughing, which had to be 
moderated at night by opiates. 
A very large amount of tenacious mucus was secreted, which required considerable 
coughing to remove. 
March 14th, or about six weeks after the tube was last removed, I was hastily sum- 
moned in the night by the husband, who said that his wife would, in all probability, be 
dead before I reached her. I found her deeply cyanosed and much worse than at any 
previous time. I was obliged to make three attempts before I succeeded in placing the 
tube in the larynx, and they had to be made very rapidly, as cutting off the small 
amount of air that was entering the lungs for even a short time would have produced 
asphyxia. I was without assistance on this occasion and had heard nothing from the 
case for some time, but when I met Dr. Lyman the next day, I learned that there was 
a new development. The left arytenoid was very much swollen and anchylosed, and 
on its anterior surface and involving a considerable part of the posterior region of the 
larynx, was a growth which overlapped the chink of the glottis. This explained the 
difficulty experienced in passing the tube and also, in part at least, the dyspnoea. 
Another physician, who examined this patient's larynx a short time previously, 
regarded it as a perichondritis. The history of the case, the appearance and location of 
the tumor, and the absence of any swelling or tenderness on the outside were, I think, 
sufficient to exclude this and to leave very little doubt that it was a gumma, which 
had developed while the patient was said to be taking large doses of the iodide and 
bichloride. 
The tube was removed in a week and immediately replaced by a larger one of hard 
rubber, which was prepared in the following manner: Those portions of it which 
would come in contact with the diseased surfaces in the larynx were coated with gela- 
tine, liquefied by heating and dusted over while still moist with dry, powdered alum, 
and as one layer dried another was applied until a sufficient thickness was obtained. 
Gelatine swells considerably as it absorbs moisture, and the dilating power of the tube 
thus treated can be temporarily increased to any extent, with or without the astringent 
or other application. This can be prolonged by covering the gelatine with a layer of 
collodion, which prevents the too rapid absorption of moisture. 
This tube was removed for the last time March 28th, having been in the larynx 
seven days. It gave rise to considerable pain and irritation, which was attributed 
principally to the alum. I have not seen this patient since, but have recently been 
informed that there is still some dyspnoea on exertion and very little voice, both symp- 
toms being probably due to remaining sub-glottic thickening, but I have no knowledge 
of the recent laryngoscopic appearances. 
This patient, who was firmly convinced that she could not swallow anything during 
the first period of treatment, subsequently learned how to swallow a sufficient quantity 
of both liquid and solid nourishment and large doses of the iodide without much diffi- 
culty. But she could not swallow nearly so well with the hard rubber as with the 
heavy metal tube, for the latter, as she expressed it, sank lower down than the light 
tube. She could not distinguish any difference in the weight, although one weighed 
one ounce and three-quarters and the other only one hundred grains. There was no SECTION XIII-LARYNGOLOGY. 
129 
difference apparently in the ability to expectorate, although the caliber of the hard rub- 
ber tube was almost double that of the other. It will be remembered that the first 
patient expressed a decided preference for the light tube, which was the same one used 
in both cases, and principally because she expectorated better through it. 
Although my experience is yet very limited I have some reason to believe that while 
deglutition will be more difficult with the hard rubber tube, which necessarily stands 
higher in the larynx on account of its lightness, secretions will be more easily expelled, 
as they do not appear to adhere so firmly as to the metallic tube. 
Case iv.-This patient was treated by Dr. J. J. Reid, in his wards at Charity Hos- 
pital, and briefly reported by him in the Philadelphia Medical and Surgical Reporter of 
May 14th, 1887. 
J. K., aged twenty-two years, entered hospital May 1st, 1886. He stated that four 
years previously he had contracted a severe cold, accompanied by hoarseness, which 
had continued more or less ever since. He sought relief at various dispensaries but, 
steadily growing worse, finally entered the hospital. 
At this time there was considerable emaciation, hoarseness, cough and dyspnoea at 
night. He gave no direct history of syphilis but there was necrosis of the hyoid bone, 
part of which had escaped by the mouth, leaving a discharging sinus on the inside. 
Ulceration existed around the base of the epiglottis and involved the left side of the 
larynx to the arytenoids, both of which were much swollen and partially anchylosed, 
as was shown by the fact that there was very little motion of the vocal cords. Not- 
withstanding the free use of the iodide the dyspnoea increased, especially at night, 
until the question of surgical interference had to be considered. I saw the 
patient with Dr. Reid and advised against intubation, as I believed the tube 
would aggravate the existing ulceration. Dr. Reid thought differently and inserted a 
small tube on Sept. 20th, 1886, which was coughed out in twenty-one hours. Strange 
as it may seem it did not give rise to much irritation, or at least the patient made 
no complaint. He was able to take nourishment well and slept comfortably without 
opiates, except a dose immediately after the insertion of the tube. The same day a 
larger tube was introduced and expelled in twenty-four hours. A still larger one was 
then used, and retained only half an hour. As the dyspnoea was now much relieved 
no tube was used for a week, when, on September 29th, one of much larger size was 
introduced and retained for eighteen days and then rejected, while the patient was 
sitting up. There was a slight return of the dyspnoea on Dec. 15th, 1886, and the same 
tube was inserted, for only 24 hours. He left the hospital soon after, to resume work as 
a cigar maker. He was seen the following June, six months after the final removal of 
the tube, and was then working at his trade, and had had no return of the dyspnoea. 
Case v.-This case was operated on by Dr. Dillon Brown, assisted by Drs. W. H. 
Wilmer and Howard Lilienthal. There were also present Drs. H. E. Sanderson, H. S. 
Stark, G. C. Rich, E. F. Walsh, and C. E. Giddings. 
The patient was a German, aged 39 years, who for some time had been subject to 
severe attacks of laryngitis, accompanied by dyspnoea ; on laryngoscopic examination 
a sub-glottic neoplasm was discovered, for the removal of which a high tracheotomy 
was performed on December 24th, 1886. The growth was found to be very vascular, 
and on scraping it out with a curette, a piece of a lucifer match, three-quarters of an 
inch long, was discovered imbedded in its centre. The cannula was replaced for three 
days, then removed and the wound allowed to heal. As it did so the dyspnoea increased, 
until, on January 18th, 1887, while the patient was almost asphyxiated and pulseless, 
Dr. A. G. Gerster reopened the trachea and inserted the cannula. Nine days later, when 
the patient had regained sufficient strength, Dr. Gerster laid open the thyroid cartilage 
to seek and remove, if possible, the cause of the obstruction. The notes furnished me 
merely state that the cannula was re-inserted, but give no further particulars of the 
Vol. IV-9 130 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
operation. He continued to wear the cannula until March 25th, 1887, when Dr. Brown 
inserted a tube in the larynx, the patient being under the influence of ether. Two 
previous attempts had been made without ether and failed, owing to the same difficulty 
that I experienced in my second case, viz., the lower end of the tube engaging in the 
external opening. He was of a very nervous, irritable temperament, and the tube gave 
rise to excessive irritation, which called for the frequent use of opiates. 
Notwithstanding the fact that he was very sensitive in regard to his personal appear- 
ance, and very anxious to get rid of the tracheal cannula, he frequently begged to have 
the tube removed from the larynx. The irritation was not so great after the first day 
or two, but it is safe to say that toleration was never established in this case. 
The tube was removed in a week and there was no return of the dyspnoea, but as 
the one used was very small it was considered safer to produce further dilatation by a 
larger tube. This was introduced April 20th, but immediately rejected and no further 
attempt was made and none was necessary. The patient was last seen Aug. 12th, in 
good health and free from dyspnoea, and had a good voice. 
He wore the tracheal cannula three months, and was cured by wearing a tube in the 
larynx one week. 
As yet I am unable to speak from my own experience in regard to the prognosis in 
chronic stenosis of the larynx. Permanent cures have been reported, particularly by 
Schroetter, of Vienna, but I have no knowledge as to the length of time that elapsed 
after final treatment before such cases were reported as permanently cured, and this is 
the important point. I might report my second case now, more than four months after 
the removal of the tube, as cured, but I believe it would be premature to do so even at 
the end of a year. 
No one would call a stricture of the urethra that required ten or more years for its 
development as permanently cured because it had not returned in one year after 
thorough dilatation or cutting. 
The contraction of cicatricial tissue may be very slow, and as it requires only a small 
portion of the normal lumen of the air passages for free respiration a considerable degree 
of contraction must exist before manifesting itself in the form of dyspnoea. 
Cicatricial tissue produced by the healing of deep tertiaiy ulcers, if situated in the 
sub-glottic division of the larynx, such as was present in my first case, will, in all 
probability, require occasional stretching throughout life. If, on the contrary, it is 
confined to the chink of the glottis the prognosis will be better, as here we have the 
inspiratory abduction of the vocal cords twenty times per minute, which must antago- 
nize to some extent the tendency to reconstruction. 
We know that cicatricial tissue in other parts of the body finally loses the power to 
contract by persistent and long-continued stretching, and if the first case reported could 
have tolerated the tube continuously for several months instead of a week the outlook 
would have been better. 
The third case was not, properly speaking, one of chronic stenosis, but a specific 
inflammatory infiltration, which required only constitutional treatment for its cure, 
the temporary use of the tube being necessary to tide over the immediate danger of 
asphyxia, although it no doubt also hastened absorption by its pressure. 
If constitutional treatment be neglected in a case of this kind deep ulceration will 
follow, and the development of cicatricial stenosis is then only a question of time. 
Syphilitic lesions of the larynx, in my experience, do not yield as readily to specific 
treatment as the manifestations of this disease in other parts, and therefore more per- 
severance is necessary. 
In Dr. Reid's case, although of long standing, the ulceration was apparently con- 
fined to the sub-glottic region and not very deep. The occasional use of mercury and SECTION XIII-LARYNGOLOGY. 
131 
the iodide, extending over a long period, would probably in this case insure a permanent 
cure ; without this it will be very likely to recur. 
In Dr. Brown's case there was no cicatricial tissue, but simply inflammatory thick- 
ening produced by the presence of a foreign body. The removal of this still left more 
or less thickening, and what was probably more important, partial anchylosis of the 
arytenoids, from want of use. All that is necessary to effect a cure in such a case is to 
produce sufficient dilatation to admit air through the larynx and thus excite contraction 
of the abductor muscles ; or, in other words, to set the machinery in motion. 
Thus far I have dealt almost exclusively with facts. In the concluding part of my 
paper, which treats of stricture of the trachea, I find it necessary to fall back on theories, 
as I have not yet treated a case of this kind. These theories are not visionary, but, on 
the contrary, are strongly supported, if not demonstrated, by the foregoing facts. 
The oval laryngeal tubes are not suitable for stricture of the trachea, which retains 
the cylindrical form and requires tubes to correspond. I had one of this kind made for 
an old lady, aged sixty-eight years, who was suffering from stricture of the trachea 
caused by a process from a large bronchocele surrounding it. I saw this patient with 
Dr. Edmund J. Palmer, at the suggestion of Dr. Henry B. Sands, with a view to prac- 
ticing intubation. The tumor was very large, especially in front, covering the whole 
of the trachea and the greater part of the larynx. Tracheotomy did not offer much 
hope, as, in order to get into the trachea below the obstruction, a large mass of vascular 
tissue would have to be cut through, and none of the ordinary tracheal cannulas would 
be long enough to reach it. To open into the larynx above, where there was less of the 
growth, would still leave the stricture below. Dr. Sands, who was first called to con- 
sider the advisability of opening the trachea, did not give much encouragement, and 
would operate only in case of impending asphyxia. 
Before I could procure the tube which I intended to use, the patient insisted on 
returning to her old home in the western part of the State, where she subsequently died. 
That portion of the tumor which surrounded the trachea, by also pressing on the 
oesophagus interfered very much with deglutition. Solids could scarcely be swallowed 
at all, and even had we succeeded in relieving the dyspnoea, death from inanition was 
only a question of time, as it would have been impossible to pass a stomach tube. 
The difficulty of intubating such a case would result from the small size of the 
stricture. I am as fully convinced as if I had tried it, that it would have been impos- 
sible to pass a tube as large as the one I have shown without previous divulsion under 
ether. This I intended doing with the smallest of Schroetter's long vulcanite tubes. 
Many years ago I heard the late Prof. F. H. Hamilton relate his experience with an 
almost identical case. His patient'was a clergyman far advanced in years, who, for the 
greater part of his life, had suffered from a large goitre. When death by strangulation 
was only a question of a little time, Dr. Hamilton performed tracheotomy, but the 
insertion of the cannula gave no relief and the patient died soon afterward. The 
autopsy showed that the trachea at the seat of the stricture was reduced to the size of 
a crow-quill. I have no recollection of further particulars, but the tube must have 
been inserted above the obstruction, and was, of course, many times too large to pass 
through, even if it had been long enough. 
There is scarcely any doubt that, of all strictures, that of the trachea is the most 
unfavorable as regards permanent cure. 
It can unquestionably be dilated if not situated too near the bifurcation, but the 
power of the contracting tissue, whether on the inside or outside, which is sufficient to 
overcome the resistance offered by the almost bony rings of the adult trachea, will not 
be destroyed by temporary dilatation. 
My second case of chronic stenosis of the larynx, who retained a tube in the larynx 132 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
continuously for over ten months without its becoming obstructed, suggested another 
plan of treating stricture of the trachea. 
It consists of first accomplishing sufficient dilatation with tubes, such as I have 
already shown, of different sizes, and then passing a tube of proper length and having 
a shoulder just large enough or small enough to pass completely through the larynx and 
rest on the upper surface of the stricture. It would also have a retaining swell near 
the lower extremity, to prevent it from being driven upward by coughing. 
If the stricture be situated too low down to be reached through the larynx, it would 
be necessary to lay open the trachea at the seat of obstruction and insert a tube of hour- 
glass shape, such as I have here, and close the wound over it. 
I do not entertain the slightest doubt that such a tube can be worn for a lifetime 
without danger of obstruction from secretions, because the expulsive power of the 
cough would not be impaired, as it necessarily is when the tube occupies the larynx 
and prevents approximation of the vocal cords. Neither would there be anything to 
fear from excessive irritation, as the trachea is infinitely less sensitive than the larynx. 
As it stands at present, without actual demonstration, I know of no impediment to 
the permanent wearing of a tube in the trachea, save the deposit of calcareous matter, 
to which I have already alluded, and this was probably caused by electrical currents 
excited by the copper and zinc alloy of which the tube was composed. I have noticed 
a slight amount of this deposit on the gold-plated brass tubes when retained for only 
one week, but not the least trace of it on the vulcanite tube when worn for the same 
time. 
To avoid this objectionable feature, therefore, and at the same time insure dura- 
bility, it will be necessary to have such tubes constructed of hard rubber burned on a 
framework of metal, or cast in pure gold. 
A tube passed into a stricture in the trachea through the larynx can also be removed 
through the same channel by making the curved part of the extractor long enough. 
I am not aware that any attempt has ever been made to exsect the strictured por- 
tion of the trachea, but it is quite probable that the great elasticity of this tube, which 
is necessary to permit of that elongation which takes place during the act of swallow- 
ing, would admit of the removal of at least half an inch without anything more than 
temporary interference with deglutition. 
A child's trachea suspended with a slight weight attached increases three-quarters 
of an inch in length, and the adult trachea, being much longer, will gain in propor- 
tion. 
I have also devised but not yet perfected a laryngeal speculum, which has never been 
used except on the cadaver. It is intended to facilitate the removal of sub-glottic 
growths by holding the glottis open and the epiglottis erect. It may be so constructed 
that it will also act as a snare for pedunculated tumors situated on the lateral aspects 
of the larynx below the cords, and should be particularly useful in young children 
where it is difficult or impossible to use the mirror. There is very little doubt that it 
will be more effectual than the dry sponge used by Voltolini for this purpose. 
DISCUSSION. 
Mr. Lennox Browne, of London, spoke in the highest terms of the grand suc- 
cess that had attended the years of study and patient work of Dr. O'Dwyer, and 
said that he was commissioned to purchase a complete outfit for his hospital. He 
was surprised that tubes could be retained in so sensitive an organ. 
Dr. O'Dwyer closed the discussion, and exhibited a laryngeal speculum and a 
snare for removal of membrane and small papillomata from below the vocal cords. SECTION XIII-LARYNGOLOGY. 
A NEW SNARE AND ÉCRASEUR. 
133 
UN SERRE NŒUD NOUVEAU ET UN ECRASEUR. 
EIN NEUER SCHLINGENSCHNÜRER UND ÉCRASEUR. 
BY CHARLES SLO VER ALLEN, M.D., 
Of New York. 
Dr. C. Slover Allen, of New York, presented to the Section a new snare and écra- 
seur. The advantages of the snare are: that it can be used with one hand entirely, 
while the other is left free to hold a speculum or other instrument; far greater power can 
be obtained than where the screw is used, and it can be applied quicker. It is made of 
steel throughout, and will stand the heaviest work. 
The ends of the wire are fastened by means of an eccentric moved by a small lever. 
The power is applied through the action of a double lever, instead of a screw. 
The wire loop can be instantly contracted around the tissue to be removed with 
the force of the fingers pulling down the slide. It is held there automatically and pre- 
vented from slipping back. Alternating pressure, with index and middle fingers in the 
rings, brings it down with enormous power, through the action of a transverse lever, 
which carries dogs or catches past ratchet teeth placed on both sides of the shaft. 
DESCRIPTION OE NEW SNARE AND ÉCRASEUR. 
A, A, rings for middle and fore finger, united by a lever, which is pivoted above and below to the sliding 
body. The ratchet catches, G, G, are pivoted to this lever on either side and fit into the ratchet teeth 
on the sides of the square frame, G. D is the thumb ring, fastened by a swivel. The lever, B, fastens 
the wire ends, H, H, by means of an eccentric, beneath which they pass. The flattened end of the 
tube prevents rotation of the wire loop, F. Simultaneous pressure on rings, A, A, contracts loop 
quickly with only full power of the fingers. If they are pressed upon alternately, then one ratchet 
catch at a time is drawn down over the teeth, while the other holds fast. The loop is then contracted 
more slowly, with great leverage power. 
The authors of the following two papers not being present, they were read by 
title only :- 
ÜBER NERVÖSEN HUSTEN UND SEINE BEHANDLUNG. 
ON NERVOUS COUGH AND ITS TREATMENT. 
VON DR. OTTOMAR ROSENBACH, 
Breslau, Deutschland. 
Wir rechnen zur Categorie des nervösen Hustens diejenigen Fälle, bei welchen die 
genaueste Localuntersuchung der Nase, des Larynx, des Pharynx und der Lungen 
weder eine der sonst als ursächliches Moment andauernder Hustenparoxysmen geltenden 
Gewebsstörungen, noch jene Form abnormer Schleimsecretion, welche bisweilen ohne 
sichtbare Texturerkrankung der Schleimhaut die Quelle eines Husten auslösenden 
SUR LA TOUX NERVEUSE ET SON TRAITEMENT. 134 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Reizes ist, nachzu weisen vermag,-Fälle also, bei denen in Ermangelung jeder palpablen 
Schleimhautveränderung eine rein nervöse Störung, eine Leitungshyperästhesie in den 
den Hustenreflex vermittelnden Bahnen, als Ursache der Erscheinungen angesehen 
werden muss. Da dieser Krankheitsgruppe äusser dem eben erwähnten eigenthü m- 
lichen Entstehungsmechanismus gewisse besondere Characteristica bezüglich der 
Aetiologie, des Verlaufes der äusseren Erscheinung und vor Allem der Therapie 
zukommen, so glauben wir ihr auf Grund eines ziemlich umfangreichen Materials eine 
Sonderstellung gegenüber den anderen Formen des Hustens einräumen zu dürfen, 
indem wir zugleich hervorheben, dass die einzelnen Fälle, aus denen wir unsere 
Erfahrungen abstrahirt haben, einer sorgfältigen Kritik und Sichtung unterworfen 
werden mussten. Es ist in der That leicht ersichtlich, dass der blosse negative Local- 
befund nicht allein genügt, einem Falle den Stempel der functionellen nervösen Genese 
aufzudrücken, weil ja auch schwere organische Läsionen des Centralnervensystems 
selbst, oder der Nachbarschaft der den Husten vermittelnden Bahnen lange Zeit ohne 
andere Symptome als die einer erhöhten Hustenthätigkeit verlaufen können (Aneurys- 
men der Aorta, die auf den Vagus und Recurrens drücken, Tabes etc.). Es muss dem- 
nach in jedem einzelnen Falle nicht nur eine genaue Allgemeinuntersuchung vor- 
genommen werden, sondern es dürfen auch nur diejenigen Kranken zu unserer Gruppe 
gezählt werden, bei denen während einer längeren Beobachtungsdauer vor oder nach 
der Heilung keinerlei auf organische Läsionen hinweisende Symptome zum Vorschein 
gekommen sind, und wir können deshalb die hier beschriebene Form des Hustens als 
die des benignen nervösen Hustens bezeichnen, eine Terminologie, die in bezeichnender 
Weise die Hauptcharacteristica des Zustandes, das blosse Symptom des Hustens und 
die nervöse Genese desselben ebenso in den Vordergrund stellt, wie sie die Abwesenheit 
jeder Gewebsstörung postulirt. 
Wir haben zwei, schon der äusseren Erscheinungsweise nach klinisch leicht zu 
differenzirende Categorien des nervösen Hustens-die im Wesentlichen von den Alters- 
verrchiedenheiteu der befallenen Individuen beeinflusst zu sein scheinen - zu unter- 
scheiden, nämlich erstens eine paroxysmale Form, die des krampfhaften, rauhen, 
bellenden, stark explosiven Hustens, bei der entweder zwischen jedem einzelnen der 
verhältnissmässig lange anhaltenden Hustenstösse eine sehr kurze Inspiration ein- 
geschaltet ist, oder bei der mehrere sehr heffige, aber kürzere exspiratorische Explo- 
sionen dicht auf einander folgen, bevor eine sehr tiefe, bisweilen tönende Inspiration 
einsetzt, die häufig den Anfall beschliesst, häufig aber auch einen neuen einleitet, und 
zweitens das kurze, trockene, aus drei bis vier ganz gleichen, durch keine inspiratorische 
Pause getrennten, räuspernden Bewegungen zusammengesetzte Hüsteln. Das wesent- 
liche Kennzeichen der ersten Categorie ist also das forcirte, stossweise, ungleichmässige 
Auftreten des Hustens, das der zweiten das gleichförmige, monotone, ohne Anstrengung 
erfolgende Räuspern ; die Anfälle der ersten Gruppe pflegen, nachdem eine grössere 
Anzahl von Hustenstössen in der oben geschilderten Gruppenform erfolgt ist, für 
längere Zeit aufzuhören (Pausen von mehrstündiger Dauer sind nicht selten), während 
das Hüsteln bei der zweiten Gruppe ein continuirliches Phänomen ist, welches oft 
kaum minutenlange Intervalle aufweist. Uebergänge zwischen beiden Formen kommen 
nicht so selten vor, seltener Mischformen ; es geht dann, wie wir beobachtet haben, die 
erste in die zweite Form über, während der umgekehrte Vorgang unseres Wissens 
nicht Platz greift. 
Was das Vorkommen des nervösen Hustens bei den verschiedenen Altersklassen 
und Geschlechtern aubetrifft, so ist hervorzuheben, dass die Anfälle der ersten Categorie 
fast ausnahmslos bei jüngeren Personen in der ersten Lebenshälfte zur Beobachtung 
kommen, dass sie in ausgeprägter Form nur die zwei ersten Lebensdecennien, nament- 
lich die Zeit bis zur Pubertät, zum Schauplatz haben, dass jenseits der zwanziger Jahre 
die Zahl der Erkrankten, sowie die Intensität und Extensität der Anfälle eine auffallend SECTION XIII-LARYNGOLOGY. 
135 
geringere wird. Beide Geschlechter werden bis zur Pubertät ganz gleichmässig 
befallen ; doch scheint von da ab das weibliche Geschlecht mehr zu der geschilderten 
Form des nervösen Hustens disponirt zu sein. 
Die Anfälle der zweiten Categorie finden sich in reiner Form nur bei Erwachsenen, 
und zwar vorzugsweise bei Frauen ; sie kommen bei Männern auch vor, aber, wie 
gesagt, doch nur in einer verschwindenden Anzahl von Fällen. Hier zeigt sich dann 
auch die oben erwähnte Mischform des Hustens am häufigsten. Bei jüngeren Leuten 
findet sich das Hüsteln nur, wenn bereits längere Zeit vorher der explosive Husten 
vorausgegangen ist ; das Hüsteln ist hier gewissermaassen das zweite, mehr chronische 
Stadium des Leidens, während es bei Erwachsenen oft auch die primäre Affection 
repräsentiren kann. 
Bezüglich des Verlaufs und der Beschaffenheit der einzelnen Anfälle mag besonders 
bemerkt werden, dass in beiden Gruppen in der Regel kein Schleim expectorirt wird, 
und dass nur bei schweren und langdauernden Fällen der ersten Gruppe am Ende des 
Anfalles etwas Speichel, der während der heftigen Exspirationsstösse nicht verschluckt 
werden kann, oder etwas zäher Rachenschleim, wie er in dünner Schicht ja stets die 
Rachenschleimhaut zu überziehen pflegt, herausbefördert wird. Hier mag indessen 
gleich erwähnt werden, dass in einer kleinen Anzahl von Fällen, die zur Categorie des 
nervösen Hustens gehören, doch auch eine beträchtlichere Schleimabsonderung vor- 
handen sein kann, die aber nicht Zeichen einer primären Texturerkrankung der 
Schleimhaut, sondern nur eine mechanische Folge der der Schleimhaut durch die 
andauernden, wiederholten, heftigen Hustenstösse zugefügten Insulte, also ein secun- 
däres Symptom, sind. Wir werden weiter unten diese scheinbare Ausnahme, die aus 
dem Rahmen unserer oben gegebenen Definition heraustritt, näher zu erörtern haben. 
Die einzelnen Anfälle können in sehr verschiedener Häufigkeit und Heftigkeit 
einander folgen, und wir haben bereits darauf hingewiesen, dass bei der ersten Form 
des Hustens oft mehrstündige Pausen zwischen den einzelnen, iu besondere Gruppen 
von Hustenstössen zerfallenden Paroxysmen bestehen, während bei der zweiten Form 
derselben das Hüsteln sich mit unveränderter Gleichmässigkeit ohne länger dauernde 
Intervalle wiederholt. 
Die Anfälle fehlen stets im Schlafe und wenn die Aufmerksamkeit des Patienten 
auf irgend eine Weise abgelenkt wird ; sie häufen sich und nehmen auch an Intensität 
zu, wenn die Kranken beobachtet oder ärztlich untersucht werden, wenn sie psychisch 
erregt sind, wenn sie aus dem Freien, wo die Anfälle oft ganz cessiren, in's Zimmer 
treten ; sie treten nicht auf, wenn die Patienten in anregender Unterhaltung lebhaft 
sprechen, oder wenn sie essen. Aber selbst in diesen Fällen kann man den Husten 
hervorrufen, wenn man die Gedanken des Patienten auf sein Leiden hinführt, oder 
wenn man ihn auffordert, zu husten. Auffallend ist es, dass grössere Kinder und 
Erwachsene nach einer gewissen Dauer des Leidens auch bei schwereren Anfällen 
weder cyanotisch werden, noch besondere Zeichen von Dyspnoe zeigen, so dass sie nach 
dem Auf hören der scheinbar so sehr quälenden Hustenstösse-im Gegensatz zu anderen 
Formen des Hustens-sofort ohne jede Anstrengung im Gespräch fortfahren können ; 
auffallend ist auch in diesen Fällen und denen der zweiten Categorie, bei denen ja 
wegen der Kürze und geringen Intensität der Anfälle Zeichen von Dyspnoe überhaupt 
nicht zu erwarten sind, der geringe Einfluss des Hustens auf den Puls, der oft weder 
Frequenz noch Character merklich ändert. Es wird dieses auf den ersten Blick 
befremdende Verhalten dann erklärlich, wenn man die Patienten während der Husten- 
paroxysmen genau beobachtet ; der ganze Act des Hustens geht in diesen Fällen eben 
unter ganz eigenthümlich veränderten äusseren Bedingungen in Scene. Die Patienten 
sind nämlich im Stande, bei einer ganz speciellen, nicht leicht nachzuahmenden Fixation 
des Thorax (in Inspirationsstellung oder einer dieser ähnlichen Position) durch ganz 
kurze Stösse mit dem oberen Theil der Bauchmuskeln einen lauten, bellenden Husten 136 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
zu erzeugen, ohne die Glottis völlig zu schliessen. Dieses Verhalten, d. h. die Anwen- 
dung eines ganz besonderen, von dem Patienten willkürlich oder unwillkürlich ein- 
geübten Mechanismus, liefert den Schlüssel für die eigenthümliche Erscheinung, dass 
die sonst mit einer starken, plötzlichen Compression des Brustinhaltes bei Fixirung des 
Zwerchfelles vergesellschaftete maximale Druckerhöhung und der daraus resultirende 
schädliche Effect für die Circulation fast vollständig in Wegfall kommt. Da ferner 
hier auch der durch die entzündlichen Veränderungen im Inneren des Larynx sonst 
bewirkte Glottiskrampf, welcher die Anfälle des Keuchhustens sonst so sehr quälend 
macht, fehlt, so ist es erklärlich, dass die Wirkung selbst anscheinend schwerer Anfälle 
eine so geringe ist, dass nach Beendigung des Anfalles keine merkliche Erschlaffung 
des Organismus oder eine wesentliche Alteration der körperlichen Functionen vor- 
handen ist, und dass schädliche Folgen bei dem nervösen Husten lange ausbleiben 
können. Hier bleibt noch zu erwähnen, dass die oben erwähnte pfeifende oder besser 
tönende Inspiration, die sich zwischen die Anfälle einschiebt, durchaus nicht durch 
einen Glottiskrampf bedingt ist, denn es lässt sich laryngoscopisch feststellen, dass sie 
bei relativ weiter Glottis entsteht, dass sie also nur durch die Reibung des willkürlich 
beträchtlich verstärkten inspiratorischen Luftstromes (an den sich nur wenig nähernden, 
sich sogar bisweilen in normaler Weise von einander entfernenden Stimmbändern) 
hervorgerufen wird. Wenn die Intensität der Anfälle eine sehr beträchtliche wird, so 
kann es im ersten Stadium der Erkrankung bei Kindern und Frauen am Ende der 
Attaque zu Würgen oder Erbrechen kommen, ein Vorgang, der - im Gegensätze zu den 
Paroxysmen des Keuchhustens - im Anschlüsse an die Mahlzeit durchaus nicht häufiger 
stattfindet, als bei leerem Magen. Gewöhnlich wird auch, selbst bei gefülltem Magen, 
nur ein geringer Bruchtheil des Inhaltes ausgeworfen. Nach sehr heftigen Anfällen 
ergiebt die laryngoscopisehe Untersuchung-bei anämischen Individuen-bisweilen eine 
leichte, schnell verschwindende Röthung der Trachealschleimhaut oder der Plica inter- 
arytaenoidea ; Blutungen scheinen selbst bei sehr starken Anfällen sehr selten zu sein; 
in zwei Fällen fanden sich in dem expectorirten dünnen, nur aus Speichel bestehenden 
Expectorate kleine Blutpunkte, für deren Ursprung die laryngoscopisehe Untersuchung 
keinen Anhaltspunkt ergab. 
Unter den Folgezuständen des nervösen Hustens sind, abgesehen von einer Reihe 
anderer nervöser Symptome, Reizbarkeit, Launenhaftigkeit, theilweise deprimirter 
Gemüthsstimmung, Verdauungsstörungen, vor Allem zwei zu erwähnen, nämlich die 
secundäre, schon oben berührte Schleimhautaffection des Larynx und die Atelectase 
gewisser Lungenpartieen. Was die erstere betrifft, so ist darüber Folgendes zu sagen. 
Bei vielwöchentlichem Bestehen sehr schwerer Attaquen tritt in den Fällen, in denen 
der oben geschilderte eigenthümliche Mechanismus des Hustens, durch den die Span- 
nung und Reizung der Stimmbänder vermindert wird, nicht in Anwendung kommt, 
eine leichte catarrhalische Schwellung der Larynxschleimhaut, namentlich an der 
Plica interarytaenoidea, auf, welche letztere dann ebenso wie die aryepiglottischen 
Falten einen geringen Schleimbelag aufweist. Während der Hustenanfälle, die oft 
durch ein quälendes Würgen eingeleitet werden, wird dann eine geringe Quantität 
zähen, fadenziehenden Schleims, der in manchen Fällen mit Eiterflocken untermischt 
ist, ausgeworfen, und dieser Auswurf kann in Verbindung mit der bestehenden Textnr- 
veränderung der Schleimhaut der Diagnose grosse Schwierigkeit bereiten, da die Ent- 
scheidung, ob der Husten die Folge eines Larynxcatarrhs oder dieser die Folge des 
Hustens ist, in den ersten Tagen der Beobachtung und oft auch nach längerer Zeit 
unmöglich ist. Eine bestimmte Diagnose ist um so schwerer zu stellen, als man ja im 
Allgemeinen dem Umstande, dass auch, abweichend von dem sonstigen Causal- 
zusammenhange, der Husten als solcher, d. h. der mechanische Akt des Hustens, eine 
wesentliche Schleimhautaffection zur Folge haben könne, sehr wenig Rechnung trägt, 
obwohl es ja auf der Hand liegt, dass die starke, mit den Hustenstössen verbundene SECTION XIII-LARYNGOLOGY. 
137 
Zerrung und Quetschung des Gewebes eine Quelle beständigen Reizes für die zarte 
Schleimhaut abgeben, und ebenso einen entzündlichen Zustand in ihr hervorrufen und 
unterhalten kann, wie jede andere Schädlichkeit. Wir kommen bei Erörterung der 
Diagnose und namentlich der Therapie des Leidens, die die Bedeutung des alten 
diagnostischen Satzes "noscere ex juvantibus" klar illustrirt, auf einige in dieser 
Beziehung wichtige Punkte noch zurück. 
Die zweite wichtige Folgeerscheinung länger dauernden nervösen Hustens besteht 
in einer eigenthümlichen Veränderung des Athemgeräusches über der hinteren Partie 
der Lungenspitzen. Man findet dann bei der Untersuchung der Fossa supraspinata das 
inspiratorische Athmen beträchtlich abgeschwächt ; bisweilen hat es den vesiculären 
Character ganz verloren und erscheint unbestimmt oder hauchend ; oft vernimmt man 
statt des Athemgeräusches nur reichliches, klangloses, kleinblasiges, oft knisterndes 
Rasseln. Dieses Rasseln ist namentlich auf der Höhe der Inspiration oder nach starken 
Hustenstössen recht deutlich ; dagegen kann es nach einer Reihe tiefer Athemzüge 
völlig verschwinden, um einem ganz normalen Befunde Platz zu machen. Wenn hin- 
gegen der Patient fortfährt, in wenig ergiebiger Weise zu athmen und seine Husten- 
anfälle in gewohnter Weise zu produciren, so kann man nach kurzer Zeit wieder das 
ausgesprochenste Rasseln und das Verschwinden des normalen Athemgeräusches con- 
statiren, und man ist im Stande, den Wechsel der beschriebenen Erscheinungen 
beliebig oft zur Beobachtung zu bringen. Mit der Abnahme der Häufigkeit und 
Intensität der Anfälle nähert sich der Lungenbefund immer mehr dem Normalen, und 
wenn die Anfälle erst einige Zeit völlig ausgesetzt haben, so kann selbst in schweren 
Fällen die genaueste Untersuchung keinen pathologischen Befund mehr constatiren : 
über beiden Lungenspitzen vernimmt man mehr oder weniger lautes, aber deutliches, 
vesiculäres Athmen ohne jedes Nebengeräusch. Auffallend und daher der Erwähnung 
werth scheint uns die Thatsache, dass sich in unseren Fällen die eigenthümliche Ver- 
änderung des Athemgeräusches nur auf die rechte Fossa supraspinata beschränkt zeigte; 
doch glauben wir, dass es sich hier nur um ein zufälliges Zusammentreffen handelt, 
da kein zwingender Grund dafür vorliegt, dass gerade die rechte Lungenspitze durch 
so starke Hustenparoxysmen mehr beeinträchtigt werde, als die der anderen Seite. 
Endlich ist noch hervorzuheben, dass - und es ist dies in differentiell-diagnostischer 
Beziehung von grosser Wichtigkeit - der abnorme Auscultationsbefund nicht mit Ver- 
änderungen des Percussionsergebnisses vergesellschaftet ist ; denn in keinem unserer 
Fälle war eine auffallende Dämpfung über der rechten Fossa supraspinata zu constatiren. 
Es scheint nicht schwer, bei Berücksichtigung der eben geschilderten Sachlage, diese 
Veränderungen des Lungenbefundes, die wir in einer nicht unbeträchtlichen Zahl von 
Fällen zu beobachten Gelegenheit hatten, auf ihre Ursache zurückzuführen, und wir 
glauben nicht fehlzugehen, wenn wir die scheinbar catarrhalischen Erscheinungen von 
einem durch die häufigen starken Exspirationsstösse bewirkten leichteren Grad von 
Atelektasenbildung oder Collaps der einzelnen, wegen ihrer geringen Ausdehnungs- 
fähigkeit dazu besonders disponirten Theile des Lungengewebes, nämlich der Spitzen, 
ableiten. Je länger die Einwirkung der forcirten Exspirationen dauert, desto stärkere 
Ausbildung erfährt der Lungencollaps, desto ausgeprägter ist die Abschwächung des 
Athmens und das subcrepitirende Rasseln ; je öfter und je tiefer spontan geathmet 
wurde, desto mehr entfalteten sich die collabirten Partieen. Dass auch diese Folge- 
erscheinung des heftigen Hustens diagnostische Schwierigkeiten mit sich führen muss, 
liegt auf der Hand, und wir müssen dies auch bei Erörterung der Diagnose berück- 
sichtigen. 
Wir haben nun nach der Schilderung des klinischen Bildes noch der Aetiologie und 
Pathogenese des nervösen Hustens, wie diese sich auf Grund unseres über dreissig Fälle 
umfassenden Beobachtungsmaterials ergiebt, einige Worte zu widmen. Die Ent- 
stehung des Leidens ist in allen Fällen auf einen acuten Larynx-, Pharynx- oder 138 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Tracheal catarrh zurückzuführen ; denn von allen Patienten wird übereinstimmend 
angegeben, dass der Husten von einer heftigen Erkältung, einem Schnupfen, einer 
Halsentzündung etc. herdatire und stets an Intensität zugenommen habe, um nicht 
mehr zu verschwinden. Wie haben wir uns nun das Bestehenbleiben des Hustens als 
einzigen Symptômes der früheren Erkrankung zu erklären ? Doch wohl durch die 
Annahme, dass nach dem Verschwinden der ursprünglich als Reiz oder doch als reiz- 
verstärkendes Moment wirkenden Schleimhautaffection in den reflexvermittelnden 
Bahnen ein Zustand gesteigerter Erregbarkeit zurückgeblieben sei, der den Mechanismus 
der Hustenbewegungen schon bei verhältnissmässig geringen, bei unternormalen Reizen 
in Function treten lässt. Aber diese Erhöhung der Reflexerregbarkeit allein genügt 
nicht, das Phänomen zu erklären ; wir müssen auch eine directe Hyperästhesie in 
denjenigen Theilen der Centralorgane, in welchen die aus den oberen Theilen des 
Athmungsapparates, aus Larynx und Pharynx zugeführten sensiblen Impulse zum 
Bewusstsein kommen, also eine Ueberempfindlichkeit der Hirnrinde annehmen, denn 
die grosse Mehrzahl der Patienten giebt an, dass sie ein beständiges Kitzeln, Drücken 
oder Ziehen in der Kehlkopfgegend empfinde, welches sie zum Husten zwingt. Unsere 
Annahme, dass es sich um eine gesteigerte Perceptionsfähigkeit und um eine vermin- 
derte Hemmungsfähigkeit von Seiten des Willens und nicht bloss um eine erhöhte 
Reizbarkeit der peripheren End- oder der Reflexapparate handelt, wird vor Allem 
dadurch bewiesen, dass bei Nacht die Hustenanfälle ausbleiben, und wesentlich 
gestützt durch die Thatsache, dass es möglich ist, bei energischer Willensanstrengung 
die Anfälle zu unterdrücken. Würde es sich um eine blosse Steigerung der Reflex- 
erregbarkeit, oder um eine Vermehrung des Hustenreizes (Schleimsecretiou, Gewebs- 
veränderungen etc.) handeln, so müssten die Anfälle, wie bei anderen Formen des 
Hustens, auch in der Nacht auftreten und den Schlafenden erwecken, oder auch wäh- 
rend des Schlafes, ohne dem Kranken zum Bewusstsein zu kommen, sich abspielen. 
Wir finden ja ähnliche centrale Reizungszustände auch an anderen reflectorisch 
arbeitenden Apparaten ; so ist z. B. das nach Blasen- und Mastdarmaffectioneu zurück- 
bleibende, so lästige Gefühl des Tenesmus auf dieselbe Ursache zurückzuf ühren, da es 
nur im wachen Zustande besteht und durch energische Willensanstrengung ebenso zu 
unterdrücken ist, wie das sogenannte ' ' Leerschlucken, ' ' welches nach Rachencatarrhen 
zurückbleibt und durch eine unangenehme Empfindung, die nach dem Pharynx pro- 
jicirt wird, bedingt ist. In manchen Fällen spielen wohl beide Vorgänge, eine abnorme 
Reizempfänglichkeit der afficirt gewesenen Endapparate und eine erhöhte Erregbarkeit 
der centralen Partieen bei dem Zustandekommen der Hustenparoxysmen, resp. der 
anderen abnormen Reflexerscheinungen, eine Rolle, obwohl der psychische Factor vor- 
waltet, wie man aus dem Umstande ersehen kann, dass die Kranken zu husten 
anfangen, sobald ihre Aufmerksamkeit auf ihr Leiden hingelenkt wird. Zum Zustande- 
kommen des nervösen Hustens ist eine nervöse Disposition durchaus nicht erforderlich, 
da eine Reihe unserer Patienten kaum in die Categorie der neuropathischen Individuen 
einrangirt werden kann, da namentlich den meisten der von uns beobachteten Kinder 
das Prädicat "nervös" nicht zukommt; jedoch muss hervorgehoben werden, dass 
"Nervosität" die In- und Extensität der Anfälle begünstigt und dass bei Kindern 
und manchen erwachsenen Personen in der Ausbildung und Entwickelung der starken 
Hustenparoxysmen zweifellos ein Factor eine Rolle spielt, der auch sonst nicht selten 
die Ursache von Klagen ist, nämlich der Eindruck, den das Leiden auf die Umgebung 
macht. Man kann im Allgemeinen annehmen, dass sich bei Kindern und bei Erwach- 
senen die Anfälle um so mehr steigern, je nachsichtiger die Angehörigen sind, je mehr 
Mitleid der Zustand der kleinen und bisweilen auch grossen Kranken erregt. Wir 
kommen bei der Therapie auf diesen Punkt zurück, da er f ür eine rationelle Behand- 
lung von grösster Wichtigkeit ist. 
Die Diagnose ist sehr leicht bei Beurtheilung der zur zweiten Categorie, zur Gruppe SECTION XIII-LARYNGOLOGY. 
139 
der ' ' hüstelnden, ' ' gehörenden Fälle, und man kann hier sofort, nachdem die Local- 
untersuchung keine Anhaltspunkte für eine locale Gewebsstörung gegeben hat, aus den 
äusseren Merkmalen, die die ununterbrochen hüstelnden und räuspernden Patienten 
gewähren, seine Schlüsse ziehen. In den Fällen von explosivem Husten führen 
folgende Criterien zur Annahme der nervösen Form. 1) Negativer Localbefund trotz 
längeren Bestehens der Affection. 2) Fehlen der Expectoration. 3) Aufhören der 
Anfälle während der Nacht und bei Ablenkung der Aufmerksamkeit. 4) Auffallend 
geringes Ergriffensein des Patienten nach anscheinend sehr schweren Anfällen. 
5) Erfolg der Therapie, die keine medicamentöse, sondern eine psychische ist. 
In Fällen, die bereits längere Zeit bestehen, ist schon die Abwesenheit einer 
Gewebsstörung, das Fehlen sonstiger secundärer und das Vorhandensein von Symp- 
tomen allgemeiner Nervosität zur Begründung der Diagnose genügend. Gelingt es, 
die Patienten während eines Anfalles zu beobachten und das oben geschilderte, für den 
nervösen Husten characteristische typische Verhalten des Thorax zu constatiren oder 
den oben erwähnten Larynxbefund zu erheben, so ist die Diagnose gesichert. 
Schwerer wird die Beurtheilung des Falles, wenn das Krankheitsbild durch die 
Folgeerscheinungen, deren wir bereits bei der Schilderung der Symptome Erwähnung 
gethan haben, sich complicirt, wenn sich die anscheinenden catarrhalischen Erschei- 
nungen an der Lunge finden, oder wenn die durch den anhaltenden Husten bewirkte 
Reizung der Schleimhaut zu entzündlichen Zuständen derselben geführt hat. Hier, 
namentlich im letztgenannten Falle, erfordert die Prüfung der Sachlage oft längere 
Zeit. Im ersten Falle ist von Wichtigkeit das Fehlen einer ausgesprochenen Dämpfung, 
die Aenderung des Befundes nach tiefen Inspirationen, welche normale Verhältnisse 
herbeiführen, das Fehlen aller sonst auf tiefere Veränderungen in den Lungen zu 
beziehenden Erscheinungen, wie z. B. der Nachtschweisse, der Abmagerung, der 
characteristischen Sputa ; im zweiten Falle muss bei Stellung der Diagnose ebenfalls 
die Art und Dauer des Verlaufs der einzelnen Anfälle, die Anamnese, genau geprüft 
und ein sorgfältiger Localbefund erhoben werden ; ausschlaggebend für die Diagnose 
ist aber erst der Erfolg einer bestimmten Therapie. Wenn es gelingt, trotz der langen 
Dauer der Erkrankung, ohne jede topische Behandlung allein durch Unterdrückung 
der Hustenanfälle, ohne Medicamente oder wenigstens ohne reichlichere Anwendung 
von Narcoticis eine Besserung oder Heilung herbeizuführen, wenn man also den Beweis 
liefern kann, dass nur der mechanische Akt des Hustens allein die Ursache der Schleim- 
hautaffection, und dass der Husten das primäre, die Texturerkrankung das secundäre 
Moment sei, so ist es möglich, den Fall richtig zu classificiren. Dies ist aber so schwer 
und erfordert eine solche Aufopferung von Seiten des Arztes und eine solche Willens- 
energie von Seiten des Patienten, dass es nur selten gelingt, in so vorgeschrittenen 
Fällen den Beweis für die nervöse Natur des Leidens in der von uns angedeuteten 
Weise zu erbringen. 
Der Verlauf des nervösen Hustens bietet im Allgemeinen nichts Characteristisches, 
da dort, wo die Hyperästhesie einmal Platz gegriffen hat, ein spontanes Auf hören der 
Anfälle nur dann zur Beobachtung kommt, wenn eine totale Veränderung der äusseren 
Verhältnisse, in denen die Patienten leben, vor sich geht, oder wenn Ereignisse ein- 
treten, die den Kranken gebieterisch von seinem Leiden ablenken. Das Leiden kann 
trotz aller Behandlung, aller localen Applicationen und allgemeinen Maassnahmen 
mehrere Jahre hindurch bestehen, ohne eine wesentliche Verschlimmerung zu erfahren 
oder die Ernährung und den allgemeinen Zustand des Patienten, abgesehen von einer 
gewissen Steigerung der nervösen Erregbarkeit, überhaupt ungünstig zu beeinflussen. 
Nicht selten folgt auf eine Periode scheinbarer Besserung, auf eine Zeit der Remission 
der Anfälle, nach Gemüthsaufregungen oder grösseren körperlichen und geistigen 
Anstrengungen eine Periode, in der die Anfälle sich häufen und extensiver werden ; 
in der Mehrzahl der Fälle tritt nach mehrmonatlichem Bestehen der Affection eine 140 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Abschwächung der Anfälle ein ; bei noch längerer Dauer des Zustandes bleibt nur, 
wie schon oben erwähnt, jenes monotone Husten und Räuspern zurück, welches den 
Kranken und oft namentlich seine Umgebung zur Verzweiflung bringt. Die zweite 
Categorie oder Form des nervösen Hustens ist also hier, um dies noch einmal zu 
betonen, oft nichts anderes, als das Endstadium der Erkrankung, dessen Dauer eine 
nicht zu ermessende ist. Die Prognose ist in diesem Stadium oder bei der zweiten 
Form des nervösen Hustens eine ungünstige, da es nicht mehr gelingt, die Energie des 
Patienten derart zu heben, dass sie im Stande ist, den so lange Zeit hindurch von 
einem verhältnissmässig geringen Reize in extensive Bewegung versetzten Reflex- 
mechanismus zu hemmen oder durch Selbstüberwindung die unangenehme, quälende, 
in den Larynx oder Pharynx versetzte Sensation zu unterdrücken, anstatt sie mit will- 
kürlichen Hustenbewegungen zu beantworten. 
Die Therapie des Leidens muss demnach im Wesentlichen darauf gerichtet sein, 
die Hyperästhesie möglichst frühzeitig zu beseitigen und den unaufhörlich arbeitenden 
Reflexapparat in Ruhe zu versetzen. Durch die innerliche Darreichung der gebräuch- 
lichen Narcotica, Nervina, Expectorantia und Sedativa (Morphium, Belladonna, Hyos- 
cyamus, die Brompräparate, Arsen etc. ) erreicht man diesen Zweck aber ebensowenig, 
wie durch die locale Application adstringirender oder beruhigender Medicamente; 
denn wenn sich auch nicht leugnen lässt, dass durch eine Reihe der gebräuchlichen 
Methoden eine scheinbare Besserung für Stunden, Tage oder Wochen herbeigeführt 
•wird, so handelt es sich doch nur um eine Abschwächung und Verminderung der 
Anfälle : eine völlige Intermission wird nie erzielt und auf die Periode scheinbarer 
oder wirklicher Remission folgt unmittelbar ein Rückfall von wesentlich gesteigerter 
Stärke. Wir haben diesen geringen Effect aller bei den Gewebsstörungen so wirk- 
samen Maassnahmen so oft zu beobachten Gelegenheit gehabt, wir haben so viele Fälle, 
die allen bekannten Manipulationen getrotzt haben, in Behandlung bekommen, dass 
wir von ihrer Nutzlosigkeit uns völlig überzeugt haben. Auch von den allgemeinen 
Maassnahmen (kalten Abreibungen, Galvanisation, Bädern) haben wir keinen dauern- 
den Nutzen gesehen und glauben deshalb, sowohl mit Rücksicht auf unsere praktischen 
Erfahrungen in solchen Fällen, als auf Grund der sich aus der Pathogenese des nervösen 
Hustens ergebenden theoretischen Erwägungen, dass in diesen Fällen nur eine einzige 
Therapie, die psychische, sich deswegen empfiehlt, weil sie allein im Stande ist, den 
causalen Anforderungen zu genügen, weil sie das Uebel an der Wurzel angreift ; unser 
hauptsächliches Streben muss, wenn wir das Leiden als ein nervöses, auf einer Ueber- 
empfindlichkeit gewisser Theile des nervösen Apparates beruhendes betrachten, darauf 
gerichtet sein, diese Hyperästhesie zum Verschwinden zu bringen. Können wir dies 
durch Medicamente oder locale intralaryngeale oder intrapharyngeale Maassnahmen 
erreichen? Wir glauben, dass dies unmöglich ist, und zwar deshalb, weil jedes 
beruhigende, narcotische Mittel zwar im Stande ist, den Reiz für eine gewisse Zeit 
unmerklich zu machen, aber nicht verhindern kann, dass nach dem Ablaufe der 
Narcose die Empfindlichkeit in womöglich noch gesteigertem Maasse zurückkehrt. 
Ebensowenig vermag die locale Behandlung wirksam zu sein, da sie in der That keinen 
Angriffspunkt hat. Welchen Nutzen kann man sich von Adstringentien dort ver- 
sprechen, wo keine Entzündung, keine nachweisbare Gewebsstörung mehr besteht? 
Man wende nicht ein, dass man bei den auf ähnlicher Basis entstandenen, z. B. nach 
Entzündungen der Blase oder des Mastdarmes zurückgebliebenen Zuständen der 
Hyperästhesie durch Adstringentien manchmal recht erfreuliche Resultate erreiche ; 
denn der Versuch ist in allen diesen Fällen kein reiner eindeutiger, da die Application 
des Medicamentes auf die überempfindlichen Stellen zugleich mit einer energischen 
mechanischen Behandlung, eben durch das Einführen des Instrumentes, verknüpft ist, 
und von dieser wissen wir ja, dass sie recht häufig die Ueberempfindlichkeit der kranken 
Partieen abstumpft und direct heilend wirkt. Wäre man im Stande, mit narcotischen SECTION XIII LARYNGOLOGY. 
141 
oder beruhigenden Mitteln eine wirklich dauernde Herabsetzung der Erregbarkeit im 
Nervensystem hervorzurufen, so würde man nicht nöthig haben, immer neue Mittel 
und Methoden zu ersinnen, um den Neurasthenischen und Neuropathischen Heilung zu 
verschaffen, Methoden, die im Wesentlichen doch alle nur den einen Zweck haben und 
nur allein dadurch wirken können, dass sie die Willenskraft der Patienten zu heben 
und ihre Energie zu stärken versuchen. Hat man die Ueberzeugung, dass nur dieser 
Factor der Behandlung der wirksame ist - und diese Ueberzeugung ist ja jetzt glück- 
licherweise allgemein geworden-, so muss man in allen Fällen, in denen die Willens- 
schwäche die Ursache der zu beobachtenden Symptome ist, hier den Hebel ansetzen, 
und darf sich keine Zeit und Mühe verdriessen lassen, Das zu erreichen, was man für 
das allein Richtige hält. 
Hat man sich in einem Falle durch sorgfältige Untersuchung und Berücksichtigung 
aller in Betracht kommenden Momente davon überzeugt, dass eine Form des nervösen 
Hustens vorliegt, so muss man die eben erwähnten Principien der Behandlung adop- 
tiren und in jeder Weise darauf hinzuwirken suchen, dass der Patient seine Ueber- 
empfindlichkeit und den dadurch bedingten Hustenreiz nach Kräften zu unterdrücken 
versuche. 
Diesen Zweck erreicht man bei Kindern und jüngeren Personen in vielen Fällen 
einfach dadurch, dass man eine schmerzhafte oder in irgend einer Beziehung unange- 
nehme Maassnahme in Aussicht stellt. Durch die blosse Drohung, es müsse geschnitten 
oder gebrannt werden, wird bei einzelnen Personen schon eine auffallend schnelle 
Veränderung und ein Cessiren der Hustenanfälle hervorgebracht ; in manchen Fällen 
wirkt die Ankündigung, dass der Patient von den Angehörigen getrennt und in eine 
Anstalt gebracht werden müsste, in sehr frappanter Weise reflexhemmend. In schweren 
Fällen genügt die Application des faradischen Pinsels am Halse, oder, um jeden Ein- 
wand einer localen Einwirkung auf die scheinbar erkrankten Organe, den scheinbaren 
Locus affectus, auszuschliessen, auf die Brust, um ein sofortiges Cessiren der Anfälle 
zu bewirken ; eine mehr als dreimalige Anwendung des Pinsels bei mehr oder weniger 
beträchtlicher Stromstärke ist in keinem Falle zur völligen Heilung erforderlich. In 
zwei sehr schweren und langdauemden Fällen hat die Isolirung der kleinen Patienten 
bei gleichzeitiger Anwendung des faradischen Pinsels einen sehr schnellen, dauernden 
Erfolg gehabt. 
Was die Therapie der geschilderten Krankheitszustände bei Erwachsenen anbetrifft, 
so ist die Behandlung und Heilung der Paroxysmen bei alleiniger Anwendung schmerz- 
haft wirkender Methoden, durch die gewissermaassen eine "Abgewöhnung" erzielt 
werden soll, eine bei Weitem schwierigere, und wir sind in den meisten Fällen genöthigt 
gewesen, von einem combinirten Heilverfahren Gebrauch zu machen. 
Bei der zweiten Categorie des nervösen Hustens haben wir überhaupt einen wesent- 
lichen dauernden Erfolg nicht zu erzielen vermocht ; wohl aber haben wir vorzügliche 
Resultate bei der ersten und bei der combinirten Form gesehen, und zwar selbst in 
Fällen, die Jahre lang allen Medicamenten und localen und allgemeinen Maassnahmen 
getrotzt hatten. Hier m üssen alle Mittel in Anwendung gezogen werden, mit denen 
man auf die Psyche des Kranken einwirken kann, da die auf die Abschreckung des 
Kranken hinzielenden, rein durch die Erregung körperlichen Schmerzes wirkenden 
Maassnahmen bei Erwachsenen, namentlich bei Männern-bei Frauen ist der electriscbe 
Pinsel oft wirksam - ihren Zweck völlig verfehlen würden. 
Wir haben als das beste folgendes Verfahren erprobt : Man setze dem Patienten 
den Mechanismus des Hustens auseinander und mache ihm klar, dass es nur darauf 
ankomme, den ihn so quälenden Reiz durch Willensstärke zu unterdrücken, dass keine 
Behandlungsweise von Erfolg sein könne, wenn sie nicht durch den guten Willen des 
Kranken unterstützt werde ; dass ein längeres Bestehen des Hustens mit Gefahr für 
die Lunge verknüpft sei ; dass er schliesslich zu Lungenblutungen, Lungenleiden 142 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
f ühren könne. Dann fordere man den Kranken auf, recht tief Äthern zu holen, den 
Äthern anzuhalten, und lasse sich in der Ueberwachung dieser Form der Lungen- 
gymnastik durch die stets eintretenden Hustenanfälle nicht irre machen. Je energischer 
man dem Kranken zuredet, je mehr man seine Willensschwäche tadelt, desto mehr 
gelingt es, ihn zur temporären Unterdrückung des Hustens zu bewegen. Ist dies eiu- 
oder das andere Mal gelungen, ohne dass darauf eine verdoppelte Explosion erfolgt, so 
hat man schon Viel gewonnen, denn der Kranke fängt jetzt an, Vertrauen zu der ihm 
Anfangs befremdlichen Methode und auch Selbstvertrauen zu gewinnen. Hat man 
längere Zeit diese Uebungen persönlich geleitet, so ordne man eine Fortsetzung dieser 
Maassnahmen ohne Beaufsichtigung von Seiten des Arztes oder der Angehörigen des 
Kranken an und fahre in dieser Behandlung, die bisweilen eine zwei- bis dreimalige 
persönliche Anwesenheit des Arztes bei den Uebungen innerhalb der ersten Tage 
erfordert, so lange fort, bis der Husten Tag und Nacht cessirt hat. So leichten Kaufes 
kommt man aber in der Regel nicht fort, denn selbst die Patienten, die unter der Auf- 
sicht des Arztes bereits recht schöne Resultate in der Reflexhemmung erreicht haben, 
sind nicht im Stande, allein und unbeaufsichtigt ihrem mächtigen langgewohnten 
Reize zu widerstehen, und namentlich die Bekämpfung der Hustenanfälle, welche sich 
einstellen, wenn der Kranke zur Nachtruhe das Bett aufgesucht hat, macht oft trotz 
aller Versuche unüberwindliche Schwierigkeiten. Die Patienten, welche den Arzt mit 
den besten Hoffnungen verlassen haben, kehren am anderen Tage verzweifelt zu ihm 
zurück, um ihm mitzutheilen, dass der Hustenreiz bei dem Versuche, ihn zu unter- 
drücken, so stark sei, dass sie zu ersticken fürchten müssten, wenn sie ihm nicht nach- 
gäben, und dass sie jeden solchen Versuch mit ungemein verstärkten Paroxysmen 
bezahlen müssten. Hier muss die Ueberredungskunst und Energie des Arztes das 
Möglichste thun ; er darf mit seinen Ermahnungen und Anordnungen nicht nach- 
lassen ; er muss die täglichen Uebungen vervielfachen und auch bei horizontaler Lage 
die geschilderte mit der Athmungsgymnastik treiben lassen, bis der Kranke den Reiz 
überwunden und den Reflexmechanismus in seiner Gewalt hat. Von grossem Vortheil 
f ür die Erzielung derartiger Resultate ist es auch, die Patienten, bei denen der Ueber- 
gang von kalter in warme Luft die Hustenparoxysmen hervorruft, die Lungen- 
gymnastik in kühler Aussentemperatur oder bei geöffneten Fenstern und in der Zug- 
luft vornehmen zu lassen. 
So anstrengend diese Art der Behandlung für Arzt und Patienten ist, so grosse 
Ansprüche sie an beide Theile stellt, so lohnend ist sie, wie unsere Erfolge gelehrt 
haben ; auf ihre energische Durchführung ist daher das Hauptgewicht zu legen, und 
die anderen Formen der Medication, die sonst in Anwendung gezogen zu werden 
pflegen und je nach der Art des Falles und der Individualität der Patienten in Anwen- 
dung kommen müssen,-oft kann der Arzt ja ihr Vertrauen und die nöthige Disciplin 
nur auf dem Umwege eines mit dem Nimbus des Geheimnissvollen umkleideten 
Mittels oder einer sinnfälligen Methode gewinnen - sind nur als die Zierrathen zu 
betrachten, die den festumrissenen Rahmen der zielbewussten methodischen Discipli- 
nirung schmücken und ihm seine Einförmigkeit nehmen. SECTION XIII-LARYNGOLOGY. 
143 
CLASSIFICATION DES MUSCLES DE L'ORGANE DE LA VOIX. 
CLASSIFICATION OF THE MUSCLES OF THE ORGAN OF THE VOICE. 
KLASSIFIKATION DER MUSKELN DES STIMMORGANES. 
PAR LE DR. MOURA. 
I. DIVISIONS ADOPTÉES PAR LES AUTEURS CLASSIQUES. 
Les muscles du larynx ont été un objet d'études et de recherches pour beaucoup 
d'anatomistes et de physiologistes, tant anciens que modernes, et malgré leurs travaux 
et leurs écrits, malgré leurs expériences in anima vili, on n'est encore fixé ni sur le nom- 
bre de ces agents moteurs, ni sur la véritable fonction de la plupart d'entre eux. 
Nous essaierons cependant de faire quelque lumière sur ces importantes questions, 
en consignant ici des résultats que nous ont fournis nos dissections au laboratoire de 
l'ancien Hôtel-Dien et nos examens laryngoscopiques sur l'homme pendant la vie. 
Jalier est considéré comme l'un des premiers anatomistes qui ait fait connaître ces 
muscles. Après lui Fabrice d'Aquapendente, dont j'ai souvent entendu faire l'éloge 
par un professeur de l'Ecole de Montpellier, Estor, père, en a donné une description 
plus complète. 
Sans nous attarder à citer tous ceux qui ont refait cette description, disons que Bichat 
et Magendie apportèrent dans cette étude un nouveau moyen de contrôle, l'expérimen- 
tation physiologique, et que l'invention du laryngoscope a, depuis 26 ans, imprimé un 
tel essor à tous les problèmes qui se rattachent à la théorie de la voix humaine que, 
d'ici à peu de temps, nous l'espérons, l'anatomie et la physiologie de l'organe vocal 
laisseront peu de chose à connaître. 
Afin de rendre notre exposition plus simple et la plus lucide possible, examinons 
quelles sont les idées qui ont servi de base aux diverses classifications des auteurs. 
La première division dont nous avons à parler est fondée sur l'anatomie. Les mus- 
cles laryngés y sont partagés en deux groupes dénommés intrinsèques et extrinsèques, 
suivant qu'ils font directement ou indirectement partie du larynx, suivant qu'ils sont 
intra ou extra laryngés. 
Une seconde division plus ancienne repose sur le rôle physiologique attribué aux 
faisceaux musculaires. Elle comprend également deux sections selon que les muscles 
ouvrent ou ferment l'orifice de la glotte. On a obtenu ainsi deux groupes appelés l'un 
dilatateur et l'autre constricteur de la glotte. 
Cette division ne satisfaisant pas tous le monde, on a cru la remplacer plus savam- 
ment et plus utilement par une troisième, celle de muscles abducteurs et de muscles 
adducteurs, qualificatifs dont la forme est séduisante, plus scientifique et moins vul- 
gaire, mais qui n'en valent guère mieux comme expression et comme exactitude. 
Notre savant et regretté physiologiste Béclard, décédé le 9 Février dernier, avait 
pensé qu'il fallait ranger les muscles du larynx sous les deux vocables de glottiques et 
vocaux, suivant, dit-il " que les uns ont pour rôle d'éloigner ou de rapprocher les lèvres 
de la glotte, d'augmenter ou de diminuer cet orifice ; et les autres, de modifier la lon- 
gueur, la tension et l'épaisseur des cordes vocales inférieures," dans le dictionnaire de 
Dechambre, article sur les fonctions du larynx, page 568 et suivant par Béclard. 
Avant d'apprécier la valeur de ces classifications, quelques considérations physiolo- 
giques sont indispensables sur le larynx comme organe de respiration et de phonation. 
II. LE LARYNX, ORGANE DE RESPIRATION. 
Comme organe de l'appareil respirateur le larynx contient un orifice appelé glotte 
qui est le passage le plus détroit et le plus important du canal aérifère. Ce passage 
simule une porte-écluse à deux vantaux ; l'air entre et sort par cette porte sans inter- 144 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
ruption tant que la vie existe et l'intégrité de la fonction respiratoire exige qu'il soit 
toujours ouvert et libre. 
Or, les deux vantaux exécutent sans discontinuer un mouvement de va et-vient 
toutes les quatre ou cinq secondes ; le degré d'ouverture du passage varie en consé- 
quence de quelques millimètres en plus ou en moins. Ils sont, en effet, le siège de deux 
déplacements contraires et opposés qui les écartent et les rapprochent sans les appliquer 
toutefois l'un contre l'autre. 
Ces vantaux ne sont autre chose que les replis ou lèvres de la glotte, les cordes vocales 
de Ferrein dont les aryténoïdes représentent les chevilles. Leur écartement et leur 
rapprochement, quelque exagérés qu'ils soient, n'offrent aucun inconvénient dans les 
conditions de la respiration calme et normale. Ce fait très important vient de ce que 
l'allée et le retour de ces valvules mobiles s'opèrent indépendamment de la volonté, et 
cette indépendance est la meilleure garantie de la régularité du mécanisme de l'acte 
de la respiration. Quand cette volonté intervient, c'est toujours pour maintenir l'inté- 
grité de leurs mouvements rythmiques, pour faire disparaître la cause ou l'obstacle qui 
les ont troublés. 
Ainsi, ce n'est qu'accidentellement que les bords de la glotte, autrement dit les 
vantaux de la porte écluse, se trouvent amenés jusqu'au contact et maintenus en cet 
état ; l'orifice étant rétréci ou fermé, l'air entre et sort difficilement, bruyamment 
comme à travers une tente de porte mal jointe. Nous n'avons pas à nous occuper de ce 
sujet en ce moment, pas plus que de l'interruption volontaire ou simulée de son écou- 
lement. 
Constatons seulement : 
1. Que l'écartement et le rapprochement alternatifs des bords de la glotte sont syn- 
chrones avec les deux actes de la respiration, savoir : l'inspiration et l'expiration. 
2. Qu'ils s'exécutent passivement, automatiquement, c'est-à-dire, sans que la volonté 
intervienne contrairement à l'opinion de nos confrères en laryngologie et à celle des 
physiologistes en général.* 
Malgaigne dont l'esprit paralysait la main, s'était occupé de la voix humain dans 
un travail inséré dans les archives générales de médecine en 1831. De ses expériences 
et de ses appréciations plus ou moins justes il avait conclu : 
" Que le thyréo-aryténoïdien est le muscle vocal par excellence, tandis que les autres 
ne sont que des muscles respirateurs ; qu'il obéit seul à la volonté et que les autres, 
quoique soumis aussi à la volonté, peuvent agir en son absence, propriété commune à 
tous les respirateurs. " Tome XXV. 
E. Fournié n'est pas du tout de son avis. 
"Contrairement à son assertion, dit-il, nous pensons que le muscle thyréo-aryténoï- 
dien est un muscle respirateur au même titre, sinon plus, que les autres. Si, pendant 
l'inspiration, la glotte s'agrandit sous l'influence des crico-aryténoïdiens postérieurs, 
elle se rétrécit pendant l'expiration et ce rétrécissement ne peut être effectué que par les 
thyréo-aryténoïdiens. " " Physiologie delà Voix et de la Parole," page 406, année 1866. 
"Pendant la respiration ces muscles (les crico-aryténoïdiens postérieurs) sont dila- 
tateurs de la glotte." Id. page 416. 
Mandl considérait ce double mouvement rythmique des bords de la glotte comme 
accidentel et caractérisant une respiration anormale, c'est-à-dire, accélérée par une cause 
passagère. Dans la respiration calme, tranquille, autrement dite normale, les bords de 
la glotte, suivant lui, restent fixes et immobiles. Voici ce qu'il écrit dans son " Traité 
des Maladies du Larynx, p. 245, publié en 1872. 
i 
* Notre manière de voir sur ce point de la physiologie laryngée a été déjà exposée dans notre 
mémoire sur la nouvelle Théorie de la voix, présenté à l'Académie de Médecine, le 29 Mars 
1887. SECTION XIII-LARYNGOLOGY. 
145 
"Par l'inspiration, les lèvres vocales sont écartées et partiellement cachées sous les 
replis supérieurs ; et cet écartement est plus ou moins considérable suivant l'action des 
muscles crico-aryténoïdiens postérieurs. Si ces muscles se contractent et si leur action 
est contre-balancée en partie par celle des crico-aryténoïdiens latéraux, l'orifice glottique 
présente un triangle isoscèle à la base duquel serait ajouté un autre triangle plus petit, 
à sommet tronqué. Si, au contraire, l'inspiration est très ample, très profonde, les 
muscles crico-aryténoïdiens postérieurs se contractent d'une manière énergique, etc." 
-Alinéa 248. 
"Tous les muscles intrinsèques sont en activité à l'exception des thyro-aryténoïdiens 
internes, car on ne voit pas les lèvres vocales s'épaissir, et à l'exception des crico-thyroï- 
diens."-Id. p. 249, Alinéa 282. 
La façon d'écrire de Mandl ferait croire qu'il ne possédait pas bien la langue fran- 
çaise. 
Au commencement de la page 245, il dit que l'immobilité des lèvres de la glotte 
pendant la respiration est l'état normal; et, dans les alinéas suivants, il attribut le peu 
d'écart dont elles sont le siège pendant cette même respiration normale, tranquille et 
calme est dû. à une action partielle des crico-aryténoïdiens postérieurs. 
" Lorsque l'inspiration s'accomplit normalement, sans effort et tranquillement, les 
replis inférieurs conservent une immobilité presque absolue pendant l'inspiration et l'ex- 
piration."-Alinéa 247, p. 245. 
" Pendant l'expiration, on voit les replis inférieurs (après une inspiration très ample 
et profonde) se rapprocher et limiter un triangle isoscèle, jusqu'à ce que la respiration 
normale se trouve complètement établie, avec une immobilité complète de ces replis. "- 
Alinéa 248, p. 245. 
C'est à tort, selon nous, que l'on attribue aux muscles intrinsèques laryngés une 
part quelconque que dans les déplacements qu'éprouvent les bords de la glotte pendant 
les deux actes de la respiration calme et tranquille, c'est-à-dire normale. 
Mandl commet une autre erreur quand il affirme que, pendant la respiration calme 
et tranquille, les lèvres vocales restent immobiles et qu'elles n'éprouvent des déplace- 
ments, des oscillations, cpi'accidentellement et volontairement. 
Les oscillations des bords de la glotte sont plus ou moins visibles chez les sujets que 
l'on inspecte. La cavité du larynx, pour un grand nombre d'entr'eux, n'est pas acces- 
sible à l'éclairage; la conformation de l'épiglotte est un obstacle des plus ordinaires, et, 
quant elle permet l'examen, la moitié antérieure de l'orifice glottique reste souvent 
invisible. 
Mais là où cette orifice est reproduit en entier par le miroir, ses bords exécutent des 
allées et des venues régulières qui sont d'autant plus apparentes que la glotte est plus 
petite, d'autant moins saisissables et étendues que lèvres vocales sont plus longues. Ces 
déplacements rythmiques varient aussi suivant que le développement de la glotte est 
ou n'est pas en rapport avec le diamètre du porte-vent (trachée) et la capacité du souf- 
flet pulmonaire. Quelque limités que soient d'ailleurs l'écartement et le rapproche- 
ment des apophyses vocales pendant l'inspiration et l'expiration, nous n'avons jamais, 
quant à nous, constaté leur immobilité complète, sauf intervention de la volonté. 
Lorsque, pour une cause ou pour une autre, le rythme de la respiration tranquille 
devient rapide, les oscillations des lèvres de la glotte sont aussi plus accentuées, plus 
fréquentes, car l'accélération des mouvements respiratoires se reproduit dans ceux des 
bords de la glotte. L'inspiration étant plus ample, plus profonde et plus courte, l'air 
aspiré entre avec force, avec précipitation ; la pression qu'il exerce contre les parois du 
conduit vestibulaire refoule les parties non résistantes et agrandit d'autant le passage de 
la porte-écluse en écartant ses deux vantaux. 
Quoique plus fréquente, la respiration n'en est pas moins facile ; elle a lieu comme 
à l'état normal et sans que les muscles intrinsèques aient besoins d'intervenir. Il n'en 
Vol. IV-10 c 146 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
est pas de même si un corps étranger ou une cause pathologique arrête ce mouvement 
rythmique et occasionnent le spasme ou la sténose de la glotte; les muscles intrinsèques 
entrent alors en action pour faire disparaître l'obstacle et ouvrir les deux vantaux avec 
énergie. 
Mais tant que la respiration s'accomplit dans les conditions ordinaires et physiolo- 
giques de la santé, qu'elle soit lente, qu'elle soit accélérée, le mouvement oscillatoire 
des bords de la glotte reste involontaire, automatique, organique, ou passif. Cet automa- 
tisme est du reste démontré physiologiquement par les expériences des vivisecteurs et 
cliniquement par le laryngoscope chez les hystériques et certains paralytiques. 
III. LES OSCILLATIONS GLOTTIQUES RESPIRATOIRES. 
Dans la " Physiologie Médicale de l'Encyclopédie " de Bayle, Tome v., 1836, Brä- 
chet s'exprime ainsi : 
' ' La section des récurrents annule la voix et produit le serrement de la glotte, tan- 
dis que l'expérience faite sur les nerfs laryngés supérieurs donne lieu à l'aphonie avec 
dilatation de l'ouverture ; c'est sans doute la différence de ces effets qui faisait dire à 
Magendie et à Richerand que les récurrents se distribuaient aux dilatateurs de la glotte 
et que les nerfs laryngés supérieurs sont destinés aux muscles aryténoïdiens et aux 
crico-thyroïdiens, Bichat, Bayer, Javard n'admettent aucune distinction entre les mus- 
cles qui reçoivent leurs filets nerveux du laryngé supérieur et les muscles auxquels sont 
destinés les ramifications des récurrents. ' ' 
Le grand physiologiste Claude Bernard a fait plus que Bichat, Magendie, Longet et 
autres. Il a non seulement sectionné le nerf spinal, il l'a aussi arraché à son origine. 
Et qu'a-t-il obervé ? l'aphonie complète et l'intégrité des mouvements respiratoires. 
Or, nous savons tous que le spinal se distribue ou plutôt apporte la contractilité aux 
muscles intrinsèques du larynx et non aux muscles extrinsèques.* Nous savons encore 
que le nerf pneumogastrique, son voisin d'origine, tient sous sa dépendance la fonction 
respiratoire et que la glotte, malgré l'absence de l'action du spinal, continue à s'élargir 
pour le passage de l'air inspiré et à se rétrécir pour celui de l'air expiré. 
"Les animaux chez qui (sic.) on a coupé les nerfs spinaux,-'Robin et Littré, 
Diet, de Méd., de Chir. et de Pharm.,' treizième édit., 1873-survivent indéfiniment 
et l'on n'a observé chez eux que l'aphonie ; les autres phénomènes de la digestion, de 
la circulation et de la respiration qui sont sous l'influence motrice du pneumo-gastrique 
ne sont point paralysés et continuent de s'exécuter normalement." 
' ' Le larynx constituant un appareil double destiné à la fois, à la respiration et à la 
phonation, est influencé par deux ordres de nerfs distincts, savoir: le pneumo-gastrique 
qui préside aux mouvements respiratoires involontaires et le spinal qui préside aux mouve- 
ments vocaux volontaires."-Id. 
" Pendant le sommeil le larynx ne sert qu'à la respiration et ne fonctionne que sous 
l'influence du pneumo-gastrique. A l'état de veille, lors de l'acte de la phonation, 
l'influence du nerf spinal intervient pour agir sur le larynx."-Id. 
Voyons ce que dit la clinique laryngée : 
Nous avons observé sur plusieurs hystériques dont la voix était perdue et dont la 
glotte restait entièrement libre, la persistance des oscillations des bords de la glotte pen- 
dant l'inspiration et l'expiration ; l'orifice s'agrandissait et se rétrécissait alternative- 
ment. Lorsque ces oscillations manquent et que les bords de la glotte sont immobiles, 
il y a suppression de l'influence motrice du pneumo-gastrique et du spinal en même 
temps. 
Nous avons retrouvé ces mouvements rythmiques chez deux sujets âgés, atteints de 
ramollissement cérébral et d'aphonie. Quand on essayait de leur faire prononcer les 
* Il faut excepter le pharyngien inférieur. SECTION XIII-LARYNGOLOGY. 
147 
voyelles è ou a les bords de la glotte se rapprochaient avec difficulté et un peu plus que 
pendant l'expiration, mais les apophyses vocales ne parvenaient pas à se rencontrer. 
Sur un malade frappé d'hémorrhagie de la moelle allongée, la lèvre glottique droite 
exécutait ses mouvements comme à l'état normal, tandis que la lèvre gauche flanide et 
relâchée, restait écartée, immobile en dehors pendant l'inspiration et ne revenait seu- 
lement en dedans pendant l'expiration. 
Ainsi la physiologie et la clinique laryngée confirment l'indépendance entre les mou- 
vements des bords de la glotte au moment de la respiration et ceux qu'ils exécutent 
pendant la phonation. Il n'est pas possible d'attribuer les premiers à l'influence des 
muscles intrinsèques du larynx, muscles qui appartiennent exclusivement à l'organe 
vocal et obéissent aux ordres de la volonté. Les oscillations des bords de la glotte sont 
un effet de la motricité organique qui leur est distribuée par les filets du pneumo-gas- 
trique, nerf involontaire ou de la vie de nutrition. 
Si les agents intrinsèques ne prennent aucune part à ces déplacements réguliers et 
symétriques, il n'en est pas de même des muscles extrinsèques, le sterno-thyréoïdien 
par exemple, celui-ci est essentiellement inspirateur ; il a son attache fixe en bas, en 
arrière et en dedans, sur la fourchette sternale ; son attache mobile est placée entrant 
sur les côtés du cartilage de la pomme d'Adam, immédiatement au dessous de l'hyo- 
thyréoïdien, appelé aussi thyréo-hyoïdien. 
En se contractant le sterno-thyréoïdien entraîne en bas le cartilage Adamique pen- 
dant que le cricoïde descend lui-même et suit le mouvement de la trachée qui se rac- 
courcit de quelques millimètres. Le thyréoïde est en même temps le siège d'un dépla- 
cement en avant ; ses petites cornes glissent d'arrière en avant sur les deux facettes 
articulaires cricoïdiennes par suite de la pression qu'exerce le poids de la colonne d'air 
inspiré contre les bords de l'orifice glottique et contre l'angle rentrant du cartilage, 
ainsi que nous l'expliquons plus loin. 
Ce changement des rapports entre le thyréoïde et le cricoïde est très accessible à 
l'extérieur au moyen de l'index placé dans l'intervalle qui les sépare et que remplit le 
fort ligament antérieur thyréo-cricoïdien. Il est d'autant plus manifeste que l'inspira- 
tion est plus profonde. Pendant qu'il se produit, un autre s'opère à l'intérieur du 
larynx ; les bords de la glotte sont écartés et l'orifice s'agrandit dans ses deux diamètres. 
Ce changement interne ou glottique a lieu passivement avons-nous dit, c'est-à-dire sans 
l'intervention des muscles intrinsèques, dit vocaux et auxquels on a appliqué, mal à- 
propos dans cette circonstance, le qualificatif de glottiques. Il a pour causes non seule- 
ment la motricité organique, mais aussi la pression atmosphérique. 
Au moment, en effet, où. l'inspiration commence, le soufflet thoraco-pulmonaire se 
dilate ; il produit un vide dans le canal aérifère tout entier. L'air extérieur entre avec 
précipitation ; ne trouvant pas un passage suffisant à travers les vantaux de la porte- 
écluse du canal, il pèse sur eux et sur l'angle rentrant du cartilage de la pomme d'Adam 
de tout le poids d'une colonne atmosphérique équivalant à la différence des deux pres- 
sions aériennes externes et internes. Les lèvres de la glotte, n'étant pas en état de 
tension, ne résistent que par leur résistence organique ; elles s'écartent et le passage 
s'ouvre à droite et à gauche ; l'air entre sans obstacle et produit le souffle trachéal si 
connu. 
Le cartilage Adamique cédant de son côté à cette même pression est poussé en avant 
et en bas ; ses petites cornes glissent dans le même sens sur les facettes du cricoïde et 
l'orifice de la glotte s'allonge d'arrière en avant. Le passage se trouve ainsi agrandi 
dans toutes ses dimensions. Pas n'est besoin, on le voit, de faire intervenir l'action 
des muscles intrinsèques diastoliques dilatateurs pour obtenir cet élargissement. 
Comme organe de l'appareil respirateur, le larynx est le siège d'un mouvement de 
totalité qui détermine sa descente et doit le faire considérer comme une dépendance de 
la trachée. 148 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Quant à son ascension pendant l'expiration, elle est plus passive qu'active; le retour 
du conduit trachéal à sa position normale de repos suffit pour la produire. 
IV. LE LARYNX, ORGANE DE PHONATION. 
Envisagé comme organe de l'appareil phonateur le larynx est une sorte de caisse 
sonore, dans laquelle sont disposées, parallèlement et symétriquement, deux anches 
membraneuses qui forment l'embouchure d'un instrument de musique ayant la plus 
grande analogie avec celle du Basson. Ces deux anches, libres seulement à leur extré- 
mité ou bord supérieur, ne sont point rigides ; elles sont élastiques en tout sens, c'est-à- 
dire modifiables dans leurs trois dimensions : longueur, largeur, épaisseur, sans altéra- 
ration de leurs éléments anatomiques. 
L'anche du Basson est formée de deux languettes accouplées, libres, il est vrai, sur 
deux côtés comme à leur extrémité supérieure. Cette anche ne possède pas l'avantage 
de s'élargir, ni de s'amincir, défauts qui sont compensés par les nombreuses variations 
de longueur qu'elle peut subir dans sa partie vibrante. 
Quant à l'anche humaine, ses propriétés élastiques ne sont mises en jeu que dans 
des limites très restreintes. Mais d'autres propriétés physiques et organiques donnent 
au son qu'engendrent ses vibrations des qualités spéciales qui le rendent inimitable au. 
moyen des instruments de fabrication industrielle. 
Nous retrouvons ici les deux vantaux de la porte-écluse transformés en lèvres et 
cordes vocales par l'action d'agents moteurs volontaires qui leur communiquent plu- 
sieurs sortes de mouvements. Le passage de l'air respiré subit en même temps, dans 
ses degrés d'ouverture, des modifications profondes qui ont pour but de régler la sortie 
de la colonne d'air expulsée, de lui conserver l'énergie et la rapidité nécessaires aux 
vibrations de l'anche glottique. 
Ce sont ces agents diversement appelés : muscles intrinsèques et extrinsèques, constric- 
teurs et dilatateurs, adducteurs et abducteurs, glottiques et vocaux, que l'on a cherché à 
classer tantôt anatomiquement, tantôt physiologiquement et tantôt comme puissances 
respiratrices et phonétiques à la fois. 
Nous avons déjà dit que ces classifications étaient insuffisantes et ne répondaient pas 
aux besoins de la science laryngologique. Il nous semble pourtant possible de réaliser 
ce désidératum en donnant pour bases à la nouvelle classification l'anatomie et la phy- 
siologie réunies et pour but la phonation. 
La division en intrinsèques et extrinsèques a le grave inconvénient de ne rien déter- 
miner à propos des changements et des mouvements que les muscles laryngés impriment 
aux lèvres de la glotte pour en faire l'anche vocale ; ce fonctionnement est cependant 
sous l'influence des muscles intrinsèques ou intra-laryngés. 
Celle de constricteurs-mot impropre-et dilatateurs s'adresse aux mouvements qui 
relèvent à la fois de la pathologie, de la respiration et de la phonation. 
La division en adducteurs et abducteurs ne comprend que des muscles ayant pour 
rôle de rapprocher et d'éloigner les bords de la glotte; comme la précédente elle ne fait 
aucune distinction entre les mouvements et les modifications qui s'y produisent pendant 
les actes de la respiration et de la phonation. 
La classification du professeur Béclard en glottiques et vocaux est une tentative faite 
vers la solution scientifique. On reconnaît que la première expression se rapporte, dans 
l'esprit du classificateur, au fonctionnement de la glotte dans l'acte de la respiration, et 
la seconde à celui des muscles dans l'acte phonateur; mais elles reposent sur un cerele 
vicieux, car les muscles vocaux sont glottiques pendant la phonation, c'est-à-dire modi- 
ficateurs de l'orifice de la glotte; en outre elles ne donnent aucune idée des changements 
de forme qui s'opèrent dans les replis de la glotte, ni des divers mouvements dont ils 
sont le siège malgré les explications de son auteur. SECTION XIII LARYNGOLOGY. 
149 
En somme, ces essais de classification n'ont pas fait avancer la question qui préoc- 
cupe tout le monde, celle de la théorie de la voix. 
V. DIVISIONS FONDÉES SUR L'ANATOMIE, LA PHYSIOLOGIE ET LA PHONATION. 
Dans notre revue clinique des laryngopathies, publié en 1874, nous disions au chapitre 
des altérations fonctionnelles, page 85 : 
" Comme le cœur, le larynx (c'est-à-dire la glotte) jouit de deux mouvements con- 
traires, la contraction et la dilatation. Les noms de systole et diastole peuvent donc 
s'appliquer à chacun d'eux." 
"Les cordes vocales jouissent d'un troisième mouvement tout-à-fait différent et 
indépendant de ceux de rapprochement et d'écartement ; c'est un mouvement de ten- 
sion proprement dit." Ce mouvement se produit d'avant en arrière alors que le car- 
tilage thyréoïdien tout fixé par les muscles élévateurs laryngiens, le cricoïde est, à son 
tour, porté en haut par les thyréo-cricoïdiens. 
"Un seul mot d'origine grecque exprime ce mouvement d'avant en arrière ; c'est 
l'adverbe ai//, dérivé lui-même de la préposition a~v. Les noms apstole et apstolique 
désigneront en conséquence et qualifieront la tension seule (en long) des cordes vocales. ' ' 
Voici maintenant un extrait de notre mémoire présenté à l'Académie de Médecine 
le 29 Mars, 1887, sur notre théorie de la voix. 
"Les physiologistes qui ont considéré les replis de la glotte comme des ligaments, des 
rubans ou des cordes ont admis que l'action musculaire avait pour effet de les allonger 
seulement, leur communiquant ainsi la tension nécessaire à l'émission des sens." 
' ' Ceux qui, au contraire, les ont regardés comme des languettes membraneuses, des 
anches ou des lèvres ont entendu par le mot tension le développement en largeur et en 
longueur, c'est-à-dire en surface, de ces replis ; selon eux, les muscles intrinsèques du 
larynx produisent à la fois l'allongement et l'élargissement, l'extension en un mot des 
lèvres de la glotte. ' ' 
" C'est bien en long et en large que cette tension a lieu en effet. L'observation 
laryngoscopique, tout en confirmant le fait, a permis de l'analyser, de le dédoubler et 
de reconnaître que l'action musculaire qui produit la tension en largeur n'est pas la 
même qui opère l'allongement. Ces deux espèces de tensions sont dûes à deux méca- 
nismes physiologiques différents. Sous le nom de systole ou de distension nous désignons 
le développement transversal ou en surface des replis de la glotte, et sous celui d'apstole 
ou tension en long leur allongement. 
Enfin, dans notre mémoire sur le rôle physiologique du muscle aryténoïdien, communi- 
qué à la Société Française d'Otologie et de Laryngologie, session d'Octobre, 1886, nous 
nous exprimons ainsi, à propos de la distribution anatomique et physiologique des mus- 
cles intrinsèques : 
11 Ces agents ont été distribués par la nature sur trois plans bien distincts, suivant 
le rôle que les faisceaux musculaires dont ils sont formés doivent remplir ; etc. ' ' 
Le premier plan, antérieur, est constitué par les thyréo-cricoïdiens dont la contrac- 
tion produit l'allongement d'avant en arrière des lèvres de la glotte, c'est-à-dire, l'apstole; 
nous l'avons désigné en conséquence par le qualificatif d'apstolique. 
Le second plan, interne ou médian, comprend les crico-aryténoïdiens latéraux, les 
thyréo-aryténoïdiens externes et internes, muscles qui ont pour rôle de rapprocher les 
lèvres de la glotte et de les tendre transversalement c'est-à-dire en surface ; ils pro- 
duisent, en un mot, la systole glottique ou laryngée et doivent être appelés par cela même 
plan et muscles systoliques. 
Enfin, le troisième plan, que nous avons dit postérieur à cause de la situation de ses 
faisceaux musculaires en arrière du larynx, est composé de l'aryténoïdien et des crico- 
aryténoïdiens postérieurs dont le rôle est d'écarter les lèvres vocales, d'ouvrir transver- 
salement la glotte. C'est donc un plan musculaire diastolique ; il effectue la dilatation 150 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
de l'orifice ou diastole glottique, c'est-à-dire le relâchement, l'écartement de ses 
bords. 
Dès à présent nous pouvons établir notre classification en nous servant de la triple 
base de l'anatomie, de la physiologie et de la phonotion ou mieux phonologie, et en 
prenant pour point de départ la division anatomique fondamentale de nos devanciers 
en muscles intrinsèques de intra-larynyés, et muscles extrinsèques ou extra-laryngés. 
VI. CLASSIFICATION PAR LE DR. MOURA. 
La première classe, que nous appelons comprend trois ordres d'a- 
gents moteurs vocaux, savoir : 
1° Les agents systoliques, dont les faisceaux musculaires ont pour rôle de fermer à 
volonté l'orifice de la glotte. 
Cet ordre renferme trois groupes ou genres : 
Le premier, que nous nommons systoliques-adducteurs, rapproche les bords de la 
glotte jusqu'au contact, les déployant et en faisant deux anches prismatiques. 
Le second, que nous désignons sous le nom de systoliques tenseurs, tend la partie 
vibrante des anches, la diminue ou l'augmente suivant que le ton de la gamme ou du 
registre vocald monte ou descend lui-même. 
Le troisième, dénommé systoliques-vestibul aires, règle la tension des parois du vesti- 
bule sus-glottique. 
2° Les agents apstoliques, dont les faisceaux musculaires ont pour rôle d'effectuer la 
tension en long, c'est-à-dire l'allongement d'avant en arrière des bords de la glotte déjà 
transformés en prismes par les systoliques-adducteurs et tendues en surface par les systo- 
liques-tenseurs. 
Un seul groupe compose cette ordre ou ce plan musculaire ; nous le nommons apsto- 
liques-tumeurs. 
3° Les agents diastoliques, dont les faisceaux musculaires écartent les bords de la 
glotte, dilatent transversalement et à volonté son orifice. 
Cet ordre comporte deux groupes ou genres : 
Le premier appelé diastoliques-interligamentaires, ouvre la partie antérieure ou mem- 
braneuse des bords de la glotte, à volonté, c'est-à-dire activement ; il produit le relâ- 
chement des lèvres vocales. 
Le second a été nommé diastoliques-interaryténoïdiens. Il a pour fonction d'ouvrir, 
à volonté, la partie postérieure ou cartilagineuse de l'orifice glottique. 
Quant aux agents moteurs extrinsèques, leur action commune consiste à aider pho- 
nétiquement celle des agents intrinsèques, en élevant ou abaissant, tantôt directement, 
tantôt indirectement le larynx, et contribuant ainsi à produire la systole ou la diastole, 
laryngée, c'est-à-dire à fermer ou à ouvrir l'orifice de la glotte. 
Une seule classe compose cette grande division anatomique. Nous la désignons sous 
le nom d'extrinsèques-glottiques, parce que, en définitive, les nombreux faisceaux muscu- 
laires qui entrent ici en action aboutissent, au point de vue phonologique, à fermer ou 
à ouvrir la glotte. 
Cette classe comprend deux ordres, savoir : 
Le premier, appelé élévateurs-systoliques, effectue l'ascension du larynx et le rétrécis- 
sement de la glotte. Il se divise eu deux groupes : 
L'un, qualifié de direct, parce que les muscles qui en font partie ont leurs attaches 
mobiles insérées sur l'une des pièces cartilagineuses du larynx, tandis que leurs attaches 
fixes le sont sur un point plus ou moins éloigné de cet organe. 
L'autre, nommé indirect, parce que les agents musculaires qu'il comprend n'ont 
aucune de leurs insertions sur l'organe vocal. 
Le second ordre est dit abaisseurs diastoliques ; ses faisceaux musculaires, en se con- SECTION XIII-LARYNGOLOGY. 
151 
tractant, entraînent la descente du larynx et la dilatation transversale de la glotte. 
Comme le premier il comprend deux groupes : 
L'un et l'autre portent les noms de directs et indirects par les mêmes raisons que 
nous venons de faire connaître. 
Telle est la classification que nous soumettons à l'attention de l'académie. Nous en 
donnons le tableau synoptique avec les noms des agents musculaires qui composent 
chaque groupe. En terminant ce travail, nous ferons remarquer que nous avons évité 
de nous servir du qualificatif constricteur de la glotte, parce qu'il convient à un état 
spasmodique ou pathologique et non à un état physiologique ou normal de cet orifice. 
CLASSIFICATION DES MUSCLES DU LARYNX. 
Divisions. 
Classes. 
Ordres. 
Groupes ou Genres. 
Faisceaux Muscu- 
laires. 
Intrinsèques 
laryngés. 
Phoné- 
tiques pro- 
duisant. 
La systole 
laryngée ou 
glottique. 
L'Apstole. 
La diastole 
laryngée ou 
glottique. 
[ Systoliques. 
Adducteurs. 
J Systoliques. 
i Tenseurs. 
| Systoliques. 
( Vestibulaires. 
Apstoliques-Ten- 
seurs. 
f Diastoliques. 
J Ligamentaires. 
1 Diastolique Aryté- 
[ noîdien. 
f Crico-Aryténoïdiens. 
1 Latéraux. 
f Thyréo-Aryténoïdiens. 
( Internes. 
f Thyréo-Aryténoïdiens. 
( Externes. 
■j Thyréo-cricoïdiens. 
J Crico-Aryténoïdiens. 
( Postérieurs. 
■j Aryténoïdien. 
Extrinsèques 
laryngés. 
Glottiques. 
Elévateurs. 
Systoliques. 
Abaisseurs. 
Diastoliques. 
(■Directs, 
(indirects. 
( Directs. 
(indirects. 
f Hyo-Thyréoïdiens. 
1 Pharyngien inférieur. 
J Pharyngien moyen. 
( Muscles Sus-Hyoïdiens. 
Sterno-thyréoîdiens. 
f Scapulo-Hyoïdiens. 
( Sterno-Hyoïdiens. 
LE SULFURE DE CALCIUM DANS LE TRAITEMENT DE LA V 
DIPHTHÉRIE. 
SULPHURET OF LIME IN THE TREATMENT OF DIPHTHERIA. 
DAS SCHWEFELCALCIUM IN DER BEHANDLUNG DER DIPHTHERIE. 
PAR LE DR. F. LABORDE DE WINTHUYSSEN, 
A Lebrija (Sevilla) Espagne. 
La diphthérie qui déjoue si souvent les efforts de notre art, a droit à la spéciale atten- 
tion des praticiens, puisqu'à son caractère infectieux et parfois épidémique, est unie sa 
fréquence, et sa presque incurabilité. 
Les études bactérioscopiques donneront, sans doute, tôt ou tard la clef de l'énigme 
de sa pathogénie. Aux microbiologistes donc l'honneur de la recherche et la gloire de 
l'enquête, et pour nous, les médecins qui ne pouvont pas nous vouer à ces études le 
flatteur espoir d'obtenir, un beau jour, la preuve expérimentale de sa nature micro- 
bienne. 
Si nos moyens d'analyses sont encore impuissants, pour décéler l'existence du germe, 
ou virus originaire de la maladie, nous n'avons qu'à être à l'attente des découvertes, et 152 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
la diphthérie, dont tous les caractères {inoculation, transmission, incubation, etc.} le font 
ressembler, aux maladies zymotiques et parasitaires, aura de même son microbe spé- 
cifique, on nous le fera connaître, nous aboutirons à le cultiver, nous arriverons même 
à l'atténuer. 
C'est du moins l'hypothèse que nous nous croyons en droit de soutenir, à juger par 
l'étude pratique de la maladie, dont les différentes formes, ne seront alors que les résul- 
tats pathologiques des générations plus ou moins atténuées, en rapport avec le terrain 
d'implantation, c'est-à-dire, avec les différences individuelles des organismes dont elle 
se greffe. Si l'observation de la maladie nous engage aujourd'hui à soupçonner sa nature 
microbienne, quand les études bactérioscopiques nous élargissent journellement le cer- 
cle des maladies parasitaires, c'est encore bien remarquable, à l'appui de cette théorie, 
que les médecins des temps plus reculés, des temps où on ne soupçonnait quand même 
l'existence de ce monde invisible et pathogénique, ont vanté dans la thérapeutique de 
la diphthérie des agents, qu'on a déjà reconnus comme de puissants antiseptiques. 
Le monde médical quoiqu'il le fasse encore à défaut, la preuve expérimentale, la 
détermination du microbe spécifique, tire ses armes contre la diphthérie de son arsenal 
antiseptique, c'est qu'en effet ou ne peut s'opposer aux ravages des poisons septiques 
que par des agents antiseptiques. Une fois la maladie soupçonnée microbienne; pas plus 
d'antiphlogistiques des évacuants ni même de toniques isolément employés. Son trai- 
tement, comme celui de la fièvre typhoïde, celui de la phthisie, de la coqueluche et 
d'autres est dès lors franchement antiseptique et si, un beau jour, comme je disais tout 
à l'heure, il nous est permis de déceler le microbe diphthérique, on pratiquera alors, 
peut-être, des inoculations du virus atténué, comme on le fait présentement, envers la 
rage (Pasteurs), le coléra (Ferran), la fièvre jaune (Freire), le charbon (Arloin), etc. 
Dans l'attente d'un charmant avenir, soyons logiques avec l'observation, et recher- 
chons un agent, qui puisse du moins rendre l'économie impropre à la culture de ce 
microorganisme, tout en restant d'une parfaite innocuité pour l'organisme humain. 
D'accord avec cette manière d'envisager la question j'ai l'honneur d'appeler l'atten- 
tion du Congrès vers un traitement de la diphthérie qui m'a fourni des résultats très 
encourageants. Je n'oserais, cependant, vous entretenir à la lecture d'une statistique, 
superbe d'ailleurs, mais dont la valeur serait nulle, sans l'observation exacte de chaque 
cas. Je crois, avec Mr. Forget : "Que la statistique est une bonne fille qui se livre au 
premier venu." Je vais donc vous faire part des conclusions auxquelles je suis arrivé 
et je vous laisse le travail du contrôle. 
Il y a longtemps que je constate presque journellement la haute puissance antisep- 
tique du sulfure de calcium. U y a une influence favorable, toujours comme médica- 
ment interne, dans certaines otorrhées, dans la tuberculose, dans la diarrhée reconnue 
infectieuse et envers d'autre affections réputées mirobiennes. J'étais, de plus en plus 
encouragé, sur son action antiseptique, quand je me suis trouvé en face d'une épidémie 
de fièvre morbilleuse qui a été compliquée de diphthérie. 
On devinera aisément que j'avais à profiter une fois de plus à l'action antivirulente 
du sulfure, je devais du moins l'employer, d'accord avec mes idées sur la diphthérie. 
Je n'ai donc pas hésité à l'administrer dans tous les cas, et mes investigations sur son 
emploi, m'ont porté aux conclusions suivantes :- 
1° Le sulfure de calcium, administré à l'intérieur, agit par l'hydrogène sulfuré 
qui se dégage. 
2° L'hydrogène sulfuré s'élimine par la peau et par les muqueuses, notamment par 
la muqueuse respiratoire, selon qu'il se décèle par les réactifs. 
3° L'action antiseptique de sulfure m'a induit à l'administrer dans la diphthérie 
dont la nature microbienne est pour moi incontestable. 
4° Sous l'influence de sulfure de calcium administré de bonne heure, la diphthérie 
se termine favorablement, l'engorgement ganglionnaire diminue, la fièvre se modère et SECTION XIII-LARYNGOLOGY. 
153 
les fausses membranes diphthériques deviennent plus minces et moins adhérentes sous 
l'action excitante que l'hydrogène sulfuré produit sur les muqueuses qui l'éliminent. 
Cets excitation semble les rendre improprete à la reproduction des produits morbides. 
5° Le sulfure de calcium qu'on peut envisager comme l'agent spécifique de la 
diphthérie, quand on l'administre de bonne heure ; est impuissant dans les cas, où la 
diphthérie est très avancée, et dans la forme infectieuse aiguë, quand les fausses mem- 
branes ont envahi presque toute la muqueuse respiratoire. Mais ce sont des cas où on 
n'arrivera jamais à la guérison, de même qu'on ne peut pas guérir une phthisie à sa 
troisième période. Tels sont alors les ravages de l'infection ! 
6° Je l'ai administré, en outre, à des enfants bien portants qui se trouvaient dans 
un foyer d'infection et je les ai vus résister à la contagion, tant que d'autres qui n'a- 
vaient pas fait usage du sulfure ont acquis la maladie. Je crois, donc, pouvoir l'attri- 
buer une action prophylactique. 
7° J'ai administré de préférence les granules dosimétriques du Dr. Burggraève de 
trois à vingt, et même plus par jour, selon les circonstances. 
8° Les excellents résultats obtenus par moi, sont dûs exclusivement au sulfure de 
calcium, parce qu'il a été employé isolément pendant la période des plus grands dan- 
gers de la diphthérie. 
9° J'ai eu, nonobstant, la précaution de nettoyer les endroits qu'on pouvait attein- 
dre, avec le suc de citron, moyen auquel je ne crois pas qu'on puisse accorder les béné- 
fices dans les résultats obtenus. 
Je regrette vivement que les limites restreintes d'une communication m'empêchent 
d'y ajouter les réflexions, auxquelles je suis porté, sur l'action d'un agent, qui doit 
mériter la préférence dans le traitement d'une si cruelle maladie, mais en vue de ména- 
ger les instants, j'ai l'honneur de laisser à la savante considération de mes illustres 
collègues le contrôle des conclusions sur lesquelles j'ai cru devoir entretenir l'attention 
du Congrès à qui j'envoie, d'ailleurs, mes plus sincères et respectueuses salutations. 
Dr. E. Fletcher Ingals, of Chicago, moved that a vote of thanks be sent to 
the President, Dr. Daly, on behalf of this Section, for his endeavors to make the 
meetings of this Section a success and also to Secretaries, Drs. W. M. Porter and 
D. N. Rankin for the valuable aid rendered. SECTION XIV-DERMATOLOGY AND SYPHILOGRAPHY. 
OFFICERS. 
President: DR. A. R. ROBINSON, New York, N. Y. 
VICE-PRESIDENTS. 
Dr. A. H. Ohmann-Dumesnil, St. Louis, Mo. 
Prof. Alfred Fournier, Paris, France. 
Dr. T. Colcott Fox, London, England. 
Prof. A. Hardy, Paris, France. 
Hans Von Hebra, Vienna, Austria. 
J. Hutchinson, f.r. s., London, England. 
Dr. W. Allan Jamieson, Edinburgh, Scotland. 
Prof. Moriz Kaposi, Vienna, Austria. 
Dr. James M. Keller, Hot Springs, Ark. 
Prof. Oscar Lassar, Berlin, Germany. 
Prof. H. Leloir, Lille, France. 
Prof. Isidor Neuman, Vienna, Austria. 
Dr. August Ravogli, Cincinnati, Ohio. 
Prof.,Schwimmer, Buda-Pesth, Hungary. 
Dr. John V. Shoemaker, Philadelphia, Pa 
Dr. George Thin, London, England. 
Dr. P. G. Unna, Hamburg. 
SECRETARY. 
Dr. Wm. S. Gottheil, N. Y, 
COUNCIL. 
Dr. Wm. T. Belfield, Chicago, Ill. 
Dr. John D. Duncan, Kansas City, Kan. 
Dr. W. F. Glenn, Nashville, Tenn. 
Dr. Chas. C. Jemans, Detroit, Mich. 
Dr. Edw. R. Palmer, Louisville, Ky. 
Dr. Chas. G. Smith, Chicago, Ill. 
155 156 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
FIRST DAY. 
ADDRESS. 
BY A. R. ROBINSON, M. B., L. R, C. P. & S., 
President of the Section. 
It devolves upon me as chairman of the Section of Dermatology and Syphilo. 
graphy to perform the very pleasant duty of offering, on behalf of my American 
colleagues, a most hearty welcome to our foreign co-workers who honor us with their 
presence, and give us such fresh proofs of their deep interest in science by traveling 
so far to attend this meeting and to take an active and important part in the pro- 
ceedings, although from our past history they must have very slight hope of any 
intellectual compensation from us. And whilst we do not promise them as warm a 
reception from the authorities who regulate our weather conditions, as, according to 
rumor, the wind organs from certain quarters promised them weeks and months ago; 
yet they may rest assured that we are very glad indeed to see them present, and 
whilst we recognize them as leaders, as representative men in our special department, 
the men who have done and are still doing real scientific work, and in whom we place 
much hope for future advancement of our knowledge of subjects, still altogether too 
numerous in this branch of medicine, of which we know almost nothing ; we would 
also gladly have welcomed a greater number of their colleagues, and regret the 
absence of several, who, from illness or other causes, are unable to be present, 
although most anxious to have come. 
It is fortunate that the heat will not be so great as the false prophets promised, 
for, knowing the effects of high temperature upon the mental powers, and the 
amount of raiment one can wear under great heat conditions ; and that these medical 
congress meetings are partly scientific and partly social in their character, it is evident 
that for a successful congress of this kind, the participants must be clothed, and in 
their right minds. If the social part is a comparative failure, I trust that the mental 
food offered will be rich in valuable material. The American supply to past congress 
meetings has been an unknown quantity; for this meeting we already know the quan- 
tity, and will soon know the quality. 
You, as specialists, are too familiar with the dermatological literature of America, 
vast in yearly amount, meagre in contributions, not to wonder why, with so many 
writers upon the subject, with so many dermatologists animated with that peculiar 
American quality called "push," we have contributed so little to the recent substan- 
tial advancement in our knowledge of skin diseases. But if we consider, as we now 
intend to do briefly, all the conditions under which we pursue our studies in this 
country, it will appear strange that good work is not even rarer than it now is. 
Taught in colleges the majority of which require only a two years course of study, 
the sessions of each year lasting five or six months, what inducement do such colleges 
hold out to their students to study medicine as it should be studied, if they are to be SECTION XIV DERMATOLOGY AND SYPHILOGRAPHY. 
157 
other than the blindest followers, in the pursuit of our profession, of the advice 
received from a few lectures or compendiums. Such a college course was, perhaps, 
not objectionable in colonial days, or when physicians were not a drug upon the pub- 
lic, as they may be said to be now, when every village is overcrowded, and continual 
efforts to get patients are necessary to enable the professional man to build up a 
practice, and at the same time, financially, to make both ends meet. It must be 
clear to the members of every teaching faculty in the land that a two, or even a three 
years course of study is quite inadequate to prepare a student-even if he be a 
student in the best sense of the term, bright and diligent-for the responsible duties 
of a medical practitioner; for the faculty is the examining body, and the superficial 
knowledge of candidates for graduation must be painfully evident to the professors. 
Lectures upon special subjects are given in the majority of the colleges, and in 
some of them dermatology is considered as a special subject, in which case one clinical 
lecture a week is usually given. As, however, no examination upon the subject is 
required for graduation, the majority of students absent themselves from the lectures, 
but afterward receive their diploma, certifying to their knowledge of medicine in all 
its branches; although they may not have seen a single case of cutaneous disease, and 
could not diagnose an ordinary syphilide from an eczema ; or even an elephantiasis 
from a scleroderma. 
Afterward, in practice, however, they treat all patients with cutaneous disease 
without hesitation, as a rule, and with the utmost coolness and outward appearance 
of confidence in their knowledge of the "rash," for to them it is rash and nothing 
more. I am not blaming those general practitioners who follow this course ; it is the 
legitimate result of the doctrine of the teaching body, for with only a two or three 
years course it is not possible to devote time to subjects upon which they are not to 
be examined. Neither do these remarks apply to those general practitioners, of whom 
there is quite a number, who have devoted post-graduate time to the study of cuta- 
neous diseases. 
But a yearning after practical points-what drug to give for this or that disease ; 
what is the best prescription for an eczema for instance-signs pathognomonic of 
imperfect mental training, and the lack of clinical experience, and of the information 
contained in good text-books upon special subjects, bring about other evils which 
particularly concern us as dermatologists, and to which I will directly refer. 
On account of the few lectures given upon skin diseases and the short course 
of study required, it is not possible to learn dermatology in this country, except under 
great disadvantages at least. It is true that private instruction can be obtained at 
some dispensaries, and that regular clinics are held at some of the post-graduate 
schools; but for any extended knowledge of the subject a trip to Europe has hitherto 
been considered necessary. Vienna has usually been the Mecca for those who wish 
to specially study this subject, as the magnificent material to be seen at the Hôpital 
St. Louis has not drawn many students to Paris, while in London the patients are 
not used specially for teaching purposes, and consequently the advantages for studying 
the subject are not to be compared to those of Vienna. 
How long the student, now a physician, remains abroad depends usually upon his 
ideas of the proper course to pursue, and the amount of money at his command. 
He should remain several years for the study of histology, pathology, morbid anat- 
omy, internal medicine, bacteriology, and skin diseases, if he intends practicing after- 
ward as a specialist; but that is not the course usually pursued. He devotes too 
much time to learning the diagnosis and treatment of skin diseases, a course very 
proper for a general practitioner, but not for one who ever hopes to advance our pres- 158 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
ent knowledge of cutaneous diseases; for who can expect to add to the descriptions 
of clinical symptoms as given by such acute observers as Hebra, Wilson, Tilbury Fox, 
etc., observers who have devoted their lives to the subject and seen their thousands 
and tens of thousands of cases. I do not say that it is impossible to do so, but he 
has not a heavy heart or weak imagination who expects to make a reputation in that 
direction. To combine, as is frequently done, the subject of cutaneous with genito- 
urinary diseases, instead of with internal medicine, is a serious error; for the two 
classes of diseases are in no way related to each other, and a knowledge of the one 
does not aid us in the study of the other; while every one must admit the close ætio- 
logical relationship of many cutaneous diseases with internal pathological conditions. 
Histology, normal and pathological, bacteriology, and general pathology hold the 
same relations to dermatology that they do to the other branches of medicine and sur- 
gery; that is, they are essential to the foundation of a broad view of the subject, and 
no one can fully discuss the aetiology of the majority of diseases-that important 
branch of medical science which at the present time is studied more than any other- 
without some knowledge of them. 
Whether the student remains abroad for a few months only, or several years, he 
receives the foundation of his dermatological knowledge in foreign lands, be that 
slight and dangerous, or broad and capable of being built upon, according to the time 
and brain energy spent. The majority of dermatologists at present practicing in 
America have obtained their schooling in dermatology in other countries, and as they 
continue afterward to be more or less influenced by the teaching received abroad, they 
may be called followers of this or that school, depending upon the country iu which 
they studied. 
A school can exist only when there is a comparatively great dermatologist in a 
given country, one whose views are more or less unreservedly accepted, and his teach- 
ings followed by his countrymen and pupils, or when the leading dermatologists of a 
country hold similar and peculiar views. As our knowledge of cutaneous diseases 
increases, and the number of dermatologists multiplies, there is more and more diffi- 
culty in founding a school, so that at the present time we are scarcely justified in 
speaking of a German, French or English school, for in all these countries, eminent 
dermatologists, of whom there are always several in each country, hold very widely 
different views concerning the ætiology, nature and treatment of the inflammatory 
affections of the skin, and it is upon the divergence of views in reference to this class 
of diseases particularly, that schools have existed. 
As there is no particular centre for dermatological study in America, as there is 
no comparatively great dermatologist, and, finally, as the majority of dermatologists 
have had their schooling abroad, and hold widely different views on the inflammatory 
and the other cutaneous diseases, there is no such a thing as an American school of 
dermatology; consequently also there cannot be a representative American dermatol- 
ogist, for there are no special American views of dermatology to be represented. 
This is specially gratifying to your chairman, for, that being true, it logically 
follows that it cannot be said of him for the present occasion that he is not a good 
representative of American dermatology. As independent workers each of us repre- 
sents but the character of our own labors, and if that is not creditable, the author is 
a corresponding dermatologist. If the work done by American dermatologists, as a 
whole, is to be represented, then the position should not be a difficult one to fill, for 
the average of that work is not astonishingly high, as shown by the articles in jour- 
nals, and the report s of our special societies. 
Returning from his European travels-" speaking a foreign language just as well SECTION XIV-DERMATOLOGY AND SYPHILOGRAPHY. 
159 
as his mother tongue "-the would-be specialist is beset by temptations, to which he 
too frequently falls a victim. With more medical journals in the land than are ne- 
cessary for the publication of papers that repay one for their perusal, there is, on the 
one hand a demand for an article on some subject-it matters not what it be-by 
the editor; and on the other hand, a desire to publish a paper by the specialist anx- 
ious for reputation and notoriety. The medical world at least must know that he is 
devoting special attention to a particular branch of medical science, and what plan so 
good as to write an article for ajournai, and, by means of reprints scattered broadcast 
let the world know your specialty, name and address. A few repetitions of this pro- 
cedure will, without fail, bring patients to the office, and reputation among the mass 
of general practitioners. Why this latter is a result is not difficult to understand. 
As already mentioned, the college graduates usually have no knowledge of the so- 
called special branches, consequently any reprint, although it be only a compilation of 
previous articles by real workers-and very often they are even very poor compila- 
tions-appears to the busy practitioner to contain valuable information, and the 
author thereof as one having special knowledge of his subject. 
This mode of action is a very serious evil, and must and does bring discredit upon 
the specialists in that branch, as a body. It is to be hoped that the protest I now 
enter against this evil will not be in vain, and that in the future only such articles 
will be published as represent real contributions to the existing knowledge of the sub- 
ject discussed. We still have so little real knowledge of diseases of the skin that there 
is a wide field for future observation, and the energy wasted in the compilation of 
these papers should be devoted to original and more creditable work. Let us show 
that American dermatologists have the spirit and ability to do their share of work for 
the advancement of our knowledge in their special branch of medical science. I do 
not wish to be considered as maintaining in this address that no good work has ever 
been done in this country, for that would not be correct; but it has borne no proper 
proportion to the number of articles which have been published, for too often the 
heading of a paper as a "contribution" to our existing knowledge of this or that 
disease has scarcely been justified by the contents. 
As we learn most from a contemplation of our errors, I have endeavored to draw 
attention, as regards dermatology in America, to the faults of the colleges with refer- 
ence to this branch and the errors of action which we as specialists are liable to com- 
mit for our personal advancement, and have pointed out the way by which creditable 
reputation, if not pecuniary success, can always be attained. 
Finally, in view of past events, I desire to express the hope that another Inter- 
national Medical Congress will not be held in America until the profession in this 
country have shown by their actions a change of heart ; that they are prepared to 
subject the desire for personal gain to the proper, nobler and more honorable feeling 
for the advancement of medical science and consequent relief of human suffering. 160 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
VACCINATION DURING THE INCUBATION PERIOD OF VARIOLA. 
LA VACCINATION PENDANT LA PÉRIODE D'INCUBATION DE LA VARIOLE 
(PETITE VÉROLE). 
ÜBER IMPFUNG WÄHREND DER INKUBATIONSPERIODE DER BLATTERN. 
BY WM. M. WELCH, M. D., 
Of Philadelphia, Pa. 
It is not an irrational supposition that the infecting principle of a contagious disease 
does not lie dormant in the system during the interval between its reception and the 
earlier manifestations of the disease, but rather that certain unknown processes go on 
during this period, although no distinct symptoms indicating such action are yet 
apparent. The question as to whether it is possible in any case to arrest or so change 
these processes as to prevent or modify the approaching disease, is one about which 
there is a difference of opinion. Pasteur claims that he is able to prevent hydrophobia 
by inoculation during the incubation period of that disease, and I shall endeavor to 
show, without any claim for originality, that vaccination during the corresponding period 
of smallpox has, in my hands, given well-marked and encouraging results. 
An ingenious effort has been made recently, by an able writer, to prove, by a process 
of reasoning alone, that when the microorganisms of smallpox have once gained access 
to the circulation, the introduction of the microorganisms of vaccinia-both microbes 
being essentially the same-can have no other effect than to quicken the action of the 
former. The conclusion is that vaccination during this period is worse than useless, 
since it serves both to precipitate and intensify the incubating disease. I refer to this 
theory only to say that it is unsupported by facts, and utterly untenable. 
In regard to the power of vaccination during the period of incubation of smallpox, 
the opinion, and I may say also, the experience of writers seem to differ. Curschmann, 
the author of the article on smallpox and vaccination in Ziemssen's Cyclopædia of the 
Practice of Medicine, writes : ' ' Are we able to exert any influence on the disease in the 
early stage preceding the eruption? Is it possible in infected persons during the stages 
of incubation and invasion to cut short the disease or to modify its course? Many 
attempts have been made to answer these questions affirmatively, but as yet without 
much result. The first idea was vaccination, and this was employed by some in the 
ordinary way ; " .... " but that ordinary vaccination during the stages of inva- 
sion and incubation cannot stay the disease, has been proved to me by chance observa- 
tions and direct experiments. On the contrary, I have seen, in cases in which vaccina- 
tion was practiced after infection with variola, vaccine pustules and smallpox pustules 
developed side by side. It is, in my opinion, very doubtful whether vaccination can 
even render the course of the disease milder." 
I quite agree with Curschmann that vaccination during the initial or invasive stage 
of smallpox is valueless ; and if it be done only a very few days prior to this stage it is 
equally valueless. But I am prepared to say if it be performed very early in the incu- 
bative stage it will frequently modify the attack, and sometimes, indeed, prevent it 
absolutely. To be more explicit : vaccination performed less than seven days prior to 
the appearance of the variolous eruption exerts, as a rule, no modifying influence what- 
ever ; the vaccine vesicles and the variolous pustules develop side by side, without 
either of them being materially changed in their course. It is my opinion that vaccinia 
does not begin to exert its prophylactic power until the vesicle has reached the stage of 
formation of the areola. If this stage be reached before sickening for smallpox occurs, 
the disease may be entirely prevented ; if not until after sickening, but before the erup- 
tion appears, it may modify the attack. Knowing the length of the period of incuba- 
tion of smallpox to be, in the majority of cases, ten or eleven days until the initial 
symptoms occur, or twelve or thirteen days until the eruption appears, it is evident that SECTION XIV-DERMATOLOGY AND SYPHILOGRAPHY. 
161 
in order to confer protection, either complete or partial, vaccination must not be very- 
long delayed after the contagium has been received into the system. Of course, it 
should be performed immediately after exposure, but if through inadvertency or impos- 
sibility this is not done, and a number of days have been allowed to pass since infection 
occurred, it still should be performed, for the period of incubation of smallpox is not 
invariable as to time ; it is sometimes, for some reason, prolonged, in which case a later 
vaccination may prove of value. 
Although the presence of the areola generally determines the period of the vaccine 
disease at which protection is brought about, yet there seems sometimes to be individual 
differences in regard to this period. I have seen persons exposed to the contagion of 
smallpox at the same time and in such a manner that there could be no doubt about 
infection taking place; have vaccinated such persons at the same time and with the 
same virus, and the vaccine disease, to all appearances, has pursued courses identical, 
yet one enjoyed perfect protection and the other only partial, or, in other similar in- 
stances, one has received partial protection and the other none at all. This difference 
is doubtless due to some individual peculiarity that cannot be explained. 
It is much easier to confer protection after exposure to the contagion, when re-vac- 
cination is required, than when the vaccination is primary. The reason of this is very 
plain : it is because the modified form of vaccinia induced by re-vaccination develops 
more speedily and completes its entire course in a much shorter time; hence prophylaxis 
is established at an earlier period. Of course, the nearer this modified form of vesicle 
approaches to the true standard, the longer is the point of protection in being reached. 
The character of the vaccine vesicle has much to do in the matter of establishing 
speedy protection. One that is prompt and typical in its manifestations is most to be 
desired. A tardy vesicle-slow in making its appearance and late in arriving at 
maturity-always increases my anxiety for the safety of an individual in whom small- 
pox is incubating. It is not uncommon nowadays to see vesicles two, three or more 
days late in making their appearance, and correspondingly slow in running their course. 
Of course such a vaccination at this stage of variola could scarcely be expected to 
modify the disease, much less to prevent it. 
Quality of vaccine virus has almost everything to do in the matter of determining 
the character of the vesicle. Animal lymph is too unreliable, and, when it does suc- 
ceed, too slow in its action to be trusted at this period of smallpox. Failure or success 
with vaccination at this time might make the difference between life and death. There- 
fore virus which is reliable and quick should be preferred. I know of none that is 
better than fresh eight-day lymph, taken directly from a typical vaccine vesicle ; but 
as opportunity for obtaining such virus seldom occurs at the propitious moment, I am 
in the habit of using humanized virus in the form of crust, preferring that which has 
had a long succession of human transmissions. 
There is no question but that vaccine virus of very long humanization induces a 
type of vaccinia of much shorter duration than that induced by animal lymph or by 
virus of recent humanization. Prior to the introduction of animal vaccination in this 
country, in 1870, by the late Dr. Henry A. Martin, the virus in general use here was 
doubtless of the same stock as that which was then in use at the National Vaccine 
Institution of Great Britain; for in either case the type of vaccinia induced had a dura- 
tion of only fourteen or fifteen days, counting from the insertion of the virus until the 
falling off of the crust. A vaccine disease of this description is attended by a more 
speedy development of the vesicle, and an earlier appearance of the areola, than is the 
case in the more typical form of the disease, and consequently it can be used with 
greater effect against incubating smallpox. 
I do not wish to be understood as preferring for general use the virus just described. 
When time is not so great an object, animal lymph or lymph of comparatively recent 
humanization is greatly to be preferred, because it gives rise to a vaccine disease corre- 
Vol. IV-11 162 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
spending very exactly to Jenner's description of true vaccinia, and confers protection 
not only for the time being, but of the greatest possible durability. That long-human- 
ized virus is capable of exerting a prophylactic power against smallpox for a time, at 
least, I am quite sure ; for in my efforts to confer protection after variolous infection has 
occurred it has given me my best results. I am, however, firmly of the opinion that 
the prophylactic power exerted by this virus is not as durable as that exerted by virus 
which induces the most typical form of vaccine disease. Therefore, I say where time 
is not an object, animal lymph or lymph of recent humanization should be preferred. 
There is yet one point of considerable importance to which I desire to call attention, 
and that is, in the use of long-humanized virus it is advisable that each vaccination be 
made up by a number of insertions. By this means we not only increase the chances 
of establishing the vaccine disease, but aid in bringing the system more decidedly and 
effectually under its influence. Furthermore, it has been claimed by competent obser- 
vers that multiple insertions serve to expedite the processes of vaccinia, and thus hasten 
the attainment of that point in the disease at which prophylaxis is exerted. 
As long ago as the year 1808, Dr. Benjamin Waterhouse, who, on account of the 
commendable enthusiasm he displayed in the matter of the introduction of vaccination 
in this country, received from his British friends the appellation of " The Jenner of 
America," wrote as follows: " I think it proper to publish an important fact for which 
we are not indebted to Europe, namely, If a person be inoculated with the kine-pock two 
days after having received the casual infection of smallpox, the kine-pock will predominate 
and save the patient. Nay, I will go further and say in some cases three days posterior to 
infection instead of two; for there is a mode of expediting the operation of the kine- 
pock virus by increasing the quantity of matter thrust under the epidermis; and it 
appears, from experiment, that this does not depend so much on increasing the quantity 
put into a deep puncture, as it does on the increase of infected surface. In other words, 
you may expedite the processes of kine-pock inoculation two days, if not three, if, 
instead of two punctures, you make sixteen or twenty," . . . "and on the sixth day 
from the operation we shall have the appearance of the eighth day in ordinary cases; 
and on the eighth day we shall find the appearance of the tenth, and so on with the 
febrile symptoms, in which commotion the prophylactic power consists." 
I am hardly prepared to say from my own observation that it is possible to quicken 
the course of vaccinia to the extent mentioned by Waterhouse, but that the processes 
of the disease may be somewhat hastened by multiple insertions, I have no doubt. In 
looking back over my experience I have to regret that my vaccinations after infection 
had occurred were, in so many instances, limited to a single insertion. 
The extent of my experience in the matter of vaccination during the incubation 
period of smallpox amounts to 144 observations. As the time at my disposal will not 
permit of a detailed account of each case, I can only present in tabular form, appended 
hereto, some of the more important facts in their clinical histories. I wish to empha- 
size the fact that the vaccinations in every case were primary, and that infection most 
assuredly had taken place prior to their performance. 
An analysis of the 144 cases referred to shows as follows: In twenty-eight instances 
protection against smallpox was perfect; in eleven, almost perfect; in nineteen, well 
marked; in twenty it was partial, and in sixty-six there was none at all. 
In fifty-four instances vaccination had been performed no longer than from two to 
seven days before the variolous eruption appeared; of these forty-two per cent. died. 
While in ninety instances it was performed at an earlier period in the stage of incuba- 
tion, and of these only fifteen per cent. died. The death-rate, doubtless, would have 
been less had not the vaccine vesicles in so many cases been so tardy in their develop- 
ment. When I tell you that the death-rate among the unvaccinated cases under treat- 
ment at the same time and place amounted to fifty-nine per cent., the value of vaccina- 
tion during the incubation period of variola surely becomes very apparent. s 
" 2 «G ÏÏ 
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Number. 
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î co::;:: :::: c :::::::::::: ? :: 
No. of Insertions. 
Regular 
Regular 
Regular 
Regular 
Fair but 
tarder 
Fafrbut 
tardy 
Fair but 
tardy 
Very 
tardy 
Regular 
Small and 
tardy 
fflWfflW 
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No. of Days Vaccinated when 
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Degree of Protection. 
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Deaths Noted. 
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No. of Days in Hospital. 
Came with mother, 
who had varioloid, 
at the fourth day 
of eruption; con- 
tinued to nurse. 
Had two convul- 
sions. 
ci uaviug small- 
pox. Vaccinated 
immediately, and 
also on the follow- 
ing day. Two 
insertions each 
time, only the lat- 
ter take. 
The vaccine vesicle 
was 4 or 5 days 
late in its develop- 
ment. 
Born 12 hours before 
admission. Moth- 
Born in hospital. 
Mother having 
smallpox. Vacci- 
nated immediate- 
l ly, and repeated 
every day for five 
days in succession. 
Only one vesicle 
matured. 
smallpox. 
Disease only slight- 
ly modified. 
Disease only slight- 
ly modified. 
Disease very greatly 
modified. 
vaao ui vaiiuid. 
Sent to hospital as a 
case of variola. 
This and all other 
admissions mark- 
ed "no disease" 
came in company 
with one or more 
members of the 
family ill with 
Sent to hospital as a 
Remarks. 
163 Number. 
Age. 
Disease Admitted with. 
Disease Developing in 
Hospital. 
Where Exposure First 
took Place. 
Vaccinated Before or After 
Admission. 
No. of Insertions. 
Character of Vaccine 
Vesicles. 
No. of Days Vaccinated when 
1 Variolous Eruption Appeared. 
Degree of Protection. 
Deaths Noted. 
No. of Days in Hospital. 
Remarks. 
\ 
Came with mother, 
who had small- 
pox; nursing. 
The eruption con- 
sisted of only a 
few papules which 
29 
5 mos. 
No disease 
Varioloid 
Home 
After 
Somewhat 
tardy 
8 
Almost 
perfect 
Died 
26 
disappeared with- 
out. becoming ves- 
icular. After be- 
ing in hospital 26 
days took convul- 
sions and died. 
Death evidently 
not due to small- 
pox. 
Delivered prema- 
tu rely, mother 
having smallpox. 
Vaccinated on day 
30 
1 day 
No disease 
Varioloid 
Home 
After 
Regular 
9 
Partial 
Died 
22 
of birth. The va- 
riolous very light. 
During convales- 
cence took convul- 
sions and died. 
Born in hospital. 
Mother did not 
have smallpox, 
but was admitted 
s: 
Just 
born 
Hospital 
After 
4 
Typical 
Perfect 
29 
to take care of 
child sick with 
that disease. Vac- 
cinated on day of 
birth, and also on 
the following day. 
32 
3 yrs. 
Variola 
Home 
Before 
Regular 
4 
None 
Died 
2 
The variolous erup- 
33 
1 mo. 
No disease 
Varioloid 
Home 
After 
2 
Regular 
7 
Almost 
perfect 
17 
tion consisted of 
only 3 or 4 small 
vesicles. 
34 
10 yrs. 
Varioloid 
Home 
Before 
2 
Fair 
10 
Partial 
21 
35 
2 yrs. 
Variola 
Home 
Before 
Fair but 
tardy 
Regular 
7 
None 
Died 
36 
9 mos. 
No disease 
Home 
After 
4 
Perfect 
14 
37 
6 yrs. 
Variola 
Home 
Before 
Tardy 
iö 
None 
Died 
6 
This and the case 
above belonged to 
38 
9 yrs. 
Variola 
Home 
Before 
Tardy 
il 
None 
28 
one family. The 
virus used'seemed 
to be particularly 
slow in its action. 
39 
1 yr. 
No disease 
Home 
After 
2 
Regular 
Perfect 
20 
40 
2 yrs. 
No disease 
Home 
After 
2 
Regular 
Perfect 
19 
41 
3%vrs. 
No disease 
Varioloid 
Home 
After 
2 
Regular 
5 
Partial 
30 
Disease apparently 
modified. 
42 
18 yrs. 
Varioloid 
Home 
Before 
Tardy 
11 
Partial 
35 
Only slightly modi- 
fied. 
43 
16 yrs. 
Variola 
Home 
Before 
Regular 
5 
None 
31 
44 
7 yrs. 
Variola 
Home 
Before 
Regular 
11 
None 
Died 
7 
45 
5 yrs. 
Variola 
Home 
Before 
Regular 
9 
None 
Died 
6 
Variola 
Home 
Before 
Regular 
10 
None 
Died 
6 
47! 6 mos. 
Variola 
Home 
Before 
Tardy 
9 
None 
Died 
7 
48 
20 mos. 
No disease 
Variola 
Home 
After 
Regular 
4 
None 
27 
The eruption con- 
sisted of only about 
49 
3 mos. 
No disease 
Varioloid 
Home 
After 
3 
Regular 
11 
Almost 
perfect 
27 
one dozen small 
vesicles. The gen- 
eral health of the 
child was but little 
if at all disturbed. 
50 
17 yrs. 
Variola 
Home 
Before 
Regular 
9 
None 
27 
51 
9 yrs. 
No disease 
Home 
Before 
2 
Regular 
... 
Perfect 
23 
164 œ 
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Ci 
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Number. 
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3 yrs. 
OO 
B 
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co 
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22 yrs. 
3 
12 yrs. 
CO 
CO 
3mos. 
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co 
co 
19 yrs. 
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to 
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1 28 yrs. 
20 mos. 
19 yrs. 
B 
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to 
cc 
Age. 
Variola 
Varioloid 
Variola 
Varicella 
Varioloid 
No disease 
Varioloid 
Varioloid 
Varioloid 
Varioloid 
Varioloid 
No disease 
o 
P- 
co' 
g 
CD 
O 
& 
CD 
g 
CD 
'Varioloid 
Measles 
« 
o 
& 
co' 
CD 
CD 
| Varicella 
No disease 
No disease 
| Measles 
Varicella 
Varioloid 
No disease 
1 Roseola 
1 Syphilis 
secondary 
Measles 
Disease Admitted with. 
Varioloid 
Varioloid 
p3 
: o 
s 
1 
(Varioloid 
O 
C 
£ 
g 
c 
o 
£ 
Disease Developing in 
Hospital. 
Home 
Home 
Home 
Hospital 
K 
o 
B 
Home 
Home 
Home 
Home 
Home 
W 
o 
B 
CD 
| Home 
Home 
Home 
c 
B 
œ 
! Hospital 
Home 
Hospital 
Home 
Home 
' Hospital 
Hospital 
Home 
1 Home 
Hospital 
i Hospital 
■ Hospital 
Where Exposure First 
Took Place. 
W 
O* 
CD 
Before 
Before 
After 
Before 
After 
Before 
Before 
Before 
Before 
Before 
Before 
After 
After 
Before 
After 
After 
After 
After 
After 
After 
After 
Before 
After 
After 
After 
After 
Vaccinated Before or After 
Admission. 
>-i 
to 
to 
4- 
to 
to 
to 
00 
03 
Ü1 
Ci 
No. of Insertions. 
Regular 
Regular 
Regular 
Regular 
Regular 
Regular 
Typical 
Regular 
Regular 
Regular 
Regular 
Regular 
Fair but 
tardy 
Fair but 
tardy 
rair but i 
tardy 
Regular 
Typical 
Typical 
Fair 
Regular 
1 Typical 
Somewhat 
tardy 
Regular 
Regular 
j Regular 
Typical 
Typical 
Character of Vaccine 
Vesicles. 
CO 
Ci 
Ci 
00 
o 
5 
CD 
CD 
o 
SD 
00 Ç 
: to 
o 
OO 
No. of Days Vaccinated when 
Variolous Eruption Appeared. 
1 None 
None 
Well 
marked 
Perfect 
Well 
marked 
Perfect 
Well 
marked 
Partial 
Well 
marked 
Well 
marked 
Partial 
Well 
marked 
Perfect 
Partial 
Partial 
Perfect 
Perfect 
Perfect 
Partial 
Perfect 
Perfect 
Perfect 
Well 
marked 
Well 
marked 
I Partial 
Perfect 
Almost 
perfect 
Degree of Protection. 
[Died 
Died 
Died 
Deaths Noted. 
CO 
co 
co 
o 
CO 
CD 
to 
4- 
Ci 
CO 
Ci 
to 
o 
to 
to 
CD 
o 
CD 
to 
Ol 
| No. of Days in Hospital. 
after admission. 
smallpox; vacci- 
nated the day 
Sent to hospital as 
Eruption very light. 
very soon d i s a p- 
peared. Child not 
sick. 
about 14 days no- 
ticed a very few 
papules which 
When in hospital 
The eruption very 
1 light. 
sisted of a dozen 
small vesicles. 
The eruption con- 
A very feeble child. 
Vaccinated the next 
day after admis- 
sion. 
Sent as smallpox. 
1 hours after admis- 
sion. 
Vaccinated a few 
co 
O 
P 
vaccinated a few 
hours after admis- 
Sent as smallpox ; 
sion. 
vaccinated a few 
hours after admis- 
Sent as smallpox; 
vaccinated a few 
hours after admis- 
sion. 
Sent as smallpox; 
sion. 
day after admis- 
smallpox ; vacci- 
n ated the next 
Sent to hospital as 
Sent to hospital as 
smallpox. 
come vesicular. 
did not even be- 
subsequent days. 
The variola erup- 
tion consisted of a 
few papules which 
nated at once, and 
also on the two 
smallpox; vac ci- 
Sent to hospital as 
Remarks. 
165 Number. 
Age. 
Disease Admitted with. 
Disease Developing in 
Hospital. 
Where Exposure First 
Took Place. 
Vaccinated Before or After 
Admission. 
No. of Insertions. 
Character of Vaccine 
Vesicles. 
No.of Days Vaccinated when ! 
Variolous Eruption Appeared. 
Degree of Protection. 
Deaths Noted. 
No. of Days in Hospital. 
Remarks. 
Came with mother, 
who had vario- 
loid. Nursed 
Exceed- 
Almost 
perfect 
throughout moth- 
er's illness. Child 
was not sick, 
79 
3 mos. 
No disease 
ing mild 
varioloid 
Home 
After 
Regular 
13 
23 
though 7 small 
variolous vesicles 
appeared. 
80 
26 yrs. 
Roseola 
Hospital 
After 
Typical 
Perfect 
Died 
26 
Sent as smallpox. 
81 
7 yrs. 
Variola 
Home 
Before 
Regular 
2 
None 
6 
Sent as a case of 
smallpox. 
82 
23 yrs. 
Varicella 
Variola 
Hospital 
After 
3 
Regular 
11 
None 
57 
83 
3 mos. 
Variola 
Home 
Before 
Regular 
2 
None 
Died 
1 
84 
10 yrs. 
Variola 
Home 
Before 
Regular 
3 
None 
39 
85 
4 mos. 
No disease 
Home 
After 
2 
Typical 
Perfect 
19 
86 
7 wks. 
Erythema 
Hospital 
After 
Regular 
Perfect 
1 1 
Sent to hospital as a 
case of smallpox. 
87 
11 mos. 
No disease 
Variola 
Home 
After 
Regular 
7 
None 
28 
88 
2 yrs 
No disease 
Variola 
Home 
After 
Regular 
5 
None 
Died 
11 
Sent as smallpox. 
Was exposed 24 
89 
21 yrs. 
Varicella 
Variola 
Hospital 
After 
Fair but 
tardy 
11 
None 
41 
hours before vac- 
cinated. Possibly 
the disease was 
slightly modified. 
90 
8 mos. 
Variola 
Home 
Before 
Regular 
7 
None 
Died 
4 
The eruption scarce- 
91 
8 mos. 
Varioloid 
Home 
Before 
Regular 
12 
Almost 
perfect 
6 
ly progressed be- 
yond the papular 
stage. 
92 
28 vrs. 
Variola 
Home 
Before 
Regular 
3 
None 
Died 
6 
93 
6 yrs. 
Varioloid 
Home 
Before 
Ï 
Regular 
9 
Partial 
12 
Came with its moth- 
94 
1 yr. 
No disease 
Varioloid 
Home 
After 
1 
Regular 
7 
Partial 
31 
er who had vario- 
loid ; was still 
nursing. 
95 
2 vrs. 
Varioloid 
Home 
Before 
1 
Regular 
9 
Partial 
12 
96 
23 yrs. 
Variola 
Home 
Before 
Regular 
4 
None 
Died 
5 
97 
7 mos. 
Variola 
Home 
Before 
Fair 
4 
None 
31 
98 
6 yrs. 
Variola 
Home 
Before 
Fair 
4 
None 
31 
99 
8 yrs. 
Variola 
Home 
Before 
Fair 
4 
None 
31 
The four last cases 
belonged to oue 
100 
14 yrs. 
Variola 
Home 
Before 
Fair 
4 
None 
31 
family. All ad- 
mitted on the 14th 
day eruption. 
101 
29 yrs. 
Variola 
Home 
Before 
Regular 
10 
None 
61 
Corneal ulcer devel- 
oped. 
102 
4 vrs. 
Variola 
Home 
Before 
Regular 
4 
None 
37 
103 
2 yrs. 
Variola 
Home 
Before 
Tardy 
7 
None 
Died 
2 
Hemorrhagic. 
104 
8 yrs. 
Variola 
Home 
Before 
Regular 
5 
None 
26 
105 
5 yrs. 
Variola 
Home 
Before 
Fair 
6 
None 
14 
Possibly the disease 
was slightly modi- 
fied. Sent to hos- 
106 
7 yrs. 
Varicella 
Variola 
Home 
Before 
Tardy 
11 
None 
35 
pital as a case of 
smallpox. 
There being small- 
* 
pox in the fam- 
107 
24 yrs. 
Roseola 
vaccinosa 
Home 
Before 
Typical 
Perfect 
3 
ily, this peculiar 
eruption was mis- 
taken for that dis- 
108 
13 yrs. 
Variola 
Home 
Before 
Fair but 
tardy 
6 
None 
Died 
6 
ease. 
Hemorrhagic. 
109 
11 yrs. 
Variola 
Home 
Before 
Fair 
6 
None 
Died 
14 
Hemorrhagic. 
hs 
Not more than two 
dozen small vario- 
1 o u s vesicles ap- 
110 
1 yr. 
Varioloid 
Home 
Before 
Regular 
13 
Almost 
perfect 
20 
peared, and ran a 
very short course. 
There was no well- 
marked febrile 
stage. 
166 g 
£ g 
8 
g ggggg 
g 
BS B g ! 
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£> CO -I 
USSB 
Number. 
= 
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I = 
s 
? 
B 
fi 5? j if 
3 
c « » s « 
? 1 ? H 
Age. 
Measles 
No disease 
I Varioloid 
I No disease 
Varioloid 
% 
o 
Varioloid 
C < ? S' ? o' <1 
H [If fl 
No disease 
No disease 
Variola 
Varicella 
No disease 
No disease 
Disease Admitted with. 
<! 
V arioloid 
Variola 
: 
Variola 
Varioloid 
: 
Variola 
Varioloid 
Varioloid 
<1 
Very mild 
varioloid 
... 
Variola 
Varioloid 
Disease Developing in 
Hospital. 
Hospital 
Hospital 
Home 
i iiiii 
Home 
hl! 
Home 
Hospital 
Hospital 
Home 
Iiiii 
Where Exposure First 
Took Place. 
After 
Before 
After 
Before 
Before 
H n 
I 11 
Before 
i H h 
Vaccinated Before or After 
Admission. 
to 
~ : 
bO 
: 
to 
- W : CO 
w w : 
: 
: : to i : 
No. of Insertions. 
Regular 
Regular 
Regular 
Fair but 
tardy 
§ 
Regular 
Tardy 
Fair 
Regular 
Tardy 
Regular 
Regular 
Ml h 
Typical 
Character of Vaccine 
Vesicles. 
No. of Days Vaccinated when 
to 
o 
Ol o OO 
o •"* 
o 
P : » es £ 
Variolous Eruption Appeared. 
Well 
marked 
Well 
marked 
Well 
marked 
Scarcely 
any 
Partial 
Well 
marked 
None 
Almost 
perfect 
None 
None 
None 
Well 
marked 
Perfect 
Almost 
perfect 
Almost 
perfect 
None 
None 
Perfect 
Well 
marked 
Degree of Protection. 
: 
I • 
: 
! 
! = = = 
: 
V : I 
: g : : : : : : 
Deaths Noted. 
5 
G S 
ê 
CO 
8 
£ g £2 
ä S 8 
CO 
S E 2 £ s 
No. of Days in Hospital. 
Sent to hospital as a 
case of smallpox. 
In the hospital 
only 15 days 
counting from the 
beginning of erup- 
tion. 
Died during conva- 
lescence from en- 
terocolitis. 
Disease apparently 
modified. Death 
was caused by gas- 
tro-intestinal dis- 
order. 
Vaccinated at first 
with bovine virus 
and on the follow- 
ing day with hu- 
= 
Bottle-fed baby. 
Very feeble. Only 
14 variolous pap- 
ules. Would 
scarcely have 
lived anyhow. 
tion consisted of 
only two dozen 
small vesicles. 
The health of the 
child was appa- 
rently not dis- 
peared. No febrile 
The eruption con- 
sisted of only 2 or 
3 vesicles. 
The variolous erup- 
> Bö t? 00 
Mül 'ï;î 
Remarks. 
167 168 
4-4- X X CO COCO CO 
4- CO tD -• O CD 00 O 
Number. 
? £ " *• ? " S 
B B m m B £ hm 
o o 2 o pr S 72 
CD CD ÇD CD CD CD g CD 5 
Age. 
M ÖJ < « h, . <t 
o O 8» O % & 
o. g. ij " o< g. s h 5. 
<»' « t* 2. 5T t» 5- 3. o 
2 2 2.0 ® ". o o sr 
i g p s i £50 * s 
Disease Admitted with. 
j? p* ■< 
: p' : ; o" 5. : s : 
ö. o' 2. 
Bi 2 * 
Disease Developing in 
Hospital. 
ffl M 
g W WM g M WM W 
•qO 2° 'S oooo 
-• B BB ~ BBBB 
îa ® a> ® p oooo 
Where Exposure First 
Took Place. 
► g " £ > fe H 1 
o (D § ? 
® CD CD ■-» 1 O ® (D 
Vaccinated Before or After 
Admission. 
»u •-* : : : : : : 
No. of Insertions. 
2 # # W & # 
o aS o a» o o ►_< l_| o 
« OQ TO TO TO 2? TO 
z. c_ c* £.-•-•*! 
p- ff STgT £T pT m" 
Character of Vaccine 
Vesicles. 
: h M ce **" 5 
No. of Days Vaccinated when 
Variolous Eruption Appeared. 
po o- p 
2.0 2 2-o -*.z o oo X 
o O o P S3 S C. 
O ® o, o o o o c° 
Degree of Protection. 
. . . 2.2. 
: : : : : o : o* : 
P- Gu 
- to co tD to - CO kU 
CO O O 4- 0 to O 
Deaths Noted. 
No. of Days in Hospital. | 
HU H H < 
o « - £■ x;• jä 2 K'<5coa.s.c'->n' < s> 
2|ô-E.k-J2è® 5'2. 
• 2 JLm m < p « 
: ©g-B <k'-: F o < : : 
• o S, C er n* • 2troBH"_£: : c 
o o ~ ® S-NOM X 2 "> - 
- q. n er Sio o o • ff J- 2- 
h-, bI & 
o § » 2® S s 3. " 6' & 
p.»S «•£■ »TVp.yf g ? 
Remarks. 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
DISCUSSION. 
Dr. Carter inquired how Dr. Welch knew that his patients would have had 
variola at all, if they had not been vaccinated. 
Dr. Cundell-Juler, Cincinnati, Ohio, was led by observation to believe with 
the essayist that a greater immunity from smallpox was enjoyed by him who had 
been vaccinated in early life from the mature vaccine vesicle than would be assured 
by vaccination from the crust that fell from the arm at the fourteenth day after the 
operation. 
He referred to the experience he had when district vaccinator and in hospital 
practice in England. He spoke of the care observed and the method of vaccinating 
in that country, and also of the method adopted in the United States. Like himself, 
there were many physicians who, when infants, had been vaccinated from the vaccine 
vesicle, who had stood by the bedside of smallpox patients and been exposed to the 
contagion iu many and various ways, who had never been revaccinated, and yet 
escaped the malady. 
Dr. William Knight, of Cincinnati, Ohio, said-Vaccination in the incubation 
stage of variola is not, in my opinion, as efficacious as inoculation. 
In an instance that occurred in my practice an unvaccinated woman in the ninth 
month of pregnancy was attacked with confluent variola. During the second stage 
of the disease I delivered her of a child. Lying in the same bed was her son, three 
years of age, who had not been vaccinated. I at once inoculated, from a pustule in 
the mother, both the boy and the newly-born infant. The boy had a mild attack of 
variola, leaving but few cicatrices. The mother died on the third day after her 
confinement. The infant died about the same time, showing no signs of the 
affection. SECTION XIV-DERMATOLOGY AND SYPHILOGRAPHY. 
169 
I mention this instance as affirmatory of my view that inoculation is preferable 
to vaccination as a prophylactic in the incubation stage of smallpox. 
Dr. Gottheil, of New York, had had occasion to see large numbers of vaccina- 
tions in some of the public institutions of that city. Every patient admitted was 
vaccinated, even if the operation had been done repeatedly and but a short time 
before. Few were successful; but as a rule the so-called "raspberry" excrescence 
was of very frequent occurrence indeed. These he had always regarded as the exu- 
berant granulations of a weak ulcer; but he would like to know whether the condi- 
tion resulted from the action of the virus upon a soil already exhausted, or whether 
it was due to some special quality of the vaccine. 
Dr. Rogers Parker, of Liverpool, England, a public vaccinator for the city of 
Liverpool, said that in the large cities of England human lymph was usually employed. 
Large vaccination stations were established, to which the parents were required to 
bring the children at certain times, and the children vaccinated one week returned 
upon the same day the next week, so that there was always an abundance of vesicles 
from which to choose in vaccinating the others. Revaccination is not compulsory, 
but was usually done in schools and public bodies at about the age of fourteen. He 
believes humanized virus gives better protection than animal virus. 
Dr. Keller, of Hot Springs, Ark., related an incident of war times. He was 
in charge of a hospital on the Southern side. An epidemic of variola broke out. A 
supply of lymph was received, with information that it came from the North, and 
was suspected of being poisoned. Such stories were then current. He decided to 
use it, and, to avoid error, divided each point, vaccinating a citizen with one part 
and a soldier with the other. Nine-tenths of the soldiers had unhealthy sores fol- 
lowing the operation, but none of the citizens, showing that they were due to the 
scorbutic condition of the soldiers, and not to impure virus. 
Dr. Yeamans, of Detroit, Mich., said his belief in the protective power of vac- 
cination, after exposure had occurred, grew yearly less and less. He had had 
considerable experience in the matter, and thought we lost sight of the many other 
influences brought to bear which may modify the case under observation. 
Dr. Robinson, the President, asked, if vaccinia is an infectious disease, depend- 
ing upon organisms which multiply with enormous rapidity and exist in the system 
as long as suitable material is present, why more than one point of inoculation is 
considered necessary. If unnecessary, multiple scarifications should not be made, on 
account of the scar deformity resulting. He would not make more than one point 
of inoculation except during the incubation period of variola, or exposure to the 
disease. 
Dr. Lathrop, of Dover, N. H., believed that he had seen vaccinia take the 
place of smallpox. 
Dr. Welch, in closing, said he had been skeptical in regard to the necessity for 
multiple inoculations, and believed one typical cicatrix gave as good protection as 
many. Animal virus, or virus of recent humanization, gives a more durable protec- 
tion. That of long humanization produces a more superficial scar, and deaths were 
more frequent in those showing superficial scars. He does not believe in life-long 
protection of vaccination. The ulcers mentioned by Dr. Gottheil he thought were 
only found after animal lymph had been used. It is not true vaccination, and it 
gives no protection. 170 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
RECTAL ALIMENTATION AND MEDICATION IN DISEASES 
OF THE SKIN. 
ALIMENTATION PAR RECTUM, ET MEDICATION DANS LES MALADIES DE 
LA PEAU. 
ÜBER ERNÄHRUNG UND MEDICATION PER RECTUM BEI HAUTKRANKHEITEN. 
JOHN V. SHOEMAKER, A.M., M.D., 
Of Philadelphia. 
The power of the rectal mucous membrane to absorb substances placed in contact 
with it is but little inferior to that of any other portion of the gastro-intestinal canal. 
Moderate quantities of milk, eggs, gruel, beef tea and all the nutritious broths are 
absorbed by the rectum almost as quickly as by the stomach. Ether and other volatile 
agents produce their characteristic effects immediately after their introduction into the 
rectum. Solutions of morphia, atropia, aconitia, quinia and hyoscyamia are taken 
up as rapidly, and strychnina and nicotine more rapidly, by it than by the stomach. 
As a general rule all substances in solution are speedily absorbed by the rectum 
unless they are so irritative in character as to produce muscular contraction, which will 
only cease upon their expulsion. Soluble non-irritating substances in powder or in the 
form of suppositories are taken up more slowly, but eventually as certainly, as if admin- 
istered in the usual manner, unless expelled along with the fæces before absorption is 
complete. The absorbent properties of the rectum are frequently availed of in the 
treatment of gastric irritability, ulcer of the stomach, carcinoma of various portions of 
the alimentary tract. By giving the stomach absolute rest, and nourishing and medi- 
cating the patient by the rectum, the duration of acute attacks is lessened, life in many 
cases saved, and in others prolonged for months. 
The same methods which yield such gratifying results in these diseases may also be 
employed with decided benefit in many cutaneous affections. 
In epithelioma of the lips and tongue, after excision has been performed patients 
are usually fed through a rubber tube, but notwithstanding the greatest care on the part 
of the patient and nurse, the movement of the muscles in swallowing conveys more or 
less irritation to the edges of the wound, and may, in some cases, stimulate the morbid 
process to renewed activity. It would be much better in such cases to place the oral 
muscles at complete rest and nourish the patient by the rectum until the wound is com- 
pletely healed. The same method should be adopted for several days after cauterizing 
or scraping lupus spots on the lips or in the mouth. 
In stubborn cases of infantile eczema, in which the little patient while retaining all 
the food it takes, and presenting no symptoms of gastro-intestinal disorder, yet does not 
increase in weight, immediate improvement will often follow the administration of one 
ounce of milk enema four times a day. In these cases, which may be termed examples 
of infantile apepsia, the skin affection is clearly the result of insufficient nutrition. 
Obstinate cases of pemphigus and impetigo in children of all ages are frequently due 
to the same cause, and are promptly relieved as soon as supplementary rectal nutrition 
compensates for deficient gastric assimilation. 
There is an intractable form of recurrent acne observed in young girls and delicate 
hoys, which, on inquiry, will be found to be closely associated with stomachic debility. 
When their appetite is good and digestion perfect the eruption disappears, but after a 
time, without apparent cause, their appetite lessens, the sight or smell of food produces 
a feeling of nausea, and if they force themselves to eat as much as formerly, they vomit 
it soon afterward. They become pallid and weak, and the eruption, usually consisting 
of from one to a dozen papules, reappears. Investigation fails to disclose the portion of 171 
SECTION XIV-DERMATOLOGY AND SYPHILOGRAPHY. 
the digestive system at fault. The tongue remains clean, the bowels are normal, and all 
the bodily functions, except those of eating and assimilating, are performed as usual. The 
routine treatment for these patients consists of iron, strychnine, the mineral acids, and 
various bitter tonics, and usually terminates in success in from two to six months. 
Many of them could be cured in from two to four weeks by combining the rectal admin- 
istration of milk, malt extract, and beef juice with the internal medication previously 
referred to. 
A general rule, which may be safely followed in the treatment of all diseases, 
whether of the skin or any other organ or portion of the body is - 
Whenever the system manifests evidences of insufficient nutrition, supplement 
stomachic assimilation by the administration of nutritious enemata. 
The only exception to this rule is when the rectum is unable, either from irritability 
or disease, to retain the enema long enough for absorption to occur. 
Care should be taken in the preparation of nutritious enemas to ensure their reten- 
tion. If too large they will over-distend the rectum, and produce vigorous contractions 
ending in expulsion. If too cold or too hot the same result •will also occur. They 
should be lukewarm and not exceed four ounces for an adult, and one ounce and a half 
for a child. They ought not to be given offener than once every four hours, or they 
may induce an irritable condition of the mucous membrane. The advice of some 
authors to empty the rectum of fecal matter by an ordinary injection before giving an 
enema intended for absorption is ludicrous. Every surgeon knows that the rectum, as 
was pointed out by O'Byrne, forty years ago, is normally an empty pouch until defeca- 
tion begins. 
Rectal Medication.-In cutaneous diseases suppositories are the most convenient 
form of medicating the system by the rectum. They are absorbed more slowly than 
solutions, but their ease, cleanliness and safety of administration more than compen- 
sate for their slightly retarded action. They are especially valuable in the treatment 
of those phenomenal children who have an invincible repugnance for medicine in any 
form, and who manage to spit it out or vomit it up, notwithstanding all sorts of threats 
and caresses. Medicated suppositories will, in these cases, relieve the parents as well as 
the patient, and make the doctor's life more bearable. The main indication for rectal 
medication in cutaneous, as well as other diseases, is inability of the stomach to receive 
or retain the medicines needed to restore health. As this is the only criterion, it is 
obvious that it would be impossible to enumerate the affections of the skin in which 
rectal medication would be valuable and those in which it would be useless. Every 
casé must be judged in accordance with its own requirements. 
If the symptoms present are such as are usually antagonized or removed by the sys- 
temic action of a certain drug, and the gastric mucous membrane is so disordered that 
that drug is immediately rejected by vomiting, our duty is to endeavor to procure its 
absorption in another manner, rather than to discard it and search for another remedy. 
In many cases of syphiloderma mercury will not be tolerated by the stomach, and 
the patient's habits or business affairs are such that inunctions, hypodermatic injections 
or fumigations cannot be employed. In these cases I have repeatedly witnessed the 
disappearance of the eruption, and the recovery of the patient, from the employment 
twice a day of suppositories containing one-half grain of calomel or one-quarter grain 
of the protiodide of mercury. Infantile syphilis may be effectually treated in the 
same way, reducing the quantity of calomel to the one-twelfth of a grain, and the prot- 
iodide to the one-twentieth or the one-hundredth part of a grain. The bichloride or 
any of the other preparations of mercury may be substituted in appropriate doses. 
Scrofuloderma is almost invariably benefited by cod-liver oil, but patients are occa- 
sionally met with who are unable to take it in any form. In two mild cases of this 
disease under my care recently, in which this idiosyncrasy was extreme, I effected com- 172 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
plete cures by the employment of rectal enemas of one ounce of cod-liver oil every 
night, continued for five weeks in one case and in the other for two months. 
Erythema multiforma and erythema nodosum, when due to malaria, are usually 
accompanied by so much gastric irritability that even water is vomited as soon as it 
reaches the stomach. Twenty grains of quinine made into a suppository and inserted 
in the rectum will relieve all the symptoms in a few hours. 
Urticaria nodosum, a somewhat similar affection, will promptly yield to the same 
treatment. Urticaria simplex, due to the presence of fermentative or irritating mate- 
rial in the gastro-intestinal canal, can be more speedily relieved by the rectal injection 
of an ounce of castor oil and an ounce of glycerine than by any other method. 
Erythema intertrigo, when produced by the irritation of diarrhoeal discharges, can 
frequently be removed almost immediately by the use of a single suppository contain- 
ing a small quantity of opium combined with from five to twenty grains of a vege- 
table astringent like geranium or hamamelis. 
Pruritus ani is often due to an œdematous condition of the tissues around the anus. 
In this event anti-pruritic lotions and ointments can be of only temporary utility, and 
occasionally aggravate instead of alleviating the patient's sufferings. A suppository 
containing ten grains of powdered geranium, or ten grains of quercus alba, will dissi- 
pate the oedema and banish the itching. Pruritus vulvæ and general pruritus are occa- 
sionally traceable to disorder of the anal nerves, and can then be almost magically 
relieved by the employment of suppositories composed of opium £ gr. and extract of 
belladonna | gr. Opium -J gr. and chloral 5 grs., quinine 10 grs. and extract of cannabis 
indica 2 gr. is also useful. Arsenic and antimony are of incalculable benefit in many 
cases of psoriasis, but they frequently disorder the stomach so much that their admin- 
istration is suspended before the eruption is removed, and some less potent but less 
irritating remedies substituted. My experience has convinced me that to discontinue 
their use under such circumstances is an error. They can be given with advantage in 
the form of suppositories. Care must be taken, however, to have them evenly divided 
throughout the mass, and to employ at least grain of arsenious acid or arsenite of 
sodium in each suppository, one to be used from one to five times a day. Iodide of 
potassium is of great service in many cases of subacute and chronic eczema, but its 
peculiar recurrent taste and the additional eruption which is occasionally developed by 
it limits its employment. If it be given in small doses in the form of suppositories, these 
unpleasant drawbacks will rarely be observed. 
There are other cases of obstinate eczema in which rectal enemata of cod-liver oil 
will be more successful than any other remedy. Ichthyosis may be signally palliated 
by the same method. 
Many other cutaneous affections might be mentioned in which rectal medication 
will prove valuable, but I prefer to limit my remarks to those in which I have realized 
its value by practical experience. 
DISCUSSION. 
Dr. P. Gr. Unna, of Hamburg, Germany, agreed with the reader of the paper in 
the good effects obtained by rectal medication in many affections. He asked concern- 
ing the experience of the author in regard to the administration of mercury ; whether 
diarrhoeas and other unfortunate effects were not likely to occur. 
Dr. Klotz, of New York, expressed his doubt that the absorbent power of the 
rectum should be found to be unimpaired under conditions where resorption by the 
gastric mucous membrane and the rest of the digestive canal is undoubtedly dimin- 
ished, for instance, in fever. This is said in regard to certain diseases mentioned 
by Dr. Shoemaker, as, for instance, pemphigus acutus in small children, which he SECTION XIV DERMATOLOGY AND SYPHILOGRAPHY. 
173 
admits is, as a rule, an acute, probably infectious disease, accompanied by more or 
less fever. 
In closing, Dr. Shoemaker replied to Dr. Unna's question, that when the mer- 
curial was given first in small doses and gradually increased, the good effects were 
secured and the ill effects obviated. 
ON THE OCCURRENCE OF ULCERS RESULTING FROM SPONTA- 
NEOUS GANGRENE OF THE SKIN DURING THE LATER 
STAGES OF SYPHILIS, AND THEIR 
RELATION TO SYPHILIS. 
SUR L'OCCURRENCE DES ULCERES RÉSULTANT DE LA GANGRÈNE SPONTANÉE 
DE LA PEAU PENDANT LE DERNIER PERIODE DE LA SYPHILIS, 
ET LEUR RAPPORT AVEC LA SYPHILIS. ■ 
ÜBER DAS VORKOMMEN VON GESCHWÜREN IN FOLGE VON SPONTANER GANGRÄNE 
DER HAUT IN DEN SPÄTEREN STADIEN DER SYPHILIS, UND IHRE 
BEZIEHUNG ZU DERSELBEN. 
BY HERMANN G. KLOTZ, M.D., 
Of New York. 
Whenever we find an nicer of round or oval shape, sharply cut as if punched out, 
with somewhat thickened, abrupt edges, extending deeply into or through the entire 
thickness of the skin, with an uneven floor of a dark-green or yellow, dirty color, in 
a person known to be under the influence of syphilis in its later stages, such an ulcer 
we generally consider to be a syphilitic one-that is to say, to owe its origin to necrosis 
of some previously formed specific tissue, most frequently to the breaking down of a 
gummatous infiltration. An observation made several years ago rendered it more than 
probable to me that similar ulcers in syphilitic persons might directly result from cir- 
cumscribed spontaneous gangrene of the skin, due to syphilitic arteritis or endarteritis 
obliterans. 
Among the patients who came under my care when, on July 1st, 1879, I took charge 
of the outdoor poor service of the German Society of New York, was Mrs. S., fifty- 
eight years of age, who, while otherwise in good health and strength and able to attend 
to her household duties, was, owing to a sore leg, prevented from leaving the house. 
Beginning directly below the knee, the right leg was considerably enlarged ; on its 
upper two-thirds the skin was congested and shining, showing numerous dilated blood 
vessels, but was otherwise in good condition. From about the lower third of the leg to 
the middle of the dorsal aspect of the foot, ulcers of irregular shape, at least one cen- 
timetre deep, with sharply cut, indurated edges, occupied nearly the entire circumfer- 
ence of the ankle. The floor of the ulcers showed an uneven surface, of a dirty green 
color, furnishing a copious watery discharge of very offensive odor. The foot, with the 
exception of the toes, was enormously enlarged in consequence of swelling of the soft 
parts, principally of the skin, which was partly smooth and glistening, partly uneven, 
owing to the formation of numerous aggregated wart-like elevations, and was kept 
constantly moist by a watery secretion. At first sight the case seemed to be one of 
simple chronic ulcers with elephantiasis of the leg ; closer examination of the patient, 
however, made it more than probable that syphilis was at the bottom of the disease. 174 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
The patient being almost deaf and not of very bright intellect, it was with some 
difficulty that the following history was extracted : Her husband is living, and does 
not show any signs of disease ; she has two grown-up sons, both in good health; she 
herself was strong and healthy until eight years ago, when a tumor formed over the 
sternum, which, without ever causing much pain, broke and left an extensive ulcer, 
which finally healed. Soon after similar ulcers developed on the dorsal side of the 
right forearm, which likewise healed. Only a few weeks later ulcers made their appear- 
ance on the back of the right foot, laying bare the bones but gradually filling up again 
to about the present state, never healing, but attaining by degrees their present size. 
Extensive, white, sharply defined scars, adherent on the sternum, confirmed the patient's 
report and left little doubt as to the syphilitic character, particularly of that over the 
sternal region, so favored a location of syphilis. 
Under appropriate, mostly specific treatment the swelling of the extremity was 
gradually reduced, the ulcers themselves presented a cleaner, healthier aspect, now and 
then good granulations cropped up, the edges had flattened down and softened visibly, 
when on one of my visits, in November, I was surprised to find the skin above the ankle 
affected at several new places, which before had been smooth and but little infiltrated. 
Being interested in the patient, I had visited her at least once a week, and had watched 
the progress closely. I felt confident that on the localities of the recent affections no 
swelling, not even any discoloration, had previously existed. Now there appeared on 
several places dark-green, oval-shaped sloughs, of about the size of a small hen's egg, 
surrounded by well-defined borders, which were not more congested or swollen than 
the rest of the skin ; their appearance was accompanied by considerable sharp pains. 
Gradually the tough, dry eschars began to separate from the surrounding tissues with- 
out losing their totality, showing an uneven floor throughout, the lower third of which 
was of semilunar shape, level and slightly elevated, and, like the rest, coated by a thin 
layer of yellowish detritus. After a while the ulcers thus formed took on the same 
appearance as the old ones, making but very slight progress toward improvement, 
without, however, evincing a tendency to increase in circumference. 
In September, 1880, the patient's left leg, which so far had remained intact, began 
to swell quite rapidly, exhibiting oedema of the soft parts with but slight congestion, 
when an injudiciously applied liuiment caused a dermatitis or artificial eczema. This 
had subsided when, in October, without any previous induration or circumscribed 
swelling, similar sloughs as above described were formed on the back of the foot, fol- 
lowed in November by more extensive sloughing of the skin above the left ankle. Soon 
after, symptoms of blood poisoning set in, which early in December terminated in 
death. 
Here I had a patient of whose syphilitic taint there could be no doubt, with ulcers 
closely resembling the typical so-called gummatous ulcer of syphilis; still I felt abso- 
lutely certain that in those localities where I had been able to watch their development 
there had been no symptoms of previous gummatous infiltration. There had been no 
reddening of the surface, no spontaneous opening of a single aperture nor ulceration 
at several distinct points, no formation of a small, deep ulcer with a core underneath, 
and final extension until the entire neoplasm was destroyed ; no thickened edges and 
no hypersemie areola. The blackish-green eschars had appeared at once, uniformly 
covering the whole area; they were closely adherent at first to the surrounding skin, 
which itself did not exhibit any changes from its former condition ; they gradually sepa- 
rated in their totality-clearly spontaneous gangrene of the skin. In looking for the 
cause of the gangrene, there was no evidence of trauma, none of the influence 
of heat or cold or of caustic or irritating chemical action, none of a diathesis 
like diabetes or of an infectious disease, none of neurotic influences, none of ergot- 
ism, or any other cause except obstruction to the circulation. The patient exhibited SECTION XIV-DERMATOLOGY AND SYPHILOGRAPHY. 
175 
no signs of endocarditis, no sclerosis of the arteries in other parts where it usually 
manifests itself ; therefore it seemed probable that syphilitic arteritis or endarteritis 
obliterans had led to the interruption of circulation. This I stated to be my opinion 
when I presented the patient at a meeting of German physicians of New York in 
January, 1880. I shall try to show later on that such an assumption seems justified, 
even without direct anatomical proof. Still, I confess the case was not entirely 
convincing, especially in regard to the right extremity, which was first affected. Here 
the whole leg was in such a condition that the obstruction of a blood vessel could 
easily take place from various causes; not so, however, on the left leg, which had 
previously been in a normal state. Certainly my attention was sufficiently aroused to 
keep me on a sharp lookout for similar cases. Several years, however, passed without 
furnishing further confirmation of my suspicion. A number of cases came under 
my observation which, indeed, somewhat resembled that of Mrs. S. In several in- 
stances I found the same dark-green sloughs, firmly adherent to their base and their 
periphery, occurring mostly at the malleolar region ; sometimes I could watch the 
separation of these sloughs and the appearance of the deep, dirty, sharply cut ulcers, 
surrounded, at least at first, by rather normal skin, in persons known to be, or highly 
suspected of being, subjects of syphilis. At other times ulcers were seen, under simi- 
lar conditions and in the same localities, which I felt convinced had been originated by 
the separation of the same escharotic sloughs. They were generally of oval shape, 
uneven, very often deeper at one side than at the other, showing a flat semilunar eleva- 
tion like the round ulcer of the stomach, with hard but sometimes inverted edges, 
furnishing a thin watery secretion and either exhibiting very little tendency to extend 
or to heal, or, after a very slow progress of healing, leaving a depressed scar that firmly 
adhered to the underlying tissue, even when not situated directly over a bone. Per 
contra, gummatous ulcers as a rule show a great tendency to heal under proper treat- 
ment with a slightly depressed, movable, and thin, parchment-like scar. Naturally, 
such ulcers at first sight do not differ much from the common chronic ulcer of the leg, 
especially if left to themselves for some time, but on close observation some peculiarities 
can indeed be found. I have observed these so regularly in ulcers of the malleolar 
region that I always consider those as suspicious of syphilis, and but exceptionally has 
the suspicion failed of confirmation by the absence of a history or other manifestations 
of syphilis. All such cases, however, which I have seen, unfortunately belonged to 
dispensary practice, so that I was not able to trace their history and development with 
sufficient accuracy. One case, however, occurring in private practice, offered a better 
opportunity. 
Mrs. B., then about fifty years of age, had contracted syphilis in August, 1880. 
Although rationally treated from the start by her physician, the disease soon developed 
a very malignant character, partly in consequence of irregularity of treatment owing to 
the miserable state of the patient's digestion, partly of constant family trouble and 
excitement. I first saw her about a year after the infection, when she presented super- 
ficial ulcerations of the forehead, scars of ulcers on the legs, and gummata of the thighs 
and arms, and ever since have had her under observation. During these six years Mrs. 
B. hardly ever has been entirely free from symptoms of syphilis, consisting mostly of 
ulcers of different parts of the body. In March, 1884, two gummata of the size of a 
small walnut made their appearance on the lower third of the right leg, breaking down 
in the usual way and leaving two deep ulcers in an area of considerably infiltrated and 
congested skin. These ulcers, after various periods of improvement and aggravation, 
presented about the end of June a clean granulating surface, giving promise of a speedy 
healing. Early in September I found these ulcers healed with a smooth, thin, scar ; 
the leg, which had repeatedly shown different degrees of oedema, was of natural size, 
but below the malleolus internus two dark-green, firmly adherent sloughs, about the 176 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
size and shape of peach stones, were visible, separated by a band of slightly œdematous 
skin and causing no particular inconvenience. Four weeks later the sloughs had come 
off, leaving tolerably clean, shallow defects, with sharply cut, uninfiltrated edges. 
These two ulcers have never entirely healed since ; they have not materially increased 
in size, but have been constantly changing in depth. At one time in January, 1885, 
the greater part of them had been transformed into a depressed adherent scar, showing 
several transverse, ridge-like elevations and causing then considerable pain, but since 
that time the ulcers have increased in depth again and do not undergo much change, 
neither healing nor extending, although the patient is keeping very quiet and is not 
obliged to use her legs much. 
So far my own experience. In literature not much is to be found. Some of the 
features of syphilitic ulcers in the chronic state are found described in the handbooks, 
for instance, by Bumstead and Taylor,* where the chronic swelling resembling elephan- 
tiasis Arabum, as in my first case, is especially mentioned, but the. original formation 
of a slough w ithout previous gummatous infiltration I have not found distinctly recog- 
nized. Some of the malignant precocious syphilides, described originally by French 
authors, often rapidly lead to sloughing, but never without a neoplasm being previously 
visible, differing from my cases by their early appearance. We find the closest resemb- 
lance to spontaneous gangrene, however, in a description recently given by Fournierf 
of what he calls gangrène primitive, and to which, he says, Bazin has given the name of 
tuberculo-gangrenous Syphilide. I have tried to find the original of Bazin, which Four- 
nier has not indicated, but have not succeeded, so that I cite the latter author:- 
' ' Here the tuberculous infiltration, as soon as it has been formed, takes a livid color 
in the centre and a chocolate color in the peripheral portions, with insensibility of the 
diseased part ; for in reality the formation of an eschar takes place under which the 
mortified, insensible, sloughy tissues are found, no external occasional cause being 
recognizable. The mortified parts take on the appearance of gangrene, they become 
detached, and underneath the syphilitic ulcer is found at last. The symptoms perfectly 
bear the character of spontaneous primary gangrene." 
Here you have an exact description of what I have stated to have observed, only 
that Bazin insists on the previous formation of a neoplasm that begins to disintegrate 
as soon as it is formed. It is true, the syphilitic newly formed tissue is perhaps the 
most short lived, but not so ephemeral as Bazin's description would lead us to believe; 
only in phagedenism do we meet with so rapid a decay, yet Bazin does not identify his 
tuberculo-gangrenous syphilide with phagedenism. Has this new formation not been 
assumed perhaps in conformity with the usual experience that syphilitic ulcers always 
result from the disintegration of a specific product? And has not the bona fide accept- 
ance of such a new formation been the cause that the gangrenous ulcer has never been 
distinguished from the gummatous one ? It seems to me that it is not necessary to 
resort to such an explanation; the sudden occlusion of a small terminal branch of an 
artery would more satisfactorily account for the almost instantaneous appearance of 
such a spontaneous gangrene. It has been satisfactorily shown that in every stage of 
syphilis its virus exerts its action most constantly on and around the blood vessels. To 
changes in the blood vessels, therefore, particularly to endarteritis obliterans, we must 
look for an explanation, if we can exclude other external or internal causes of gangrene. 
Endarteritis in syphilitic persons is an established fact; it does not detract from its 
importance that this arteritis is really not a specifically syphilitic process; that it owes 
its origin to syphilis in a great many cases is generally conceded. Such an origin 
would at the same time explain the inefficiency of anti-syphilitic treatment in such 
■» Bumstead and Taylor, "Venereal Diseases," fifth ed., p. 601. 
f "Gaz. d. hôpitaux," 1887, Nos. 37 and 40. SECTION- XIV-DERMATOLOGY AND SYPHILOGRAPHY. 
177 
cases. The product of endarteritis of the skin will no more be influenced by the same 
than the nerve or ganglion that was destroyed by cerebral hemorrhage due to specific 
endarteritis. The mischief is done by syphilis, but its result ceases to be syphilis. 
Lang, who, in his lectures on the pathology and treatment of syphilis,* has devoted an 
entire lecture to the syphilitic affections of the circulatory system, has paid more atten- 
tion to this question than other authors. He speaks first of arteritis of the larger blood 
vessels, leading in some cases to gangrene of entire extremities or portions thereof. 
Besides an observation of his own, he cites cases of Zeissl and Lomikowsky, to which 
others of Nicoladoni,f Billroth, j Podres§ (cited by Bumstead and Taylor), and Cabot 
and Warren|| might be added. The latter report gangrene of the two lower thirds of 
the right leg, and a gangrenous spot three to four inches in diameter on the inner side 
of the right thigh. I observed the following case of endarteritis of the popliteal artery 
or one of its branches, which, like Lang's case, took a favorable course under the specific 
treatment. 
Mr. R., who had contracted syphilis in 1874, consulted me in June, 1882, for a 
thickening of the epidermis between the toes and on the sole of the left foot. On 
August 16th this thickened epidermis was found to be detached, covering a superficial, 
irregularly-shaped, serpiginous ulcer, which, under local applications and mixed treat- 
ment, had healed about September 3d. After continued treatment, on October 13th 
the sole appeared smooth, but for several small scaling spots beneath the first phalanges 
of the toes, but the whole leg, which had been slightly cedematous before, appeared 
considerably swollen from the knee downward to the toes; the skin was pale, cool to 
the touch, and not sensitive on pressure except at the lower part of the tibia. Under 
the use of iodide of sodium within the next few days the swelling somewhat subsided ; on 
removal, however, of the scales from the sole, ulcers were again found. On October 
19th the treatment was changed to hypodermic injections of a one per cent, solution of 
the bi-cyanide of mercury, and soon the swelling began to diminish steadily; on the 
25th the toes were smaller, and on the 28th, when nine injections had been adminis- 
tered, the ulcers of the sole had healed, the fourth and fifth toes were of normal size, 
while the second and third and the inner half of the great toe were still enlarged, and on 
the sole the interdigital spaces between the first, second and third toes were nearly 
obliterated by a pad-like protuberance of the soft parts. The dorsal aspect of the foot 
still showed moderate swelling over the tibio-tarsal joint ; on the leg the outlines of the 
tibia were still concealed by oedema of the soft parts, which, on both sides of the bone, 
gave a peculiar elastic sensation ; the front aspect of the tibia seemed to be thickened 
by periosteal new formation, but was not sensitive. On November 13th the swelling 
had still more subsided, but, owing to my protracted sickness, I did not see the patient 
again until the following May, when the leg was in perfectly normal condition, except 
slight periosteal thickening of the upper and lower third of the tibia. The extremity 
at all times had been cool, pale and almost free from pain; at no time could I detect a 
thickened, hard or enlarged blood vessel, like in Lang's case, still I cannot think of 
another cause for the apparent obstruction of the circulation but of endarteritis oblit- 
erans. 
To return to Lang, he then proceeds to the consideration of the affections of the 
medium-sized and small arteries, dwelling particularly on the importance of the endar- 
teritis of the smaller cerebral vessels, which was first studied by Heubner and con- 
firmed by other authors; Birch-Hirschfeld's and Schuetz's observations of endarteritis 
in hereditary syphilis, and Huber's of calcification of blood vessels are then men- 
* Wiesbaden, 1884-'86. J Wiener med. Woch., 1879, No. 51. 
f Wiener med. Wochenschrift, 1881, p. 231, No. 8. $ Centralblatt f. Chirurgie, 1876, No. 33. 
i| Boston Med. Journal, 1880, II, No. 7. 
Vol. IV-12 178 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
tioned. I here wish to call your attention to the publication of Galliard * on the occur- 
rence in syphilitic persons of the round ulcer of the stomach, to the similarity of which 
with the gangrenous ulcers of the skin I have repeatedly alluded, and on the pro- 
bable connection of the same with endarteritis. 
Lang then continues:-f 
" Naturally, the symptoms which follow an affection of the blood vessels will vary 
a good deal according to the nature and extent of the pathological process, to the size of 
the affected vessel, and in smaller ones according to the dignity of the organ the vascu- 
lar supply of which is the seat of the affection. Either dilatation or narrowing and 
obliteration may result; therefore, we must expect in due time either an aneurism or 
such phenomena as usually follow obliteration of blood vessels. The constringing and 
obliterating arteritis will be the less pronounced the smaller the area supplied by the 
affected vessel, the less important its physiological function, and the more favorable the 
circumstances for the establishment of a collateral circulation, which, in the slow devel- 
opment of the arteritis, may be effected with hardly any disturbance. But if terminal 
or a larger number of blood vessels are the seat of the affection, an insufficient or 
entirely interrupted circulation and consequent diminished nutrition and necrobiosis 
are inevitable. Death of the foetus in consequence of affections of the umbilical or 
placental vessels, circumscribed softening of the brain or of the heart, ulcerations of 
skin and of the mucous membranes, have to be looked for as the natural consequences 
of arteritis." 
The probability that arteritis may begin in small peripheral vessels and spread to 
larger trunks has been distinctly insisted upon by Jonathan Hutchinson in a paper 
published in 1884, J which seems to have escaped Lang; its title is, "A Case of Syphilis 
in which the Fingers of One Hand became Cold and Livid-Suspected Arteritis." 
The case had been under Hutchinson's observation twenty years ago, but had not 
been published because no satisfactory conjecture as regards diagnosis could then be 
offered. " Only in reading over the notesagain, it occurred to me," Hutchinson says, 
' ' that the cause of the symptoms must have been inflammatory occlusion of the arter- 
ies of the hand. Lividity, coldness and pain were indicative rather of disturbance of 
nutrition and circulation than of nervous influence. It will be seen," further on Mr. 
Hutchinson says, "that, although the finger-tips never actually went into gangrene, 
they were very near it. Since this occurrence I have seen several cases favoring the 
belief that arteritis may begin in the small peripheral vessels and may travel to large 
trunks." 
I am well aware that it will require the anatomical proof that changes in an artery 
leading to a gangrenous portion of the skin must actually be shown to exist to estab- 
lish as an irrefutable fact what I have maintained. This, I confess, I have not been 
able to do thus far, nor can I hope to find the opportunity myself in the future. To 
awaken the interest of the profession in such an investigation, I have taken leave to 
bring my observations before this assembly and to submit to your present and future 
consideration the following conclusions:- 
1. Ulcers resembling the so-called gummatous syphilitic ulcer may occasionally 
result from circumscribed spontaneous gangrene of the skin without the previous forma- 
tion of a syphilitic neoplasm. 
2. Such ulcers may be distinguished by several peculiarities in shape, formation of 
the floor and course. 
* " Archives générales de médecine," janvier, 1886. "Syphilis gastrique et ulcère simple de 
l'estomac." 
f Loc. rit., p. 305. J Med. Times and Gazette, 1884, I, p. 374. SECTION XIV-DERMATOLOGY AND SYPHILOGRAPH Y. 
179 
3. They are not at all or but very little affected by anti-syphilitic treatment. 
4. The spontaneous gangrene in such cases is probably due to endarteritis obliterans. 
DISCUSSION. 
Dr. Unna remarked that if endarteritis obliterans has any causal relationship to 
necrosis, the frequency of extreme endarteritis in the initial lesion and the rarity of 
necrosis there is remarkable. It is very apparent that other factors, such as a local 
absence of anastomoses, hemorrhages, traumata, pressure, etc., must also be present 
before cutaneous necrosis can occur. 
Dr. Zeisler, of Chicago, mentioned a case of chronic ulceration of the lower leg 
in a man, for which no other cause could be found but that the patient had violently 
struck his leg below the knee about a year ago. The ulceration was very obstinate 
to treatment, and finally yielded to mercurial plaster and the internal use of iodide of 
potassium. Soon new ulcerations appeared, of decidedly kidney-shape, and close 
inquiry revealed the fact that the patient had contracted syphilis about ten years ago. 
As in this case no gumma preceded the formation of the ulcers, it seems to belong 
to the class described by Dr. Klotz. 180 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
SECOND DAY. 
STUDIES IN HIRSUTIES. 
ÉTUDES SUR L'HIRSUTIE. 
STUDIEN ÜBER DIE HIRSUTIES. 
GEORGE H. ROHÉ, M.D., 
Baltimore, Md. 
The generally hairless condition of the human body is ascribed by Mr. Darwin to 
the influence of sexual selection. The great naturalist recognized the inadequacy of 
the principle of natural selection to account for this variation from the probable primi- 
tive type. Mr. Alfred Russell Wallace likewise points out the improbability of natural 
selection having produced the disappearance of the hairy coating from the skin of man; 
but as this observer fails to accept the Darwinian hypothesis of sexual selection, he 
infers the influence of "some other power than the law of the survival of the fittest," 
to account for this phenomenon. This "other power " of Mr. Wallace is "a superior 
intelligence which has guided the development of man in a definite direction and for 
a special purpose."* Mr. Joseph J. Murphy, in his profound essay on "Habit and 
Intelligence," takes substantially the same view as Mr. Wallace. On the other hand, 
Mr. Grant Allen, a writer of some note on subjects in the domain of natural science, 
maintains, with some plausibility, that the modification was begun under the influ- 
ence of natural selection, and, as a secondary sexual character, completed by sexual 
selection, f 
It is not proposed in this paper to give further consideration to this question. Atten- 
tion is merely directed to it as having an incidental bearing upon the problem to be 
discussed. 
The occurrence of generalized hirsuties in human beings is considered by Darwin as 
a reversion to the type of the hairy ancestors of the race, and Unna has very cleverly 
suggested that universal hirsuties is merely an arrest of development. It is known, for 
example, that the foetus, during the pre-natal life becomes thickly covered with hair, 
which usually falls out before birth, but which sometimes remains until after the child 
is several weeks old. The new growth of hair is, according to Unna-who has so 
greatly advanced our knowledge of this subject-of a totally different type. In hyper- 
trichosis, then, according to this observer, this change of type in the growth of the hair 
does not take place, and hence the primitive or ante-natal type becomes permanent. 
Neither of these theories seems to the present writer sufficiently well established 
to explain the occurrence of the deformity under discussion, and it has seemed to him 
excusable to attempt the further elucidation of the problem of hirsuties as it presents itself 
to the consideration of the anthropologist, the physician or the dermatological specialist. 
* "On Natural Selection," page 359. 
f "A Problem in Human Evolution." Fortnightly Review, 1879. SECTION XIV DERMATOLOGY AND SYPHILOGRAPHY. 
181 
Hirsuties, or hypertrichosis, is an abnormal condition, manifested by excessive 
growth, abnormal distribution or heterochronic development of hair. Inasmuch as 
there is no generally accepted standard of hairiness, the terms used to describe the 
condition are merely relative. What is considered excessive hairiness in one race, or 
individual or class of individuals, may be thought normal in others. For example, the 
Hebrew race has, as a rule, an abundant pilous development upon the surfaces usually 
covered with hair, but in ordinary cases this would not be called hypertrichosis. The 
degree of hairiness which may be considered normal varies within pretty wide limits, 
principally because, in the male sex, moderate examples of hypertrichosis have not 
attracted much attention. 
To the dermatologist, hypertrichosis is of interest, especially as it occurs upon the 
face in the female sex. Through the fertilizing suggestion of Michel, of St. Louis, 
developed by Hardaway, Fox and others, in this country, a sovereign remedy is at our 
command in the electrolytic current, but our knowledge of the aetiology of the condi- 
tion is still vague and indefinite. 
If one studies the literature of this subject and makes good use of his opportunities 
to examine cases of hypertrichosis, it soon becomes apparent that the differences between 
so-called universal hirsuties and local hypertrichosis are only of degree, and that prob- 
ably the causes of the one will also account for the other. 
Readers of the Old Testament Scriptures are familiar with the marked case of uni- 
versal hirsuties described in the twenty-fifth chapter of Genesis. ' ' As hairy as Esau ' ' 
has passed into a proverb, and the description given of this son of Isaac is sufficiently 
detailed to indicate that it was intended to represent an abnormally hairy individual. 
This is evident from the character of the disguise by which Jacob was enabled to 
defraud his twin brother out of his father's blessing. It seems somewhat surprising 
that no mention is made in the Scriptures of any abnormality in hirsute development 
among Esau's descendants. 
In modern literature several remarkable cases of universal hirsuties are recorded. 
Among the earliest of these is Barbara Ursler, of whom contemporary chroniclers give 
a good account. She lived in the seventeenth century and was exhibited in various 
European cities. Nothing is known of her family history, and the bizarre explanations 
given by the older authors to account for the abnormal hairiness are not profitable mat- 
ters for discussion at the present day. 
The first instance of hirsuties running through several generations of which we have 
any account is that of the Amras or Ambriz family, from the west coast of Africa. It 
is recorded by Aldrovandus in his " Monstrorum Historia." * The family consisted of 
a father aged forty, a son aged twenty, and two daughters of eight and twelve years 
respectively. In the hairy family of Burmah, first described by Crawford, the hirsuties 
has run through three generations. The grandfather was presented to the King of 
Burmah at the age of five, having been brought from Laos. This individual, Schwe- 
maong (or Schevé-mwong), was of the average height of the Burmese and of a delicate 
constitution. Barring his excessive hairiness and defective teeth, he presented no 
abnormality. Crawford saw him for the first time in 1829, when he was thirty years 
old. Schwe-maong asserted that none of his ancestors were hairy, but as he was only 
five years old at the time of his capture, his evidence upon this point is not very trust- 
worthy. 
At the age of twenty-two, Schwe-maong was married by the King to a Burmese 
woman, who bore him four daughters. Two of these died in infancy, showing nothing 
abnormal. Of the remaining two, the elder was normal at the age of five, after which 
age nothing further could be learned of her. The other child, Maphoon, began to 
* Opera, Vol. n. 182 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
develop an excessive hairy growth at the age of six months, and became entirely cov- 
ered with hair. 
Maphoon was married (although, according to Darwin, the king was compelled to 
bribe a man to marry her), and had two sons, to both of whom she transmitted her 
abnormality. One of these sons died some years since, but the other, Moung Phoset is 
living, and was on exhibition with Maphoon last year, in London. 
The case of Adrian Jeftichjew, of Kostroma, in Russia, is also a remarkable one. 
He was " discovered " about 1870, and exhibited in various cities of Europe, where he 
attracted much attention, and was examined by a number of scientists, among whom 
was Prof. Virchow, who made him the subject of a lecture before one of the Berlin 
medical societies. Neither the reputed father nor the mother of Adrian are known to 
have been similarly affected. Inquiries have elicited the fact, however, that he was 
born during his father's absence in military service, and that in a neighboring district 
lived a woman who had a very long beard. The inference is that a hairy family was 
known to exist near the Kostroma district at the time of Adrian's birth, and that some 
member of this family performed some of the duties of husband to Adrian's mother 
during the absence of her legitimate spouse in the army. 
Adrian had several children, to one of whom, Fedor, he transmitted his deformity. 
This son has been extensively exhibited as "the Russian dog-faced boy" in this 
country during the last few years. 
The remarkable case of the Mexican dancer, Julia Pastrana, belongs to this class. 
Her appearance was exceedingly repulsive, but she must have possessed some charms or 
powers of fascination, for she died giving birth to a child. This child developed 
hirsuties a few months after birth. No trace of its further history could be obtained. 
A few years since, a young girl completely covered with hair was exhibited in 
London as " Krao, the missing link." She was found in the interior of Laos, whence it 
will be remembered Schwe-maong is also reported to have come. Krao's parents are 
said to have been hairy people. This is a point of great interest, as it seems to indicate 
the existence of a large family, or possibly tribe, of hairy people in fartherlndia. 
Two instances of moderate hirsuties running through three generations are reported 
by Michelson.* 
Surgeon Major A. Leith Adams gives a listf of nine recruits with "redundance of 
hair on the body." In six the testimony showed that the abnormality was hereditary, 
being usually transmitted in the male line. 
A remarkable feature in most of these cases is the defective development of the teeth. 
In the Burmese family, Schwe-maong had four upper and five lower teeth. The molars 
were entirely absent. The teeth were small, but in good condition when examined, at 
the age of thirty. Maphoon, his daughter, has the same anomalous dentition. Moung 
Phoset, the grandson, has four teeth in the upper and six in the lower jaw. 
Adrian Jeftichjew had only the left upper canine, but all the teeth were present in 
the lower jaw.i His son Fedor has two upper canine and two lateral and one middle 
incisor in the lower jaw. One of these seems to have been lost, as Fedor was reported 
to have four lower teeth in 1873. 
According to Max Bartels, all the deciduous teeth were developed in Krao, but in a 
photograph of this girl in my possession the teeth seem very defective. Julia Pastrana, 
on the other hand, is said, by a Mr. Preswich, who examined her, to have had a double 
set of teeth § in each jaw. A curious pendant to this anomaly occurs in hairless dogs, 
* Virchow's Archiv, Bd. 100. f London Lancet, May 16th, 1874, page 688. 
J Statement of Michelson. Other accounts state that only four teeth developed, but traces of 
others. 
§ Beigel. " Ueber Abnorme Behaarung beim Menschen." Virchow's Archiv, Bd. 44, page 427. SECTION XIV-DERMATOLOGY AND SYPHILOGRAPHY. 
183 
as pointed out by Mr. Darwin. These animals are said to always have defective 
teeth.* 
The attempt to account for the occurrence of hirsuties by ascribing it to atavism, or 
reversion to an ancestral type, has failed to explain it. In no pathological condition 
has such an atavistic tendency been shown. The theory which ascribes it to an arrest 
of development (Unna) is a very attractive and plausible one, but seems to me not yet 
sufficiently established. In my opinion, the only view that may be safely accepted is 
that the hirsuties is an hereditary trait. It is true the hairy character is not always 
transmitted to the descendants, but it must be recollected that two factors enter into the 
production of offspring, the male and the female element. The laws of heredity do 
not yet admit of a scientific explanation, but the observations on record show many 
curious facts bearing upon this process. 
The history of cases of hirsuties shows that heredity of the abnormality is usually 
direct and generally in the male line. From the preeminently greater hairiness of 
males, this might reasonably be expected. The cases of the Burmese family, the 
Ambriz family, the Kostroma people, Julia Pastrana and her child, and Krao, show 
that universal hirsuties is nearly always hereditary, and there is good reason to believe 
that most cases of local hypertrichosis may be explained in the same way. 
In the cases of hypertrichosis in females which have come under my notice during the 
past five years there are three cases of heredity or family tendency to the disease. Beigel 
and others have noticed the same tendency to inheritance of a beard or moustache. 
Max Nordau says, probably with some exaggeration, that the Provençal women gener- 
ally have beards, moustaches and whiskers. In women of the Hebrew race facial 
hypertrichosis is often very marked. The bridge of hair connecting the eyebrows 
across the root of the nose is frequently seen in entire families, transmitted from gen- 
eration to generation. 
The apparent exceptions to the laws of heredity presented by hypertrichosis are 
difficult to account for, but not more so than in other malformations and diseases. Thus 
pigmented nævi are often hereditary -they frequently run through several generations, 
and yet certain members of a "marked " family may be entirely free from these blem- 
ishes. Psoriasis and xanthoma present similar peculiarities. The difficulty of explaining 
these anomalies is owing to our ignorance of the laws of heredity. Recent embryo- 
logical researches seem to indicate that the male and female elements give rise to 
different germinal layers, the epiblast being chiefly derived from the male element, 
while the hypo- and mesoblast are developed from the female pro-nucleus. This, if 
established, would explain some of the phenomena of heredity. Thus, abnormalities 
of epithelial structures would be more likely to be transmitted in the male line, while 
those of the connective tissue and vascular structures would be principally inherited in 
the female line. The fact that the hair on the face of women so often begins grow- 
ing at puberty or after the menopause does not contradict the view here expressed, that 
hypertrichosis is a hereditary abnormality. Many hereditary diseases or peculiarities do 
not make their appearance until later in life. The chief difficulty lies in explaining how 
the parental influence is exercised in producing similar physical traits in the offspring. 
While expressing the opinion that hirsuties is, in most cases, hereditary, I am not 
unmindful of the fact that the condition may be acquired. Certain neurotic and irrita- 
tive conditions are recognized as favoring the development of hypertrichosis in cases 
where no hereditary tendency can be traced. The occurrence of facial hirsuties in 
insane women may be looked upon as belonging to the neurotic variety. Irritative 
hypertrichosis is frequently seen by surgeons upon portions of the skin subjected to the 
constant and long-continued action of irritants. 
* " Origin of Species," page 9. 184 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
DISCUSSION. 
Dr. Unna, of Hamburg, regarded the paper as prudent, so far as the patholog- 
ical portion wa's concerned. He stated that he upheld his theory, which he had put 
forth as a more scientific one than other theories which had up to that time been 
advanced. He had not been able to study the skin histologically. This is the only 
way in which advances can be made, and he urged those who have an opportunity 
to make such studies. The direction of hair development changes after birth, and it 
would be interesting to secure portions of skin to examine for these changes in the 
different layers of the skin. It is certainly an hereditary disease, but scientifically 
this is not a sufficient explanation. 
Dr. Thin made some general remarks on abnormal hairiness. He considered that 
in the perfect physiological type the hairy regions are sharply demarkated from the 
non-hairy regions, and that disorderly growth of hair either indicated coarseness and 
defective development of the individual or deficiency in sexual differentiation. He 
instanced the fact of great hairiness of the limbs, which the vulgar have associated 
with strength, but which, on the contrary, is associated with constitutional debility. 
This had been first pointed out to him by Paget, in consultation on a case of tuber- 
culosis of the testis. When examining the man for evidence of scrofulous taint, Sir 
James considered that the great hairiness of the patient's legs was evidence in that 
direction. 
Sir James mentioned to Dr. Thin that a recruiting officer of large experience in 
England had found that hairy recruits were less resistant to exposure and disease 
than recruits whose limbs and bodies were not hairy. Since his attention had been 
called to this point by Sir James, Dr. Thin has had many opportunities of verifying 
its accuracy, and has satisfied himself that hairiness of the legs and arms, particularly 
of the legs (he spoke of men chiefly), is a sign of constitutional weakness. 
In regard to the disorderly growth of hair as an indication of deficient sexual differ- 
entiation, he instanced the cases in which women have more or less moustache or hair 
on the chin. Although the presence of hair on the upper lip in a woman does not 
necessarily coincide with sterility, it often does, and the chances of a woman with a 
moustache being fertile are not so great as the chances of a woman whose face is not 
disfigured by hair. 
As regards the growth of hair on the chin more particularly, his experience, 
although not sufficiently large to enable him to speak dogmatically, had led him 
to consider it probable that the power of conception in a woman is possibly very 
feeble or nil when strong hairs begin to develop on the chin. It is notorious that in 
many women the growth of a formidable moustache coincides with the suppression 
of sexual activity. 
Dr. Thin further related a remarkable case in which a woman, aged twenty-nine, 
was sent to him on account of an enormous growth of hair over the sternum and 
round both mammæ. She had also some stout hairs on the chin. This woman was 
tall and somewhat masculine in build, appearance and walk, as well as voice. The 
catamenia were regular, but lasted only about one day, and were deficient in quantity. 
The sexual instincts must have been present, as her object in coming to Dr. Thin was 
to get rid of the hairs before marriage. The hairs on the sternum were black, thick, 
and from a quarter of an inch to three-quarters of an inch long. The mammæ were 
rather larger than usual, natural in appearance, and the nipples and areolæ fully 
developed. The areolæ were free from hairs, but the whole mammæ were swathed 
by a mass of black, thick hairs, averaging from a quarter of an inch to an inch and a SECTION XIV-DERMATOLOGY AND SYPHILOGRAPHY. 
185 
half long, and growing symmetrically in a circular direction. All these hairs were 
destroyed successfully by electrolysis. This woman stated that she had a younger 
sister who had had a large growth of hair on the mammæ. She had married and 
suckled her child, and shortly after the secretion of milk was established in the 
mammæ the hairs had fallen out and had never returned. 
Dr. Gottheil, of New York, had removed upward of 10,000 hairs from the 
face of a single woman, by electrolysis. The patient was a tall and robust Jewess, 
aged thirty, and the mother of two children. Four years ago, her youngest child 
being two years old, the menses stopped suddenly and entirely. She had always 
been regular; and when, some months later, it became evident that she was not 
pregnant, she was repeatedly examined and treated for her amenorrhoea by leading 
gynæcologists, without, however, reaching a diagnosis or being cured. Coincidently 
with the appearance of the amenorrhoea she noticed a sudden increase in the size 
and quantity of the hair upon her face, breast and limbs. For a time she attempted 
to control the growth by depilatories and the scissors; but it increased so rapidly that 
her beard equaled that of an ordinary man. Hysteria and other nervous affections 
appeared; mental depression was very marked, and the patient became a burden to 
herself and her friends. Electrolysis was used then as a depilatory measure, and she 
eagerly availed herself of its help. When I first saw her, several thousand hairs 
had already been thus removed. Her beard was as thick as that of a heavily-bearded 
man; and the hairs were as strong and coarse as we are accustomed to see them in 
very dark men. For three years electrolysis was persistently used, and over 11,000 
hairs removed. In spite of most careful procedure many returned, and the stimula- 
tion of the electric current seemed to incite the lanugo hairs to constantly increasing 
growth. At last it was gotten under control; but as the destruction of each hair 
papilla involved necessarily the destruction of a certain amount of the surrounding 
tissues, the loss of substance was very considerable. The entire bearded area was 
depressed below the level of the skin of the rest of the face ; but the cicatrix was 
diffused and very superficial, and the patient was well pleased with the result. A 
few hairs yet remained, and for these I treated her from time to time. Early this 
year, without any cause, and without any change in any other way, her courses re- 
appeared, and have since been normal. Soon afterward she noticed that the long, 
dark hairs were disappearing from her limbs and chest, and no more dark hairs 
appeared upon her face. To-day she is hardly more hairy than brunettes of her 
type usually are. 
Dr. Ravogli, of Cincinnati, O., said that the human race could be divided into 
classes by the nature of their hair. He had noticed that men have a greater devel- 
opment of hair upon the face and about the ears and nostrils at about the age of 
forty-five than in earlier life, and he believed that up to this time, or until the skele- 
ton was perfectly formed, the calcareous salts were taken up by the bones, and after 
this period were appropriated by the hairy growth. If hair be burned, we find salts 
of lime in the ash, and he thinks there is a relation between the quantity of calcare- 
ous salts and abnormal growth of hair. 
Dr. Henry J. Reynolds, of Chicago, Ill., said the ætiology of hirsuties was a 
very intricate question, and one in which it was almost impossible to arrive at any- 
thing definite. The question had already been very thoroughly discussed by those 
who had preceded him, but after all, it was only an exchange and interchange of 
opinion regarding the subject. He believed, however, that there should be two 
forms of hirsuties recognized, viz., the hereditary and that which is acquired during 186 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
the life of the individual. It was a generally conceded fact that in the hereditary or 
congenital form there was a deficiency in the development of the teeth, notwithstand- 
ing the fact that in the very interesting case of Krao, referred to by the essayist, 
which Dr. Reynolds had had the opportunity of examining, the teeth were well 
formed. 
In the acquired form, which was almost always met with in the female, it was 
his observation, or rather his opinion, whether that was based upon intelligent obser- 
vation or not, that the condition depended, in many cases, upon sexual or menstrual 
disorder. He thought there was a connection between the two, very much as there 
is between acne and disorder of the sexual functions. 
Dr. Rohé, in closing, said there were some cases not explicable on the theory of 
heredity, and he could not explain such cases as that mentioned by Dr. Gottheil. 
The statement made by Dr. Thin, that excessive hair upon the body should be 
regarded as a sign of weakness, was new to him, and he was inclined to believe in 
the popular idea that the man with plenty of hair upon the body was usually a 
strong man. 
ON A NEW METHOD OF TREATING SKIN DISEASES LOCALLY. 
NOUVELLE MÉTHODE DE TRAITEMENT LOCAL POUR LES MALADIES DE PEAU. 
ÜBER EINE NEUE METHODE IN DER LOKALEN BEHANDLUNG DER HAUTKRANKHEITEN. 
BY DR. H. VALENTINE KNAGGS, 
London, England. 
For more than two years I have used the local applications to which I am about to 
refer in the treatment of skin diseases, and have obtained results which have far exceeded 
my original expectations, especially in such cases as are accompanied by a weeping surface, 
or are of an inflammatory or irritable character, as in the various forms of eczema and 
other non-specific exudations. 
The introduction of lanolin will, in many respects, help to pave the way for the 
introduction of these remedies, since one of the attributes of this peculiar fat, to which 
considerable attention has of late been directed, is its remarkable power, within certain 
limits, of absorbing and mixing with water. Indeed, the extreme utility of the addition 
of water and medicated watery fluids to ointments is daily becoming more fully 
recognized. 
The inunction of the body with fixed oils has been proved, by numerous independent 
observers, to be of immense service in febrile and other diseases, especially in children. 
When so applied it has been found that glycerine fats, and, to a less extent mineral 
fats, greatly promote skin action, and even in some cases excite inflammatory action 
and produce eruptions, by causing an increased flow of blood to the skin. As a conse- 
quence, the blood is temporarily withdrawn from the deep-seated structures of the body 
and a high temperature often becomes rapidly lowered. Inunction also, in some 
measure, protects the surface from atmospheric changes, and nutrition is promoted by 
the diminished tissue changes that take place, as well as by a limited amount of 
absorption. When applied to small areas of the surface, especially such as are affected 
by disease, skin action would, if it is possible to reason by analogy, be similarly increased, 
with consequent augmentation of inflammation. 187 
SECTION XIV DERMATOLOGY AND SYPHILOGRAPHY. 
Fixed oils, with perhaps the single exception of lanolin, can no more be termed 
adhesive, in the strict sense of that word, than water or watery solutions can be. What- 
ever their consistence may be, their use undoubtedly entails greater functional activity 
of the skin, with an accompanying increase either of perspiration or of discharge, the 
exit of which is not impeded, because the particles of oil and water, when brought into 
contact, serve to repel one another. A layer of any oily substance applied to the skin 
is but slightly attached to the surface, and is, therefore, easily raised, exuding fluids 
will be able to escape readily, and will pass directly through this layer when a fluid oil 
is used, and when the fat is of a solid character the secretions will travel along its under 
surface until a suitable outlet presents itself. 
In order to render oily substances adhesive, there are two methods which present 
themselves to our notice:- 
The first consists in adding to the oil various resinous, gummy or alkaline sub- 
stances. Thus, tar may be added to ointments constituting ung. picis. Ung. resinæ 
is another instance. Powdered gum acacia or gum tragacanth will also markedly 
increase the adhesiveness of oils which dry on in the form of a solid cake. Insoluble 
powders and other medicaments will act slightly in the same way if used with ointments, 
where they would no doubt act mechanically by increasing the consistence of the appli- 
cation. Glycerine, too, although not capable of permanently mixing with fluid oils, 
when incorporated with ointments increases their adhesive properties. 
Combinations of this kind merely act by taking a firmer hold of the epidermis; 
they do not penetrate the cuticle deeply, and are, for all practical purposes, insoluble in 
the watery fluids derived from the skin. 
The second method consists in making use of gums in order to combine or emulsify 
a fat or oil with water in such a manner that the repulsive force exercised upon the 
watery secretions and discharges of the skin is either partially or entirely overcome. 
Even water or medicated solutions alone will, to a slight extent, effect the same pur- 
pose when thoroughly incorporated with ointments. 
An application of this description is not merely extremely adhesive, but when pre- 
pared in the manner described is also soluble in all proportions in water and watery 
fluids. 
Adhesive preparations, unlike oils or fats, tend to arrest skin action. This is par- 
ticularly the case with such substances as varnish, tar or collodion, which, owing to 
their being totally unacted upon by the secretions or to their inability to penetrate the 
cuticle, form an impervious covering. Every one is doubtless aware when an animal 
happens to receive a coat of varnish which is allowed to remain on its body that death 
will speedily occur, on account of the total abolition of all the cutaneous functions. 
Ointments prepared by adding to them adhesive substances to some extent diminish 
skin action but do not abolish it. The presence of the fat will prevent the arrest of 
cutaneous functions on the one hand, while on the other the adhesive ingredients serve 
to neutralize the increased functional activity which would be produced by the use of 
the uncombined oil. 
The well-known use of white lead paint in the treatment of erysipelas may be 
taken as an instance of this form of skin medication. Many of these adhesive bodies 
are, however, of a more or less irritating character, and they are, consequently, unsuited 
to the generality of skin diseases of an irritable or inflammatory nature, although for 
indolent ulcers and similar lesions which require much stimulation they answer admir- 
ably. 
Should the preparation, as is the case with an oil when emulsified with gum and 
water, be one that is soluble in perspiration, or in the case of disease, in serum, then, 
provided it be without irritating properties, this same neutral action, which is so con- 
ducive to local rest, will be made manifest, and the functional activity of the skin will 188 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
neither be augmented nor annulled. This, to my mind, is the end to be attained in 
respect to external applications suited to inflamed conditions of the skin, when the 
soothing and healing properties of sedative or mildly stimulating medicaments, and the 
sheathing and emollient qualities of the gum-encased particles of oil are brought into 
action, in a soluble medium, with the greatest possible degree of benefit to the affected 
parts. 
Such applications, or in other words, well-made emulsions, resembling milk or cream 
in appearance, while perfectly soluble in watery fluids, are also markedly adhesive, 
and the remedies I use consist of emulsions which are prepared by combining an oint- 
ment basis (preferably a mineral fat) with water, a vegetable gum and a suitable 
antiseptic. 
It has been my practice hitherto to use boracic acid for this purpose. It preserves the 
gum from decomposition and at the same time neither irritates the skin nor in any way 
interferes with the action of other medicaments when used with it in the emulsion. 
For example : Supposing soft paraffine to be selected as the ointment basis. One 
ounce of this substance is placed in a mortar previously warmed, and incorporated with 
160 grs. (or thereabouts) of powdered gum acacia. About half an ounce of hot water 
is then added and the whole is stirred until emulsified. Boracic acid in powder is 
mixed in and the emulsion is diluted with water until a mixture of the consistence of 
thick cream is obtained. 
The formula will stand as follows :- 
Paraffine molle, 1 oz. 
Pulv. gum acacia, 160 grs. 
Boracic acid, 16 grs. 
Water to make about 2 ozs. 
Suitable medicaments can be added to the above formula, or to a formula made with 
other ointment bases, and made use of according to the disease to be treated, such as 
subnitrate of bismuth and oxide of zinc in eczema, sulphur and balsam of sulphur in 
scabies, salicylic acid in lupus, and so on. 
Smeared over the skin, emulsions after a variable time form a film or crust of pecu- 
liar character, which is flexible from contained oil and, adhering closely to the surface, 
effectually protects the eruption from atmospheric influences. The emulsion compound 
is capable of penetrating the scabs or crusts of certain cutaneous diseases, and of mix- 
ing with the serous discharges of superficial wounds, the coagulative power of which is 
increased thereby. By the use of antiseptic ingredients the parts can be kept per- 
fectly aseptic, and the various medicaments that are used with the emulsions, dissolved 
or suspended as they are in a soluble menstruum, have the best possible opportunity of 
exercising a beneficial influence. 
Under such conditions inflammatory action will become rapidly allayed, and the 
distressing and intolerable irritation which so frequently accompanies a subacute or 
chronic eczematous condition of the skin will be speedily and usually permanently 
relieved. 
It is, of course, necessary to leave the affected parts alone and undisturbed as much 
as possible by keeping them at rest, and by refraining from the usual ablutions with 
water or soap and water, until all traces of discharge have disappeared, and the scabs 
have become spontaneously detached, and one of the principal points to which I 
would call particular attention is that by the employment of these preparations it is 
absolutely unnecessary to resort to the use of all lint and textile dressings, since being 
of an adhesive nature, they constitute perfect dressings in themselves. 
In conclusion, permit me to add that although gum emulsion will not displace older 
methods of treatment, yet I am sanguine enough to believe that we have iu them a 
very valuable addition to Dermatology. Should these observations of mine relative to SECTION XIV DERMATOLOGY AND SYPHILOGRAPHY. 
189 
the use of these applications be still further confirmed by the extended experience of 
others, I cannot help thinking that my brother practitioners will have a new power 
at their command with regard to the treatment of many cutaneous disorders which are 
not only greatly dreaded by the public at large, but when once set up are often intract- 
able under ordinary treatment. 
DISCUSSION. 
Dr. Unna, at the President's request, spoke at some length upon cutaneous 
varnishes in general. He classified them according to their greater or less permea- 
bility to water, and according to their volatility. 
Group 1.-Elasticin, gutta-percha solution, oleate of aluminium, etc. 
Group 2.-Solutions of resins, waxes, fats and oleates, in alcohol, ether, benzine, 
chloroform, mixtures (myrrh, rhubarb), spiritus saponatus, etc. 
Group 3.-Emulsions, soap solutions, etc. 
Group 4.-Water-glass,-gelatine, dextrin, albumen and rubber solutions. 
Knaggs' emulsion appears to belong to the third class. It is no new ' ' method ' ' 
in the treatment of skin diseases, but a new and probably very excellent basis for 
the varnishes which have long been used in dermatological practice. The emulsifying 
of vaseline with gum arabic is new, however. 
A NEW METHOD OF TREATING THE VEGETABLE PARASITIC 
DISEASES OF THE SKIN. 
NOUVELLE METHODE POUR TRAITER LES MALADIES DE PEAU PARASITAIRES 
VEGETALES. 
ÜBER EINE NEUE METHODE IN DER BEHANDLUNG DER DURCH PARASITÄRE PILZE 
VERURSACHTEN HAUTKRANKHEITEN. 
BY HENRY J. REYNOLDS, M.D., 
Chicago, Ill. 
My paper will refer to the treatment of what are commonly known among derma- 
tologists as the vegetable parasitic diseases, viz., tinea favosa, tinea versicolor and the 
three forms of tinea trichophytina. As the form of tinea tricophytina known as tinea 
circinata, or ordinary ringworm, and tinea versicolor are very superficial, they are there- 
fore readily cured by any of the ordinary methods. The method I am about to describe 
will therefore be more applicable to those wherein the deeper structures, as the hair 
follicles, etc , are involved, viz., favus, ringworm of the scalp and barber's itch. Though 
in the latter diseases many methods of treatment at different times have been suggested 
and tried, they are nevertheless very stubborn to treatment, particularly so unless all 
the diseased hairs be systematically removed. For this reason I feel warranted in 
assuming that a suggestion regarding a method which, to me, bids fair to be preferable 
to any other, and which has never before, to my knowledge, been referred to, will be 
tolerated, as also a brief report of the few cases which I have treated in this manner. 
The great object in all methods is to apply the parasiticide in such a manner as to 
insure its penetration to the bottom of the hair follicles and into the hair structure 
itself beneath the surface of the skin. Theoretically, and I think practically likewise, 
the method I am about to describe accomplishes this purpose. 190 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
There is a long-recognized law in electro-physics by which fluids in a galvanic cur- 
rent move from the positive to the negative pole, and it has been demonstrated years 
ago, and over and over again, that the absorption of medicinal substances may be 
induced by applying this principle, viz., by applying the substance to be absorbed on 
the positive electrode, placing it on the skin, and completing the circuit by placing the 
negative electrode on some other part of the body. This is perhaps best substantiated 
by the fact that a solution of cocaine applied to the surface of the sound integument in 
this manner will in a very few minutes so permeate the skin as to produce complete 
local anaesthesia of all the cutaneous and subcutaneous structures covered by the posi- 
tive electrode, upon which subject I read a paper at the last meeting of the American 
Medical Association ( Journal American Medical Association, August 20th, 1887). It was, 
in fact, in making these local anaesthesia experiments by this method that the thought 
first occurred to me that the same principle might be used to advantage in the treat- 
ment of these very stubborn and annoying maladies. 
The means, then, employed by the method which I am about to describe, to induce 
the penetration of the parasiticide remedy, are the galvanic current, though in apply- 
ing the method it is possible, if not probable also, that the electricity itself has a salu- 
tary effect upon the diseased condition, or, in other words, has a destructive influence 
upon the fungus giving rise to the disease. 
With your permission, I shall now proceed with a description of the method as I 
have employed it. 
Battery, Strength of Current, etc.-Though not an expert electrician myself, I believe 
it is an established fact that a large number of small cells give more electrolytic action 
than the same area of large cells. I have therefore used a battery constructed on this 
principle-the same instrument, in fact, which I use for the removal of superfluous 
hairs by electrolysis, known as the McIntosh battery. For reasons not necessary to 
discuss at present, the Faradic current will not answer, neither will the negative pole 
of the galvanic. The strength of the current must vary with the sensitiveness of the 
part, the size of the electrode, etc. It is always necessary to use the strongest current 
that can be borne without discomfort by the patient, which, with the battery I use, 
when in good order, varies from five to ten cells, but for which no rule can be laid 
down, the only guide being the feelings of the patient and the experience and discretion 
of the physician. For instance, to state a given number of cells would be inaccurate, 
inasmuch as the strength of the cell always varies with the freshness of the battery 
fluid, the length of time the plates have been in use, etc. To specify the strength of 
current as so many milliamperes would be unscientific, without giving the size of the 
electrode or stating the amount of the resistance. When there is much irritation or 
hyperæmia of the part to be treated, the current will not be tolerated so strong, and 
it is not necessary that it should, as there is then less resistance. The sponge on the 
electrode used for the parasiticide solution should be of the finest and softest quality. 
Mode of Application.-The surface to be treated should be first thoroughly cleansed 
of crusts, scales and sebaceous matter, by the usual process of oiling and washing with 
soap and hot water, etc., and if thought necessary, of course, the loose hairs may be 
removed, though in the cases I have treated this was not done. Saturate the sponge of 
the positive electrode with whatever parasiticide lotion is preferred, which may be 
aqueous, alcoholic or ethereal, and place it directly upon the part to be treated. Place 
the negative electrode well saturated with water on some point near by. A more remote 
point, as the hand, for instance, will answer, but it will take longer time to get the 
same effect than when placed near by. The electrodes should be kept firmly pressed 
to the skin, the positive being now and then moistened as required, with more of the 
solution, and the negative with more water. In order to get a sufficient effect the posi- 
tive electrode should remain on each diseased patch several minutes before applying it SECTION XIV-DERMATOLOGY AND SYPHILOGRAPHY. 
191 
to another place ; and I think on the scalp it is not wise to continue the treatment over 
ten or fifteen minutes in all at each sitting, and, perhaps, not offener than once a day. 
The parasiticide used in the cases I treated was a one per cent, solution of bichloride 
of mercury. 
I had hoped to be able to report a considerable number of cases, but I have as yet 
only beep able to treat three patients by this method ; one of favus, and two of tinea 
tonsurans. 
Case i.-John A., aged seventeen, otherwise fairly healthy, was first seen January 
12th, 1887. Had eruption on the scalp for ten years, during which time he had been 
treated by numerous physicians without receiving any permanent benefit. To confirm 
the diagnosis in this case all local treatment and washing of the scalp was ordered sus- 
pended for two weeks. January 26th, examination revealed a patch midway between 
vertex and forehead, about two inches in diameter, covered more or less with the char- 
acteristic yellow, sulphur-colored crusts, showing in many places distinctly the cup- 
shaped character Hairs dry, brittle, broken off, and loose, and considerable thinning ; 
also two or three other small patches similar in character. Examination with the 
microscope showed the crusts to be composed of the characteristic spores and mycelia. 
The part was thoroughly cleansed and the treatment begun as described, and con- 
tinued daily. In addition an ointment of one part of citrine ointment to four of lard 
was applied every night, and the following morning the scalp was thoroughly cleansed 
preparatory to the electrical treatment. This treatment was carried out daily till Feb- 
ruary first. The patient was not again seen until the latter part of May, when he was 
found to be entirely free from the disease. 
Case ii.-Mary L., aged ten, applied for treatment February 21st, 1887. Had scaly 
patches on scalp for four years, one patch in region of parietal eminence of right side, 
about two inches in diameter, and two other smaller patches. Hairs broken off, etc. 
Microscope revealed the trichophyton in and around the hairs. Treatment, same as case 
one, except that no ointment was applied, was continued almost daily for three weeks. 
June 12th, patient has had no treatment since March 14th, and has been well ever 
since. 
Case hi.-Susan L., aged twelve, sister to Case ii, applied for treatment at same 
time. Had the disease similar to her sister-though to not quite the same extent-for 
two years and a half. Diagnosis also verified with the microscope. Treatment com- 
menced at the same time as her sister, and continued in the same manner for the same 
length of time. Cured. 
Though I have been unable, from the very limited number of cases treated, to deter- 
mine to my entire satisfaction the full merits of the method, or the comparative merits 
of this and other methods, I am nevertheless satisfied that I accomplished results in 
these cases that could not have been done by any other line of treatment, and I there- 
fore feel warranted in recommending its adoption by those in dermatological practice, 
and I feel convinced that with further experience, more extended observation, and the 
more general adoption of the method, it will be found superior to all others that have 
been tried. 
DISCUSSION. 
Dr. Thin said he had been impressed with the great variety of remedies found 
in literature reputed to cure tinea tonsurans quickly. He regarded the strong solu- 
tion of bichloride of mercury as dangerous to life, and also likely to cause permanent 
baldness, although it was the most likely remedy to cure the disease. 
He has seen cases of ringworm of the scalp which have resisted for months and 
months the usual methods of treatment, and he believes there is no one method that 
will cure the disease quickly in all cases. 192 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Dr. Davis, of London, thought that in America skin diseases were more easily 
cured than in England, from the report of rapid cures, especially of ringworm and 
the like. 
Dr. Rohé thought perhaps the differences in results were due to the differ- 
ences in application. He thought the bichloride, in solution of 1 to 1000, sufficient 
if applied often enough, before new spores had an opportunity to be produced. 
Fully developed organisms resist agents much less than spores. So long as one spore 
remains undestroyed, so long will the danger last. The hyposulphite of soda will 
destroy in a short time the organism of tinea versicolor. 
Dr. McGuire, of Louisville, had obtained good results in the treatment of ring-' 
worm from the use of chrysarobin in gutta percha. 
Dr. Ravogli said that more rapid cures can be obtained if epilation is practiced, 
as then the remedy employed can be brought into more direct contact with the 
organisms in the hair follicles. 
Dr. Yeamans said the whole matter turned upon whether we can or cannot reach 
the spores. He believed that it was unnecessary for any case of favus to exist under 
proper scientific treatment for over four weeks, epilation being practiced daily. 
In closing the discussion, Dr. Reynolds said he had nothing further to add ; the 
subject had been very thoroughly discussed, though a great deal of the discussion was 
not pertinent to the question. He said it was well known to every dermatologist that 
almost any parasiticide, when applied so as to reach the fungus, would destroy it ; this 
was demonstrated by the fact that when the disease was superficially located, as in ordi- 
nary ringworm or tinea circinata, the local application of the parasiticide would cure 
it. Then the object of the method was to induce the absorption or penetration of 
the parasiticide into the bottom of the hair follicles and into the hair structure 
beneath the surface of the skin. Now it is becoming a well-known fact that cocaine 
applied in this manner would so penetrate the skin as to render every portion of the 
cutaneous structure, follicles and all, anæsthetic. Now the drug must in all prob- 
ability be brought in contact with all the tissues to produce this result, and reasoning 
by analogy he would attempt in this way to show that the parasiticide would prob- 
ably do the same thing, and such being the case, would cure the disease when situ- 
ated in the bottom of the hair follicles, as it does in disease of the non-hairy skin. SECTION XIV-DERMATOLOGY AND SYPHILOGRAPHY. 
193 
THIRD DAY. 
ZUR KENNTNISS DER IMPETIGO HERPETIFORMIS. 
A CONTRIBUTION TO THE KNOWLEDGE OF IMPETIGO HERPETIFORMIS. 
UN TRAITÉ SUR L'IMPÉTIGO HERPETIFORME. 
VON DR. JOSEPH ZEISLER, 
Chicago. 
Wenn zur Behandlung einer Krankheit eine grosse Zahl von Arzneimitteln empfohlen 
ist, so pflegt dies gewöhnlich ein Zeichen dafür zu sein, wie unsicher unser therapeu- 
tisches Handeln in dem Falle ist ; ähnlich scheint es mir mit der pathologischen und 
klinischen Erkenntniss einer Affection bestellt zu sein, zu deren Bezeichnung von fast 
jedem neuen Beobachter ein neuer Name gewählt worden ist. Speciell gilt dies von 
der Krankheit, die den Gegenstand meiner Mittheilung bildet. 
Unter der sehr characteristischen Benennung ' ' Herpes vegetans, " zuerst von Auspitz 
im Jahre 1869 beschrieben, * wurde die Affection, auf Grund von fünf klinischen 
Beobachtungen, im Jahre 1872 von Hebra zuerst als "Impetigo herpetiformis" 
bezeichnet ; f später (1873) folgten die Namen "Herpes pyæmicus " und "Herpes 
puerperalis" durch Neumann, f Einige zweifellos hierher gehörige Fälle von wahr- 
scheinlich milderem Character werden als " Herpes gestationis " (Bulkley) und "Hydroa 
gestationis ' ' (Smith) beschrieben. In seinem ' ' System der Hautkrankheiten ' ' § giebt 
Auspitz den früher von ihm gewählten Namen auf und ersetzt ihn durch eine Variante 
des Hebra'schen, "Herpes impetiginosus. " Unna || critisirte in einer trefflichen Arbeit 
über "Impetigo contagiosa, nebst Bemerkungen über pustulöse und bullöse Haut- 
affectionen," auf Grund von anatomischen Betrachtungen die Berechtigung des Namens 
Impetigo herpetiformis, überliess es jedoch der Zukunft und besserer ätioliogischer 
Erkenntniss, einen passenderen Namen zu wählen. Duhring hat das unbestrittene 
Verdienst, für die in Frage stehende Krankheit neues und lebhaftes Interesse erweckt 
zu haben ; unter Festhaltung eines von allen früheren Beobachtern verschiedenen 
Standpunktes und unter wesentlich breiterer Auffassung des Krankheitsbegriffes führte 
er den Namen " Dermatitis herpetiformis " ein, von der er mehrere Varietäten unter- 
schied, darunter eine pustulöse, die mit der Hebra'schen Impetigo herpetiformis 
identisch sei ; in einer grösseren Reihe von Arbeiten und durch Mittheilung zahlreicher 
Krankengeschichten versuchte Duhring seinen Ansichten Anerkennung zu verschaffen. 
Es lag ursprünglich in meinem Plane, an dieser Stelle die erwähnten Arbeiten Revue 
passiren zu lassen und die Berechtigung von Duhring's Stellung zu untersuchen. 
Seither sind aber maassgebendere Autoren dieser Aufgabe gerecht geworden und ich 
darf mich daher diesbezüglich kurz fassen. Zunächst hat Bulkley im Vorjahre 
* Arch. f. Derm. u. Syph., 1869, pag. 247. 
j- Wien. Medic. Wochenschrift, 1872, No. 48. 
J Lehrbuch, 1873, pag. 185. 
Vol. IV-13 
g 1880, pag. 73. 
Il Viertelj. f. D. u. S., 1880, pag. 13 u. ff. 
Journ. C. u. Ven. D., April, 1886. 194 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
sowohl den von Duhring gewählten Namen, als auch die Zusammenfassung von so 
vielen verschiedenartigen Processen unter einem Begriffe angegriffen ; dann aber hat 
Kaposi in einer ganz kürzlich erschienenen, ausgezeichneten und erschöpfenden Arbeit * 
seine gewichtige Stimme erhoben und vor Verwirrung in der der Klärung so bedürf- 
tigen Frage gewarnt ; diese Arbeit ist wohl jedem Interessirten zu frisch im Gedächt- 
nisse, als dass ich es nöthig hätte, auf dieselbe näher einzugehen. Wenn sich auch so 
Manches gegen den Namen Impetigo herpetiformis einwenden lässt, so liegt vorläufig 
kein Grund vor, denselben aufzugeben, so lange kein besserer, das Wesen der Krankheit 
deutlicher bezeichnende Name zur Verfügung steht ; dies mag erst der Fall sein, wenn 
wir der Aetiologie dieser bislang so räthselhaften Affection näher gerückt sind. Eines 
scheint mir aber doch schon heute ziemlich allgemein adoptirt zu sein: dass der von 
Hebra als Impetigo herpetiformis beschriebene Process durch das ganze klinische Bild, 
das bisher fast regelmässige Auftreten bei Weibern und den meist nachweisbaren 
Zusammenhang mit dem Puerperium, den letalen Ausgang, die so characteristischen 
und kaum zu verkennenden Hautefflorescenzen sich von allen anderen wohlbekannten 
Dermatosen so plastisch abhebt, dass es kaum am Platze sein kann, denselben mit 
anderen, so ganz und gar verschiedenen Affectionen in einen Topf zu werfen. Fast 
scheint es, als ob Systemen und Namen in unserem Specialfache zu viel Bedeutung 
beigelegt würde ; die Möglichkeit, eine durch besondere nosologische Eigenschaften 
ausgezeichnete Krankheit von anderen scharf abzugrenzeu, ist wohl die wichtigere 
Aufgabe. 
Die folgende Beobachtung soll nun dazu beitragen, ein weiteres Beispiel zu der von 
Hebra aufgestellten Form zu liefern. 
Am 20. Januar 1885 wurde ich auf gütige Veranlassung von Prof. C. Fenger zu 
Frau Rosa Unger wegen einer angeblich sehr schmerzhaften Lippenaffection gerufen 
und erhielt damals die folgenden anamnestischen Daten : 
Die Patientin, 28 Jahre alt, aus Ungarn gebürtig, ist seit etwa sieben Jahren in 
diesem Lande, seit sechs Jahren verheirathet und hat während dieser Zeit drei Kinder 
geboren, von denen zwei am Leben und vollkommen gesund sind. Sie selbst soll bis 
zur gegenwärtigen Erkrankung sich stets des vollkommensten Wohlseins erfreut haben. 
Die Menses waren seit jeher sehr reichlich und sollen in der letzten Zeit jedesmal acht 
Tage gedauert haben. Die gegenwärtige Erkrankung hat vor dreieinhalb Monaten 
mit Halsschmerzen begonnen. Bald darauf wurden die Lippen wund ; es bildeten 
sich auf denselben Krusten, nach deren Entfernung stets starkes Bluten erfolgte, ohne 
dass jedoch anfänglich erhebliche Schmerzen bemerkt wurden. Nachdem durch einen 
Monat eine Anzahl von Hausmitteln erfolglos versucht worden war, wurde hierauf eine 
ganze Reihe von Aerzten consultirt, ohne auch nur Linderung der inzwischen sehr 
heftig gewordenen Schmerzen zu erreichen ; im Gegentheil, die A ffection breitete sich 
auf die Mund- und Nasenschleimhaut aus, und an dem rechten Zeigefinger und der 
grossen rechten Zehe traten Nagelbettentzündungen auf. Als Ergänzung dieser 
Angaben wurde - allerdings erst einige Wochen später - in Erfahrung gebracht, dass 
das dritte, vor einem Jahre geborene Kind bei seiner Geburt nicht näher beschriebene 
Hautausschläge gehabt haben soll, besonders auch ad anum, dass das Kind an starkem 
Nasenbluten gelitten haben soll und nach acht Wochen zu Grunde gegangen sei. 
Diese Mittheilung war, wie begreiflich, nicht wenig geneigt, die Auffassung des Falles 
zu compliciren und an Lues denken zu lassen. Aber es sei schon an dieser Stelle 
hervorgehoben, dass sehr sorgfältige, in dieser Richtung angestellte Nachforschungen 
dieses ätiologische Moment sehr zweifelhaft erscheinen liessen, und sei noch erwähnt, 
dass der Gatte stets vollkommen gesund gewesen und geblieben war. Der Geburt des 
genannten Kindes sollen durch einige Monate starke Uterinblutungen gefolgt sein, 
* Viertelj.f. D. u. S., 1887, n. Heft. SECTION XIV DERMATOLOGY AND SYPHILOGRAPHY. 
195 
welche endlich durch ärztliche Intervention zum Stillstand gebracht wurden. Mit 
diesem Aufhören der Blutungen bringt Patientin das gegenwärtige Leiden in causalen 
Zusammenhang. 
Stat. præs : 20., i., 85. Die Kranke ist eine wohlgenährte, recht kräftig aussehende 
Frau mit reichlichem Fettpolster. Die Haare hellbraun, die Augen blaugrau. Auf 
dem behaarten Kopfe, in der Mitte der Scheitelgegend, eine etwa thalergrosse, von 
dicker, schwappender, gummiartiger Kruste bedeckte Stelle, nach deren Abhebung 
eine von dünner, schmutzig-grauer, eiterähnlicher Flüssigkeit bedeckte, dunkelrothe 
Fläche sichtbar wird. Aehnliche kleinere Stellen noch sonst auf dem Schädel, dem 
Nacken und der vorderen Thoraxgegend. Die Naseneingänge durch lockere Krusten 
verklebt. Beide Lippen durchaus von schwarz bis hellbraun gefärbten, schildförmigen 
Borken bedeckt, die leicht als Ganzes ablösbar sind, wobei mässiges Bluten erfolgt 
und die ihrer Oberhaut entblössten, theils blutenden, theils grauweiss belegten Lippen 
sichtbar werden, die nun noch viel schmerzhafter sind als zuvor. Die Inspection der 
Mund- und Rachenhöhle kann in Folge heftiger Schmerzen nur unter grossen Schwierig- 
keiten vorgenommen werden. Auf der Schleimhaut derselben zeigen sich durch 
serpiginöse, dunkel injicirte Ränder scharf abgegrenzte Flächen, die ihres Epithels 
verlustig sind und gleichsam wie verbrüht aussehen. Sehr starker Feetor ex ore. Am 
rechten Zeigefinger besteht eine Nagelbettentzündung, durch die der getrübte Nagel 
theilweise abgehoben und das Fingerendglied angeschwollen und schmerzhaft ist. Die 
Haut der Genito-Crural-Gegend beiderseits dunkel geröthet, stark nässend und zum 
Theile von blumenkohlähnlichen Wucherungen, breiten Condylomen nicht unähnlich, 
besetzt. An der Aussenseite des linken Oberschenkels eine etwa thalergrosse, gleichsam 
excoriirte Stelle. An der rechten grossen Zehe eine von dicker, gummiartiger Borke 
bedeckte, etwa centgrosse Stelle. Der Harn von Eiweiss und Zucker frei. Die Unter- 
suchung der inneren Organe ergiebt normale Verhältnisse ; jedoch besteht mässiger 
Cervicalcatarrh. Temperatur 37.8° ; Puls 80. 
24., I. Auf dem Rücken und der Kreuzbeingegend eine reichliche, frische Eruption 
von in Gruppen gestellten Pusteln, in vollster Entwicklung, auf dunkel gerötheter 
Basis, sehr ähnlich Blatternefflorescenzen. Die früher beschriebenen Stellen am Ober- 
schenkel und der grossen Zehe mit fungösen Wucherungen bedeckt. 
31., i. Die meisten der eben genannten Pusteln abgetrocknet ; unter den Borken 
findet sich theils eine mit junger Epidermis bedeckte, braunrothe Fläche, theils zeigt 
sich eine nässende, etwas infiltrirte und mit grauweissem Exsudate bedeckte Stelle. 
Um die Zehennägel herum Auftreten von miliaren Pustelchen. Der rechte Zeigefinger- 
nagel von seiner Unterlage ganz abgehoben, lässt sich leicht entfernen. Auch mehrere 
andere Fingernägel zeigen sich getrübt, offenbar durch unter denselben stattfindende 
Exsudation. Der Zustand an den Lippen insofern unverändert, als sich die Krusten 
nach Entfernung sehr rasch wieder erneuern. 
Vom 3. bis 13. Februar befand sich die Kranke in einem Hospitale, wo das Leiden 
für Syphilis gehalten und dem entsprechend behandelt wurde, ohne jedoch irgendwie 
günstig beeinflusst zu werden. 
13., II. Nachdem im Spitale das Kopf haar abgeschnitten worden, zeigt sich nun 
«lie Kopfhaut in grösseren, von serpiginösen Contouren begrenzten Strecken erkrankt, 
von dicken Krusten bedeckt, unter denen die oben erwähnte Beschaffenheit sich findet. 
Das periphere Fortschreiten des Processes kann nun sehr deutlich durch an den Rändern 
sichtbare Röthung und Schwellung und miliare Pustelbildung verfolgt werden. Der 
Kopf verbreitet einen höchst widerlichen Geruch. Lippen, Mund- und Rachenschleim- 
haut, sowie Naseneingänge wie anfänglich geschildert. An der Zungenspitze einige 
kleine, fungöse Wucherungen. An Händen und Füssen verbreitet sich die Krankheit 
in centripetaler Richtung durch in der Peripherie der vorher ergriffenen Stellen reichlich 
auftretende miliare Pustelchen. In ähnlicher Weise breitet sich die Affection in der 196 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Genito-Crural-Gegend nach hinten gegen die Crena ani und nach aussen und unten aus. 
Das Endglied des rechten Zeigefingers kolbenartig angeschwollen, sehr schmerzhaft. 
Der allgemeine Kräftezustand hat sehr abgenommen, das Fettpolster ist theilweise 
geschwunden, der Puls klein, schwach, beschleunigt. Während das Jucken entsprechend 
den befallenen Hautpartieen nur mässig ist, wird constant über furchtbare Schmerzen 
an den Lippen geklagt, die Essen und Trinken sehr erschweren. 
Es würde zu weit führen, wollte ich meine seinerzeit fast täglich gemachten Notizen 
hier recapituliren. Ich will nur summarisch mittheilen, dass von nun ab der Process, 
ohne deutliche Etappen einzuhalten, unaufhaltsam fortschritt ; von den Fingern ver- 
breitete sich die Pustelbildung über die Handgelenke, von den Zehen über die Sprung- 
gelenke hinaus aus, ebenso von der Leistenbeuge nach allen Richtungen zu ; neue 
Herde zeigten sich in den Achselhöhlen, in den Falten unter den herabhängenden 
Brüsten, um den Nabel herum, an den Ellenbogen. Während früher das Fortschreiten 
durch Aufschiessen yon miliaren Pustelchen geschah, zeigen sich jetzt meisst grössere 
Blasen, oft bis zu wallnussgross ; die Blasendecken sind dünn, matsch, erscheinen oft 
schon nach vierundzwanzig Stunden braun bis schwarz gefärbt. Der Blaseninhalt 
meist dünnflüssig, trübe ; nach Entfernung der Blasendecken erscheint das dunkel- 
geröthete Rete von einer dicken, grauweissen, schmierigen Masse oft über grössere 
Strecken hin bedeckt, die sich leicht in ganzen Stücken abheben lässt. Nun bilden 
sich an diesen Stellen sehr rasch jene oben genannten Vegetationen aus. Hie und da 
trat auf kleinen Stellen Ueberhäutung ein. Niemals kam es zur Ulceration. Besser, 
als ich es beschreiben könnte, werden die Abbildungen, die ich Ihnen hier zeige und 
die der citirten Arbeit Kaposi's entlehnt sind, den damaligen Zustand der Kranken 
illustriren ; als ich diese Bilder zuerst sah, war ich von der colossalen Aehnlichkeit mit 
meinem Falle höchst frappirt. Prof. Hyde, der die Kranke am 1. März 1885 mit 
Prof. Allen und mir sah, zögerte nicht einen Moment, die Diagnose Impetigo herpeti- 
formis zu stellen. Der Process war damals in vollster Entwicklung und der grösste 
Theil des Integumentes mehr weniger ergriffen, so dass an ein Verbinden der erkrankten 
Stellen kaum zu denken war ; ich hatte daher die Patientin schon seit dem 25. Februar 
in ein zu dem Zwecke hergerichtetes Wasserbad gebracht, in dem sie den grösster 
Theil des Tages und der Nacht zubrachte. 
Der weitere Verlauf gestaltete sich nun recht trostlos. Die Kranke wurde immer 
schwächer und schwächer, der Puls immer kleiner und schneller. Hie und da schien 
für eine Reihe von Tagen Stillstand einzutreten ; dann erschien wieder neuerliche, 
mächtige Blasenbildung, die sich immer durch Temperatursteigerung und einen an der 
Peripherie der alten Plaques auftretenden erythematösen Saum ankündigte. Äm 
1. April trat eine complicirende Peritonitis unter Schüttelfrösten hinzu ; die Kranke 
wurde bald soporös ; vollkommene Depression wechselte mit heftigen maniakalischen 
Zuständen, in denen sie die nächsten Angehörigen misshandelte ; der Puls -wurde immer 
rascher, bis zu 160, dabei fadenförmig, und unter den Erscheinungen von Gehirn- 
lähmung starb die Kranke am Morgen des 6. April. Eine Autopsie wurde leider nicht 
gestattet. 
Von der Behandlung habe ich bis nun nicht gesprochen, und leider habe ich dies- 
bezüglich nichts Erfreuliches zu berichten. Gegen die Schmerzen au den Lippen wurde 
eine ganze Reihe von Salben, Pulvern und Einpinselungen mit nur vorübergehendem 
Erfolge versucht ; selbst fünf Procent Cocainlösung erwies sich ungenügend. Eben- 
sowenig schien die topische Behandlung der erkrankten Hautstellen irgend einen Ein- 
fluss auf den Stillstand oder die Rückbildung des Processes zu haben. Salben wurden 
sehr schlecht vertragen ; Jodoformpulver schien noch am ehesten die Schmerzen etwas 
zu lindern und den bisweilen furchtbaren Gestank an den Vegetationen zu vernichten. 
Das Wasserbett, in dem die Patientin mit geringen Unterbrechungen fast fünf Wochen 
zubrachte, erwies sich als ein wahrer Segen, denn im Bette klebte die Kranke förmlich SECTION XIV-DERMATOLOGY AND SYPHILOGRAPHY. 
197 
an ihren Kissen und Linnen an, während sie dort sich relativ wohl fühlte. Zusätze 
von Sublimat und Alcohol zu dem Bade schienen ohne Effect auf die Eiterungsprocesse 
an der Haut. Die interne Behandlung versuchte theils roborirend, theils umstimmend 
zu wirken ; aber weder Eisen, noch Arsen, Secale, Jodkalium oder Quecksilberpräparate 
schienen irgend welchen Einfluss auszuüben, und so kann ich denn nur sagen, dass die 
von mir versuchte Therapie dieser furchtbaren Krankheit vollkommen machtlos 
war. 
Was nun die Diagnose des vorliegenden Falles anlangt, so kann für Denjenigen, 
der jemals einen ähnlichen Fall gesehen oder die Beschreibungen von Auspitz, Hebra, 
Kaposi gelesen hat, kaum ein Zweifel sein, dass derselbe ein höchst klassisches Beispiel 
der Impetigo herpetiformis bildet. Das Auftreten an einem weiblichen Individuum, 
im Anschlüsse an eine, wenn auch nicht näher eruirte Uterinaffection, die offenbar von 
dem letzten Puerperium datirte, die characteristische, gruppirte Pustelbildung, die 
Affection der Schleimhäute, der Nägel, die Localisation des Leidens, die beschriebenen 
Vegetationen, der rasche, fast unaufhaltsame Verlauf, sprechen wohl stark genug dafür. 
Ich kann nicht verhehlen, dass beim Lesen einer im Vorjahre aus der Feder Neumann's 
erschienenen Arbeit über "Pemphigus vegetans"* mir für einige Zeit Zweifel 
erwuchsen, ob ich es nicht mit dieser seltenen Form des Pemphigus zu thun gehabt ; 
aber der stets eitrige Inhalt der Blasen und Bläschen in meinem Falle spricht dagegen. 
Jedenfalls scheint mir eine ausserordentliche Verwandtschaft zwischen diesen beiden 
Processen zu bestehen und eine Differenzirung derselben, besonders in den Anfangs- 
stadien, zu den schwierigsten Aufgaben der Diagnostik zu gehören. Von einzelnen 
Beobachtern wird ja direct ein Uebergehen der Impetigo herpetiformis in Pemphigus 
berichtet, wie z. B. in dem Falle Heitzmann's, * der allerdings von Auspitz und Kaposi 
anders gedeutet wird. Den von Einzelnen für characteristisch gehaltenen Vegetations- 
bildungen legen Kaposi und Andere keinen diagnostischen Werth bei, indem dieselben 
nur als der Ausdruck eines bei herabgekommenen Individuen gestörten Epidermis- 
ersatzes gedeutet werden. Die Mittheilung eines zum ersten Male bei einem Manne 
beobachteten Falles durch Kaposi f unterbricht die bisher geschlossene Kette einer 
allerdings relativ kleinen Anzahl von nur bei Weibern constatirten Fällen und ist 
geeignet, unsere bisherigen Ideen über die Aetiologie der Krankheit zu stören ; andere, 
von Duhring, Robinson j und Anderen mitgetheilte gehören wohl kaum hierher. 
Weitere Erfahrungen müssen hier Klärung bringen. Es kann nicht genug betont 
werden, wie wichtig die Unterscheidung derartiger Fälle von Syphilis ist, und was 
Neumann am Schlüsse der oben citirten Arbeit in beredten Worten mit Bezug auf 
Pemphigus vegetans sagt, gilt wohl auch in unserem Falle. Auch in dem von mir 
mitgetheilten Falle schien Manches aus der Anamnese dafür zu sprechen ; aber wie 
unverlässlich sind für gewöhnlich die Angaben, die wir von unseren Patienten erhalten, 
wie verschwindend unwichtig gegen Das, was wir mit unseren Augen sehen ! Ob ich, 
nach Dem, was ich mitgetheilt, zu der Diagnose Impetigo herpetiformis berechtigt war, 
muss ich dem Urtheile älterer und erfahrenerer Beobachter überlassen. 
Dass ich mit der vorstehenden Mittheilung zur Pathologie und Aetiologie unserer 
Krankheit nichts Nennenswerthes beigetragen habe, ist mir wohl bewusst ; Fälle der 
Privatpraxis können eben nicht so ausgenutzt werden, als solche in Spitälern. Aber da 
bis nun eine so spärliche Anzahl von Beobachtungen dieses seltenen Leidens vorliegt, 
so mag meine Absicht, meinen Fall in weiteren Kreisen zu veröffentlichen, berechtigt 
erscheinen. 
* Viertelj. f. D. u. S., 1886. 
■j" Amer. Arch, of Derm., IV, 78. 
i L. c. 
g J. of C. & V. D., 1885. NINTH INTERNATIONAL MEDICAL CONGRESS. 
198 
DISCUSSION. 
In the discussion which followed, Dr. Unna related a case which resembled both 
impetigo herpetiformis and dermatitis herpetiformis, but differed from both and was 
probably neither. It was similar, as regarded treatment, in that iodine in abundance 
was the only treatment which gave good results. 
It resembled more an impetigo, because the blebs appearing did not from the 
first contain pus, as is necessary to establish the diagnosis. He believed in the exist- 
ence of a dermatitis herpetiformis, but is satisfied that the impetigo herpetiformis of 
Hebra is a distinct disease, and should not be classed by Duhring with the other 
forms which go to make up his dermatitis herpetiformis. 
ON ÆTIOLOGY AND TREATMENT OF LUPUS ERYTHEMATOSUS. 
SUR L'ÉTIOLOGIÊ ET LE TRAITEMENT DU LUPUS ÉRYTHEMATIQUE. 
ÜBER DIE ÄTIOLOGIE UND BEHANDLUNG DES LUPUS ERYTHEMATOSUS. 
BY A. RAVOGLI, M.D., 
Cincinnati, Ohio. 
Before this honorable body of scientists, it is of great interest to me to introduce 
the subject of Lupus Erythematosus (Cazenave), which, although excellently treated 
and scholarly illustrated by the most reputed dermatologists, I find is still surrounded 
with darkness. Its aetiology is in darkness; in every work on skin diseases we find 
that this disease may be produced by a large number of different causes, and yet not 
one of these opinions can stand a severe criticism. The opinion of its being a result 
of a trophoneurosis is that which can best be defended, as it does not explain much and 
can be reduced to the old proverb, obscura obscurioribus dilucidare. 
No less obscure appears to me the knowledge which we have in regard to the inti- 
mate process of lupus erythematosus, which, by some, has been referred to a neoplastic 
affection and ranked with lupus vulgaris, by others to a cellular infiltration originating 
from an inflammatory process in the meshes of the cutaneous tissues. 
The prognosis and treatment go hand in hand with our other knowledge, and we 
can say that it is very difficult to answer the question of the patient as to whether he 
will be cured and how long the treatment will last, on account of the great uncertainty 
in the remedies recommended. 
In my opinion, lupus erythematosus is a kind of rock in our medical branch, and 
I have always been better satisfied to have to treat a case of lupus vulgaris than one of 
lupus erythematosus. 
It would be entirely superfluous for me to give a description of the symptoms of 
lupus erythematosus before this scientific body, or to describe some cases of the disease. 
The main point for me is to find out the solution of the question, What is the intimate 
process of lupus erythematosus, and what is its cause ? 
I confess that the solution of these questions has been a difficult task, but when we 
agree on the two main points, I think that we will have more light on this subject. 
Professor Kaposi, although he ranks lupus erythematosus among the neoplasmata, 
next to lupus vulgaris, insists upon its inflammatory nature. He bases his views 
mostly on the clinical symptoms which he ascribes to an inflammatory process. SECTION XIV-DERMATOLOGY AND SYPHILOGRAPHY. 
199 
When Hebra at first described this disease as seborrhœa, he originally used the 
modifier congestiva, from its most prominent symptom, the congestion. The same 
disease has been described by Biett with the name of erythema centrifugum, and all 
show that every author maintained erythema and congestion as the bases of their 
Fig. 1. 
nomenclature. The erythema is seen from the disappearance of the redness under 
pressure of the finger, and its reappearance when the pressure is removed, and, in some 
cases, from the acute inflammation which occasionally accompanies the lupus erythe- 
matosus discoides, and constantly occurs in the lupus aggregatus. 
Fig. 2. 
The few figures here shown have been chosen from several specimens. The mate- 
rial has been cut off from the edge of a recent spot of lupus erythematosus on the neck 
of a gentleman who had the disease for about three years. The piece of skin was left 
for two days in alcohol and then cut for examination with the microscope. 200 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
The first thing which I consider remarkable in the sections is the hypertrophy of the 
epidermic cells. These cells are enlarged and furnished with large nuclei and abundant 
nucleoli ; even in the most superficial portion of the horny layer, where the nuclei are 
not frequently perceptible, they are swollen and enlarged. Between the cells w'e do 
not find infiltration cells, but the only change is the hypertrophy of the epidermic cells. 
In the same way the epidermic cells which invest the interior of the sebaceous glands 
and of the follicles of the hairs are hypertrophic. In the tissue forming properly the 
stroma of the corium, we see that the papillæ are of a much larger size than in the 
normal condition, and an infiltration of small inflammatory cells is spread between the 
fibres of the connective tissue. The most striking feature is the hypertrophy of the 
fascicles of the fibres of the connective tissue constituting the stroma of the papillæ. 
The corpuscles of the connective tissue, which in the skin of the adult are no longer 
perceptible, are seen again, furnished with their nuclei and nucleoli, as at an embryonic 
stage. The elastic fibres, which I believe are nothing else than the product of the 
fibres produced by the corpuscles of the connective tissue, are also enlarged and swollen. 
When we look at the structure of the corium in Fig. 3, we find that the loculi formed 
by the fibres of the connective tissue are exceedingly enlarged, and they ought to con- 
tain this intercellulary fluid which is the cause of the hypertrophy of the histological 
elements of the skin. 
The blood vessels are enlarged and filled with blood corpuscles. 
From what we can see from the above figures we must be persuaded that the inti- 
mate process of lupus erythematosus is not a neoplastic but an inflammatory one. It 
was at first believed to be an inflammation of the sebaceous glands only, but we can 
demonstrate that the skin in all its elements and in each layer is affected. 
Lupus erythematosus leaves the skin white, thin, like parchment, which has been 
considered as a scar. A few days after a spot of lupus erythematosus appears we see 
in the middle of the spot a depression produced by the atrophy of the elements of the 
skin. This does not surprise us, when we consider the intimate process of lupus ery- 
thematosus based only on an hypertrophy of the connective tissue and of the epidermic 
cells. Any element of the living body when surcharged with nutrition and advancing 
into hypertrophy, cannot remain in this condition, and, therefore, in the excess of the 
process of denutrition, becomes shriveled and atrophic. Kaposi asserted already that SECTION XIV-DERMATOLOGY AND SYPHILOGRAPHY. 
201 
the scar following lupus erythematosus was not a cicatrix, properly speaking, but a local 
atrophy of the skin. In the midst of the inflammatory changes of the tissues, and some- 
times at an early age, fatty and molecular cloudiness of the cells of the rete and of the 
glands, and also of the corpuscles and fibres of the connective tissue take place, and all 
shrivels up, with the result of a true atrophy of the skin. The cause of this atrophy I 
find in the blood vessels, which, being compressed by the infiltrating cells and by the 
hypertrophy which is spreading in the surrounding skin, are closed and obliterated. 
The same process of hypertrophy causes the obliteration of the glands, which also, at 
first, participate in the process of hypertrophy, and afterward atrophy like the other 
tissues. The connective tissue fibres, after the atrophic process has taken place, are 
thin, shriveled and mixed together in different directions, and the connective tissue cor- 
puscles are no longer to be distinguished. The enlarged loculi are diminished and 
scarcely perceptible. The whole tissue is atrophic. 
This is the end of the process which we call lupus erythematosus, a process which 
can be reduced to only two factors : at first hypertrophy of the histological elements, 
and, subsequently, atrophy of the same. 
But, in order to have those above-mentioned effects of inflammatory nature, we must 
admit a primary cause which is capable of giving rise to the disturbance of the nutri- 
tion of the cells. The greatest factor of these disturbances is irritation, which by a 
heterogeneous stimulation of the nerves increasing the blood supply in the vessels aug- 
ments the nutrition and causes disturbance in the biological activity of the cells. 
Kaposi, in treating this question, remarked that in many cases the affection begins 
as a local disease and runs its course as such without in the least affecting the con- 
stitution during the whole duration of the malady. He refers to cases in which lupus 
erythematosus has proceeded from a seborrhœa of the nose and face, which had its 
origin in the scars of smallpox. In these cases he says there is not the least induce- 
ment to consider it as a constitutional disease. He furthermore declares that lupus 
erythematosus, although pointed out by many authors as occurring mostly in chloro- 
anæmic women, occurs also in healthy females and in robust and vigorous men. 
In the cases where lupus erythematosus shows an acute general eruption, he admits 
the existence of a decided sympathy of the whole organism. He sees an intimate rela- 
tion between the inflammatory process of the skin and the high fever, typhoid state, 
pleuro-pneumonia, affections of the joints, which were observed in those unfortunate 
cases. To the exacerbation of the lupus spots he refers the outbreak of the erysipelas 
perstans faciei. He regards the nervous system as the cause of all the trouble. But 
the results of the autopsies in eight cases of this kind did not authorize the opinion that 
the primary cause of the disturbance lies in the trophic nerves or in the centre of the 
vasomotor nerves. 
Here we are again in darkness. 
Now you will allow me to discuss my specimens again. I have taken scales from 
three cases of lupus erythematosus. The scales have been macerated from one to two hours 
in a caustic solution of potassa and then carefully washed in water, then colored with 
hæmatoxylon, then washed again in a mild solution of acetic acid. 
What impresses us at first is the presence of epidermic cells enormously enlarged, 
containing a large number of small, brilliant, round cells (Fig. 4), all of the same size, 
slightly stained by the hæmatoxylon. They appear to be microorganisms, which can 
be designated as belonging to the strongly obligatory parasites of de Bary. 
In Fig. 5 we can see those cells separated and others forming groups or little, colonies, 
which gives us the idea that they were contained in a cell like in Fig. 4, and the cell 
has been destroyed by the caustic potash, leaving the microorganism intact in its place. 
The resistance to the action of the caustic potash strengthens us in the opinion of their 
being microorganisms exhibiting their own microbiotic life. 202 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
It was now interesting to establish whether these microorganisms remain on the 
surface of the epidermis or go deeply in the structure of the skin. 
To determine this I took sections of skin affected with lupus erythematosus, which 
had been previously hardened with alcohol; the sections were treated with a solution 
Fi«. 4. 
of caustic potash and boiled in it from a few seconds to three minutes. The section so 
treated was washed in distilled water and then colored partly in methyl violet and 
partly in vesuvine, then subjected to partial discoloration, either in distilled water or 
in a solution of acetic acid. 
Fig. 5. 
In these specimens we see that the microorganisms of similar size, having resisted 
the caustic potash at the boiling point, colored in yellow-brown by the vesuvine and in 
blue by the methyl-violet, are ranged in chains and in groups in the layer of the epi- 
dermis. The epidermic cells have been almost destroyed, and the cocci remain in their 
place. Micrococci we find in the papillary layer mostly abundant in the places where SECTION XIV-DERMATOLOGY AND SYPHILOGRAPHY. 
203 
some exudation exists. Small colonies of cocci are found in the interior of the fibres, 
and some are found also in the capillary blood vessels. 
In one specimen, where the tissues have been nearly destroyed by boiling too long 
in caustic potash, the microorganisms are much more apparent and abundant. 
Now when we find in a section (Fig. 3) masses or chains of small bodies which are 
of similar size, and which withstand both the action of alcohol and ether, and the treat- 
ment with concentrated acetic acid, and the alkalies after warming, these are to be 
considered, according to Friendlander, as microorganisms. There is no doubt that 
microorganisms exist in lupus erythematosus, and not only on the surface, but in the 
structure of the skin, as in Fig. 3 is clearly seen. The question now is to try cultivation 
and inoculation of these cocci, which I have been unable to do up to the present time, 
for want of material. 
Having established, then, the presence of the coccus in this disease, it seems probable, 
reasoning from analogy, that we have here the essential cause of the affection. This 
admitted, the intimate nature is clearly explained in lupus erythematosus discoides. 
In the other kind, called aggregatus, we can find also a better explanation by the 
presence of the micrococci. Their quantity and their reabsorption into the meshes of the 
skin I think to be the cause of the erysipelas perstans described by Kaposi, and the 
reabsorption into the general system the cause of the severe symptoms which may 
sometimes cause the death of the patient. 
What about the treatment ? In every book and pamphlet internal remedies are 
considered of no effect on the lesions, only in case of trouble in the general system are 
remedies used which the individual case may require. In the same way in case of 
lupus erythematosus aggregatus, when producing erysipelas and general systemic symp- 
toms, these remedies are used accordingly. 
In ordinary cases of lupus erythematosus the medication is limited to the locality. 
The application of emplastrum hydrargyri has been considered as one of the best 
means, combined with washing with spirit, saponat. kalin. In this medication every 
one is aware that we are dealing with powerful antimycotic agents. I must return to 
the theory of Cromoisy, that parasites are not destroyed by the remedy, but we obtain 
the result on account of the necrosis produced on the epidermic cells, and, consequently, 
their desquamation. With the tincture of soap we obtain the dissolution of the epi- 
dermic cells, and with the application of the emplastr. hydrarg. we may obtain the 
destruction of the microbes by the production of some sublimate in the layer of the 
skin. Caustics were used very profusely, and especially iodide of mercury, trichlor- 
acetic acid, pyrogallic acid, chloride of zinc, etc. We come always to the same conclu- 
sion, when we destroy the skin we destroy the microbe too, and a scar will replace the 
destroyed skin. The use of the sharp scoop for scraping the spots of lupus erythema- 
tosus, I think should be ranked with the strong caustics; the skin having been 
destroyed it will be replaced by scar tissue. But if this would always occur, I think 
we would be very happy. I have had in my experience cases of lupus erythematosus 
where, after having burnt or scraped the spot and a scar followed, lupus cancrosus 
appealed on new spots, or almost in the scar. I think that the use of strong caustics 
and of the sharp scoop for lupus erythematosus, must be very limited, if not entirely 
objectionable. 
After the introduction of ichthyol by Unna, I tried it in lupus erythematosus, and 
in three cases obtained complete recovery. Its first action is displayed on the epidermis 
with which it is brought in contact, and appropriating the oxygen of the cells produces 
an induration of the epidermic tissue. The same action which we see on the horny 
layer is produced on the epithelium investing the sebaceous glands, and after a few 
applications we see diminution of their secretion, and sometimes the hard, dry cells 
obstruct the opening of the glands and pustules result. The astringent and reducing 204 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
action of ichthyol is also displayed in the underlying tissue and the blood vessels, in 
diminishing by contraction their caliber. In the same way as we see the redness dis- 
appear after a few applications of this remedy in erysipelas, in erythema, and in eczema 
erythematosum, we see it disappear also in lupus erythematosus. Pyrogallic acid is of 
the same class of remedies, being one of the phenol group, and till now it has been 
considered one of the most efficient remedies in lupus erythematosus. But the action of 
ichthyol is much milder and more effective than that of pyrogallic acid. 
Unguent, diachyl. Hebræ mixes very well with ichthyol, and I use it from three to 
fifteen per cent. Ten per cent, ichthyol in diachylon ointment is a powerful remedy, 
and spread on a piece of cloth and applied affects the epidermis, changing it into a kind 
of parchment and giving rise to blisters and suppuration. After a few applications of 
this salve I diminish the quantity of ichthyol to three per cent. ; in this way good epi- 
dermis is formed, and flat and scarcely perceptible scars replace the spots of lupus 
erythematosus. 
In order to finish the treatment, a solution of ichthyol in collodium was used, to 
brush once a day on the place- 
H. Natr. sulfoichthyol, 
Spirit æther., ââ grm. 10.00 
Collodion, grm. 20.00 
until the spots had entirely disappeared and the skin returned to the normal condi- 
tion. 
Scarification can be used while ichthyol is applied, in order to diminish the stasis 
and facilitate the obliteration of the enlarged blood vessels. 
DISCUSSION. 
In the discussion, Dr. Knaggs, of England, asked if the reader considered the 
micrococci as causative, and whether the ichthyol destroyed them and the tissues, 
too, or acted as an antiseptic. 
Dr. Ravogli replied in the affirmative. The ichthyol acted, he thought, by 
abstracting oxygen, upon which the life of the cocci depended. 
Dr. Unna, of Hamburg, regarded as the most important part of the paper that 
relating to microorganisms, and he considered it the weak point as well. The cocci 
must be seen in all parts of the thickness of the skin, and, he believed, in the 
sweat glands, too. He thought microorganisms probably existed in the disease, and 
would some day be discovered, but could not regard the specimens presented as 
showing them, and hoped Dr. Ravogli would continue his investigations and make 
cultures. He asked if the sections were made deep enough to show the sweat 
glands. 
Dr. Ravogli said he had not paid special attention to these glands. 
Dr. Unna was glad to hear of the good influence of ichthyol, never having used 
it alone in this disease, but with the addition of salicylic acid. He had found resor- 
cin beneficial and most useful as a varnish or collodion dressing. 
Dr. Thin had examined Dr. Ravogli's preparations, but was not able to satisfy 
himself that the minute particles he saw in them were organisms. Minute objects 
in preparations of this kind can only be looked on as cocci if they showed the char- 
acteristic staining by the aniline dyes. Dr. Thin made some remarks regarding the 
general nature of lupus erythematosus. Its clinical course and pathological histol- 
ogy are both reconcilable with the bacterial theory, but the bacteria have yet to be SECTION XIV DERMATOLOGY AND SYPHILOGRAPHY. 
205 
shown. He referred to some remarkable cases that had been observed in London, in 
which the clinical features consisted in a localized, raised eruption, of a bright red 
color, the diseased surface being separated from the surrounding skin by a sharp 
line and by the absence of scales and crusts or secretions. " The cases had been pro- 
fessionally spoken of as the cocks-comb disease. ' ' In one of these cases a portion of 
skin had been excised, which Dr. Thin had examined, and which exhibited the mor- 
bid anatomy of lupus erythematosus. The epidermis was raised and separated for 
a considerable distance from the pars reticularis of the corium by a dense layer of 
small cells, which were intersected by blood vessels and .which completely occupied 
the place of the pars papillaris. In vertical sections the distance of the lower bor- 
der of the rete mucosum from the reticular layer was many times greater than the 
thickness of the papillary layer. 
Clinically, the leading features of the eruption were the bright red color, the 
remarkable prominence and the absence of secretion or desquamation and the strict 
limitation. Clinically, experienced observers had found it difficult to establish a 
diagnosis. 
Dr. Klotz said he was glad to hear Dr. Ravogli speak in favor of milder appli- 
cations in preference to the stronger and caustic ones or to surgical interference, as 
he had come to similar conclusions. He had been employing for the last year, with 
satisfactory results, a compound plaster of salicylic acid and soap plaster. 
The discovery of microorganisms would bring lupus erythematosus in closer 
relationship again with lupus vulgaris, from which it had been alienated too far. 
There certainly exist cases in which it is extremely difficult to decide between the 
two forms of lupus, and where a combination of the same seems to exist. 
Dr. Zeisler, of Chicago, thought the microorganism theory a very plausible 
one ; still, it remains a theory as long as pure cultures and successful inoculations 
have not been demonstrated. He wondered that reference had not been made to the 
investigations of Morrison, of Baltimore, recently published. He mentioned the 
rare occurrence of lupus erythematosus on mucous membranes, of which he had 
lately observed a case in a lady from Wisconsin, in whom the mouth was affected. 
There were several lesions present on the gums and the mucous membrane of the 
cheeks, of a whitish color and scar-like appearance, bleeding very readily and prov- 
ing very obstinate to treatment. Caustic nitrate of silver seemed to beneficially 
influence these spots. He agreed with Dr. Unna as to the value of resorcin. He 
had found ichthyol without much value, while a ten per cent, solution of resorcin in 
collodion had acted very well in the above-mentioned case. 
Dr. Robinson, the President, spoke especially in regard to the microscopic speci- 
mens. He agreed with Thin and Unna that in all probability a microorganism 
exists, but he does not think that Dr. Ravogli has pursued proper methods in 
his studies, nor do the specimens show the bodies to be cocci. It is not clear that 
they are not extraneous matter. We must exercise great care in placing importance 
upon the microorganisms found upon the general surface. He urged Dr. Ravogli 
to follow up his investigations, and instead of using caustic potash, make sections 
from specimens hardened in alcohol and stained in the usual manner with aniline 
dyes. Caustic potash he considered a very deceptive agent to work with when seek- 
ing for spores, as we are likely to imagine their being present when the product is 
only an artificial one, from the agent employed. 
In closing, Dr. Ravogli said that he labored under difficulties in making his dem- 
onstrations at this time. He considered the test with caustic potash a convincing 206 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
one, as it never attacked microorganisms, but did attack everything else. He was 
glad to hear the opinions of so many that microorganisms probably existed. He 
would not say positively at the present time that they were causative, but would wait 
until he had been able to make cultures, etc., as suggested. 
ERYTHEMATOUS LUPUS OF THE HANDS. 
LE LUPUS ERYTHÉMATIQUE DES MAINS. 
ÜBER DEN LUPUS ERYTHEMATOSUS DER HÄNDE. 
A. H. OHMANN-DUMESNIL, A.M., M.D., 
Of St. Louis, Mo. 
Lupus erythematosus (Cazenave), or erythematous lupus, is an affection which has 
proven not only interesting from a clinical point of view, but has given rise to much 
discussion in regard to its pathology. Its clinical characteristics and appearances have 
been minutely described and made thoroughly familiar; yet they have not been as care- 
fully elaborated as they might have been. What I intend to convey is this: that while 
erythematous lupus of the face and head has been often observed and described in every 
particular, and every phase of its evolution noted, the invasion of other portions of the 
skin has either escaped attention or has occurred so seldom that but few cases have been 
observed, and of these but a small number have been accurately described. 
That erythematous lupus occurs most frequently upon the face is fully proven by the 
statistics of every dermatologist, and that its occurrence upon the trunk or extremities 
is comparatively unusual is also the general experience of those who have paid any 
attention to the subject of skin diseases. It is the universal opinion of authors that 
erythematous lupus of the hands is a rare form of the disease, and more so when the 
disease is not to be found upon any other portion of the body. This being the case, it 
is very strange that the reports of such cases which have been made should, in a certain 
degree, be so meagre in details, and I must urge this very incompleteness as an apology 
for the apparently incomplete manner in which I have been forced to tabulate the cases 
which I have succeeded in gathering together. 
There js no doubt whatever in my mind that these represent but a very small 
number of the cases which have occurred, as many are unable to recognize the 
disease, and others observed it before it had acquired a distinct place in nosology ; 
yet it must be comparatively infrequent, when we consider the number of competent 
dermatologists, and the large amount of material which passes through their hands in 
connection with the few cases of erythematous lupus seen by them, and the extremely 
small number of patients affected on the hands by this disease. Of course, in the ma- 
jority of cases there is but little pain and scarcely any inconvenience attending the 
trouble, relief being most often sought on account of the appearance produced. This 
may also be assigned as a reason for the small number of cases observed. 
On account of these and other reasons it has been deemed proper to report somewhat 
fully a case of erythematous lupus of the hand and arm, which possesses some interest- 
ing features, more especially as the report could be made tolerably full by the addition 
of photographs and microscopic preparations illustrating the pathology of the process 
in this particular case. This is done in spite of the fact that the case is still under SECTION XIV DERMATOLOGY AND SYPHILOGRAPHY. 
207 
treatment and observation. However, this does not militate against the clinical features 
of the case nor against a clinical analysis of the cases which I have collated. 
Case.-W. C. C., male, age fifty-five, was referred to me June 3d, 1886, by Dr. F. 
Foster, of Memphis, Mo. The history which was furnished was as follows: The 
patient, whose occupation is that of a carpenter, is an American and married. His 
general health has always been good, and he has never had any other skin disease. 
There is no history of syphilis. He has always lived a regular, temperate life. In 
June, 1882, he noticed a small macule upon the dorsum of his right hand. This 
remained and slowly increased in size, until, in the course of a month, it had attained 
the dimensions of a silver dime, the color being that of a cherry. He cut into this 
with his penknife, and from this time on it began spreading rapidly. He was treated 
by a number of physicians, who treated the trouble with caustics, using chiefly chlor- 
ide of zinc, but with negative results. In fact, he thought that the treatment greatly 
aggravated his trouble. In March, 1883, he went to Hot Springs, Ark., where he 
again went through a caustic treatment without any benefit. On July 6th, 1883, he 
was seen by Dr. Foster. The lesion then extended to the entire dorsum of the hand 
and up to the second phalanges of the fingers. The Doctor removed a portion with the 
knife, for the purpose of microscopic examination, and was much gratified to see the 
wound heal kindly. After that time he removed several large portions, this being 
always followed by " healthy granulations." The patient could never be persuaded to 
take chloroform and have the disease removed entire, but being a poor man he con- 
tinued to work at his trade, and only ceased doing so when compelled by absolute 
necessity. 
June 3d, 1886. Status Præsens. -The patient is about five feet eight and one-half 
inches in height, weighs about 160 pounds and appears to be well developed physi- 
cally. His pilous system appears to be well developed and his skin is of normal thick- 
ness and elasticity. In color it is normal on the covered parts, the face and hands being 
browned through exposure to the sun. His hair is of a brown color. Upon no portion 
of the body, except the parts about to be described, can any affection of the skin be 
found. The part involved includes the hand and forearm of the right side. Here it 
may be noted (see Plates I and n) that, in general, it is the dorsum of the hand and 
extensor surface of the forearm that are implicated. The patches are distributed rather 
irregularly, on account of the cicatrization which has taken place. Upon careful exam- 
ination, patches are found distributed about as follows : one on the dorsal surface of the 
thumb, involving the metacarpal and first phalangeal surfaces, and a smaller one on the 
second phalangeal surface, up to the nail but not implicating it. A very small patch 
is found on the first phalanx of the forefinger ; another on the first phalanx of the mid- 
dle finger, one on the first phalanx of the ring finger and one on the first and second 
phalanges of the little finger. An irregularly clover-leaf-shaped patch involves the 
metacarpo-phalangeal joints of the middle and ring fingers and extends up the dorsum 
of the hand. Two or three patches are located over the carpo-metacarpal joints, on the 
dorsal aspect, one of the patches-the largest-encroaching upon the ulnar aspect of the 
wrist. A number of small patches are irregularly distributed over the dorsum of the 
hand. About two and one-half inches above the wrist joint, a heart-shaped patch 
exists, and this is surrounded by cicatricial tissue. At the junction of the middle and 
the upper third of the forearm, we find an irregular horse-shoe-shaped patch, which is 
so large that it encroaches upon both the ulnar and radial surfaces of the arm. Its con- 
vexity is directed upward and, in the space included in its curve, a few small patches 
are to be found. A reference to Plates I and II will show this condition more clearly, as 
also the comparative sizes of the patches and their distribution. 
The sizes of the different patches vary considerably. Some of them are about one- 
fourth of an inch in diameter, and all sizes can be found between this and four inches 208 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
by one, which is approximately the dimensions of the largest one. The shapes of the 
patches are irregular, although all of them seem to have a tendency to assume convex 
contours. 
The patches have a somewhat dark-red color inclining to a lighter hue. On the 
fully developed lesions may be observed dirty yellow crusts, one or two lines in thick- 
ness, and consisting chiefly of inspissated sebum. At some points these crusts are 
brownish, and everywhere are hard and stiff. They are pretty well defined against the 
skin, and feel quite rough to the touch. 
Between and surrounding some of the patches are superficial cicatrices. These are 
especially pronounced between the highest patch and wrist joint. Some are to be seen 
upon the fingers, and they have the same characteristics as the others. These cicatrices 
are nearly white, having a very slight pinkish tinge. They are quite flexible and, to 
the feel, communicate the sensation of a skin rather thinner than that of scar tissue. 
Upon close inspection it is noted that small pits or depressions can be found, irregularly 
distributed, giving the cribriform appearance seen to accompany the cicatrices which 
are due to the healing of superficial destructive processes of the skin. No hairs can be 
found, nor is there evidence of the presence of sweat or of sebaceous glands. 
In regard to the subjective symptoms accompanying this disease, the patient states 
that he has never had occasion to complain, beyond experiencing a sharp pain at varied 
intervals. Sensation appears to be very fair in the forearm and there is apparently no 
disturbance of innervation. The patient protects the arm by continually applying wet 
bandages over the site of the disease ; and this avoidance of all sources of external irri- 
tation may, in part, account for his comparative immunity from pain. He complains 
of pain on flexing the fingers, and says that there is a diminution in the power of the 
hand when flexed. He is not as strong as he formerly was in that hand and arm. 
With this history, the diagnosis was made of erythematous lupus and one of the 
smaller patches was excised for microscopic examination. The treatment ordered was 
as follows : To apply a paste, made of concentrated lactic acid (Merck's), to which was 
added kaolin, sufficient to form a firm paste, to the patches, the edges of which had 
been previously oiled. As the patient left for home immediately after consulting me, 
Dr. Foster carried out the treatment. 
June 18th, 1886. The paste was applied and proved to be exquisitely painful, so 
much so, indeed, that it was necessary to keep the patient under the influence of chloro- 
form for nearly three hours, and it was only twelve hours later that he felt com- 
fortable. 
June 22d. A slough separated, and the case is looking well. 
Aug. 11th. Dr. Foster writes: " The case is progressing finely, and is full of promise 
for the future. " Applications of sapo viridis, to be followed by zinc oxide ointment, 
were ordered. 
Aug. 20th. Dr. Foster reported : "The case is doing excellently and is nearly 
well." 
Jan. 16th, 1887. Nothing more was heard of the case until this date. Then I 
received word that the result of the treatment was good in its effects. The patient 
wrote that the parts that were not deep had all sloughed after the application of a pyro- 
gallic acid ointment, previously ordered; also that the "sores" looked smooth and 
healthy. He stated that his general health continued to be good. 
Feb. 3d. The patient writes: " The ' sores ' are pretty near the surface of the skin, 
and some of them below it. They have shown no disposition to heal up. ' ' I wrote to 
him to come and see me soon, sending him at the same time a stronger pyrogallic 
ointment. However, he did not come, as requested. 
Feb. 19th. Word received from the patient, to the effect that the " ' sores ' do not 
seem to improve as they did at first. Some parts are healing, while others remain as SECTION XIV DERMATOLOGY AND SYPHILOGRAPHY. 
209 
they were. ' ' The condition seemed to be in statu quo, ând I again urged Mr. C. to 
come, in order that I might see the condition present and give proper treatment. 
March 10th. Mr. C. writes that there has been no improvement whatever for the 
past two weeks. The condition is about the same, with the exception that a new patch 
has shown itself above the elbow. Not caring to do anything without seeing the case, 
and writing to that effect, I heard no more of it for some time. 
June 5th. I received a letter from the patient, informing me that the hand had 
become worse. The patch on the arm was now four inches in diameter. I answered, 
urging the man to come and see me. Of course, being a poor man, it is rather a hard- 
ship for him to be compelled to travel such a distance; but, in justice to myself, I 
could not attempt the treatment of a case I did not see occasionally. I am confident 
that the result would have been much better had the patient been kept under observa- 
tion continuously. 
It is a well-known fact that, as a rule, cases of erythematous lupus are essentially 
chronic and very rebellious to treatment. It is also a matter of observation that, in 
the majority of cases, the patients disappear before complete results are attained. It 
is also a matter of record that relapses occur quite frequently, and it is very difficult to 
form just estimates of the effects of treatment. On this account, I have refrained from 
particularizing or dilating on this point, deeming that a clinical analysis of cases and a 
report on the microscopical appearances of the case reported would be of more interest. 
Clinical Analysis.-A search through literature, and correspondence held with der- 
matologists in this country, has resulted in the record of 44 cases or 45, including the 
one just described. Of these ten are unpublished. Upon looking over this list I find 
that the majority have one fault in common, viz. ; the incompleteness of the record. 
This is due to a number of causes. One is that some observers directed their attention 
to but a few points ; others did not keep notes of the cases, at the time they were seen ; 
and others again kept but incomplete records or made insufficient reports. I have been 
informed by some that they could not supply me with information, from the fact that 
they kept no notes of any cases. Some may doubt that all of the cases tabulated were 
erythematous lupus; they were reported to me as such or published as such, and I am, 
perforce, bound to admit them as such until they are proven to be otherwise. 
In looking over this table we find that of the 24 cases where sex is specified, four- 
teen were females and ten males, thus confirming the statistics of erythematous lupus 
upon other portions of the body. Where the sex is not specified (in 21 cases) it is very 
probable that it occurred more often in females. The proportion is approximately two 
to one in the experience of all observers. In the above cases it is one and one-half to 
one nearly, but the record is not sufficiently complete to arrive at a satisfactory conclu- 
sion. 
The earliest period of life at which the disease occurred is given as seven years ; 
the latest, as fifty. The average age is 26.8. Here we must take into consideration 28 
cases in which these details are not reported. The age at which the reporter saw the 
case is more fully reported, there being but 22 cases in which this item is omitted. In 
the remaining 23 cases, the youngest was seen at twelve years of age ; the oldest at 
sixty. The average age at which relief was sought is 32.8. Taking the eighteen cases 
in which the age at which the disease first made its appearance and the age at which 
relief was sought are given, we find that the shortest time which elapsed between the 
appearance of the disease and its presentation to a competent observer is two years; the 
longest, fifteen years. The average duration is six and one-half years. Of course, many 
of these had been seen and treated by physicians, and one of the cases was cured when 
seen by the observer who reports it (No. 36). The length of time allowed to elapse is 
always somewhat considerable, and shows the comparatively small amount of annoyance 
caused by the disease. 
Vol. IV-14 No. 
Age when 
Affected. 
Age when 
Observed. 
Part First 
Affected. 
Parts Affected 
other than 
Hands. 
Hands. 
Fingers. 
Part of Hand or 
Fingers Affected. 
Remarks. 
Sex. 
Result. 
Observer. 
When Published. 
Ann. des Mai. de la 
1 
28 
38 
Face. 
Both. 
Fingers. 
Dorsum. 
M. 
Cazenave, E. 
Peau et de la Syph., 
1850-1. 
2 
Fingers. 
44 
Wilson, E. 
Jour, of Cut. Med., 
Jan., 1869. 
tt 
44 
44 44 
Jour, of Cut. Med., 
Jan., 1869. 
4 
Nose. 
It 
« <> 
Jour, of Cut. Med., 
Jan., 1869. 
It 
44 
K 
44 44 
Jour, of Cut. Med., 
Jan., 1869. 
tt 
cc 
44 
44 44 
Jour, of Cui. Med., 
••• 
Jan., 1869. 
tt 
Nose and 
<4 
44 44 
Jour, of Cut. Med., 
cheek. 
Jan., 1869. 
tt 
< 
II 
44 4« 
Jour, of Cut. Med., 
Jan., 1869. 
9 
Ears and cheek. 
44 44 
Jour, of Cut. Med.. 
Jan., 1869. 
10 
Lids and neck. 
... 
Jour, of Cut. Med., 
Jan., 1869. 
tt 
Cheek, ears and 
44 
44 44 
Jour, of Cut. Med., 
scalp. 
... 
Jan., 1869. 
12 
•• 
Ears and nose. 
44 
44 44 
Jour, of Cut. Med., 
Jan., 1869. 
13 
<1 
•< 
44 44 
Jour, of Cut. Med., 
Jan., 1869 
14 
17 
20 
Face. 
Face. 
Both. 
44 
Palms and Dorsum. 
- 
F. 
Neumann, I. 
Wiener Me d. Wo- 
chenschr., 1869. 
15 
« 
M 
<4 
44 
Palm. 
Rhagades. 
44 
Kohn (Kaposi). 
Archiv f. Dermot. 11. 
Spyh., 1869. 
16 
20 
23 
«< 
« 
44 
... 
44 
Kaposi, M. 
Archiv f. Dermal. 11. 
Syph., 1872. 
17 
36 
« 
44 
44 
Sides. 
44 
44 44 
Archiv f. Dermal. 11. 
Syph., 1872. 
18 
24 
<< 
«4 
44 
Ends. 
44 
44 <4 
Archiv f. Dermal. 11. 
Syph., 1872. 
19 
29 
<• 
« 
Sides. 
44 
44 44 
Archiv f. Dermal. 11 
Syph., 1872. 
20 
32 
<< 
« 
44 
Dorsum. 
44 
44 44 
Archiv f. Dermat. 11 
21 
Hand. 
44 
44 
Fox, T. 
Syph., 1872. 
''Atlas of Skin Dis.," 
Phila., 1876. 
Transactions Brit. 
22 
... 
44 
**• 
Stowers, J. H. 
Med. Ass., in Arch, of 
Dermal., 1879. 
TABLE OF CASES OF ERYTHEMATOUS LUPUS OF THE HANDS. 
210 23 
24 
25 
18 
24 
Fingers. 
Nose. 
Hand. 
Left. 
Third and fifth. 
Dorsum. 
CC 
One finger ampu- 
tated. 
F. 
Stowers, J. H. 
cc cc 
Milton, J. L. 
Transactions Brit. 
Med. Ass., in Arch, of 
Dermat.. 1879. 
Transactions Brit. 
Med. Ass., in Arch, of 
Dermat., 1879. 
Transactions Brit. 
Med. Ass., in Arch, of 
Dermat., 1876. 
26 
Face. 
Fingers. 
Dorsum. 
Diminished power 
of flexion. 
Jamieson. 
Edin. Med. Jour., 
1878. 
27 
21 
25 
Face. 
« 
Both. 
Palms. 
F. 
Bulkley, L. D. 
Jour. Cut. and Ven. 
Dis., 1879. 
28 
7 
14 
Forearms. 
<• 
CC 
Fingers. 
Fingers '* pulpless." 
M. 
Hutchinson, J. 
" Leet, on Clin. Sur- 
gery," Part II, 1879. 
29 
12 
Face. 
cc 
cc 
M. 
Ci cc 
" Leet, on Clin. Sur- 
gery," Part ii, 1879. 
30 
42 
44 
« 
« 
Fingers. 
F. 
cc cc 
" Leet, on Clin. Sur- 
gery," Part ii, 1879. 
31 
46 
cc 
Both. 
M. 
cc cc 
" Leet, on Clin. Sur- 
gery," Part ii, 1879. 
32 
14 
19 
Hand. 
Left. 
Fingers. 
Dorsum. 
F. 
Cured. 
Hyde, J. N. 
Jour. Cut. and Ven. 
Dis., ii, 1884. 
33 
23 
38 
•< 
Lip and chin. 
Right. 
CC 
Right-handed. 
F. 
Patient disap- 
peared. 
CC cc 
Jour. Cut. and Ven. 
Dis., ii, 1884. 
34 
14 
29 
Left. 
Fingers. 
Palm. 
Melanodermie 
striæ of face. 
F. 
Slightly im- 
proved. 
cc cc 
Jour. Cut. and Ven. 
Dis., ii, 1884. 
85 
26 
38 
•* 
Right. 
CC 
Dorsum. 
Rhagades ; used 
right hand con- 
stantly. 
M. 
cc cc 
Jour. Cut. and Ven. 
Dis., ii, 1884. 
88 
26 
30 
Hands. 
Both. 
Index, middle 
and right, right; 
all on left. 
CC 
F. 
Cured before 
seen. 
Taylor, R. W. 
Unpublished, 1887. 
Cured. (Much 
37 
31 
35 
Face. 
Face. 
Right. 
M. 
relieved in six 
months.) 
CC cc 
38 
48 
50 
Right 
thumb. 
Both. 
Thumb and in- 
dex right; thumb 
and middle left. 
Dorsum and radial 
aspect of right 
thumb. 
M. 
Curedin eight 
months. 
Heitzman, C. 
cc cc 
Nearly well in 
39 
20 
22 
Left index 
finger. 
Nose. 
CC 
Dorsum of index. 
Dorsum ; few spots 
on palm. 
M. 
a m o n t h ; re- 
lapses in one 
year. 
Fox, G. H. 
cc cc 
40 
50 
60 
Left hand. 
Left. 
Index and little 
finger. 
Dorsum. 
M. 
Cured. 
Sherwell, S. 
cc cc 
41 
Hand. 
Hands. 
Only the hand af- 
fected. 
White, James C. 
cc cc 
12 
<c 
CC 
cc 
CC cc 
Cl cc 
43 
<< 
cc 
<c 
cc cc 
CC iC 
44 
cc 
cc 
cc cc 
cc cc 
45 
50 
55 
Right hand. 
Forearm. 
Right. 
All. 
Dorsum. 
Diminished power 
of flexion. 
M. 
Nearly cured ; 
relapse in one 
Ohmann-Dumes- 
nil, A. H. 
cc cc 
year. 
211 212 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
The part first implicated is a matter of some interest. This fact is reported in 39 
cases. In these, the fingers were the portion first affected in fifteen cases ; the face in 
twelve, the hand in eleven and the forearm in one. In this last case the arm was 
exposed, bnt this seems to have played no part in the production of the disease. 
Besides the hands or fingers, we find that, in a number of cases, other portions of the 
skin were involved. In the twenty-eight cases where this involvement is noted, the 
nose and face are mentioned most often. In fact, it is only in my case-of those where 
other portions were affected-that it was not some portion of the face or head that was 
also involved. In twelve of these cases the disease began in the face ; so that, in six- 
teen cases, the parts other than the hands were invaded subsequently to the appearance 
of the disease upon the hands. 
In the entire list of forty-five cases specific information as to the hands implicated 
is given in thirty-one; of these, both hands suffered in fifteen cases; the right only, in 
four; the left only, in four; "one hand" is mentioned in four cases, and four are 
unspecified. Or, adding those specified distinctly, we find that in fifteen both hands 
were involved, and in twelve one hand only, or very nearly in equal proportions. Six 
males and nine females had both hands involved ; three males and one female had the 
right hand, only, involved; and one male and three females had the left hand only as 
the seat of the disease. The affection was as severe on the left hand of a right-handed 
individual as on the right one of another right-handed patient. The amount of use to 
which the hand is put seems to exercise no influence upon the severity of the involve- 
ment. 
In thirty-three of the cases it is reported that the fingers were involved. In all 
those where any details are given, however, it is noted (as I did in my case) that the 
lesion never goes beyond the border of the nail. The process seems to stop short here, 
and the nail continues to grow in a normal manner, a fact which is confirmatory of the 
view that the process is a superficial inflammation, an opinion which is also confirmed 
by the appearance of the scars following the lesions and by microscopical examination. 
The seat of erythematous lupus of the hand is also a matter of some interest. The 
dorsal aspect of the hand is, apparently, the site of predilection. In twenty-three cases 
where the location is mentioned the dorsum was the sole seat of the disease in fifteen 
cases. In three the palm alone was affected, and in two both dorsum and palm were 
implicated. In three cases the side of the hand was affected, and in one the ends of the 
fingers. 
In two cases there were fissures observed in the hands, and in one (No. 28) the pulps 
of the fingers were atrophied, this being probably due to the fact that the ends of the 
fingers were affected. In several the power of flexing the hand was markedly dimin- 
ished. 
In regard to the general condition, it may be stated that while a number of authors 
report a depraved general condition, others state that their patients were apparently in 
good health. As this matter is not fully dwelt upon by authors and reporters, it is not 
possible to form a just conclusion on this subject. In the case which I have reported 
the patient has always been in a first-class condition physically, and has never com- 
plained of any other affection but that of his hand and arm. 
PATHOLOGICAL HISTOLOGY. 
Being engaged at the time in microscopic work, I requested my friend, Dr. F. L. 
James, of St. Louis, to examine the specimens, and the following is his report :- 
The material from which the microscopical preparations described and figured herein 
were made was obtained by Dr. Foster, of Memphis, Mo., who, with a bistoury, shaved 
off from the affected surface three buttons or plaques of diseased skin. Unfortunately, 
the plaques were put into strong alcohol at once, and hence were considerably and per- SECTION XIV-DERMATOLOGY AND SYPHILOGRAPHY. 
213 
manently distorted, and still more unfortunately, in removing them in the manner 
stated, I was furnished with none of the surrounding or subjacent tissues, a study of 
which is absolutely essential to arriving at anything like a satisfactory examination of 
the morbid processes and appearances and a correct delineation of the pathological 
changes wrought in the skin by the progress of the disease. These facts are the more 
to be regretted as the pathological histology of lupus erythematosus is far from being 
properly understood, as is well known. 
In a section of a plaque stained with osmic acid and hæmatoxylon, drawn with a 
three-quarter-inch objective and two-inch eyepiece, giving an amplification of sixty-five 
diameters approximately, the stratum corneum was almost entirely absent. On the 
peripheræ of the plaque a portion of it is found. The stratum lucidum, in a disinte- 
grated condition and separated from the stratum granulosum by layers of round-cell 
infiltration, still remains over a large portion of the surface. 
When we undertake to compare the balance of the structures with the normal skin, 
all is chaos. The invasion of the destroying agency-the small, round cell, which is 
found deposited everywhere in countless numbers-has totally altered and changed the 
relationships of the parts. In portions of the plaque the papillæ can be clearly made 
out, but they are distorted into strange, fantastic shapes and enormously enlarged. 
In other parts they are entirely absent or their outlines have been merged, by means 
of infiltrating deposit, into the surrounding tissues, so that they can no longer be fol- 
lowed. In some sections taken from the centre of one of the plaques the overlying layers 
of the skin have been destroyed, and the papillæ, enlarged to ten or even twenty times 
their natural size, rise to the very surface. In these cases there are deposits of what 
appears to be effused blood. 
The sebaceous glands are distorted and swollen into almost unrecognizable shapes, 
and are filled with the ubiquitous round cell. Among these round cells we occasionally 
find nidi of very large nucleated and caudate cells, resembling the so-called giant 
cell, as also a few fat globules. At one point we find masses of caudate cells arranged 
in circles resembling somewhat the so-called ' ' pearls ' ' of epithelioma. 
In a close and prolonged study of the large number of sections made by me of the 
several plaques placed at my disposal, I have found the remains of but one single hair. 
It is split and frayed and broken, and the bulb is separated from its sheath. 
As to the nature of these destructive infiltrating cells, so far as the microscope can 
determine from the specimens furnished me, and from which my preparations and draw- 
ings are made, I am unable to discover that they differ in any respect from the embry- 
onic corpuscle of the inflammatory process. 
As to the method of invasion, it is impossible, from the specimens at my disposal, 
to form any theory, or to come to any definite conclusion, since all parts of the plaques 
seem equally invaded. From the greater destruction, however, that is apparent in the 
sebaceous follicles and sweat glands, it is evident that these are the earliest seat of the 
invasion. It is in these that we occasionally find masses of granular matter of a dirty 
yellow hue, and which do not take the stains applied, even osmic acid having no marked 
effect on them. 
A large number of differential stainings with chloride of gold and with osmic acid 
failed to show any trace of nerve terminals left. This fact probably accounts for the 
total absence of pain which the patient declared to exist in the plaques. He also states 
that the knife, in removing the plaques, caused no pain. 
It was intended, could the patient have been induced to allow the removal of further 
material, to make differential stainings, in search of specific microorganisms. His 
failure to respond to our requests has, however, prevented the fulfillment of this design, 
and the work is left for future investigation. 
Frank L. James. 214 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
The microscopic appearances described above would- naturally lead to the same con- 
clusions that the clinical features do, in a general sense, that the process is essentially 
an inflammatory one, and that it seems to be more generalized in the epidermic struc- 
tures, attacking them and the organs developed from them in preference to the deeper 
ones, the latter becoming but superficially implicated. That the correctness of the 
views maintaining the position that the process is not essentially connected with the 
sebaceous glands is firmly based upon sound reasoning does not admit of a doubt, pro- 
vided that clinical observation has been accurate; for by referring to the Table, it will 
be found that in five cases the palms were affected and in one the ends of the fingers - 
all regions where no sebaceous glands exist. 
In conclusion, I wish to acknowledge valuable assistance from several papers, espe- 
cially Dr. J. N. Hyde's, on this subject, and I take this occasion to extend my most 
heartfelt thanks to all the gentlemen who had the kindness to answer my letters of 
inquiry on this subject, for their uniform courtesy. 
Drs. Unna, Hamburg, Thin, London, Klotz, New York, Zeisler, Chicago, 
Robinson, New York, discussed the paper, and Dr. Ohmann-Dumesnil closed. 
DISCUSSION. SECTION XIV-DERMATOLOGY AND SYPHILOGRAPHY. 
215 
FOURTH DAY. 
DAS SEBORRHOISCHE EKZEM. 
SEBORRHŒIC ECZEMA. 
L'ECZÉMA SÉBORRHOÏQUE. 
VON P. G. UNNA, 
Hamburg, Deutschland. 
Es war seinerzeit entschieden ein grosses Verdienst vom 'älteren Hebra, eine Reihe 
von Krankheitszuständen der Haut, welche bis dahin vereinzelt abgehandelt wurden, 
so gewisse Porrigines, Impetigines und squamöse Ausschläge, als verschiedene Stadien 
einer einzigen Krankheit, des chronischen Ekzems, erkannt und zusammengefasst zu 
haben. In der Folge ist dann der Begriff des Ekzems in der von Hebra erweiterten 
Gestalt mit dem des Hautcatarrhs verschmolzen, und wir sind gewohnt, alle möglichen 
Reizzustände der Haut, welche mit Bläschen, Jucken und Schuppen einhergehen und 
den Eindruck einer oberflächlichen Dermatitis hervorrufen, heute Ekzem zu nennen. 
Ich glaube, es wird wenige unbefangene Dermatologen geben, welche diesen heutigen 
Standpunkt der Ekzemlehre aus vollem Herzen gut heissen. Zunächst ist es die 
nicht zu leugnende Thatsache, dass es eine Reihe wohl characterisirter Ekzeme giebt, 
welche bei noch so langem Bestände niemals die typischen Formen des Bläschens, der 
rothen nässenden Fläche und schliesslich der Schuppen durchmachen, sondern von 
Anfang bis zu Ende entweder nur Papeln auf erythematösem Boden und später 
Schuppen oder überhaupt nur Schuppen auf verdickter, gerötheter Haut zeigen. Der 
Praktiker hilft sich in solchen Fällen mit dem Ausdruck "trockenes Ekzem," um sich 
dem Collegen verständlich zu machen, nicht ohne einen ironischen Seitenhieb auf 
unsere eigenthümliche Nomenclatur, die hier wirklich an den Lucus a non lucendo 
erinnert. 
Ich lege auf diese Contradictio in adjecto keinen besonderen Werth, denn sie ist 
nur eine scheinbare. Beim "Ekzem" sollte allerdings eine Feuchtigkeit aussickern ; 
aber seitdem dieser Begriff mit dem des Hautcatarrhs identificirt ist, braucht unser 
Ekzembegriff nicht weniger und mehr zu sagen, als der des Catarrhs überhaupt. Und 
bei den Schleimhäuten ist es bereits lange Gebrauch geworden, von einem trockenen 
Catarrh so gut zu reden, wie von einem feuchten. Es ist auch in der That nicht 
nöthig, dass die grössere Durchfeuchtung der Oberhaut, die wir bei jedem Catarrh vor- 
aussetzen müssen, gerade sichtbarlich in Bläschen, Pusteln und rinnenden Tropfen zu 
Tage tritt. 
Diese Erweiterung des Ekzembegriffes auf trockene Hautcatarrhe würde ich an und 
für sich, wie gesagt, gut heissen. Aber gerade die verschiedenen, von Anfang bis zu 
Ende trockenen, nur selten hier und da nässenden Formen des Ekzems sind auch in 
anderen klinischen Symptomen so eigenartig, dass gerade kein besonderer klinischer 
Scharfblick dazu gehört, hier wirklich verschiedene Krankheitstypen auszusondern, 
die mit Unrecht heute in die Olla potrida, genannt chronisches Ekzem, zusammen- 
geworfen werden. 216 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Von diesen trockenen Formen ausgehend, gelang es mir denn auch schon vor Jahren, 
eine Reihe wohlcharacterisirter Ekzemtypen zunächst zu meinem Privatgebrauch und 
zu rascher Verständigung mit meinen Assistenten und Zuhörern aufzustellen, und in 
einigen neueren Arbeiten habe ich bereits, so kurz wie es die sonstige Tendenz derselben 
gestattete, einige derselben angeführt. In meiner Privatpraxis und Klinik ist deshalb 
schon seit Jahren die einfache Diagnose "chronisches Ekzem" verpönt ; ich begnüge 
mich nicht mit dem rein äusserlichen, bisherigen Behelfe der Lehrbücher, das chro- 
nische Ekzem nach den Körpergegenden zu bezeichnen, im Uebrigen aber überall für 
ein und denselben Krankheitsprocess, nämlich das Ekzem, zu halten, sondern ich 
mache es mir und meinen Assistenten zur Pflicht, nach genauer Untersuchung und 
Aufnahme der Anamnese die Diagnose auf ein ganz bestimmtes Ekzem zu stellen, und 
ich kann Sie versichern, dass in wenigen Monaten der Blick eines jeden Arztes, der auf 
die typischen Unterschiede dieser Hautcatarrhe aufmerksam gemacht ist, für dieselben 
so geschärft ist, dass er diese feineren Diagnosen überall zu machen im Stande ist. 
Nehmen wir z. B. das Gesichtsekzem eines Säuglings, so wissen meine Schüler sehr 
wohl, dass hier hauptsächlich drei absolut verschiedene Typen zu unterscheiden sind : 
nämlich 1) das rein nervöse Dentitionsekzem, 2) das tuberkulöse Ekzem und 3) das 
seborrhoische. Wenn das Ekzem nicht schon sehr lange bestand, ehe es in Behandlung 
kommt, so ist diese Unterscheidung sogar meist prima vista gemacht. Eine Localisation 
an den Schleimhauteingängen des Auges, der Nase, des Mundes und der Ohren, eine 
Complication mit phlyctänulärer Keratitis, mit scrophulöser Rhinitis, mit Otorrhœ, 
ein grossblasiger Typus des Ekzems mit Oedem und starker, verbreiteter Drüsen- 
schwellung bei fast fehlendem Juckreiz, characterisirt das tuberkulöse Ekzem, welches 
Lupus und Tuberkulose prognosticiren lässt. Ist dagegen die Umgebung der Augen, 
der Nase und des Mundes frei, so dass das Ekzem wie eine in der Mitte ausgeschnittene 
Maske das Gesicht umrahmt, so kann es sich entweder um ein Dentitionsekzem oder 
um ein seborrhoisches Ekzem handeln. Das erstere tritt bei vollkommen gesunder 
Haut meist in der Mitte der Backen, dann auf der Stirn ganz symmetrisch und fast 
stets zugleich auf der Radialseite beider Handrücken und der Handgelenke auf, juckt 
ganz enorm, um so mehr, je kräftiger das Kind und je gesunder und derber noch die 
Oberhaut ist ; es ist ganz abhängig von reflectorisch wirkenden Reizen und speciell 
von dem Fortschritt der Dentition, verschwindet manchmal nach dem Durchbruch 
einiger Zähne ebenso schnell, wie es gekommen ist, um nach einigen Tagen wiederzu- 
kehren ; es erinnert an Herpes Zoster, indem auch hier eine Gruppe zunächst verein- 
zelter, schön geformter Bläschen auf gerötheter Basis rasch aufschiessen, unterscheidet 
sich aber durch die stricte Symmetrie und die Neigung zu fortwährenden Recidiven. 
Ganz anders das seborrhoische Ekzem. Hier war die Haut nicht ganz gesund, son- 
dern es ging regelmässig eine, wenige Wochen nach der Geburt auftretende, oft gar nicht 
bemerkte, aber stetig sich ausbreitende Seborrhoe des behaarten Kopfes voraus. Diese 
überzieht, oft erst, nachdem sie einen nässenden Character angenommen, die Ohren, 
Stirn und Backen, springt, ohne die Umgebung der Augen zu berühren, auf die Augen- 
wimpern über und breitet sich dann nach der Schulter und den Oberarmen zu in meist 
trockenen, fettigen Herden aus. Dieses Ekzem behält überall, auch an nässenden 
Stellen, seinen fettigen Character bei, juckt bedeutend weniger als das Dentitionsekzem, 
aber doch mehr als das tuberkulöse, und kann sich eher als die anderen beiden 
genannten Ekzeme zu einem universellen Ekzem ausbilden, indem es dann gewöhnlich 
auf die Genitalien überspringt und von hier aus Beine und Rücken überzieht. 
So verschieden wie der klinische Typus, so verschieden ist die Behandlung, und 
deshalb ist die sofortige richtige Diagnose auch praktisch von grossem Werthe. Beim 
nervösen Ekzem ist die Aufpinselung von Zinkichthyolleim, eventuell als Maske mit 
Binden, anzurathen, die das Kind nicht abkratzen kann, daneben aber die geeignete 
Behandlung des inneren Nervenreizes durch Bromkalium, Calomel, Cocaïnbepinselung SECTION XIV DERMATOLOGY AND SYPHILOGRAPHY. 
217 
des Mundes u. s. f. Viel radicaler ist das tuberkulöse Ekzem zu behandeln. Da das 
heftige Jucken fortfallt, ist eine feste Maske unnöthig. Hier ist das rothe Quecksilber- 
präcipitat und ebenfalls das Ichthyol als Zusatz zur Zinksalbe vortrefflich. Beim 
seborrhoischen Ekzem hilft dagegen in allen Fällen ein Zusatz von Schwefel zur Zink- 
salbe, oder auch von Resorcin, während Ichthyol hier nutzlos ist. 
Ich möchte nun auch nicht so missverstanden werden, als wenn ich mich anheischig 
machte, in jedem Falle von chronischem Ekzem diè Art desselben bestimmen zu 
können. Aber in acht oder neun Fällen von zehn gelingt dies doch, und die übrigen 
sind solche, welche schon sehr lange bestanden haben oder in welchen der klinische 
Anblick und die Anamnese gleichmässig wahrscheinlich machen, dass eine Mischung 
zweier Ekzeme vorliegt, dass z. B. zu einem rein nervösen Dentitionsekzem eines der 
beiden anderen, parasitären, Ekzeme sich hinzugesellt hat. Auch dann noch lässt sich 
zuweilen während der Heilung an der Art der Wirkung der Mittel oder an einem 
frischen Recidiv die genauere Diagnose stellen. 
An diesem Beispiele, meine Herren, mögen Sie erkennen, dass man, ohne das 
klinische Gebiet zu verlassen, genauere Ekzemdiagnosen machen kann als die bisher 
beliebten Diagnosen eines chronischen Ekzems des Scrotums, eines impetiginösen 
Ekzems des Nackens, eines trockenen Ekzems der Arme u. s. f. Und zugleich hat sich 
diese Art, die Dinge anzusehen, für die Praxis ungemein bewährt und den Blick für 
die verschiedene Wirkung unserer Mittel sehr geschärft. 
Aber als klinische Diagnosen bleiben dieselben zunächst vorläufige, d. h. sie bleiben 
abhängig von dem Zutrauen der Fachcollegen und dem praktischen Nutzen, welchen 
diese aus ihrer Annahme ziehen. Zwingende Beweise für ihre Existenz und eine 
genaue Abgrenzung derselben unter einander können erst erwartet werden, wenn von 
den parasitären Formen die Parasiten sämmtlich rein gezüchtet vorliegen und von den 
nervösen Formen die Abwesenheit des Parasitismus und ihre Abhängigkeit vom Nerven- 
system erwiesen ist. 
Erst in dem Maasse und in der Reihenfolge, als es mir und Anderen gelingt, diese 
den klinischen Takt weit überbietenden objectiven Beweise beizubringen, werde ich es 
wagen, den Fachcollegen diese verschiedenen Ekzemtypen detaillirt vorzulegen, und 
die Folgezeit wird eben lehren, ob auf diese Weise eine befriedigende Eintheilung der 
Ekzeme möglich ist, ob diese rein klinischen Unterscheidungen richtig inspirirt waren. 
In diesem Sinne will ich Ihnen, meine Herren, heute etwas ausführlicher die 
klinische Seite eines der wichtigsten meiner Ekzemtypen vorlegen, meines Ekzema 
séborrhoicum. 
Da dieser Begriff für mich schon lange an die Stelle des Begriffes der sogenannten 
"trockenen Seborrhoe " getreten ist, so würde ich, wollte ich in einem Vortrage dieses 
Thema erschöpfen, auch in eine historische Kritik jenes auf sehr schwachen Grundlagen 
aufgebauten Krankheitstypus eingetreten haben. Es würde mich das viel zu weit 
führen, und ich muss Sie bitten, sich in dieser Beziehung die im letzten Hefte meiner 
Zeitschrift erschienene kritische Uebersicht : "Was wissen wir von der Seborrhoe ? " 
anzusehen. Es genügt für den heutigen Zweck, wenn ich Ihnen kurz als Resultat 
meiner diesbezüglichen Studien mittheile, dass es eine Talgdrüsenhypersecretion, welche 
sich klinisch als sogenannte trockene Seborrhoe durch Auflagerungen festen Talgdrüsen- 
productes geltend machte, nicht giebt. 
Was man bisher als Seborrhœen zusammenfasst, sind zwei ganz verschiedene Dinge. 
Erstlich eine wirkliche, fettige Hypersecretion, die aber nicht von den Talgdrüsen, 
sondern von den Knäueldrüsen ausgeht. Diese Hypersecretion, die sogenannte ölige 
Seborrhoe, entleert sich durch die Schweissporen nach Aussen, ist also durchaus nur als 
eine Hidrosis zu bezeichnen, und zwar als eine Hyperidrosis oleosa. Trennen wir diese 
vollständig ab, so bleibt die Gruppe der verschiedenen sogenannten trockenen Seborrhœen 
übrig. Von diesen nehme ich wiederum die Form der Vernix caseosa aus, welche eine 218 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Sonderstellung einnimmt und nur beim Fötus vorkommt ; sie ist das Product einer 
echten Hypersecretion der Knäueldrüsen, vermischt mit sich abschuppenden Horn- 
lamellen. Und ich nehme zweitens vorläufig die sogenannte Pityriasis tabescentium 
aus, weil ich dieselbe noch nicht microscopisch untersucht habe. Alle anderen soge- 
nannten trockenen Seborrhœen, welche ich sämmtlich microscopisch zu untersuchen 
Gelegenheit hatte, sind chronisch entzündliche Processe der Haut und nichts weniger als 
Hypersecretionen der Talgdrüsen. Ganz besonders gilt dieses für die zur Alopecie 
führende Pityriasis capitis, die ich mit F. Hebra als identisch betrachte mit der Sebor- 
rhœa capitis, aber nicht in dem Sinne, als wären beide Talgdrüsenaffectionen, sondern 
deshalb, weil ich klinisch und histologisch nachweisen kann, dass beide nur verschiedene 
Formen einer ganz bestimmten, entzündlichen Hautkrankheit sind, welche vermöge 
einer Hypersecretion der Knäueldrüsen einen abnormen Fettreichthum aufweist. Dieser 
Fettreichthum sitzt nicht nur, wie man gemeiniglich glaubt, in den Schuppen, sondern 
er durchsetzt die gesammte Lederhaut und Oberhaut wie bei keiner anderen bisher 
bekannten Krankheit. Die Lymphbahnen der gesammten Haut sind förmlich injicirt 
mit Fett, und die Production fettiger Schuppen ist daher eine nothwendige, nicht 
weiter überraschende Folge. Die Herkunft dieses Fettes können nicht die Talgdrüsen 
sein, da dieselben nach den übereinstimmenden Resultaten von Malassez, Schuchardt 
und mir durchaus keine Zeichen von Hypertrophie und gesteigerter Thätigkeit zeigen, 
vielmehr durch abnorm feste Hornmassen vollständig verstopft sind. Gerade die in die 
Follikel eintauchenden Fortsätze seborrhoischer Schuppen, welche man bisher stets 
als Beweis ansah, dass die fettigen Schuppen Product der Talgdrüsen seien, hätte man 
bei genauerer Untersuchung für Das erkennen müssen, was sie sind, nämlich für die, 
die Follikel verstopfenden Hornmassen. Dieselben beweisen nur, dass dieselbe ent- 
zündliche Parakeratose, welche die Oberfläche der Haut befällt, sich auch auf die 
Haarbalgtrichter, resp. den Talgdrüsenausführungsgang fortsetzt, und sind der schla- 
gendste, microscopisch-klinische Beweis für die mangelnde Thätigkeit der Talgdrüsen. 
Andererseits wird dieser Umstand aber auch durch das Product der Schuppen bewiesen, 
welches niemals Talgdrüsenzellen und deren Inhalt aufweist, sondern nur Hornmassen 
von dem Character, wie er allen entzündlichen Parakeratosen und Catarrhen der Haut 
zukommt, welche als specifische Eigenthümlichkeit aber noch einen abnorm hohen 
Fettgehalt aufweisen. Dass die wahre Quelle dieses abnormen Fettgehaltes in den 
Knäueldrüsen zu suchen ist, kann ich durch vier histologische Momente beweisen : 
durch die Identität des Fettes, welches die Cutis, Oberhaut und die Schuppen durch- 
setzt mit dem Knäueldrüsenfett, durch die entzündliche Veränderung, Hypertrophie 
und die Zeichen abnorm gesteigerter Thätigkeit in den Knäueldrüsen, durch die Dila- 
tation der Schweissporen innerhalb der verdickten Hornmassen und durch die constante 
Hypertrophie des normalen Knäueldrüsenproductes in der Tiefe der Haut, nämlich 
des Fettpolsters. 
Die genauere Ausführung aller dieser hier nur in groben Umrissen vorgeführten 
Punkte muss ich mir für eine grössere Arbeit über diesen Gegenstand aufsparen. 
Ebenfalls will ich hier nicht auf die-noch nicht abgeschlossenen-bacteriologischen Ver- 
suche eingehen, welche den parasitären Character des seborrhoischen Ekzems erweisen, 
sondern ich begnüge mich, nachdem ich so in vorläufiger Weise den Rahmen dieser 
Krankheit nach Aussen hin abgesteckt und ihr Verhältniss zu den historisch verwandten 
Typen beleuchtet habe, mit einer kurzen Schilderung des sehr vielgestaltigen klinischen 
Bildes. 
Der Ausgangspunkt fast aller seborrhoischen Ekzeme mit wenigen Ausnahmen liegt 
auf dem behaarten Kopfe. Sehr selten beginnt die Krankheit mit der entsprechenden 
Affection des Augenliderrandes oder einer der bekanntlich an Knäueldrüsen reichen 
Contactstellen der Haut (Achselhöhle, Ellbeuge, Cruroscrotalfalte). Auf dem Kopfe 
entsteht sie meistens aus unmerklichen Anfängen, und erst eine plötzliche Verschlim- SECTION XIV DERMATOLOGY AND SYPHILOGRAPHY. 
219 
merung nach monate- oder jahrelangem Bestände, ein auffälliger Haarschwund, eine 
ungewöhnliche Schuppen- oder Borkenansammlung, heftigeres Jucken oder endlich ein 
umschriebenes Nässen, ein offenbares Ekzem, führt den Patienten zum Arzt. Die 
Affection beginnt also als ein latenter Catarrh. Die ersten Spuren desselben äussern 
sich als ein festerer Zusammenhalt der Hornschicht, die daher nicht in insensibler, son- 
dern in sensibler Weise, d. h. in grösseren Hornlamellen abschuppt, und weiter als eine 
fehlerhafte Vertheilung des Hautfettes, indem die Haare durch Verschluss der Haar- 
balgtrichter abnorm trocken werden, während die Oberhaut selbst und die von ihr 
abschilfernden Schuppen (durch Knäueldrüsensecret) abnorm fettig sich anfühlen. 
Von hier aus geht der Process in drei Richtungen auf dem Kopfe selbst weiter. 
Entweder die Schuppenmassen vermehren sich einfach, bleiben aber stets weiss und 
nur mässig fettig ; allmählich gesellt sich stärkerer Haarausfall dazu und es entsteht 
die bekannte, characteristische Glatze der Alopecia pityrodes, während die Kopfhaut 
an den kahl werdenden Stellen immer weniger verschieblich wird. Das Schuppen 
lässt wieder nach, um schliesslich bei ausgesprochener Glatze ganz aufzuhören und 
einer Hyperidrosis oleosa Platz zu machen. 
In einer anderen Reihe von Fällen nimmt die Schuppenmenge so zu, dass dieselbe 
während der ganzen Krankheitsdauer das Hauptsymptom darstellt. Dieselben häufen 
sich entweder als dicke, fettige Borken zwischen den Haaren an, welche der Haut mehr 
oder minder fest adhäriren, aber doch meist ohne Blutung mit einer stumpfen Kante 
abzulösen sind; oder sie umgeben bei vor wiegendem Befallensein der Haarbalgtrichter 
die austretenden Haare mit Manschetten aus Hornsubstanz. Die Farbe der fettigen 
Borken variirt von weiss durch gelb und braun bis braunschwarz ; aber die dunkle 
Farbe ist keineswegs ein Product des Alters der Schuppen und der Unreinlichkeit, 
sondern sie ist in den einzelnen Fällen individuell verschieden und dann im Verlaufe 
der ganzen Krankheit constant. Einige Patienten, bei welchen die dann gewöhnlich 
feineren, fest anliegenden Schuppen die Farbe des Ohrenschmalzes oder ein noch dunk- 
leres Braun zeigen, beklagen, sich überhaupt nur über den vermeintlichen Schmutz 
auf dem Kopfe, welchen sie vergeblich mit Seife zu entfernen gesucht haben. Während 
die erste Form meistens den ganzen Kopf ziemlich gleichmässig befällt, findet diese 
zweite sich meist an einigen Stellen des Kopfes stärker ausgeprägt, so dass es hier zu 
hervorragenden, dicken Borken kommt, welche dann auch auf einer mässig verdickten, 
hyperämischen Haut aufsitzen. Solche Prädilectionsstellen sind die Höhe der Scheitel- 
beine und die Hinterhauptsgegend. Diese stärkere Form hat nun auch eine grosse 
Tendenz, den behaarten Kopf zu verlassen und sich über die benachbarten, mit Flaum 
bedeckten Hautstellen auszubreiten. Der erste Vorstoss geschieht gewöhnlich an der 
Haargrenze der Stirn und Schläfe. Sofort, wie die Affection hier erscheint, ist ihr 
Character auch viel deutlicher ausgeprägt als auf dem behaarten Kopfe. Sie schreitet 
hier mit einem scharf markirten, fast stets, manchmal sogar stark gerötheten, mit 
gelben, fettigen Schuppen belegten Rande fort und umsäumt die Haargrenze guirlanden- 
f örmig in einer etwa fingerbreiten Zone. Hier macht sie in vielen Fällen zunächst 
Halt. Es ist dieselbe Region, für welche die Syphilis und die Acne varioloformis die 
bekannte Vorliebe hegt. Es giebt also auch eine Corona seborrhoica, die den Befallenen 
einen sehr typischen Anblick verleiht. Weiterhin zieht sich die Affection gewöhnlich 
an den Schläfen, über die Ohren nach dem Hals herab, oder sie springt auf die Nase 
und Backen über. Auch bei dieser Form concurrirt sehr häufig ein beträchtlicher 
Haarausfall, jedoch nicht mehr oder minder als bei der ersten Form. In beiden Fällen 
ist die Alopecie durchaus nicht der Schuppenmenge proportional, sondern lediglich der 
Straffheit, mit welcher die Kopfhaut in dieser Krankheit an die Galea aponeurotica 
angeheftet wird. 
Die dritte Form ist diejenige, bei welcher die catarrhalischen Erscheinungen am 
stärksten ausgesprochen sind und es zum Nässen kommt. Gewöhnlich ist es die dem NINTH INTERNATIONAL MEDICAL CONGRESS. 
220 
Ohre zunächst gelegene Partie der Schläfengegend, in welcher sich, nachdem eine 
einfache Pityriasis mit Jucken, Spannung und Röthung vorausgegangen, das Nässen 
einstellt. Die fettigen Schuppen werden abgehoben und es tritt, wie immer beim 
Ekzem, die basale, feucht glänzende Hornschicht dunkelroth zu Tage. Bei stärkerem 
Nässen wird auch diese an einzelnen Stellen erodirt, so dass hier die Stachelschicht frei 
liegt. Dabei geht die fettige Absonderung fort, so dass die gebildeten Krusten immer 
dick, bröckelig, feucht und fettig zugleich sind. Fast immer werden bald auch die 
Ohren, wenigstens die äussere Kante derselben, befallen ; es tritt, wie gewöhnlich, 
Oedem, Schwellung des äusseren Gehörganges und die subjectiven Beschwerden hinzu, 
die jedes Ohrekzem begleiten. Während sich die nässende Form beim Erwachsenen 
meist vom Ohr aus auf den Hals weiter ausdehnt, schreitet sie bei Kindern, und beson- 
ders bei Säuglingen, die an Dentitio difficilis laboriren, auf die Wangen und die Stirn 
fort, indem die habituelle Hyperämie dieser Theile den Boden vorbereitet. Durchaus 
nicht immer verbreitet sich das Nässen auch über den ganzen behaarten Kopf ; häufig 
bleibt auf dem Mittel- und Hinterkopfe eine einfache Pityriasis oder Seborrhoe bestehen, 
während Hals und Gesicht das Aussehen eines Ekzema madidans bieten. 
Diese drei Formen oder Grade des seborrhoischen Ekzems am Kopfe entsprechen 
bisher meist getrennt bearbeiteten Affectionen der Autoren. Die erste ist die gewöhn- 
liche Pityriasis capitis, die allmählich gewöhnlich zur Alopecia pityrodes führt ; die 
zweite ist die sogenannte Seborrhœa sicca capitis ; die dritte umfasst eine grosse Anzahl 
der bisher unter dem Sammelbegriffe des Ekzema chronicum capitis unterschiedlos 
zusammengefassten Affectionen, und zwar gehören von den Ekzemen der Kinderköpfe 
nur ganz bestimmte, oben näher characterisirte hierher, von den Kopfekzemen der 
Erwachsenen jedoch die meisten, besonders fast alle der besser situirten Stände. 
Indem wir das seborrhoische Ekzem jetzt auf seiner Reise um den Körper begleiten, 
um die ungemein verschiedenen Gestalten zu bestimmen, unter welchen es uns auf den 
verschiedenen Hautregionen entgegentritt, trennen wir innerhalb jeder Region am 
besten die genannten drei Formen derselben, die ich zum Zwecke rascher Verständigung 
kurz die schuppende, die borkige und die nässende nennen will. 
Vom Kopfe abwärts gehend, gelangen wir an den nächsten Lieblingsplatz in der 
Sternalgegend. Hier findet sich fast nur die borkige Form; viel seltener bei starker 
Behaarung die schuppige und noch seltener die nässende, im Zusammenhänge mit 
einem nässenden, seborrhoischen Ekzem der ganzen oberen Körpergegend. Das borkige 
Ekzem dieser Region ist bereits von verschiedenen Autoren als eine besondere Affection 
beschrieben worden, so neuerdings noch von Colcott Fox unter dem Wilson'schen 
Namen : Lichen annulatus serpiginosus, von den Franzosen als Ekzema marginatum. 
Es sieht ungemein characteristisch aus, - ich möchte sagen, es ist die zierlichste Form 
des seborrhoischen Ekzems. Runde oder ovale Flecken von der Grösse eines Finger- 
nagels stehen hier gruppenweise zusammen, zum Theil coalescirend und dadurch zu 
einem etwa thalergrossen Flecke mit polycyklischer Contur vereinigt. Der Eindruck 
einer vielblätterigen, geränderten, bunten Blume wird durch die nach Aussen scharf 
abgeschnittenen Ränder und die Farbenschattirung hervorgerufen. Jeder einzelne 
Fleck ist nämlich von gelblicher Farbe und besitzt nach Aussen einen ganz feinen, 
rothen Rand, wenn nach dem Reinigen das feine Schüppchen dieses Randes entfernt 
ist. Dieses ist die gewöhnlichste Form unserer Affection in der Sternalgegend bei 
geringer Entwickelung. Man findet sie öfter dort, wo über dem Sternum etwas Fett- 
polster entwickelt ist und längere Haare producirt werden, als wo die Haut sehr zart, 
dünn und haarlos ist. Nimmt die Affection hier grössere Dimensionen an, so ist die 
ursprüngliche Stätte in ein gelb gefärbtes, ziemlich glattes, nur mässig schilferndes 
Centrum verwandelt, an dessen Peripherie, zum Theil unregelmässig zerstreut, zum 
Theil zusammenhängend, aber immer in Form convex nach Aussen gerichteter Bogen- 
linien, sich frische Eruptionen finden, die den Character des ursprünglichen Herdes SECTION XIV-DERMATOLOGY AND SYPHILOGRAPHY. 
221 
besitzen, also eine rothe, papulöse Erhebung darstellen, bedeckt mit gelblichweissen 
oder ganz gelben, bröckeligen, fettigen Schuppen. Diese letztere Form findet sich auch 
meist auf dem Rücken in der Interscapulargegend, der Schweissrinne des Rückens. 
Wieder etwas anders sehen die Flecke in den Achselhöhlen aus, wo sie sich nebenbei 
durch stärkeres Jucken auszeichnen. Schuppen und Borken sind hier fast nie zu sehen, 
sondern nur eine rothe, serpiginös fortschreitende, feine Bogenlinie. Auch die gelbe 
Farbe des Centrums hebt sich hier kaum ab. Diese übrigens seltenere Localisation 
zeigt manchmal eine Steigerung zur nässenden Form, wobei sich dann das Ekzem 
gewöhnlich rasch über den Thorax verbreitet. 
Von der Schultergegend steigt das seborrhoische Ekzem - fast immer in der borki- 
gen, selten der nässenden Form - auf die Arme herunter. Auch hier zeigt es eine 
besondere Vorliebe zu den Beugeseiten, obwohl es die Streckseiten nicht verschont. 
Aber - im stricten Gegensätze zur Psoriasis - bildet der Ellbogen durchaus keine 
Prädilectionsstelle. Gewöhnlich ist er sogar ganz frei ; nur bei universeller Ausbrei- 
tung wird er, immer erst secundär, mitbefallen. Diese Vorliebe für die Beugeseiten 
und Contactstellen erklärt sich aus der Rolle, welche die Knäueldrüsen beim Ekzema 
seborrhoicum spielen. 
_ Die Handrücken sind wieder ein Lieblingssitz der nässenden Form, besonders die 
Rückseiten der Finger. Es ist eine ungemein häufige Combination, dass von einem 
borkigen, seborrhoischen Ekzem des Kopfes ein nässendes der Ohren und des Gesichtes 
und dann sofort mit Ueberspringung des Rumpfes und der Arme ein nässendes Ekzem 
des Hand- und Fingerrückens ausgeht. Sehr selten zeigen Arme und Hände das einfach 
schuppige Ekzem in der Form flacher, gelblicher, juckender und schuppender Flecke. 
Ganz besondere Gestalt nimmt dagegen wieder die Affection an den Handtellern und 
Fusssohlen an, wenn sie hier sich - wie es allerdings selten vorkommt - localisirt. 
Dass sie hier überhaupt auftritt, ist allein schon ein stricter Beweis, dass sie von den 
Talgdrüsen ganz unabhängig ist. Anstatt zusammenhängender Flächen und serpigi- 
nöser Kreise finden wir hier einzelnen Knäueldrüsen entsprechende, erbsen- bis kirschen- 
grosse Schuppenhügelchen, welche einer Psoriasis guttata ähnlich sehen. Bei der 
Abheilung dieser Stellen, die ungemein langsam vor sich geht, schilfert die Hornschicht 
in grösserem Umfange ab und die Hand- und Sohlenfläche nimmt ein landkartenartiges 
Aussehen an. Hier kommt es niemals zum Nässen. Ich habe diese Localisation ganz 
isolirt mit der schuppigen und borkigen Form des behaarten Kopfes und wenigen 
Stellen am übrigen Körper gesehen, wie andererseits bei universellem Ekzema sebor- 
rhoicum des Körpers vom Scheitel bis zur Sohle. 
Am unteren Theile des Rumpfes, auf dem Gesässe und den Hüften sehen wir 
meistens allein die borkige Form, in Ringen und Gyris serpiginös fortschreitend, mit 
Hinterlassung gelblicher Flecke. In der Analgegend findet sich wieder die zierlichere 
Gestalt der Kreise und Ringe, wie wir sie vom Sternum und der Axilla her kennen. 
Die Cruroscrotalfalte und die anliegende Partie der Oberschenkel und des Hodensackes 
ist dagegen ein Lieblingssitz der gröberen, borkigen Ringe, und stellt daher eine nicht 
seltene Art des sogenannten Ekzema marginatum Hebra dar, worunter gewiss eine 
ganze Reihe verschiedener Pilzkrankheiten heutzutage zusammengeworfen wird. Am 
Hodensack geht die borkige Form bei längerem Bestände so gut wie regelmässig in die 
nässende über. Die Oberschenkel sind, wie auch der untere Theil des Rumpfes, seltener 
Sitz der Erkrankung und participiren nur bei universellerer Ausbreitung mit einigen 
Flecken. Ebenso wenig bilden die Streckseiten der Kniee einen Anziehungspunkt für 
unser Ekzem. Dagegen kommt es wieder häufiger vor in den Kniebeugen und vor- 
züglich am Unterschenkel. Hier finden wir im Beginne der Affection stets nur die 
grosspapulöse, grobborkige Form, welche hier aber mehr Platten und münzenförmige 
Flecke als Ringe bildet ; bei längerem Bestände pflegt jedoch die nässende Form nicht 
auszubleiben, besonders bei der Complication mit Varicen. Sehr selten finden sich 222 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
vereinzelte Flecke am Fussrücken. Die Fusssohlen leiden nur gleichzeitig mit den 
Handtellern und in völlig analoger Weise. 
Mit Willen habe ich die Beschreibung des seborrhoischen Ekzems im Gesicht bis 
zuletzt aufgespart, nachdem wir die Hauptformen am Körper haben Revue passiren 
lassen; denn hier finden sich noch einige ganz besondere Eigenthümlichkeiten. Die 
schuppige Form tritt bei Vorhandensein eines Bartes als diffuse Pityriasis einerseits, 
andererseits aber auch als umschriebene, etwas geröthete, stärker juckende Flecke im 
Schnurr- und Backenbart auf. Haarausfall folgt hier nie, auch bei noch so langem 
Bestände, da die straffe Anheftung der Cutis hier ja fehlt. Bei Frauen ist die diffus 
schuppige Form selten, kommt aber hin und wieder vor in Form einer feinen Abschil- 
ferung und leicht gelblichen Verfärbung der Stirn und seitlichen Wangenpartieen. 
Meist finden wir hier umschriebene, schuppige, gelbliche oder graugelbliche, leicht 
erhabene Flecke, welche oft nur bei guter, seitlicher Beleuchtung sichtbar sind und von 
den Patientinnen meist selbst übersehen werden, obgleich sie an diesen Stellen hin und 
wieder Jucken zu haben angeben. Diese Flecke occupiren meist die Stirn, die Backen, 
bis zur Nasolabialfurche und ziehen sich von dort auf die seitlichen Theile des Halses 
herab. 
Häufig begegnen wir einer stärker entzündlichen Form des seborrhoischen Ekzems 
im Gesichte, und dies fast regelmässig da, wo, wie im Klimacterium, Blutwallungen 
nach dem Gesichte stattzufinden pflegen. Hier siedelt sich im Gefolge einer jeden 
stärkeren Erhitzung eine grosse Anzahl feiner und grösserer rother Papeln auf Stirn, 
Nase und Wangen an. Die kleinsten sind von der Grösse eines Senfkornes und rund, 
die grösseren etwa erbsengross und mit zackigen, unregelmässigen Ausläufern versehen. 
Diese rothen Papeln sind schuppenlos oder mit feinen, gelblichen Schuppen versehen, 
je nachdem Waschungen vorgenommen oder gemieden werden. Zwischen den Papeln 
röthet sich die Haut und es besteht ein beständiges, leises Brennen in dieser mittleren 
Partie des Gesichtes. Allmählich entwickelt sich, wenn nicht künstlich Heilung 
herbeigeführt wird, aus diesen Anfängen eine regelrechte Rosacea, und zwar die von 
mir als ekzematös bezeichnete Form. Das Ekzema seborrhoicum ist bei den Frauen eine 
der häufigsten Ursachen der Rosacea überhaupt, und viele Fälle von Rosacea bessern sich 
sofort, sowie das verursachende Ekzema seborrhoicum des behaarten Kopfes geheilt 
wird. Uebrigens ist auch bei Männern häufig der Alkoholgenuss nur die disponirende, 
entferntere, ein übersehenes Ekzema seborrhoicum des Kopfes die nähere, directe 
Ursache der Rosacea. 
Ungemein selten bei j üngeren Leuten ist die grobborkige Form im Gesichte. Dort 
kommt sie als ein fettig bröckeliger, schwer abzuhebender, gelber, brauner, ohren- 
schmalzähnlicher Belag auf umschriebenen Stellen der Wangen, Nase und Stirn vor 
und ist mit ziehenden Schmerzen in diesen Theilen verbunden. Viel häufiger und in 
schmerzloser, schleichender Weise entstehen solche seborrhoischen Flecke bei alten 
Leuten um Mund und Nase herum und geben bekanntlich den Ausgangspunkt für 
■Carcinome (Volkmann's seborrhagische Carcinome) her. 
Endlich neigt das Gesicht auch zur nässenden Form des Ekzema seborrhoicum, und 
zwar besonders, wie wir schon gesehen haben, bei Kindern, sehr viel seltener bei 
Erwachsenen, und hier wohl nur im Zusammenhänge mit einem nässenden Ekzem des 
ganzen Kopfes und Halses. Das Jucken bei diesem Ekzem ist unbedeutend ; Bläschen 
sind nie vorhanden, sondern nach Abhebung der fettigen Borken ist sofort das Ekzema 
rubrum, etablirt, welches durch das schuppende Stadium wie gewöhnlich abheilt. Bei 
intercurrenten Verschlimmerungen des Ekzems treten auf der nässenden Fläche Schübe 
von zuerst stark juckenden, frischen Papeln auf. Auch bei stärkerer Ausbildung dieser 
Form bleibt Nase und Mund vom Nässen fast immer verschont. 
Es erübrigt noch ein Wort über das seborrhoische Ekzem der Augenlider und des 
Gehörganges. In den Meibohm'schen Drüsen etablirt sich dieses Ekzem so gut, wie SECTION XIV-DERMATOLOGY AND SYPHILOGRAPHY. 
223 
in den Knäueldrüsen und ist von besonderer Hartnäckigkeit. Gerade diese Localisation 
bildet beim Mangel jeglicher Affection des behaarten Kopfes den Ausgangspunkt eines 
sich weiter verbreitenden Ekzema seborrhoicum. In den meisten Fällen ist aber schon 
vorher die Affection am Kopfe aufgetreten, und es wäre stets wichtig, für den Hausarzt 
sowohl, wie für den Augenarzt, diese Quelle der Augenaffection zu kennen, da ohne 
ihre Berücksichtigung eine dauernde Heilung der Augenaffection nicht zu erzielen ist. 
Die Borken bei dieser Ekzemform der Augenlider sind trocken fettig ; nur selten kommt 
es zum Schwund der Cilien, welche sich allerdings rascher hären. Häufig besteht eine 
concomitirende, durch die Lidaffection unterhaltene Conjunctiritis chronica palpebrarum. 
Im Gehörgange kommen alle drei Formen vor. Bei irgendwie erheblichem Ekzema 
seborrhoicum des Kopfes besteht fast immer ein einfaches Schuppen des Gehörganges, 
welches mit Trockenheit und Jucken einhergeht. Regelmässig ist eine abundante, 
feste Absonderung der Knäueldrüsen des Gehörganges, d. i. der Ohrenschmalzdrüsen, 
dabei vorhanden. Die borkige, seltenere Form geht gewöhnlich bald in die nässende 
über. Die Nägel werden nur selten vom seborrhoischen Ekzem befallen und zeigen 
dann eine von vorne nach hinten schreitende, die Nagelplatte abhebende Hyperkeratose 
des Nagelbettes, wie andere Pilzkrankheiten. 
Wenn ich nun noch erwähne, dass an behaarten Stellen, vorzüglich auf dem Kopfe, 
das seborrhoische Ekzem hin und wieder Veranlassung zur Production richtiger, spitzer 
Warzen, spitzer Condylome giebt, so habe ich, so kurz wie möglich, die ungemein ver- 
schiedenartigen Krankheitsbilder dieser einen, höchst versatilen Affection vorgeführt, 
und wende mich nun zum ganzen Habitus, zum Verlaufe der Krankheit. 
Das Ekzema seborrhoicum schreitet stets langsam peripherisch weiter, nachdem es 
am Orte seines Ursprunges oft Jahre lang unter geringen Symptomen bestanden hat. 
Da dieser Ort meist der behaarte Kopf ist, so resultirt daraus in weitaus den meisten 
Fällen ein Gang der Krankheit von oben nach unten, vom Kopfe über die Ohren und 
das Gesicht abwärts zum Halse, von hier nach dem Sternum und der Interscapularrinne 
und an den Armen hinunter. Auch die rascher sich ausbreitenden Fälle bleiben hier 
lange stehen, und diese Aussaat der Krankheit vor oben nach unten mit Bevorzugung 
der genannten Punkte der oberen Körperhälfte ist so characteristisch, dass sie für das 
Ekzema seborrhoicum geradezu als pathognomonisch gelten kann. Kein anderes Ekzem 
und keine Psoriasis hält diesen Gang ein. Unter abwechselnden spontanen und künst- 
lich herbeigeführten Remissionen breitet sie sich dann langsam, mit sichtlicher Ver- 
meidung der für Psoriasis so characteristischen Kniegegend, nach unten weiter aus. 
Meistens bleiben grössere Hautstrecken von der Affection frei, so dass bei der Neigung 
derselben zur Scheiben- und Ringform ein sehr buntscheckiges Aussehen entsteht. 
Dieses hört erst wieder auf in jenen seltenen Fällen, wo nach Jahre langem Bestände 
buchstäblich der ganze Körper überzogen wird. Dann erinnert die Affection an eine 
Pityriasis rubra, unterscheidet sich aber - äusser durch den verschiedenen Geruch - 
auf den ersten Blick durch die Dicke, die gelbe Farbe, die Bröckeligkeit und Fettigkeit 
der Schuppen, weiterhin auch durch ihre Benignität. 
Denn selbst in diesen Fällen ist das Allgemeinbefinden nicht mehr gestört als bei 
universellen Ekzemen überhaupt, und sie enden bei zweckmässiger Behandlung nach 
noch so langem Bestände regelmässig in Genesung. Das Ekzema seborrhoicum ist auch 
dadurch gutartig, dass es relativ wenig juckende Empfindungen hervorruft. Bei der 
schuppenden und borkigen Form spüren die Patienten eigentlich nur Jucken und hin 
und wieder auch Schmerzen an der Peripherie der Flecke, so lange dieselben fortschrei- 
ten, bei der nässenden Form fast nur, wo frische Papeln aufschiessen. Die Lymph- 
drüsen sind nicht nothwendig intumescirt. Ich halte es sogar für möglich, dass ihre 
Schwellung die Folge von Secundärinfectionen sind, da ich immer nur die Nackendrüsen 
und die Inguinaldrüsen geschwollen fand und die Intumescenz überhaupt häufig 
vermisste. 224 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Für die Differentialdiagnose kommen hauptsächlich andere chronische Ekzeme und 
die Psoriasis in Betracht. Ein nässendes chronisches Ekzem irgend welcher Provenienz 
ist von dem nässenden, seborrhoischen Ekzem nicht anders mit Sicherheit zu unter- 
scheiden, als durch die characteristischen, schuppenden und borkigen Scheiben an der 
Peripherie und durch die seborrhoische Ursprungsstätte, resp. den Gang der Affection; 
denn die besten Characteristica, die fettigen Borken, die Configuration der Scheiben 
und Kreise, fällt dann ja fort. Für die richtige Behandlung ist diese Erkenntniss 
aber sehr wichtig. Typische Fälle von universellem, borkigem Ekzema seborrhoicum 
von universellen Psoriatiden zu unterscheiden, ist nicht schwer. Aber doch treten 
manchmal bedeutende Schwierigkeiten auf, besonders bei der Differenziirung beider 
Krankheiten auf den unteren Extremitäten in alten Fällen. Diese Schwierigkeiten 
werden auch bestehen bleiben, wenn die Kenntniss des seborrhoischen Ekzems eine 
allgemeine geworden ist. Bis jetzt liegt die Sache freilich anders, und man kann 
sagen, dass geradezu fast alle Fälle von universellem, borkigem Ekzema seborrhoicum 
unter der falschen Etiquette " Psoriasis " umhergehen und geheilt werden. Ich stütze 
dieses Urtheil nicht auf die Diagnosen von Hausärzten, sondern ich habe in meiner 
Klinik Gelegenheit gehabt, Patienten an dieser Krankheit zu behandeln, bei denen 
fr üher die Diagnosis : Psoriasis von Fachcollegen gestellt wurde, die ich selbst als Meister 
in unserer Kunst verehre. Ich kann deshalb auch nebenbei bezeugen, dass diese Affec- 
tion ebensogut in Russland, Skandinavien, England, Holland, Frankreich und Nord- 
amerika bleibt, wie in Deutschland. Ich glaube mich daher nicht zu irren, wenn ich 
sage, dass bei gründlicher Kenntnissnahme des Ekzema seborrhoicum nicht nur ein 
Theil der Ekzeme genauer erkannt und rascher geheilt, sondern auch ein grosser Theil 
psoriasis-ähnlicher Exantheme von der echten Psoriasis abgetrennt werden und einer 
günstigeren Beurtheilung unterliegen wird. 
Deshalb ist die Differentialdiagnose zwischen unserem Leiden und der Psoriasis so 
wichtig. Äusser verschiedenen geringfügigen Momenten sind hier vor Allem stets die 
vier Hauptpunkte eingehend zu berücksichtigen. Erstens : der Gang unseres Ekzems 
von oben nach unten, meist in der Mitte des Körpers stationär bleibend, bei der Pso- 
riasis die Ausbreitung von Ellbogen und Knieen aus in mehr plötzlicher Weise über 
den ganzen Körper. Zweitens : die nie fehlende Vorgeschichte einer oft heimlich und 
ganz unbekannt verlaufenen seborrhoischen Localaffection. Drittens : der nie fehlende 
Factor der Fettbeimischung, der sich in zwei Momenten ausspricht - in dem bekannten, 
fettig bröckeligen Character der Schuppen und in der gelblichen Farbe der ganzen 
Affection. Viertens : die eigeuthümliche Configuration der Einzelefflorescenz im Fort- 
schreiten derart, dass die dicken Scheiben spontan in der Mitte oder nach einer Seite 
hin sich abflachen, ihr Roth sich in Gelb, die schuppige Oberfläche sich in eine glatte 
verwandelt, um plötzlich am Rande wieder in einen erhabenen, rothen, schuppen- 
belegten, bogenförmigen Wall überzugehen. Deshalb ist nun die Differential diagnose 
an den Unterschenkeln gerade so schwierig, weil hier sehr oft die Scheiben in der Mitte 
nicht einsinken und das cyanotische Blau aller Unterschenkelaffectionen das specifische 
Gelb der Affection compensirt. Man stelle also seine Diagnose nach den Efflorescenzen 
des Oberkörpers. 
Aus diesen differentialdiagnostischen Bemerkungen geht hervor, dass die genaue 
Diagnose hier auch für die Prognose und Therapie eine grosse Bedeutung besitzen muss. 
Und in der That ist die Prognose des seborrhoischen Ekzems wesentlich günstiger als 
die der Psoriasis. Wir kennen eben die Ursprungsstätte, und diese ist unseren localen 
Mitteln leicht zugänglich. Wenn daher ein noch so schlimmes, seborrhoisches Ekzem 
geheilt ist, so haben wir in der Pflege des Haarbodens, oder eventuell der Augenlider, 
ein sicheres Vorbeugungsmittel gegen einen Rückfall der Erkrankung der übrigen Haut. 
Schon oft war es mir möglich, auf diesem Wege die Prognose einer bis dahin für 
Psoriasis und für unheilbar gehaltenen Hautkrankheit in eine absolut gute nm zu- SECTION XIV DERMATOLOGY AND SYPHILOGRAPHY. 
225 
gestalten. Wo immer man bei einer universellen Psoriasis Kniee und Ellbogen relativ 
oder ganz frei, die Schuppen gelblich fettig findet, da sollte man sofort Verdacht auf 
eine nicht richtige Diagnose schöpfen und instinctiv mit Auge und Hand den Haarboden 
untersuchen. 
Damit ist aber nicht gesagt, dass die Heilung des seborrhoischen Ekzems immer 
eine leichte Sache sei. Sie ist es schon deshalb nicht, weil bei ihr wesentlich die tief- 
liegenden Knäueldrüsen ergriffen sind, und verlangt oft grosse Consequenz. Aber wir 
haben eine Reihe vorzüglicher Mittel gegen dasselbe. Allen voran stelle ich den 
Schwefel, der fast ein Specificum darstellt. Mit Zink in Form von Salben, Salben- 
müllen, Pasten und Leimen ist er für die nässende Form das empfehlenswertheste, 
weil am raschesten wirkende Mittel. Gegen die schuppige und borkige Form wirkt 
der Schwefel auch gut, noch rascher aber Chrysarobin, Pyrogallol und Resorcin, wäh- 
rend Ichthyol hier dem Schwefel weit nachsteht. Sodann haben sich mit den obigen 
reducirenden Mitteln in Combination Salicylsäure und Borsäure bewährt. Dagegen 
wirken hier die Hebra'sche Salbe und die Theerpräparate nur ungenügend. Selbst 
bei der nässenden Form ist die Zinkschwefelsalbe der Bleisalbe weit vorzuziehen. 
Innerliche Mittel habe ich selten nöthig gehabt. Von anderen Aerzten verschrie- 
benes Arsenik fand ich beim seborrhoischen Ekzem nicht ganz so prompt wirkend wie 
bei Psoriasis, obgleich auch hier eine gute Wirkung unverkennbar ist. Da jedoch die 
locale Prophylaxis der Ursprungsstätte die Hauptrolle nach der Heilung der Haut-, 
krankheit spielt, so bin ich nicht sehr für die Arsentherapie eingenommen, denn sie 
führt doch dazu, dass die Patienten die prophylactische Haut- und Haarpflege vernach- 
lässigen, ohne welche auch der Arsenik die Récidivé nicht verhindert. 
DISCUSSION. 
Dr. Zeisler, of Chicago, admired the striking picture which Dr. Unna had given 
of a disease so familiar with us, which we usually term seborrhœa. He thought the 
occurrence of numerous warts on the scalp not very common, and regarded these as 
due to hypertrophy of the endothelium of the sebaceous gland. 
ÜBER DIE BEHANDLUNG DER SYPHILIS MIT INJECTIONEN 
UNLÖSLICHER QUECKSILBERSALZE. 
ON THE TREATMENT OE SYPHILIS BY INJECTIONS OF INSOLUBLE SALTS OF 
MERCURY. 
SUR LE TRAITEMENT DE LA SIPHILIS PAR LES INJECTIONS DES SELS MERCURIALS 
INSOLUBLES. 
VON DR. MED. V. WATRASZEWSKI, 
Warschau, Russland. 
Der von Prof. Scarenzio ausgegangene erfolgreiche Versuch, statt der Sublimatlösun- 
gen für subcutane Einspritzungen eine Calomelemulsion zu benutzen, muss entschieden 
als ein reeller Fortschritt in der hypodermatischen Therapie der Syphilis angesehen 
werden. Mit einigen, in wöchentlichen oder zweiwöchentlichen Intervallen vollzogenen 
Calomelinjectionen sind wir imStande, therapeutische Effecte zu erzielen, wie dieselben 
nur von einer langen Serie Sublimateinspritzungen zu Stande gebracht werden können. 
Vol. IV-15 226 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Die praktische Seite der Methode liegt also auf der Hand. Gestützt auf die Ergebnisse 
der Forschungen in Betreff der Quecksilberausscheidung bei den mit Calomelinjec- 
tionen behandelten Patienten, erlangen wir die Ueberzeugung, dass dabei ein gleich- 
mässiger und langdauernder mercurieller Einfluss auf das in den Geweben und Säften 
circulirende Gift geschaffen wird, was wieder, mit Rücksicht auf die bei der Syphilis- 
therapie gewonnenen Erfahrungen, wir bei unseren Curen zu bezwecken pflegen. 
lieber die günstigen Behandlungserfolge sind wohl alle die Herren FachcoHegen 
einig, die bei ihren Kranken die Calomelinjectionen in Anwendung gebracht haben. 
Durch eine entsprechende Technik und zweckmässiges Verhalten der Patienten ist, wie 
wir aus den späteren Angaben verschiedener Autoren uns überzeugen können, auch 
die Anfangs grosse Zahl consecutiver Abscesse bedeutend reducirt worden. Trotzdem 
aber waren es: der locale, längere Zeit andauernde starke Schmerz, verbunden mit zu- 
weilen umfangreichen Infiltrationen der angestochenen Gegend, sowie die recht häufig 
vorkommenden Störungen des Allgemeinbefindens der Kranken, Umstände, die sowohl 
die Aerzte wie die Patienten nur zu oft von dem genannten Behandlungsmodus abzu- 
schrecken vermochten. 
Nachdem nun mit dem Calomel der erste Schritt gethan ward, lag der Gedanke 
nahe, auch andere in Wasser unlösliche Quecksilberverbindungen, die bis dato nicht 
hypodermatisch angewandt wurden, einer ähnlichen Prüfung zu unterziehen, um viel- 
leicht in deren Zahl für das Calomel ein Substitut zu finden, das neben einer energischen 
specifischen Action keine so unangenehme Nebenwirkungen wie jenes besitzen würde. 
Aus erwähnten Gründen untersuchte ich nun in dieser Richtung folgende Queck- 
silberverbindungen : 
Hydrarg. oxydulat. nigr enthaltend 96.16% Hg. 
Hydrarg. oxydât rubr " 92.6 % " 
Hydrarg. oxydât, flavum " 92.6 % " 
Hydrarg. Sulfuratum " 86.24% " 
Hydr. präcipetat. album " 70.5% " 
Hydr. jodat. flavum " 61.3% " 
Hydr. jodat. rubrum " 44.1% " 
Hydrargyr. tannicumoxydulat... " 50 % " 
Hydrarg. carbolic, oxydât " 50 % " 
Es lassen sich nun die Ergebnisse meiner Erfahrungen folgendermaassen resumiren : 
1. Alle die aufgezählten Präparate können in entsprechenden Quantitäten ohne 
Gefahr in Form von Schüttelmixturen hypodermatisch angewandt werden, gelangen 
auf diese Weise in den Kreislauf und entfalten im Organismus die dem Quecksilber 
eigenen Wirkungen. 
2. Beim hypodermatischen Gebrauche derselben lässt sich in kurzer Zeit, spä- 
testens nach 48 Stunden Quecksilber im Harne nachweisen, und nach einer Serie von 3 
bis 6 Injectionen kann dasselbe noch lange Zeit nach der letzen Einspritzung (circa 
2 bis 4 Wochen) in dem Harne uachgewiesen werden. 
3. Es werden durch die genannten Präparate die Syphilismanifestationen erfolg- 
reich beeinflusst, und daher können alle dieselben bei der subcutanen Behandlung der 
Lues ihre Anwendung finden. 
4. Bei gleichen hypodermatisch benutzten Quantitäten der aufgezählten Mittel, 
steht im Allgemeinen deren specifische Wirkung auf den Organismus, resp. auf die Lues- 
manifestationen im directen Verhältnisse zu den in denselben enthaltenen Queck- 
silberprocenten. Die Ausnahme hiervon bilden die Jodverbindungen des Quecksilbers, 
worüber ich später noch ein Wort mir vorbehalte. 
5. Für den Grad und die Intensität der localen Reaction lassen sich (natürlich 
unter Berücksichtigung der Technik, des Verhaltens des Kranken etc. ) keine bestimmten 
Regeln aufstellen. Abgesehen von der individuellen Empfindlichkeit der Kranken, SECTION XIV-DERMATOLOGY AND SYPHILOGRAPHY. 
227 
ist im Allgemeinen die locale Reizung bei den meisten Präparaten und gleichen Quan- 
titäten derselben eine ziemlich gleiche und wächst dieselbe mit dem Grade der Con- 
centration der injicirten Flüssigkeit. Bei manchen Präparaten sehen wir dagegen in 
dieser Hinsicht erhebliche Unterschiede, die mit deren chemischen Zusammensetzung 
(vielleicht mit ihrer Beständigkeit) in Verbindung zu stellen sind. Letzteres gilt für 
das Calomel und das Hydrarg. präcipitat. album (amidato bichloratum), deren An- 
wendung in der Regel von einer viel stärkeren localen Reaction gefolgt wird. Mit dem 
Grade der localen wäre auch die allgemeine Reaction auf den Organismus in Zusam- 
menhang zu bringen, d. h. je stärker die eine, desto mehr ist das Allgemeinbefinden des 
Kranken beeinträchtigt und umgekehrt. Doch habe ich in dieser Hinsicht manche 
Ausnahmen beobachtet. 
Was nun die Abscessbildung an den Injectionsstellen anbelangt, so haben ent- 
schieden die speciell nach dem Calomel entstandenen Infiltrationen die grösste Tendenz, 
in eiterige Schmelzung überzugehen, obwohl durch eine entsprechende Technik, voll- 
kommen reine Präparate und das Verhalten der Patienten die Zahl der Abscesse auf ein 
Minimum herabgesetzt werden kann. Ich möchte fast behaupten, dass von der ganzen 
Reihe der aufgezählten Präparate diese unerwünschte Complication den unlöslichen 
Chlorverbindungen des Quecksilbers in erster Linie zukommt, da ich (immer unter 
Berücksichtigung der genannten Cautelien) bei den zahlreichen Injectionen anderer 
Präparate fast nie die Bildung eines Abscesses an der Einstichstelle zu Stande kom- 
men sah. Auch ist sowohl bei dem Calomel als dem Hydrarg. amidato bichloratum 
in Betreff der Dauer und der Entwickelung der localen Reaction (Infiltration und 
Schmerzhaftigkeit) ein erheblicher Unterschied im Vergleiche mit den anderen Queck- 
silberverbindungen zu verzeichnen. 
Während nämlich bei Letzteren die localen Reizerscheinungen am stärksten in den 
ersten 24 bis 48 Stunden nach vollübter Einspritzung sich kundgeben, entwickeln sich 
dieselben bei dem Calomel und dem weissen Präcipitate allmälig und erreichen erst 
gegen den vierten und fünften Tag ihr Maximum. 
Je nach dem Procentsatze an Quecksilber können von den aufgezählten insolubilen 
Mercursalzen Quantitäten von 0.04 bis 0.15 und 0.20 in Form von Schüttelmixturen 
ohne jeden Schaden für den Organismus demselben in therapeutischen Zwecken beige- 
bracht werden ; und es stellen sich die von mir zur Beseitigung der Luesmanifestationen 
für eine Injection benutzten Quantitäten der verschiedenen Salze folgendermaassen vor : 
Quecksilberverbindung. 
Concentration 
derlnjections- 
flüssigkeit. 
Quantität des einver- 
leibten Salzes. 
1. Hydr. oxydulatum nigrum 
2. Hydrarg. oxydât, rubr 
3. Hydrarg. oxydât, flav 
4. Hydrarg. Sulfurât 
5. Hydr. prace. alb 
6. Hydr. jodat. flav 
7. Hydrarg. jodat. rubr 
8. Hydrarg. tannic.oxydul 
9. Hydr. carbol, oxydât 
1 : 10 
1 : 10 
1 : 30 
1 : 10 
1 : 10 
1 : 10 
1 : 7.50 
1 : 7.50 
1 : 7.50 
0.12 grm. 
0.12 
0.04 
0.12-0.13 
0.12-0.13 
0.12-0.13 
0.18 
0.18 
0.18-0.19 
Da nun von allen den aufgezählten Präparaten die Quecksilberoxyde den grössten 
Procentsatz an Mercur enthalten, so genügen zur Erzielung einer erwünschten Wir- 
kung auf den Organismus, resp. auf die Lues, weit geringere Quantitäten derselben als 
aller anderen Quecksilberverbindungen, inclusive des Calomel, das 84.9% Mercur 
enthält, d. h. weit weniger als die Oxyde. Die geringen Quantitäten des in die Gewebe 228 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
eingefiihrten Mittels bilden nun in erster Linie den Grund, weshalb die örtlichen 
Reactionserscheinungen bei den Oxyden am geringsten ausfallen. Ein weiterer Umstand, 
der uns diese Thatsache erklärlich macht, würde in der Einfachheit ihrer chemischen 
Zusammensetzung und deren leichtem Zersetzungsvermögen zu suchen sein, was bei 
den schwer zersetzlichen Salzen und speciell bei dem Calomel nicht der Fall ist. 
Die guten Erfahrungen, die ich bei der Behandlung der Syphilis mit Injectionen der 
Sauerstoffverbindungen des Quecksilbers und speciell des gelben Oxydes erzielt habe, 
und dessen ich mich deswegen seitdem ausschliesslich bediene, wurden bereits im 
vergangenen Jahre der Oeffentlichkeit übergeben. Meine weiteren Beobachtungen, sowie 
die verschiedener Fachcollegen bestätigen dieselben, in vollem Maasse. Vier bis sechs 
à 0.04-0 06 Hydr. oxydât, flavi in wöchentlichen Intervallen gemachte Einspritzun- 
gen genügen in den weitaus meisten Fällen von recenter sowohl, wie von tardiver Lues, 
zur Erzielung eines erwünschten therapeutischen Effectes, ein Erfolg, der mit gleichen 
Mengen keines der aufgezählten, sowohl löslichen als unlöslichen, bis jetzt zu hypoder- 
matischen Injectionen benutzten Mitteln hervorgebracht werden kann. Bei Benutzung 
der anderen Präparate ist entweder eine grössere Anzahl Injectionen erforderlich, wobei 
die practische Seite der Cur in den Hintergrund tritt, oder müssen mehr concentrirte 
Mischungen angewandt werden, was wiederum für die locale, resp. allgemeine Reaction 
nicht ohne Belang ist. 
Die Ausnahme hiervon bildet das rothe Quecksilberjodid (besonders die ersten 
Injectionen desselben), das bis 0.15-0.18 grm. pro Injection ohne auffallende locale noch 
allgemeine Reizerscheinungen hypodermatisch angewandt werden kann, und womit 
ich nach 3-8 Einspritzungen, bei tertiären Luesformen rasche Besserung, resp. Heilung 
erzielt habe. Ungleich schneller wurden aber in analogen Fällen dieselben Resultate 
erzielt nach Injectionen des Hydrarg. oxydât, flavum, unter gleichzeitiger Anwendung 
von Kali jodatum innerlich. Es würde sich daher erwähntes Präparat bei Patienten 
eignen, die das Jod innerlich schlecht vertragen, ebenso das gelbe Jodquecksilber, und 
sind nach dessen hypodermatischer Application der locale Schmerz, sowie die Infiltration 
um Vieles beträchtlicher, und in zwei Fällen habe ich sogar Abscessbildung beobachten 
können. 
Indem ich in Betreff der Injectionstechuik auf meine früheren diesbezüglichen 
Publicationen verweise,* sei es mir gestattet, hinsichtlich derselben nur auf einige 
wichtigen Punkte aufmerksam zu machen, nämlich : 
1. Es müssen während der Injection die Glutealmuskeln sich im Zustand einer 
völligen Erschlaffung befinden. . 
2. Muss die Injectionsflüssigkeit ungefähr die Körpertemperatur besitzen, d. h. 
es muss dieselbe dem Kranken warm einverleibt werden. Es genügt dazu, die mit dem 
Injectionsliquidum gefüllte Spritze auf einige Secunden über die Flamme einer 
Weingeist- oder gewöhnlichen Lampe zu bringen. 
3. Es muss nach geschehener Injection, um das Eindringen der Flüssigkeit in den 
Stichkanal zu verhindern, sofort der Zeigefinger der anderen Hand auf die Einstich- 
stelle gebracht und damit ein Druck in die Tiefe ausgeübt werden. Dabei ist es 
zweckmässig,durch drückend-rotirende Bewegungen der auf die Glutealgegend aufgeleg- 
ten ganzen Flachhand, womit die oben gelegenen Theile über die tieferen verschoben 
werden, die Flüssigkeit in den Maschen der Gewebe zur möglichsten Vertheilung zu 
bringen suchen. 
Einen Umstand kann ich nicht unerwähnt lassen: In einigen, obwohlrecht seltenen 
Fällen beobachtete ich nach geschehener Injection von insolubilen Quecksilbersalzen 
Wallungen nach dem Kopfe, die sich durch Hyperämie des Gesichtes, Schwindel und 
einem Gefühl von Brustbeklemmung kundgaben. Binnen Kurzem und besonders 
* Wiener Medicinische Wochenschrift, 1886. SECTION XIV DERMATOLOGY AND SYPHILOGRAPHY. 
229 
nach Application kalter Compressen auf die Stirne schwanden die geschilderten 
Symptome ohne weitere Folgen. Ob nun die erwähnten Erscheinungen, die ich nie 
nach den ersten Injectionen, und, wie gesagt, nur recht selten auftreten sah, in einer 
allgemeinen Nervosität der Patienten ihren Grund hatten oder vielleicht durch directe 
Reizung der unmittelbar in den Kreislauf, resp. das Herz gelangten Partikeln des 
Medicamentes in Zusammenhang zu bringen wären, lasse ich dahingestellt. Mit 
Rücksicht jedoch auf das Gesagte wäre es jedenfalls rathsam, bei sanguinischen, zu 
Kopfwallungen geneigten, oder mit Symptomen von Artériosclérose behafteten Indivi- 
duen sich nur ausnahmsweise der Injectionen zu bedienen. 
Zum Schluss will ich hinzufügen, dass ich bei zwölf Kranken statt der als Injec- 
tionsvehikel benutzten Gummilösung (im Verhältnisse von 1 : 120) mich des von 
Frankreich aus empfohlenen Vaselinum liquidum bediente. Es besitzt jedoch dieses 
Vehikel keine nennenswerthen Vorzüge vor dem Ersteren: obwohl nämlich während 
und unmittelbar nach geschehener Injection absolut gar keine Schmerzen von den 
Kranken angegeben werden, pflegen die späteren örtlichen Reizerscheiuungen entschie- 
den stärker auszufallen als nach der Anwendung des Gummischleims, zu dessen 
Gebrauche ich daher bereits zurückgekehrt bin. 
Indem ich nun die Resultate meiner Beobachtungen in Betreff der subcutanen 
Anwendung unlöslicher Quecksilberverbindungen bei der Luestherapie hier vorzulegen 
mir erlaube, thue ich es mit der Ueberzeugung, dass sobald deren Wirksamkeit im 
Allgemeinen, speciell aber einiger derselben, sowie deren Bequemlichkeit in praktischer 
Hinsicht eine entsprechende Würdigung finden, den insolubilen Mercurialsalzen eine 
Stelle ersten Ranges bei der subcutanen Syphilisbehandlung gebühren dürfte, und dass 
mit Rücksicht auf deren Vorzüge vor den bis dato gebräuchlichen, in Wasser löslichen 
Quecksilberpräparaten, diese Letzteren binnen Kurzem aus der Luestherapie vollständig 
verdrängt zu werden verdienen. 
DISCUSSION. 
Dr. Zeisler emphasized that the advantage of the method advocated by the 
reader lays in the small number of injections necessary. He thought that to inject a 
grain of sublimate at a dose was rather dangerous, and said that in Vienna, where he 
had used such injections, one centigramme (one-seventh grain) was the usual dose. 
Dr. Gottheil said that we are favored almost every few weeks by our German 
colleagues with some new method or new mercurial combination for the treatment 
of syphilis. There was, however, one great obstacle in the way of our treating syphilis 
in this manner here, and that was the absolute impossibility of getting our patients, 
either in public or in private practice, to submit to painful procedures such as these, 
when so very satisfactory results can be obtained from oral medication. The placing 
of insoluble mercurial compounds under the skin does not seem likely to become very 
generally adopted in America for the treatment of syphilis. 
Dr. Klotz stated that he had some experience with injections of insoluble salts, 
having made somewhat over 130 injections in eighteen patients, 34 of which were 
of calomel. He is able to corroborate what Dr. Watraszewski had said about the 
advantages and disadvantages of the method, the balance being decidedly in favor 
of the same. Abscesses he had seen only three times, all occurring after the injec- 
tions of calomel, and in his earlier cases ; of late, he had seen, only rather painful 
infiltration in some cases. The yellow oxide of mercury caused much less pain and 
swelling, but was inferior to calomel in its effects, while three to four injections of 
calomel, of 10 centigrammes, had given better results than twenty-five to thirty inunc- 230 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
tions. He would have been glad to hear something about the frequency of relapses 
after the injections in comparison with other methods. 
In contradiction to the statement made by Dr. Gottheil, that patients in this 
country would not submit to the treatment by injections, Dr. Klotz stated that his 
experience was almost entirely with private patients, some of them being born and 
brought up in America. He found that the more intelligent and the better educated 
the patients were, the more readily they would bear the pain, which, indeed, is some- 
times rather severe, as soon as they had understood the advantages of the method 
and saw the effects. In fact, some of his patients had voluntarily asked for the 
injections again, in cases of relapse, in preference to taking medicines by the mouth. 
Dr. Watraszewski, in conclusion, said that while the injections were undoubt- 
edly painful, even with the best management, the patients were very willing indeed 
to submit to them when they saw their good results. He had experienced no trouble, 
even in private practice, in that way. The necessity of long persistence in the oral 
medication was an argument in favor of the new method. 
DOUBLE COMEDO-AN ANATOMO-PATHOLOGICAL STUDY. 
DOUBLE ACNÉ (COMEDO)-UNE ÉTUDE ANATOMO-PATHOLOGIQUE. 
ÜBER DOPPEL-COMEDO-EINE ANATOMISCH-PATHOLOGISCHE STUDIE. 
BY A. H. OHMANN-DUMESNIL, A.M., M.D., 
Of St. Louis, Mo. 
I. 
It is a notorious fact that statistics in general, and the statistics of skin diseases in 
particular, are not only incomplete, but, as a general rule, unreliable. In the case of 
skin diseases it is well known that no adequate estimate can be formed of the compar- 
ative number of certain affections, and prominent among these are to be noted the 
diseases of the sebaceous glands, such as rosacea, acne and comedo. There is but a very 
small number of such cases treated at all, and of these only aggravated forms of the 
trouble, as a general rule, find their way into the hands of specialists ; and it is only 
those especially interested in the subject who keep any statistics of diseases of the skin. 
On this account, it is particularly difficult to estimate the comparative frequency of 
comedo, and still more so, perhaps, because it is such a common affection. It is now a 
well-settled fact that, like acne, it is a very common affection, making its appearance at 
or about the time of puberty, and disappearing spontaneously when adult life is fully 
entered into. 
In regard to double comedo, all that can be said in regard to its frequency is that it 
is of comparatively frequent occurrence. Like comedo, it is not seen as often in females 
as in males, a fact which would seem to argue in favor of the position that the accu- 
mulation of extraneous matter exercises some influence in the plugging up of the open- 
ings of the sebaceous follicles, as men are much more subjected to such influences than 
women. I have not taken any particular notice of the occurrence of double comedo in 
women, my attention having been almost entirely limited to men. At the St. Louis City SECTION XIV-DERMATOLOGY AND SYPHILOGRAPHY. 
231 
Hospital I have found this affection present in about three and one-half per cent, of all 
the patients, and this after the examination of several hundreds of individuals whose 
ages ranged from 16 to 60. These observations were made at various intervals of time, 
sufficiently far apart to ensure at least a reasonable amount of time to allow of the 
rotation of a considerable number of the patients. Of course this, in strict truth, is 
only the percentage in male individuals who are hospital subjects, which is conclusive 
evidence of the fact that, taking individuals in general-the healthy as well as those not 
in health-the percentage of cases of double comedo must, without doubt, be still much 
greater. Still, without actual figures to rely upon, it is well-nigh impossible to give 
an accurate estimate, or one of value. But even admitting that the frequency of occur- 
rence is as low as one per cent., there can be no doubt of the relative importance of 
this variety of comedo, and its study is a subject which is not only interesting in itself 
but of sufficient importance to engage the attention of every thinking dermatologist. 
This is more especially true as an investigation into its pathology and pathogeny is 
doubtless destined to shed some light upon processes occurring in other pathological 
conditions of the sebaceous glands, and thus, perhaps, add a little more to the meagre 
stock of information which we possess upon this subject. 
It has been a matter of surprise to me that this variety of comedo remained unde- 
scribed until I published two preliminary notes on the subject, in the Journal of Cuta- 
neous and Venereal Diseases for February and July, 1886. After that a number of der- 
matologists observed this condition, and some told me subsequently that they had 
observed it prior to my publication, but had paid no especial attention to the fact. 
Without even desiring to impugn the motives of these gentlemen, I must confess 
Fig. 1. 
that I cannot understand this, as the very first observation made by me gave rise to 
quite a number of mental inquiries in regard to this variation of comedo, and excited 
such an interest that I regarded the fact as one worthy of record, and I understand 
that others have begun to study the subject, in order to elucidate it more fully and 
completely. 
It may, perhaps, not be out of place to give a short description of this affection, 
which, while it may not claim the honor of being a distinct disease, is, at least, entitled 
to the position of a variation-and a marked one, too-from the typical form of a very 
common affection of the sebaceous glands. The appearance of double comedo, in gen- 
eral, is that of comedo, as far as individual lesions are concerned. We find, however, 
that there are two black points situated near to each other, at a distance of from one to 
three lines, or perhaps a trifle more. The two points form a distinct pair, and, to the 
practiced eye, are easily recognizable as forming a double comedo. Between these two 
points the skin is normal in appearance, with the exception of one thing, viz., it appears 
to be more or less elevated, and to shade gradually from its lateral aspect into the 
normal skin (Fig. 1). That is, the appearance presented is that which we might sup- 
pose would be produced were a cylinder of the 'caliber of an ordinary pin or a little 
larger, and of a length equal to that between the points, introduced beneath the skin. 
Upon passing the hand over this portion of skin, this slight elevation can be distinctly 
perceived. Both points are markedly blackened, and may be situated on a level with 
the surrounding skin, or they may be slightly raised with it and produce a small papular 
elevation, or be very slightly elevated above the general plane of the cutaneous surface, 232 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
giving the nutmeg-grater sensation which is sometimes observed in comedo. If lateral 
pressure be exercised over one of the black points by means of a spatula or similar 
instrument, a plug will be forced out, whose shape is cylindrical and which has a black- 
ened end at each extremity (Fig. 2). The length of this plug corresponds to the dis- 
tance between the two black points observed before its expulsion. If we now take a 
pin or piece of wire it can be easily introduced at oùe orifice and be caused to protrude 
at the other, thus demonstrating that there exists a horizontal canal (Fig. 3). This 
canal is one whose shape is slightly curved, but not sufficiently so to prevent the easy 
introduction of a probe, such as mentioned above, even if the instrument be straight, 
although greater ease of introduction is obtained by giving the instrument a slight 
curve corresponding to that of the canal. 
In this connection I wish to mention here that I have met further modifications of 
this condition. There are cases in which are found not only two, but three and even 
four comedones, communicating with each other in the same manner, and a probe can 
be passed through any two without any difficulty, thus showing the connection existing 
between the various openings (Fig. 4). These forms might properly be denominated 
multiple comedo. Any attempt made to express the contents of any one of these varie- 
ties results either in the form of a portion of a plug, pigmented at one extremity, or 
of one colored at both ends. This, of course, would be naturally expected when we 
consider the conditions which are present. Owing to certain unavoidable circum- 
stances, I have not been enabled to remove the portion of skin included by the black- 
Fig. 2. 
Fig. 4. 
Fig. 5. 
Fig. 3. 
ened points, or I might have had the opportunity of removing the underlying sebaceous 
mass entire. There is no doubt in my mind, however, that the condition present is one 
in which there are three or more plugs, having a common centre and blackened, each 
one at its extremity (Fig. 5), and, consequently, of a more or less stellate form. The 
reason for this conclusion will be developed later on. 
This form occurs wherever we find comedo, and this is, in general terms, limited to 
the face, neck and shoulders, the back being also the seat of the disease. The principal 
locality affected by double comedo, in my experience, is that portion of the integu- 
ment of the face which is located over the malar eminences, or directly underneath them. 
I have never observed any upon the forehead or chin. The posterior and lateral aspects of 
the neck are frequently affected ; more so, in fact, than other portions of the cervical area. 
The upper portions of the shoulders and the skin over the scapulæ are the parts of the back 
most frequently the seat of double comedo, although I have seen cases where the trouble 
was irregularly distributed over the entire dorsal aspect of the trunk. A careful examina- 
tion has revealed the presence of this affection upon the chest, in but a very few cases. 
The number is so small that its location here may be considered as being rather unusual. 
I have also observed it in the ears, but its location at this site is rather exceptional, as 
also upon the nose. I may state, parenthetically, here, that the number of double 
comedones in comparison with that of single ones, in any individual, is excessively 
small. Yet I have seen a case in which there seemed to be no other form than the 
double, and these were present in large numbers. SECTION XIV-DERMATOLOGY AND SYPHILOGRAPHY. 
233 
The size of the openings of the glands, in double comedo, varies to some extent. 
The holes are often larger than an ordinary sized pin ; while, at times, they are exceed- 
ingly small, so small, in fact, that it is with difficulty that the wires employed for 
keeping fine hypodermic-syringe needles clean, can be introduced. In this fine form, 
the bridge of intervening skin is of a marked degree of thinness and the dark points, 
showing the openings of the ducts, are quite closely approximated, the distance being 
a line or even less. 
II. 
Before considering the pathology of double comedo, it may not be out of place to 
give a hasty review of the development and anatomy of the sebaceous glands, together 
with a short notice of the pathology of comedo. The subject of development is one 
which is always of the highest interest, and there has been but comparatively little work 
done, so far, in this branch, on account of the vast territory which must of necessity be 
covered. Although the modern division of medicine into a number of special depart- 
ments has given an impetus to special research, the time has been too short to permit 
any one to say that he has completely exhausted any one subject. It is for these reasons 
that I do not hesitate to say a few words concerning the development of the sebaceous 
glands, upon which there seems to have been but little written, up to the present time. 
In all the literature to which I have had access, the only author who makes any 
extended mention in regard to this subject is Kölliker in his "Entwickelungs- 
geschichte," and his work on this subject is by no means as complete as it might be. 
The sebaceous glands begin to make their appearance at about the fourth month of 
development, in the human embryo. This is the earliest indication, and we find it on 
the sides of the forehead. About the fifth month these glands are developing in nearly 
every portion of the body and, at this period, can be found in almost every stage of 
development. The drawings which are appended are from preparations obtained from 
the scalp of an embryo between the fifth and sixth months, and three stages in the 
development of the sebaceous gland are represented. Even in a very small space we 
are enabled to find such examples. What the reason of this is has not been satisfac- 
torily explained. As Eschricht observed long since, this development is pari passu with 
the development of the hair and its follicle, a circumstance which would seem to indi- 
cate that the gland is a mere outshoot of the other, confirmatory proof of which is 
furnished by the various stages of development. 
The first indication of a sebaceous gland consists in a thickening of the wall of the 
hair follicle (Fig. 6). This consists, apparently, of a proliferation of cells which has 
taken place between the internal and external layers, and has thus formed this boss or 
bulging portion. At first scarcely perceptible, it becomes more and more prominent, 
and pretty soon it stands out in a well-defined manner. In another and more advanced 
stage we find that some differentiation of form begins. A greater or less constriction 
takes place at a point of the projection which corresponds approximately to the niveau 
of the outer part of the external layer of the root sheath of the hair (Fig. 7). This 
constriction then increases on the lower side, and the entire mass apparently falls and 
assumes somewhat of a pyriform or flask shape, or looks like a bud growing downward 
(Fig. 7). In time, this form becomes more or less marked, until it may extend even 
lower down than the level of the hair follicle, or it may never extend beyond a very 
slight distance from the point where the original bulging took place. 
We see all of these stages well defined, and there is no difficulty whatever in tracing 
the relations between them. They are plainly derivatives one of the other. The scalp 
of a five and one-half months' fœtus will show these very well, especially if that por- 
tion be taken which lies directly in front of and above the ear. 
As will be shown later on, the sebaceous gland is surrounded by a very thin and 234 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
apparently structureless membrane which holds a layer of cells in position. We find 
that, in the development of the hair, a membrane forms around the external layer of 
the root sheath, and when the bulging takes place, to form the future sebaceous gland, 
this membrane is pushed out, and ultimately becomes the support of the walls of the 
gland. 
The structure of the mass which is to become the sebaceous gland is the same, in 
general, as that of the root sheath at the point where the bulging takes place. We 
have this boss, composed chiefly of polygonal or round cells, distinctly nucleated (the 
nuclei being large) and somewhat closely packed together. These cells are, at first, 
continuous with those of the root sheath (Fig. 7), but changes take place later on. 
We know that the hair is an epidermal structure, and that it is formed by a dipping 
in of the epidermis into the skin. The layers of the root sheath correspond to those of 
the epidermis. After the primitive hair cone has become differentiated, the develop- 
ment of the sebaceous gland begins. By this time we are enabled to see that the inner- 
Fig. 6. 
Fig. 7. 
most layer of the root sheath corresponds to and is continuous with the horny layer of 
the epidermis ; in like manner, the external layer of the root sheath corresponds to the 
lowest layer of cells of the mucous layer of the epidermis, or what becomes, later on, 
the pigment cells of the rete mucosum. 
Now, it is well known that this layer differs from the other portions of the rete 
Malpighii, in the fact that, while those portions are composed of polygonal cells of a 
particular character-the prickle cells-those forming the lowest layer, and situated 
immediately over the papillæ, are columnar and arranged side by side in a very regular 
manner; besides which, they generally contain pigment. These very characteristics, 
of being columnar cells and arranged in a regular manner, are observed in the lining 
cells of the sebaceous gland in a very early stage of its development (Fig. 7), and by 
exercising a little care in the examination, this layer of cells will be found to be con- 
tinuous with a similar one in the root sheath, and this latter, in turn, with that of the 
rete Malpighii. 
To return to the development proper of the gland: When its growth has arrived at SECTION XIV-DERMATOLOGY AND SYPHILOGRAPHY. 
235 
that stage when it is pyriform, a change begins to take place in the central portion. 
Some of the cells begin to change in appearance, and it is noticed that fatty degenera- 
tion is beginning to take place. This goes on in all directions and in a comparatively 
rapid manner. After a certain time, this fatty metamorphosis extends into the con- 
stricted portion of the mass (Fig. 8) and works its way gradually toward the internal 
surface of the root sheath. When this locality is finally reached, the cells, filled with 
oil globules, find their way between the hair shaft (which is now formed) and the root 
sheath, and we have the first indication of sebum. In this process the innermost 
layer of the root sheath is destroyed at the point where these cells force their way, and 
we have the duct from the sebaceous gland to the hair sac fully established. 
This, of course, is merely an outline sketch of the development of one acinus. The 
others are formed in a similar manner by, so-to-speak, secondary bulgings, and these in 
turn become pedunculated and form their canals. The limitation of the number of 
lobules is probably due to the relative density of the surrounding tissues, as the more 
Fig. 8. 
dense they are the greater will be the resistance to be overcome, and consequently, the 
smaller the number of acini. Should there be but little or no appreciable resistance in 
any particular direction, it may happen that lobules forming there will become much 
larger than the parent and usurp, to a considerable degree, its functions. 
The sebaceous gland, in general, is merely a secondary growth. It is developed from 
the root-sheath of the hair and only after the hair itself has developed to a certain 
degree. The gland depends for its existence upon the hair-sheath, and although it may 
grow to such dimensions as to make the hair really secondaiy to it in importance, it 
still remains the offspring of the latter. This would seem to confirm the opinion long 
held by many dermatologists, that the glands have for their function the lubrication of 
the hair. It is only natural that, where hair has apparently disappeared, as a result of 
evolution ; or rather, that in those localities where hair is very rudimentary, the more 
vital, the better nourished and more important layers of cells should thrive more, and 
this may, in part at least, account for the presence of large sebaceous glands in con- 
junction with the fine lanugo hairs. 236 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
In considering the development of the sebaceous gland, it was stated that the central 
cells undergo fatty degeneration, this being probably due to pressure and lack of pabu- 
lum combined. Now, why do not the other cells also suffer this change ? This is a 
difficult question to answer with any degree of accuracy or of satisfaction ; yet, it seems 
not unreasonable to suppose that the columnar cells retain a good many of the charac- 
teristics which were inherent in them when they formed a part of the developing skin. 
In the mucous layer, they possess a great deal of resisting power and carefully guard 
the corium against any encroachments from without. They seem well adapted to resist 
pressure, and this is probably the reason they escape fatty metamorphosis in the seba- 
ceous glands. Besides this, they constitute a wall, and give form and solidity to this 
wall. They are rather cuneiform at first, and are arranged so as to form arches as per- 
fect in construction as could be possibly desired. This construction, of course, greatly 
increases the power of resisting external pressure during the process of development of 
the gland. Later on, when some pressure is not only necessary but desirable, we find 
that the form and the distribution of these cells have changed, and this will be men- 
tioned in the consideration of the anatomy of the sebaceous glands. 
There is a somewhat different development which takes place in the case of glands 
which open directly upon the surface of the skin. Here, instead of a bulging of the hair 
sheath, we have, so to speak, an absence of hair development ; and, what might other- 
Fig. 9. 
wise have become a hair becomes a sebaceous gland, in a manner similar to that already 
described. A dipping in of the epidermis takes place (Fig. 9) and the lower extremity 
becomes larger, the entire prolongation consisting at first of a mass of cells, as in the 
primitive hair. The process already described takes place, and by the further enlarge- 
ment of the lower portion we have a sebaceous gland formed whose different acini are 
secondarily formed by a species of budding. The fact that the mode of development is 
primarily the same as that of a hair, and that the differentiation takes place as it does, 
would seem to argue that the arrest of hair development which takes place is merely 
in accord with the general process of evolution which is going on gradually in man. 
Even in some of these glands it is not so clear that a primitive attempt at a hair does 
not take place only to be cast off without the formation of a papilla. 
As is well known, sebaceous glands are of three varieties, viz. :- 
1. Those which open directly into a hair follicle. 
2. Those opening upon the skin and associated with rudimentary hairs. 
3. Those opening directly on the surface but not associated with hair. 
The minute anatomy of all of these is about the same. There is an outer envelope 
of a more or less structureless membrane which is supported by connective tissue. This 
membrane is the basement membrane of the gland and serves as a framework upon 
which the lining cells find support. These cells still continue to retain their charac- SECTION XIV DERMATOLOGY AND SYPHILOGRAPHY. 
237 
teristics, being in general columnar, with large and distinct nuclei, and capable of 
resisting quite an amount of pressure, as will be shown later on. Although these cells 
are said to be arranged with great regularity, we occasionally find specimens in which 
they appear rather irregularly placed (Fig. 10). Within these cells are found numerous 
polygonal or roundish cells containing nuclei which are large. These cells, as the centre 
of the gland is approached, are seen in various stages of fatty degeneration, and some- 
times there seems to be an abrupt change from the cells to the swelled-up, bladder-like 
vesicles containing almost nothing but fat and very indistinctly-marked nuclei (Fig. 10. ) 
The origin of the cells, which are constantly appearing to undergo fatty degeneration, 
is a question which has for a long time occupied the attention of microscopists and it 
seems destined to be solved ere long. The whole question rests upon the solution of 
the problem as to whether the basement layer of columnar cells is concerned in this 
reproduction, or whether the polyhedral cells nearest this basement layer are produc- 
tive of the proliferation. A study of the karyokinesis of these elements will probably 
give the requisite solution. Be this as it may, the greater portion of the interior of the 
gland is filled with fatty matter and epithelial débris which is continually finding its 
way to the outer world and being produced. 
The somewhat irregular distribution and slight variations in the forms of the col- 
umnar cells lining the sebaceous gland are most probably due to the varying amount of 
pressure brought to bear upon them by the skin under varying conditions. This also 
Fig. 10. 
tends to produce a greater or less adaptability of the gland walls to pressure without 
seriously interfering with the texture of the gland, and thus afford them some aid in 
the expulsion of their contents. To say, however, that this expulsion is due to the 
action of the arrectores pilorum, or that the movements of the skin play any consider- 
able part in this, seems to me to be incorrect. A much simpler explanation is that the 
cells nearest the duct, being the oldest, have undergone fatty degeneration much more 
thoroughly than those immediately behind them, and so on. As new cells proliferate 
near the periphery, they exercise pressure on those immediately in front of them, and 
this pressure is transmitted in the line of least resistance, and we have, in consequence, 
an escape of sebum into the hair follicle or upon the skin, as the case may be. In the 
second and third varieties of sebaceous glands mentioned above, there are no hair 
muscles and yet the sebum finds its way to the surface, thus demonstrating that the 
muscles play no essential part in this. 
III. 
In regard to the production of comedo, there seems to be some difference of opinion 
in respect to details. A careful consideration will show, however, that one of two 
causes is generally at work. One is external and purely mechanical; the other internal 
and, to some degree, organic. In the first, the mechanism consists simply in a plug- 238 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
ging up of the mouth of the duct, foreign matter becoming wedged in, so to speak. 
The sebaceous material behind this is unable to overcome the resistance, and, as a 
natural result, accumulates. More or less inspissation takes place, especially of that 
portion in the duct; and the material, continuing to increase in quantity, exercises a 
slow and constant pressure. If this continues long enough, the gland dilates and its 
acini, also, until we have the organ simply transformed into a sac, the duct disappear- 
ing more or less completely (Fig. 11). When the cause is internal, the cells do not 
undergo complete fatty metamorphosis, and the resulting mass is somewhat hard, the 
Fig. 11. 
envelope tough, and a combination of several produce a plugging-up of the outlet of the 
gland. The process is the same as in the first instance, with the exception of being, 
perhaps, a little more irritating. Extraneous matter falls in the opening of the follicle, 
and a comedo, which is extremely dry and difficult to force out, is the result. It seems 
that, after a certain length of time, there is an apparent cessation of cell formation and 
dessication goes on, the plug separating from the walls of the sac-like gland, as shown 
in Figs. 11 and 12, but seemingly attached to the opening of the duct. 
In all the specimens which I have examined, I have found that the cavity was lined 
Fig. 12. 
by a membrane, seemingly structureless, and upon which no cells could be found. 
They may have fallen out, but it is more probable, as Bärensprung suggested long ago, 
that after the accumulation of sebum has remained a long time the secreting structure 
becomes lost to a certain extent, the continued pressure producing more or less absorp- 
tion. That a comedo may be old and still contain secretory cells, has been demon- 
strated by Bulkley, but that these cells may entirely disappear has also been well 
established. SECTION XIV-DERMATOLOGY AND SYPHILOGRAPHY 
239 
In double comedo we have a condition that is the exact analogue of that found in 
the single variety. A large roundish cavity is found, lined throughout, as in comedo, 
and filled with a plug of sebaceous matter having two extremities, each one of which 
shows its darkened end at an opening (Fig 12). The plug has the same general char- 
acteristics as in the other form, and differs from it only in the fact that it has two ex- 
tremities. The manner of formation is the same as in the other, after the cavity has 
been formed. 
In regard to the formation of this cavity, there can be but one of two solutions. In 
the first place we must suppose a condition which I consider entirely untenable, viz. : 
that there is a congenital deviation in the form of the sebaceous gland-in other words, 
that one gland has two ducts. The careful examination of many infants and children 
has failed to show this condition. In adults, it has not been found in those cases where 
no comedo existed. Yet the comparative frequency of double comedo is such that we 
might reasonably expect to find such a condition where the disease depended upon a 
congenital condition of this kind. The only reasonable solution which I can offer is 
this, that two sebaceous glands, in close proximity to each other, are each one the sub- 
ject of comedo. In each one the inspissation is marked and accumulation of the con- 
Fig. 13. 
ik* III I »(Al 
tents becomes such that the small amount of tissues existing between the two is sub- 
jected to a pressure such that it simply produces absorption of that septum and fuses 
the two cavities into one. That there is a tendency for such pressure to exist and be 
produced is probable from the fact that, in " single " comedo from the same individual 
and in the neighborhood of the double one observed, there remains nothing of the inter- 
nal or lining structure but the membrane already alluded to. The objections to this 
are the following: 1st. If this lining membrane is absorbed in both glands, where they 
touch, why is it that it is not absorbed in other portions ? This is answered by the 
fact, that, where absorbed these membranes cannot push other tissues before them, being 
opposed one to the other ; whereas, in other portions, the connective tissue surround- 
ing them gives way. 2d. Why are not remains of this septum to be seen ? This, of 
course, is not easy to answer. As a matter of fact, I have not been able to discover 
any remains, the minute structure of the wall of the gland being throughout as repre- 
sented in Fig. 13. We have here a structureless membrane outside of which there 
exists a cellular layer, containing fibres; and, external to this, connective tissue. There 
is no break in the membrane, at any point, nor is there any projecting tissue or por- 
tion of it. It appears all around as a homogeneous, structureless mass, of equal thick- 240 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
ness throughout and staining a lighter color than the rest. It seems to participate in 
the nature of epidermal tissue in composition. 
The probability of double comedo being formed by the fusion of two single lesions 
is rendered still greater by the fact that lesions are found in which three or four open- 
ings communicate with one sebaceous cavity. It is more reasonable to ascribe these 
' ' multiple ' ' comedones to the action of several single ones, by pressure absorption than 
to suppose the existence of a number of anomalies, with the necessity of having a new 
one to fit each new case, whereas, in the other instance, one general and simple law 
suffices to explain every example. 
DISCUSSION. 
Dr. Unna believed double comedo never developed in a normal skin ; that at some 
time there had been an inflammatory process in that part, followed by cicatrization. 
Dr. Ohmann-Dumesnil, in closing, said he did not believe in the necessity of a 
preexisting inflammatory process, and had failed to find scars in many cases. SECTION XIV DERMATOLOGY AND SYPHILOGRAPH Y. 
241 
FIFTH DAY. 
Dr. Thin, London, presiding. 
THE PATHOLOGY AND TREATMENT OF ALOPECIA AREATA. 
LA PATHOLOGIE ET LE TRAITEMENT DE L'ALOPÉCIE PAR PLAQUES. 
ÜBER DIE PATHOLOGIE UND BEHANDLUNG DER ALOPECIA AREATA. 
BY A. R. ROBINSON, M.B., L.R.C.P. &S., EDIN. 
Of New York. 
In attempting to open a general discussion on alopecia areata I am not unaware of 
the difficulty of the task; for perhaps no subject in dermatology has given rise to more 
scientific discussion, or upon which such opposite views exist, than that of the ætiology 
of this disease. The believers in the parasitic origin have advanced many arguments 
founded upon microscopical study of the hairs and epidermis of the affected parts, as 
well as deductions and analogies from the clinical symptoms and result of methods of 
treatment, to prove either the positive presence of organisms or the almost certainty of 
their existence as the ætiological factor of the disease; at the same time they have 
endeavored to show that there is no real basis, either in the clinical symptoms or other- 
wise, for the trophoneurotic theory. And, on the other hand, those who regard the 
disease as a neurosis-and they are at present greatly in the majority-maintain, with 
equal positiveness, that the clinical symptoms are not those of a parasitic disease, and 
that microscopical examination has failed to show any organism having a proven ætio- 
logical relationship to the affection ; but that all of the symptoms of the disease, even 
the peculiar manner of extension of the patches at the periphery, are not only not 
opposed, but are in favor of its having a neurotic origin. As an impartial, even if a 
somewhat incompetent, judge of the value of the statements and views of the advocates 
of the two theories, I will now endeavor to briefly review and criticise the arguments 
of both sides as given us by their advocates up to the present time, and thus attempt 
to find out whether we are justified from the facts obtained concerning its ætiology-the 
result of a study of the symptoms, natural history, results of treatment, and micro- 
scopical examinations, in forming definite conclusions as to the cause of the disease. 
Before accepting the parasitic theory it must be shown that a definite organism is 
always present at the commencement of the disease-an organism not found under 
normal states or concerned with other pathological conditions; that the pathologico- 
anatomical changes in the affected part are the result, directly or indirectly, of their 
presence, or, finally, that the disease is contagious. Cultures with inoculations would, 
if successful, naturally confirm the view of their positive ætiological significance, but 
this is not absolutely necessary. I say an organism must always be present at the 
commencement of the disease, but if the eruption is not spreading their absence in that 
case would not be proof against their existence in an earlier stage, as the continued 
existence of an area of the skin devoid' of normal hair could be the result of anatomical 
conditions of the part arising from their previous presence, just as we may have a per- 
Vol. IV-16 • 242 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
manent alopecia produced by the favus fungus and continuing long after the organisms 
have ceased being present. 
So, also, if we find organisms which are not met with on or within the skin in any 
other condition, and their situation, number, etc., would clearly explain any patho- 
logico-anatomical changes of the part in which they are situated, and no other explana- 
tion of these changes would be at all probable, then I think we would be justified in 
accepting them as the cause until the opposite was proven, as is the case, for instance, 
in tinea versicolor. If the disease is contagious-and I mean by that positive, indis- 
putable proof of its occurrence, and not a possible coincidence of the same disease 
occurring in persons who associate together-a contagious power-such, for instance, as 
we have in measles-then, with our present knowledge of bacteria, it would not be 
necessary to demonstrate the organism to prove the origin of the disease. 
Before accepting the neurotic theory, the clinical history should point very strongly 
in that direction, or the microscopical examination should show changes in the nerve 
tissue or in the skin somewhat similar to those occurring in well-known neuroses, or, 
finally, one should be able to produce the disease at will by producing certain injuries 
to certain portions of the nervous system. The upholders of this theory must show 
that the almost invariably circular shape of the patches, their manner of spreading at 
the periphery, as well as many other characters, are consistent with their view; that 
anatomical changes, if any, are such as are known to result from trophic disturbances 
of nutrition; and, finally, that if an alopecia, the result of certain experiments, be 
produced, all the spots must have the characters, in every respect, of ordinary alopecia 
areata. 
Any criticism I shall attempt upon the views of gentlemen who have written upon 
the subject will be based upon the foregoing conditions for proof of causation, using the 
clinical symptoms of the disease, the anatomical changes of the part, as they have 
hitherto been described, and the results of modes of treatment, as evidence for or 
against the two theories, as the case may be. 
Let us first consider the value of the arguments advanced by those who believe in 
the parasitic origin. And here I wish to state that, in my mind, no good grounds have 
as yet been given for the division of alopecia areata into forms depending upon the 
extent of area affected; for, apparently, at least, the aetiology, method of extension and 
condition of the parts affected, judging from the clinical history, are similar, whether 
the disease remains confined to a single small spot, or whether there are several circum- 
scribed patches of various size, or, finally, whether the entire body becomes hairless. 
Gruby, Malassez, Eichhorst, Thin, Buchner, Lassar and Von Sehlen may be regarded 
as the principal observers who have endeavored by their studies and arguments to prove 
its origin from organisms. 
As it has long been decided by subsequent observers that the fungus described by 
Gruby * is the trichophyton tonsurans, and that by Malassez f is an organism acci- 
dentally but not very infrequently found on the skin, with no relation whatever to the 
disease, alopecia areata, I will pass on to a consideration of the observations and deduc- 
tions of the other observers mentioned. 
Eichhorst J found spores in diseased hairs once in nine cases. They were situated 
between the hair and root sheath, did not color in Bismarck brown, and consisted of 
round elements of a yellowish-brown color, variable in size, the smallest appearing as 
*Gruby. " Recherches sur la Nature, le Siège, et le Développement du Porrigo Decalvans ou 
Phytoalopecie." Compt. rend, de V Acad. des Se., 1843. 
f Malassez. " Note sur le Champignon de la Pelade." Arch. de Phys. Norm, et Path., 1874, 
I, 203. 
| Eichhorst. "Beobachtungen über Area Celsi." Virch. Arch., Bd. 78, vin, p. 197-209. SECTION XIV DERMATOLOGY AND SYPHILOGRAPHY. 
243 
shining, homogeneous bodies, and the larger ones somewhat like red blood corpuscles, 
with light double contour. In the latter, a small, shining, transparent body was often 
seen. The usual seat of the spores was between the hair and inner root sheath, but an 
occasional one was observed between the epithelial cells of the root sheath. Spores 
were found on the hair as far as the root sheath remained connected with the shaft, that 
is, in the upper two-thirds of the hair follicle. Mycelia were not found. He thought 
that the fungus was related to that of tinea versicolor. 
Buchner (H.) * believes that the disease is parasitic, although he was unable to 
detect a special fungus. He suggests the small size of the organism or imperfect lenses 
as possible cause for the rarity of detection by observers of the fungus; and adds the 
fact that it is possible that single celled, non-colonized organisms can be present, yet 
indistinguishable from lifeless granules, or be hidden from observation by the tissues. 
He tried cultivation in one case, and in eight experiments always found the same 
fungus, a form of organism never observed by him as accidentally occurring in the hair. 
It consisted of small, shining, sharply-limited granules, with two fine, thread-like pro- 
jections in opposite directions. He does not, however, maintain that this fungus is with 
certainty the one causing alopecia. Regarding the symptoms, he thinks that the method 
of spreading of the disease is a sufficient proof that it is parasitic in its nature. 
Dr. Thin (Geo.) f found small, shining bodies, which from their arrangement and 
other qualities he believes to be organisms, in the hair shaft and between the shaft and 
the hair sheaths. He believes that the fungus enters the hair follicle between the 
internal root sheath and the shaft, and toward the root of the hair penetrates the hair 
substance, and as it multiplies, ascends upward in the hair, breaking it up and loosen- 
ing it. 
Von Sehlen J colored his preparations by a special method, and also made cultures 
of certain organisms which he saw. He found micrococci, especially in the outer part 
of the follicle, above the sebaceous gland opening, but also as low down as the papilla 
in some cases. They were not found in all hairs, but mostly in those with retained 
root sheaths. His drawings show the presence of micrococci without doubt, and in 
•colonies. He made cultures and inoculations, but although a falling out of hair was 
■observed to follow the inoculations, the course of the disease thus experimentally pro- 
duced did not very closely resemble that of alopecia areata. 
Other observers have written upon the subject and described organisms in the hair 
follicles, but as their observations give us no more proof than those already quoted, it 
is not necessary to refer to them, as the same arguments to be used against the above 
observations will hold good for these also. 
Before considering the value of these observations, it will be necessary to bear in 
mind the symptoms and clinical history of the disease, and to these I will now briefly 
draw your attention. 
As a rule, no subjective symptoms of any kind mark its onset; sometimes it is pre- 
ceded by neuralgic pains or a sense of slight burning or itching of the part from which 
the hair is about to fall out. The patient may notice for several days that his hair is 
falling out, and soon a bald spot is observed ; or a large spot may form very quickly. 
* Buchner. Ueber Pilze bei Area Celsi : Sitzung d. ärztl. Vereins in München. Kritische 
Bemerkungen zur Aetiologie der Area Celsi. Archiv f. pathol. Anatom., 1878, Bd. 74, p. 527. 
f Thin. "On Bacterium Decalvans; an organism associated with the Destruction of the Hair 
in Alopecia Areata." Proceedings of the Royal Soc., Lond., xxxm, 1881, No. 217. "Alopecia 
Areata and Bacterium Decalvans." Monatsch. f. prakt. Dermat., 1885, 8, p. 241. 
J Von Sehlen. "Zur Aetiologie der Alopecia Areata." Virch. Arch., Bd. 99, p. 327. " Mikro- 
kokken bei Area Celsi." Fortsch. d. Medic., 1883, 23, p. 763. "Zur Aetiologie der Alopecia 
Areata." Aerzt. Intelligbl., No. 28, p. 317. 244 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
The bald spots are more or less circular in outline, are usually at first quite small, 
but may gradually increase until a large surface is covered. They increase in size by 
extension at the periphery, and may remain small or cover a very large area. The 
patch devoid of hair, whether large or small, is smooth, shining, pale, sunken beneath 
the general surface; the hair at the margin of the patch is thinner than normal and 
comes out with a very moderate amount of traction. A certain number of broken-off 
hairs are frequently present. There is no redness or scaling to be observed, and usually 
all the hairs within the bald area fall out. There may be only one spot or many; when 
the latter is the case, they arise successively, and even some spots may heal while new 
ones arise. After existing for a variable time, usually several months, the disease 
frequently disappears spontaneously; in other cases permanent alopecia results, without 
giving rise to any change in the existing characters of the patch. The hairs which lall 
out show signs of interference with the nutrition of the whole hair, and not a local 
interference, as in ringworm. 
Sections of the skin have been examined by Schultze,* E. Wagner,f and Duckworth 
and Harris. J The two former found no changes whatever. The latter, in sections 
stained with hæmatoxylon, found atrophy of the hair follicles, these appearing as long, 
fibrous cords ; considerable increase in the connective tissue in the neighborhood of the 
atrophied follicles, but not elsewhere; almost entire absence of the sebaceous glands; 
sweat glands normal ; infiltration of the hair follicles, especially of their outer sheath, 
with a new round-celled growth. In some instances remains of hair papillæ were seen ; 
but the papillary loops were infiltrated with the round cell growth. No parasitic ele- 
ments were found ; but as they stained the sections with hæmatoxylon only, their nega- 
tive observation is of no value whatever. The absence of any statement as to the 
duration of the disease, and as to the previous treatment, detracts much from the value 
of the case studied by them ; but from the absence of the sebaceous glands, and the 
new connective tissue formation, it was very likely one of long standing. 
The portions of the clinical history to which I wish especially to refer, are the 
manner of origin and spreading of the patches, the absence of superficial inflammatory 
symptoms in almost every case, the almost complete falling out of hair in a given area, 
the rarity of signs of local interference with nutrition of the hair shaft, the irregular 
duration of existence of the spots, the size of different patches, and the usually finally 
complete restoration to a normal condition. 
As the upholders of the parasitic theory all describe the fungus as situated either in 
the hair follicle, hair shaft, or corneous layer, we must first consider what effects are 
produced by organisms present upon or within the living or dead tissues. 
As shown by Bizzozero § and others, many organisms are constantly present on the 
normal skin, not acting upon the living tissues or taking their nourishment from them, 
but living upon the dead material, the product of secretion and desquamation. As this 
latter is inert matter it is incapable of reacting from the presence of these fungi, con- 
sequently there are no signs of interference with nutrition. In the living tissues fungi 
can produce tissue growth or degeneration, or cause inflammatory action, varying in 
intensity from a slight nutritive change to suppuration or necrosis ; or can act injuriously 
upon the normal nutritive processes of the part by abstracting nourishment from the 
* Schultze. "Die Theorien über Area Celsi." Virch. Arch., 1880, Bd. 80, p. 193. 
f Wagner. Arch. f. phys. Heilkunde, 1859. 
| Duckworth and Harris. "Case of Area Celsi, in which the parts were examined after death." 
Transactions Path. Soc., Lond., 1882, p. 386. 
§ Bizzozero. "Ueberdie Microphyten der normalen Oberhaut des Menschen." Virch. Arch.,. 
Bd. 98, p. 451. SECTION XIV DERMATOLOGY AND SYPHILOGRAPHY. 
245 
tissues, either directly or by the plugging of vessels, or by the organisms or the produc- 
tion of a fibrinous coagulum within the latter. 
The upholders of the parasitic theory claim that the manner of spreading of the 
■eruption, the occasional redness or slight scaling observed, the presence of broken hairs, 
the presence of organisms, the occasional contagious character, as apparently shown by 
reported cases, and the results of treatment, fairly prove the correctness of their view, 
at the same time that they disprove the theory of a neurotic origin. 
First as regards the manner of spreading. Every one will admit that the manner in 
which the patches increase in area, viz., by contiguity of tissue, thus producing more 
or less circular areas of baldness, is such as to lead us to strongly suspect a parasitic 
affection, even if a fungus be not found, as this manner of spreading is the rule with 
local parasitic affections. Buchner even declares that it is absurd to suppose that an 
affection of the nerves or blood vessels can give rise to such spreading areas as occur in 
alopecia areata. As will be shown later on, however, Schultze endeavors to show that 
it is compatible with the neurotic theory, and the recent experiments of Joseph, to 
which I will presently refer, seem to confirm his statements. Nevertheless, the fact 
that all the spots spread in the same manner, although not conclusive, is a strong point 
in favor of the parasitic theory, on the grounds already mentioned, and should have its 
value as rather favorable evidence. 
As regards the method of falling out of the hairs, it seems to point rather against 
than for the cause consisting in organisms, existing either on the general surface or in 
the hair follicles. Thus not infrequently a patient finds that quite a large patch of 
baldness has evidently formed in a very short period of time, waking up in the morning, 
as they say, to find a bald spot, the first intimation they have had of their having any 
disease of the scalp. If the disease depends upon such organisms as have been described, 
organisms so difficult to find on account of their small number rather than their diminu- 
tive size, one would not expect such rapidly forming areas of baldness, certainly not 
without being accompanied by more inflammatory symptoms than are observed. So 
also the usually complete falling out of hairs in the affected area is to my mind opposed 
to the view of the fungus having its seat in the hair follicles alone, for then, as the disease 
spreads, many hairs would probably escape invasion, and there would merely be thinning 
of hair. If the fungus lived in hair follicles, and on dead epidermis of the corneous layer, 
as in ringworm, then we could have all the hairs affected as the fungus invaded contiguous 
elements. Butin this case what would we discover ? No doubt just what is seen in 
ringworm, viz., signs of inflammation or interference with nutrition, or else no change 
in the hair, as in tinea versicolor ; that is, there w'ould be a large number of broken off 
hairs caused by a fungus at the seat of fracture, and signs of inflammation, or there 
would be no interference with the nutrition of the part invaded. We find, however, in 
alopecia, that the majority of the hairs fall out entire, accompanied frequently with the 
root sheaths, the shafts showing signs of atrophy, which I need not here describe, as 
they are not those whiqh bear any resemblance to what would be expected from the local 
action of an organism. If the organisms were situated at the base of the follicle, they 
could, of course, possibly deprive the hair of its proper nourishment, if present in great 
numbers, by abstracting it from the follicle sheath region for themselves ; but then they 
would be in living tissue and would probably give rise to inflammatory changes, and 
should be easily detected by microscopical examination. According to Duckworth and 
Harris, already quoted, inflammatory changes were observed in sections from their case, 
but they found no fungus. I have already drawn attention to the incompleteness of the 
history of that case, and consequent difficulty of properly estimating the value of the 
histological changes observed, as the inflammation may have been produced by external 
applications for the cure of the disease. 246 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Then as regards the broken off hairs to be observed in greater or less number, 
although the number is frequently very small, in the majority of cases no fungi are ta 
be detected at the seat of fracture. Furthermore, the condition of the hair in its imme- 
diate neighborhood is not such as to suggest the disintegration of fibres from organisms, 
neither, as far as I am aware, have organisms been found at that part. While, there- 
fore, the method of spreading of the patches favors the parasitic theory, the manner of 
falling out of the hairs and their anatomical condition, oppose the idea of the presence 
of a fungus within them and acting injuriously upon their structures. The possibility 
of a fungus existing in the living tissue at the base of the follicle is not, however, 
excluded ; but that is not the situation which has been given by any one, except Dr. 
Thin, as the seat of the organism, but rather the part of the follicle above the place 
where the sebaceous gland duct enters it. The above criticism is, therefore, especially 
opposed to the conclusions of Von Sehlen, and those who think the fungus is situated 
upon the general surface or within the upper part of the follicle. 
That occasionally, even if very rarely, there is some redness or slight itching or 
scaliness observed at the commencement of the disease, would show some inflammation 
with a probable local cause; but as this redness is an exceptional condition, and further- 
more, does not persist with the continuance of extension of the eruption, it can scarcely 
be considered to be the result of organisms such as have been described, even if we da 
not forget that a patch of ringworm sometimes shows no signs of inflammation. 
We will now consider the situation of the organisms, as described by the authors 
already mentioned, and the proof of their ætiological connection with alopecia. 
Gruby found them surrounding the hair shafts, but his cases were evidently exam- 
ples of ringworm. Malassez found them only in the most superficial layers of the 
epidermis, and never in the hair follicles. The organisms described by him are con- 
sidered, probably by all who have worked upon the subject, as accidental organisms, 
having no pathological significance for the tissues of the scalp. Buchner found no 
fungus for certain except after cultivation of hairs. Eichhorst found once in nine cases 
a fungus between hair and root sheath, having some resemblance, according to him, 
to the fungus of tinea versicolor. These four observers all describe a different organ- 
ism, and all have failed to show the slightest relationship between the fungus and the 
alopecia. As regards Eichhorst's fungus, on account of its size there should have been 
no difficulty in detecting it in every case of the disease, if it was a constant element 
and thecause of the disease. As he found it only once in nine cases, we can dismiss 
the observation as being valueless in the question of aetiology. 
There remain still for consideration the studies of Dr. Thin and Von Sehlen. 
Dr. Thin found the elements which he considered to be bacteria, in the situations 
already described, and attributed to the growing organisms the loosening and falling 
out of the hairs. He did not stain the bodies he saw, or make cultures and inocula- 
tions. The objections to the conclusions are that the hairs, as a rule, do not show signs 
of breaking up and disintegration, such as would be produced by a fungus growing 
within them. It is not necessary to repeat the observations of Hutchinson* (J. ), 
Michelson, Rindfleisch, f Kaposi, £ Schultze, % and others, all of which tend to show 
that the splitting up or fibrillation of the hair shafts, which sometimes occurs, is the 
result of an atrophy from interference with the factors engaged in hair production, and 
not from direct action of an agent upon the hair structure, after its formation is com- 
* J. Hutchinson's "Report on the Natural History, Diagnosis and Treatment of Alopecia 
Circumscripta." London Medical Time» and Gazette, 1852, I, page 165. 
j- Michelson, Rindfleisch. " Area Celsi." Arch. f. Dermatol, und Syph., Prag, 1869, I, p. 
483. 
J Kaposi. " Pathologie und Therapie der Hautkrankheiten," 1880. Schultze. Ibid. SECTION XIV DERMATOLOGY AND SYPHILOGRAPHY. 
247 
pleted. It can be argued that the deductions from these observations are not correct, 
and that the fatty degeneration, the longitudinal fibrillation, or transverse fractures 
observed, are the result of interference with the hair struct ure. As these nutritive 
changes are found in only a small proportion of the hairs of an affected area, and organ- 
isms have not been invariably found at the seat of fracture, while the majority of the 
hairs have an unchanged consistence and show none of these breaking-up changes, the 
loose hairs, accompanied with or without their root sheaths, having the hair root usually 
thin and pointed and pale in color, while the upper part of the hair is larger and darker, 
and the free end fibrous or brush-like in character, these deductions may be considered 
j ustifiable. Schultze found that the splitting up of ripe hairs appears only on certain 
parts of the shaft, the best examples occurring in dry atrophic hairs, poor in pigment, 
and in a stage of "Schalt" or "Beeth" hair condition. In these cases a frequent 
absence of the root sheath and of the normal hair cuticula favors splitting of the shaft. 
The medulla is frequently absent. These, together with the other changes which have 
been described by observers, make the seat of origin of the nutrition changes not 
within, but outside of the follicle, i. e., in the factors concerned in hair production. 
Still, as already mentioned, organisms might be situated within the follicle, and, by 
abstracting or taking up the nourishment intended for the hair growth, produce the 
falling out of the hair. They are, however, not found in the ordinary atrophied hairs, 
or in hairs not yet loose; and other observers have very rarely found organisms in the 
lower part of the follicle; and, furthermore, if they were confined exclusively to the 
lower part of the follicle, not existing upon ordinary dead epidermis, the patches would 
not be round in form, since for this to occur the organisms, if on the exterior of the 
body, must be able to exist on the general surface-the corneous layer, to produce a 
regular spreading patch. On these grounds we must conclude that no connection has 
been shown, from a clinical or histological standpoint, to exist between the elements 
described by Dr. Thin and the disease alopecia areata, although some of the changes 
observed in the broken hairs may be caused by the organisms described by him. 
Von Sehlen,* whose work drew renewed attention to the ætiology of this disease, dis- 
covered micrococci organisms in considerable numbers, situated principally in the hair 
follicles, above the place where the sebaceous gland duct enters the follicle. They were 
not found in all hairs, but mostly in those with retained root sheaths after epilation, 
and possessed sufficient distinctive characters for other observers to substantiate his 
observations. He also made cultures and inoculations, with the result of causing a loss 
of hair in the part subjected to the experiment, although the hair did not fall out in 
the manner peculiar to alopecia areata. 
From these observations, then, we learn that a certain organism is very generally 
present, but, as already shown, organisms upon the general surface, or at the openings 
of hair follicles, cannot produce the symptoms of this disease. That inoculations fail 
is to my mind no proof against its parasitic nature, for the tissues in the animals 
experimented on may not have been favorable for their growth. The fatal objection, 
however, to these organisms having any ætiological connection with alopecia is that 
Bizzozero.t Bordoni-Uffreduzzi, j: Michelson § and others maintain that they have found 
a similar fungus under normal conditions, that they have cultivated this fungus and 
*Ibid. j'Bizzozero. Ibid. 
i Bordoni-Uffreduzzi. "Ueber die biologischen Eigenschaften der normalen Hautmikrophy- 
ten." Fortschr. d. Mediz, 1886, No. 5. 
g Michelson. Fortschritte d. Med., 1886, No. 7, p. 230. "Ueber die sogen. Area. Kokken." 
Virchow's Archiv, 1885, Bd. 99, p. 572. Bemerkung zu den Arbeiten des Herrn. Dr. von Sehlen 
" über die Aetiologie der Alopecia Areata. Zur Discussion über die Aetiologie der area celsi." 
Virch. Arch., 1880, Bd. 80. 248 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
made inoculations, with the result that, if much material was used, signs of inflamma- 
tion were produced. 
Bender * found similar organisms to Von Sehlen's in all his seven cases but one, and 
also in the normal scalp, and made cultures and inoculations, but with negative 
results. 
Bordoni-Uffreduzzi thinks these organisms are normal to the part. He made inocu- 
lations after cultivation, and if many organisms were used the scalp was irritated, 
while if there were only a few no signs of inflammation appeared. He examined 
hairs from the normal scalp of himself and others, and found micrococfci colonies of 
similar appearance as those described by Von Sehlen. 
These observations and experiments by inoculation strengthen the arguments which 
I used against the cause of the disease being any organism on the general surface, or 
within the hair follicle, on account of the absence of signs of inflammation. 
Von Sehlen denies the correctness of the observations of his opponents, and I think 
we should not forget that previous to the time Von Sehlen described these organisms, 
organisms present in considerable numbers, some of these observers stoutly denied the 
existence of fungi of any kind on the scalp in Alopecia areata, showing surely that they 
were not very careful observers. 
If the disease is parasitic and the organism situated in the parts described by Von 
Sehlen, anti-parasitic remedies should almost invariably and quickly control the disease. 
As the inoculation experiments were unsuccessful ; as similar organisms have been 
found in normal skin ; as the situation of the fungus is such that the production of hair 
would not be interfered with; as inflammatory symptoms are absent, and anti-parasitic 
treatment frequently unsuccessful, we cannot admit that Von Sehlen has proven his 
view, or even made it probably a correct one. 
As regards the contagiousness of the disease, although some cases have been reported 
which would suggest its contagious nature, yet the disease may be regarded as non-con- 
tagious in the ordinary sense of the word. In Hutchinson's forty-two cases no two 
occurred in members of the same family or playmates. Experiments by inoculation 
from head to head, and upon places of a scalp of a person already affected, have always 
given negative results, so that the upholders of the parasitic theory receive no support 
on this point, but rather the opposite. I believe, however, that we should not lay much 
stress upon the absence of proved contagion. Alopecia is a rare disease, and conse- 
quently if it is parasitic, the ground is rarely in a favorable condition for the 
growth of the organism ; hence failure of inoculation is no proof of its non-parasitic 
nature. We know how numerous the organisms are in tinea versicolor, and that fur- 
thermore they live upou the very surface, a situation most favorable for contagion, yet 
the disease is not a contagious one clinically speaking. The same is true of tubercu- 
losis, and even in such a severe disease as osteo-myelitis organisms injected into the sys- 
tem have failed to induce the disease until the bones were previously injured. All this 
goes to show that absence of frequent examples of contagion is no proof of a disease 
not being parasitic in its nature. At the same time, the few cases of alopecia reported 
as showing its contagiousness should not be regarded as of much value when the non- 
contagious character is generally so evident. 
When we come to study the treatment recommended, it is to be observed that reme- 
dies that are anti-parasitic in their action are the only ones recommended ; and, according 
to the latest views, such remedies as corrosive sublimate and sulphur are positive in 
their effects That the disease has a tendency to disappear spontaneously and at very 
uncertain periods of its existence, interferes considerably with our ability to judge of 
* Bender. " Ueber die Aetiologie der Alopecia Areata." Deutsch. Med. Wochenschrift, Berlin, 
1886, xii, p. 817. SECTION XIV-DERMATOLOGY AND SYPHILOGRAPHY. 
249 
the results of treatment in single cases ; but when a large number have been treated 
by anti-parasitic remedies with uniform success, as in the fifteen cases reported by Dr. 
Thin,* we are justified in attributing the result to the remedy. It has been maintained 
that all these remedies are more or less irritant in their action also, and that, perhaps, 
it is to this quality that any beneficial effect is due. Irritating applications, as blister- 
ing, or croton oil of a strength sufficient to produce marked dermatitis, have been em- 
ployed exclusively by some, and these applications continued for weeks if necessary. 
Those who have treated cases in this manner must have observed very often favorable 
results; but such results do not show the disease to be non-parasitic; for do we not use 
the same means sometimes to cure inveterate cases of tinea tonsurans ? So, also, the 
fact that many cases resist the use of anti-parasitic remedies is not a proof that organ- 
isms do not cause the disease. How many cases of ringworm resist treatment for 
months and months, although the fungus is situated in not very inaccessible regions; 
and if the organisms are deeper seated, as in lupus vulgaris, anti-parasitic applications 
are of but little value, indeed. Then, further, it does not follow that if an organism 
is the cause of the disease, it is still present in old, non-spreading areas, no more 
than the fungus of favus, for instance, is present, because we see the results of its action 
in permanent alopecia. It may have been present and produced directly or indirectly 
the changes which led to the alopecia areata; and the nutritive disturbances continue 
indefinitely, although the organism has long ceased to be present. In that case, anti- 
parasitic remedies as such could have no effect. To judge of their value, then, they 
should be used in an early stage of the disease, or while the alopecia spot is increasing 
in size; and in these cases they have been found to be very frequently of benefit by 
many observers, while, according to Lassar f and Thin, their action is prompt, positive 
and decided. 
To sum up the results of treatment, we find that remedies anti-parasitic in their 
action are the most certain means we possess at present for the treatment of alopecia 
areata, although they are not always to be relied upon. 
We have thus seen that the absence of signs of superficial inflammation, the char- 
acter of the falling out hairs, the negative results of inoculation of the cultured organ- 
isms observed, the apparently non-contagious nature of the disease, and the frequent 
failure in treatment of anti-parasitic remedies, render it fairly certain that the disease 
does not depend upon organisms situated either upon the general surface or within the 
hair follicles. The finding of organisms in these situations is of itself no proof what- 
ever of an ætiological relationship to the disease, for Bizzozero and others have shown 
that many forms exist upon the normal scalp. 
The upholders of the neurotic theory have, until lately, depended principally upon 
the clinical symptoms, and the failure of observers to show an organism having an ætio- 
logical relation to the disease. 
The clinical symptoms which they believe point to a neurosis are 1st, changed sen- 
sibility of the part; 2d, neuralgic symptoms appearing before or during the disease; 
3d, heredity. They further support their view of the significance of these symptoms, 
by inferences from comparisons with other diseases of a known neurotic character, in 
which there is falling out of hair, and from experiments which show that alopecia can 
be produced at will by injury to certain parts of the nervous system. 
We will pass rapidly over the arguments for the neurotic origin, with the exception 
of the experiments of Joseph; for, as Michelson justifiably wrote before these experi- 
* Thin. " Alopecia Areata." Br. Med. Jour., 1882, n, 783. " A further contribution to the 
Treatment of Alopecia Areata." Brit. Med. Journ., 1882, n, 828. 
f Lassar. " Die Uebertragbarkeit der Alopecia praematura." Monatschr. f. pr. Derm., 1882, 
p. 131. Deut. Med. Wochenschft., 1885, p. 531. 250 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
ments were made, "dass auch dieser Theorie (der neurotischen) bei dem derzeitigen 
Stand der Wissenschaft eine solide Basis noch durchaus fehlt." 
Michelson * found tactile sensation, electro cutaneous sensibility, pressure and tem- 
perature sense unchanged, sometimes even increased. The absence of perverted sensi- 
bility, however, is not against a nervous origin, as in Joseph's experiments there was 
no change in the sensibility of the part. Hence, the argument of a changed sensibility 
in the part has no decided value. 
That neuralgia frequently precedes or accompanies the disease is an accepted fact; 
but alopecia areata also frequently occurs without antecedent or present nervous symp- 
toms. Collier f reports a case of a boy who was struck with the fist over the left ear, 
causing intense neuralgia, lasting two weeks; it then ceased and was followed by alopecia 
areata of the left parietal region. In Mr. Hutchinson's forty-two cases only four com- 
plained of severe headaches. Cases have been reported of the headache ceasing when 
the hair had fallen out. But the number of cases accompanied or preceded by neural- 
gic symptoms is too few to justify us in attaching any special importance to the condi- 
tion, at least in the sense of cause and effect. 
The argument of deduction from analogy by observation of certain nervous dis- 
turbances producing alopecia is of more value. A few examples will suffice. 
Dr. Crocker reports a case of a boy who fell upon his head, and soon became com- 
pletely and permanently hairless. Kinney J reports a case of general alopecia six to 
eight days after a shock caused by lightning striking a tree near the patient. Unna | 
reports a case in which epilepsy, hemicrania, Graves' disease and alopecia areata all 
appeared simultaneously after a severe fright. 
Fredet || reports a case of a female, age seventeen, of previous good health, who was 
sitting at a window when the floor fell in. She caught hold of the window frame, and 
held on till released. No loss of consciousness or nervousness followed. On the follow- 
ing night she had headache, chilliness and disturbed sleep, and on the following morning 
weakness of the legs, nervous excitement, convulsive movements of the fingers and 
great itching of the scalp. Two days later the hair began to fall out on the scalp, and 
in a few days there was general alopecia. One month later the scalp was pale, smooth, 
with normal sensibility, no itching and no lanugo hairs. After two years' treatment 
there was no return of growth of the hair. 
Schütz (Jos.) reports a case of alopecia from peripheral lesion. The bald spot, 
however, was not round, but triangular in shape, was not sharply limited, and there 
was general thinning of the hair. The bald spot corresponded to the area of the occipi 
talis magnus nerve. 
Many cases could be reported of somewhat similar character, all of which show us 
that alopecia can be the result of a neurosis. They have not shown, however, sufficient 
similarity in the clinical symptoms with alopecia areata as to justify us in regarding 
the latter as depending on similar conditions. Furthermore, the shape of the bald 
patch in Schutz's case suggests a different cause from that producing ordinary alopecia 
areata. 
Nevertheless, all these observations only allowed theoretical deductions and ana- 
* Michelson. "Ueber Herpes Tonsurans und Area Celsi." Volkmann's Samnilg., 1877, No. 
120 ; also PïrcÂ. Arch., Bd. 80 and 99. f Collier. Lancet, London, 1881, I, p. 951. 
I Kinney. Virginia Med. Monthly, 1881, vir, p. 937. 
§ Unna. Vierteljahrsch. f. Dermat. und Sy ph., Bd. xiv, p. 138. 
|| Fredet. Archiv. Général, 1878. 
Jos. Schütz. " Beitrag zur Aetiologie und Symptomatologie der Alopecia Areata." Monatsch. 
f. Prakt. Dermat., 1887, p. 97. SECTION XIV-DERMATOLOGY AND SYPHILOGRAPHY. 
251 
logical conclusions of doubtful justification, without giving a positive proof that alo- 
pecia areata depends upon some abnormal condition of the nervous system. 
The experiments of Max Joseph * are entitled to much more consideration, even if 
all will not agree with him, that they justify us in considering alopecia areata as a tro- 
phoneurosis, a disease depending upon an affection of trophic nerves. 
He removed the spinal ganglia of the second cervical nerves, and observed between 
the fifth and twenty-seventh day following the operation, falling out of the hairs in the 
region supplied by the injured nerve. On one or more circumscribed, twenty-pfennig- 
piece-sized places, with normal-looking skin, the hair became thinner in round, oval, or 
longish areas, and, later, complete baldness occurred. The spots also afterward increased 
in size to a fifty-pfennig or mark piece. The falling out of the hair was not accompa- 
nied by any marked change in the sensibility of the part. Microscopical examination 
showed atrophy of the hair papillae, with complete absence of hair, the root sheaths 
lying close together or separated by a small vacant space. The sweat and sebaceous 
glands were unaffected, and there were no symptoms whatever of inflammation present, 
the characters of the tissues being those of the purest simple atrophy. As he was able 
to exclude traumatic influences and vasomotor nerve action as factors in the production 
of the alopecia, he believes that he has proved the existence of pure trophic nerves, and 
that alopecia is the result of injury to them. In contradistinction to alopecia, as has 
Fig. 1. 
been observed after injury to the nervous system, in which the form of the spots has 
been triangular, longish, irregular, with thinning of the hair, the spots were roundish 
and rather sharply limited. He endeavors to explain why the spots may be round, and 
also why they present this form as they spread peripherally and occupy new nerve ter- 
ritory; but his explanation will hardly convince those who have seen immense areas 
deprived of hair by peripheral spreading of the disease from a small, round spot. 
While it is true that the spots of alopecia areata generally retain the rounded form 
as they continue to increase in size, and have this form even when occupying a large 
area of the skin, yet it not infrequently occurs that the disease ceases to spread at one 
part of the circle while it extends by contiguity of tissue at other parts, in the manner 
so frequently observed in a serpiginous tubercular syphilide or a lupus vulgaris of the 
extremities. Thus, a patch which was previously round may assume the form shown 
in Fig. 1, where the parts at b continue to spread, while at a it is stationary. Now, if 
Joseph's explanation is correct, the extension at the periphery must be equal at all 
parts; that is, such a method of spreading of a patch as I have described above could 
not occur as the result of an injury to the trophic nerves. 
*" Experimentelle Untersuchungen über die Aetiologie der Alopecia Areata." Monat, f. 
Prakt. Dermat., 1886, v. 483. 252 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
It is not necessary to relate the objections-evident to every one-to this theory, for 
the explanation of the occurrence of widely separated and irregularly distributed sec- 
ondary spots of alopecia, or of the disappearance of some spots with the simultaneous 
appearance of new ones, or of the manner of spreading when general alopecia results 
from gradual invasion of all parts of the cutaneous surface, from peripheral spreading, 
bald spots. 
The symptoms in the case reported by Wagner, of measles in a patient with alo- 
pecia, in whom the eruption did not appear upon the bald spots, as being one support- 
ing the neurotic theory, can be much easier explained by deficient blood supply in the 
part, in consequence of which the inflammatory symptoms of measles could not well 
show themselves. 
Joseph's experiments prove the presence of trophic nerves, and the dependence of a 
form of alopecia upon a neurotic affection. Whether this alopecia is similar to the 
usual form observed we will endeavor, later on, to consider and decide. 
Joseph's experiments have been confirmed by Mibelli.* In the latter's experiments 
the bald places appeared not only after excision of the spinal ganglion of the second 
cervical nerve, but also after simple interruption of continuity of this ganglion, and of 
the nerve bundle passing from it. Also the bilateral and symmetrical appearance of 
spots far removed from the region supplied by the trigeminus was observed. 
That alopecia is sometimes observed in persons with lowered nutrition, that it is 
sometimes hereditary, or that relapses occur, as in Hardaway's case,f in which there 
was a return for four successive years of alopecia, always in the Spring, and always 
upon the same spot-all these facts have no weight for or against the parasitic or 
neurotic theory. 
Against the neurotic theory is the usual absence of nervous symptoms, the manner of 
spreading of the patches, the results of treatment based on this theory, and the tendency 
of the disease to spontaneous recovery with restitution of the part to a normal con- 
dition ; for atrophic processes of neurotic origin show a tendency to progressive loss of 
tissue. 
While, therefore, the upholders of the parasitic theory have not definitely proven 
anything, although the course of the disease and the results of treatment favor this 
view, the defenders of the neurotic theory have shown that hair can fall out from 
injury to cutaneous nerves, and that the manner of falling out and the shape of the 
bald patches may resemble very much that of alopecia areata as ordinarily encountered. 
My own observations on the aetiology and histology of alopecia areata comprise the 
microscopical examination of portions of affected skin removed from the scalp of seven 
different individuals. The duration of the disease in these different cases varied from 
one week to several years, and the clinical characters from a rapidly disappearing to a 
permanent alopecia. These observations have been carried on at intervals during the 
last eight years-at intervals, because it is difficult to obtain the consent of persons to 
the removal of a portion of skin from their scalp for purposes of study only. Some 
of the excised pieces were hardened in Miller's liquid and alcohol, and afterward cut 
into sections and stained for the anatomical changes ; while others were immediately 
put into alcohol and afterward cut and stained for examination for organisms and ana- 
tomical changes. The majority of the pieces excised were removed from the peripheral 
portion of a bald spot in process of extension, and included a portion of skin from which 
the hairs had not yet all fallen out. In three patients, including recent and old cases, 
pieces were also removed from the centre of a bald area in order to study late changes. 
*Mibelli (V). " Riserche sperimentale sulla etiologia dell' alopecia areata." Boll. d. sez. d. 
cult. sc. med. n. r. Accad. d. fisiocrit. di Siena, 1887, v. 636-68. 
j- Hardaway. Journ. Cutan. and Vener. Diseases, 1884, p. 260. SECTION XIV-DERMATOLOGY AND SYPHILOGRAPHY. 
253 
In four of the cases more than one piece was excised, and in one patient four pieces 
were removed at different periods of the disease. 
I will first describe the tissue changes observed in a case of about one week's dura- 
tion, the size of the patch being about two-fifths of an inch in diameter, round, sunken 
beneath the general surface and devoid of hair. The excised portion included some of 
the hairy margin. When I say the spot was of one week duration, that refers to the 
length of time since falling out of the hair was observed ; the cause of the alopecia must 
have been acting for a considerably longer period to produce the atrophied condition of 
the hairs present. This patient, a boy fourteen years of age, had another spot of two 
years' and one of several months' duration. His physical condition and general health 
were excellent, and he had never suffered from headache or neuralgic symptoms in any 
part of the body. The alopecia disappeared in two spots in a few weeks, and in all 
within four months. 
Fig. 2. 
a, epidermis ; b, embryonic cell collection around blood vessels ; c, corium ; d, external root sheath of 
hair ; e, space previously occupied by hair shaft. 
After hardening in alcohol and sections made, the microscopical examination showed 
the following anatomical changes : The epidermis, including both the corneous layer 
and rete, were normal. The papillary layer of the corium was but very slightly changed ; 
in some papillæ there were signs of slight inflammation, as shown by the collection in 
limited numbers of embryonic corpuscles (white blood corpuscles ?), while others 
appeared to be normal. In the corium proper, especially in its upper portion, beneath 
the papillary layer, signs of inflammation were very evident, especially in the peri- 
vascular regions, as shown by a marked embryonic cell infiltration and dilated blood 
vessels, as shown in Fig. 2. 
This cell infiltration was not general throughout the corium, but limited to areas ; 
that is, there were parts of the section which appeared to be in a normal condition, 
while others showed varying degrees of inflammation. There were no signs of special 
serous exudation, the changes being more like those observed in a small-celled infiltra- 254 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
tion, such, for instance, as occurs in a chronic interstitial nephritis. Neither did the 
inflammation appear in the perifollicular region more than in other parts, although in 
some sections a marked perifolliculitis was observed. 
The connective tissue corpuscles were much more distinct than normal, and it 
seemed that in many places there must have been an active proliferation of them-a 
formative inflammation. 
The subcutaneous tissue was normal. The blood vessels were dilated where the 
embryonic corpuscle infiltration existed to any extent, and some of the smaller arteries 
contained a fibrinous coagulum. 
Some of the lymph vessels in the corium and subcutaneous tissue were greatly 
dilated, and in some situations contained a fibrinous coagulum similar to that already 
mentioned as being present in the blood vessels. 
With the exception of this coagulum the subcutaneous tissues were normal. 
The sebaceous and sweat glands were normal in appearance. 
The hair follicles were either empty or contained normal or languo hairs. In Fig. 2 
is shown a hair follicle from which the hair has fallen out; the external root sheath, as 
far as shown, is normal in appearance and the internal root sheath is also to be seen. 
In some cases no papilla was to be found, the lower part of the contents of the follicles 
consisting of epithelial cells devoid of pigment, these cells forming a small hair shaft- 
a lanugo hair further up in the follicle. 
In other hairs and hair follicles nothing abnormal was to be detected. Some of the 
hair shafts showed signs of interference with nutrition, there was splitting up and 
fibrillation of the shaft in a few cases and an occasional stubbed hair. 
The anatomical changes, then, in this case were, a mild inflammatory condition of 
the corium, especially of the upper part, and occasionally of the papillary portion, a 
small-celled perivascular infiltration and connective tissue corpuscle proliferation, a 
falling out of the hairs and their replacement by lanugo ones, and finally coagulation 
within some of the blood vessels and lymph channels. In another case, in which the 
disease lasted only a few weeks, the hair rapidly growing again after using an oleate of 
mercury application, similar conditions were found. 
The next case from which sections were studied, was that of a man who in six 
months' time had lost fully one-half of the entire hair of the scalp. The loss he 
attributed to mental despondency in consequence of the death of a child just previous 
to the appearance of the alopecia. 
In Figs. 3, 4, 5, 6, 7, 8, 9 the anatomical changes are shown. There were the same 
signs of inflammation as in the first case, only they were more marked in all parts of 
the corium, including the papillary layer. The embryonic cell collection in perivascular 
areas was quite considerable, and beyond that region not a few were also observed. 
The inflammatory changes are very evident by examination of a part of a section 
shown in Fig. 3. 
Fibrinous coagula within the blood and lymph vessels were very distinct, and in Figs. 
4 and 5 it is shown within a lymph vessel at the commencement of the subcutaneous 
tissue; in Fig. 4 the extent and situation of this coagulum are shown under a low 
power, and in Fig. 5 a part of the coagulum is drawn under a higher power. As the 
drawing, Fig. 4, was made by means of a capiera lucida, the proportions are correct, 
and the lymph vessel at A is seen to be much dilated and the coagulum to be a long 
one. 
Some of the arteries also contained a fibrinous coagulum, not only the vessels of the 
corium but also of the subcutaneous tissue. This coagulum completely or only par- 
tially filled the lumen of the vessel. 
In Fig. 6, is shown a transverse section of such a vessel. 
The sweat glands were normal. Fig. 3. 
a. Corneous layer ; b. rete mucosum ; c. papillary part of corium ; d. upper part of corium; e. deep part 
of corium ; /. blood vessel with round cell infiltrai ion around it ; g. micrococci. 
Fig. 4. 
Section under a low power, a. Epidermis; b. corium ;c. subcutaneous tissue ; d. hair-follicle orifice ; 
e. unstriped muscle ; /. sebaceous gland ; g. sweat gland ; h. lymph vessel. 
Fig. 5. 
Fig. 6. 
Fibrinous coagulum in lymph vessel of upper part of subcu- Transverse section of an artery ; a. 
taneous tissue; a. lumen of lymph vessel; b. fibrinous fibrinous coagulum in lumen of 
coagulum ; c. subcutaneous connective tissue. vessel. 
255 256 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
In one or two instances there were signs of commencing degeneration of a part of a 
sebaceous gland, but beyond that they appeared to be normal. 
The hairs had either fallen out of their follicles or showed characters pointing to 
such a process. The root of the hair showed atrophic changes-the external root 
sheath was becoming separated from the follicle sheath preparatory to being cast off 
with the hair, or remained united, and the hair withojit the sheaths falls out. 
In Fig. 7, at e, the separation between the follicle and hair-root sheath is shown, 
and can be compared with the normal condition present at c. 
The round-cell collection is shown under a higher power, and also its limitation to a 
small area. In this drawing two hair follicles are cut across-in the one the external 
root sheath is seen to be separated from the follicle sheath while in the other it is con- 
nected with it, as in normal conditions. 
Fig. 7. 
Fig. 8. 
Transverse section of a hair follicle, a. sweat gland ; 
b. round-celled infiltration ; c. first row of cells of 
external root sheaths united to follicle sheath ; d. 
section of hair; e. abnormal space between follicle 
sheath and hair-root sheath. 
Lanugo hair; a.hair 
shaft; b. external 
root sheath. * 
None of these three patients had used any local applications previous to removal 
of the portions of skin, yet in all the inflammatory symptoms in the corium were 
distinct, while the epidermis appeared to be normal. Where lanugo hairs existed 
the hair papilla was absent or only an indication of its existence could be detected; the 
lower part of the follicle being filled with epithelial cells corresponding to those of the 
external root sheaths and the slight hair shaft commenced to be formed high up in the 
follicle. 
All the lanugo hairs which I have studied in this disease had their origin in this 
manner, and probably continue to be produced as long as the external root sheath is 
composed of well-formed epithelial cells. If that view is correct, then an absence, for 
any length of time, of hair of any description would indicate atrophy or destruction of 
the hair follicle and consequent permanent alopecia. SECTION XIV DERMATOLOGY AND SYPHILOGRAPHY. 
257 
In Fig. 9 is shown the upper part of a hair follicle with a lanugo hair and the 
inflammatory round-cell infiltration in the perivascular tissue of the corium. 
The external root sheath very frequently shows irregularity of contour from hyper- 
plasia of the epithelium, the increase in growth occurring at any part of the follicle, 
although most frequent in the lowest portion. 
In Fig. 10 is shown such a hyperplasia, and the occurrence of similar conditions in 
this disease is altogether too frequent to be regarded otherwise than pathological, and 
signifies increased nutrition to the structures affected. 
The next two cases, from whom portions of skin were removed, had had the disease 
for years, and one still has it; the hair of the scalp, eyebrows and beard of the latter has 
all fallen out, and in the former the hair grew in after several months' treatment, in all 
the situations affected, except the lower part of the occiput, and here not even lanugo hairs 
Fig. 9. 
Fig. 10. 
Fig. 11. 
Transverse sec- 
tion of artery 
showing 
thickened 
walls, a. lu- 
men of vessel. 
Section in lanugo hair area. 
a. hair-follicle orifice ; b. 
perifollicular round-cell 
infiltration. 
Hair follicle filled with epithelial cells and 
having irregular outline, from increase 
in cells of external root sheath. 
were to be observed when he first came under my observation seven or eight years ago, 
and none have appeared since, consequently the spot will be permanently bald. In 
removing pieces of the skin I always took some from the spreading periphery. In these 
two patients the same inflammatory changes already described were observed, but in 
addition there was thickening of the walls of many of the blood vessels, as shown in 
Fig. 11, and atrophy of others. 
In some vessels the lumen seemed almost closed, while the walls were several times 
thicker than normal. In both cases there was thinning of the epidermis and diminu- 
tion in the size of the epidermic cells. In the case of subsequent recovery the sebaceous 
glands were particularly well developed, as a rule ; in the other patient more or less 
degeneration was frequently observed in some glands, while others were unaffected. 
The hair follicles were either devoid of hair or contained a lanugo hair, or a hair in 
process of being cast off. In this case the hair showed the nutrition changes already 
described by observers, and which do not differ much from those seen in normally fall- 
Vol. IV-17 258 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
ing out hairs. These changes will be fully described in a more complete paper on this 
subject, and they are not necessary for the purpose of the present discussion. 
The fat tissue was normal in both cases, as also the subcutaneous tissue, which was 
present in normal amount, the fat cells being well developed. 
Fig. 13. 
Fig. 12. 
Portion of a sebaceous gland in a case of chronic per- 
manent alopecia areata, a. degenerated gland 
epithelium ; b. connective tissue framework ; c. 
unstriped muscle bundle. 
Lower part of hair follicle in case 
of chronic alopecia areata, a. 
hair papilla; 6. empty space 
between papilla and "follicle 
epithelium ; c. space, probably 
artificial, from hardening in 
Müller liquid ; d. pigment col- 
lection. 
The appearances I am now about to describe were observed in a case that I saw only 
once, about eight years ago. The disease at that time had existed several years and 
occupied almost the entire scalp, and I ha ve lately learned that it still continues in as 
severe a form as at that time. Sections of the skin removed showed more or less atrophy 
of all the structures except the blood vessel walls. The epidermis was thinner, the 
corium also somewhat thinner ; there was considerable atrophy of the fat tissue, the 
sebaceous glands in some cases were normal, but in many instances were degenerating 
and disappearing. Sometimes only the remains of the glands were to be observed. In 
Fig. 12 is represented a part of a sebaceous gland, the structure of which is already 
broken down in the greater part and the rest undergoing degeneration. SECTION XIV DERMATOLOGY AND SYPHILOGRAPHY. 
259 
The fat tissue showed the ordinary appearances observed in simple atrophy, but, as 
in the case of the sebaceous glands, there was considerable fat tissue but slightly, if 
any, affected. 
The hair follicles showed signs observed in normal falling of hair, or marked signs 
of atrophy and disappearance of papilla and follicle. 
Depending upon the extent of these changes lanugo hairs were present, or only an 
empty space within the hair follicle previously occupied by a hair. The anomalous dis- 
tribution of pigment was very striking in several instances. Instead of being in the 
usual situation, it was distributed in clusters irregularly within the hair papilla, among 
the epithelial cells of the hair follicle and in the perifollicular connective tissue. In 
Fig. 12 this anomalous pigment deposition is shown. 
In Fig. 13, however, very different anatomical changes are seen. The follicle 
sheaths are atrophied and shrunken, the basement membrane is greatly thickened, show- 
Fig. 14. 
Section of hair follicle in advanced permanent alopecia areata, a. root of hair ; &. basement membrane ; 
c. follicle sheaths. 
in g the teeth-like striæ, the hair papilla has disappeared, and the hair itself is being 
cast out. 
Here it is seen that the process does not resemble the normal one, for there are no 
structures left behind from which a new hair could arise. Fig. 13 represents, no doubt, 
an earlier stage of a similar process. In it the entire follicle has lost its usual form, the 
papilla is still normal as regards shape, and pigment is deposited in it in irregular 
masses. The condition shows interference with hair growth from disturbance in the 
circulation apparatus. 
This patient was sent to me for consultation, and from the above changes in struc- 
ture, I gave the opinion that the alopecia would be permanent. 
The hairs were either absent from the atrophied hair follicles, or, if present, were of 
the lanugo variety almost without exception. In the rare example of papilla hairs the 
shaft showed longitudinal splitting up, fibrillation and easy transverse fracture. 260 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
In Fig. 15 is shown the degeneration of a sebaceous gland and fibrillation of a hair. 
The base of the follicle is filled with round cells and the follicle sheaths are indistinct. 
The section did not color well, and the transverse fracture observed in the shaft is, no 
doubt, mostly artificial, consequent on the hardening of the section, the normal coher- 
ence of the cells with each other having become much interfered with, from atrophy. 
The blood vessels in some places were atrophied while the arteries showed thickened 
walls, from increase in the connective tissue, with diminution in the size of the lumen 
of the vessel, a condition similar to that shown in Fig. 11. 
Such were the anatomical characters observed in these different cases of alopecia 
areata; in all of them inflammatory changes were present, a round-celled infiltration of 
limited extent, confined, in great part, to the perivascular regions, with increase in the 
Fig. 15. 
a. sebaceous gland ; b. broken-down external root sheath ; c. hair shaft ; d. root of hair ; e. follicle sheaths, 
connective-tissue corpuscles of the parts. This inflammation was not specially peri- 
follicular, only as the glandular structures have a richer supply of blood vessels than the 
corium tissue, the inflammation was often well-marked around these structures; there 
was also coagulation of lymph in a number of lymph vessels in the more recent cases, 
with consequent stoppage of the current in that part; there was, further, coagulated 
fibrine in some of the arteries, large and small, and, finally, a thickening of the blood 
vessel walls in the more advanced cases. As regards the glandular structures, only the 
hair follicles were affected in recent cases; in more advanced ones the sebaceous glands 
also, and in the worst case there was a partial, but only a partial, atrophy of the sub- 
cutaneous fat tissue. The seat of the inflammatory changes pointed to the causative 
agent as one not acting specially upon the hair follicles, but in a more general manner SECTION XIV DERMATOLOGY AND SYPHILOGRAPHY 
261 
throughout the corium; and the coagulation within the lymph and blood vessels 
denoted that the agent had not a central but a local seat. 
The changes observed in the recent cases show that the depression of the patches 
observed in this disease depends at its commencement upon the absence of the hair, as 
already suggested by Hutchinson, and not upon a primary disappearance of the subcu- 
taneous fat tissue and atrophy of the cutis, as maintained by Michelson. 
From these observations, that question is no longer one of doubt; the sections show 
anything but an atrophy of the connective or fat tissues in the early stages of the 
disease. Afterward, in the very severe cases, the secondary disappearance of the seba- 
ceous glands and hair follicles are additional factors in the production of the depression 
of the skin. This disappearance of the glands and apparatus, however, as we have 
seen, occurs only rarely, and probably never occurs in these cases of temporary alo- 
pecia. When it does occur, as is shown by the absence for a length of time of even 
lanugo hairs, there is no possibility of the hair growing again. These changes in the 
glandular apparatus depend evidently upon an atrophy, the result of interference with 
their proper nutrition from inflammatory changes and thickening of the blood vessel 
walls and consequent narrowing of their lumen. A temporary narrowing is observed 
in all cases, and in the worst case observed by me, new connective tissue was present 
in considerable amount, and the muscular layer also appeared to be thicker than 
normal. The interference to the growth of the hair would seem to depend, partly at 
least, upon the thickened blood vessel walls, and in the recent cases, also upon the pre- 
sence of coagula in the arteries and lymph vessels, interfering with the nutrition supply. 
If an artery should be closed, the hair could fall out very suddenly in an area of con- 
siderable size, namely, the area supplied by that vessel; or a considerable extent of 
lymph vessels could be clogged, as shown in Fig. 4, and the same result could follow. 
Thus, I would explain the falling out of the hairs suddenly at the commencement 
of the disease, and why sometimes a larger area is affected than at other times. The 
paleness of the skin and absence of all inflammatory symptoms depends upon the 
deficient blood supply to the part and the fact that the inflammatory changes occur 
principally in the sub-papillary layer, and that the process is a small-celled infiltration. 
Perhaps, from a clinical standpoint, it could be questioned that there is an inflamma- 
tion present; the section, however, from even the most recent case, cannot leave any 
doubt upon the subject, for the inflammatory changes are easily recognized. In the 
most advanced and severest case studied there was some atrophy of the subcutaneous 
fat tissue, so that this can aid in making the depression of the affected part, but as 
already mentioned, it does not occur in recent cases. 
The process, then, is an inflammatory one; a small-celled infiltration leading to per- 
manent or temporary nutrition changes; to permanent or temporary alopecia; an inflam- 
matory affection of the corium, and not a disease primarily of the hair structures. 
In Joseph's experiments, it will be remembered that he produced a falling out of the 
hair, the result of a pure atrophy of the hair structures, and that there were no signs 
whatever of an inflammatory character in the sections studied by him. If these micro- 
scopical examinations of sections were correct, and we have no reason to doubt their 
correctness, then the process in the six patients studied by me were not examples of the 
disease produced experimentally by him, that is, the disease was not a trophoneurosis. 
That being admitted, we must seek for some other cause than a trophoneurotic one. 
As a vasomotor disturbance of central origin, I think no one would consider it for a 
moment, so we must look for a local cause. 
As regards its dependence upon organisms, I have studied sections after staining 
them in the manner recommended by Von Sehlen, as well as after the usual methods 
for their detection, and will briefly give the results of my observations. On the surface 
of the skin, around hairs and sometimes around the shaft, I found organisms resembling 262 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
the tinea trichophytina and tinea versicolor fungus occasionally. In one case I saw 
organisms apparently like those described by Von Sehlen. 
Staining sections from the most recent case, that of a week's duration, by Gram's 
method and by the different aniline dyes, decolorizing with alcohol, and examining with 
the microscope, showed in the lymph spaces of the corium and in the walls of some of 
the small blood vessels small round bodies arranged in groups and deeply stained. They 
were about the same size, were arranged in groups and zooglea masses, and were unaf- 
fected by acetic acid or alkalies. The majority were to be found in the lymph spaces 
of the middle part of the corium ; a few were present in some of the papilla, and occa- 
sionally they were found deep down in the corium. They were shown to be micrococci 
by the staining and the action of the acids and alkalies. They were present in tissue 
which often showed no signs of inflammation in the area of their location, and fre- 
quently one could trace a long row of these organisms from the zooglea mass into the 
surrounding tissue, along the course of the lymph capillaries. When these rows of 
Fig. 16. 
Section showing organisms in lymph vessels and walls and lumen of blood vessels, a. corneous layer 
b. rete; c. corium; d. blood vessel; e. micrococci. 
organisms were studied by high powers it could be seen that diplococci are quite 
frequent. In a case of several months' duration, similar organisms were found in simi- 
lar situations but were more numerous. 
In Fig. 16 their situation in the lymph vessels and blood vessels is shown. As the 
specimens were decolorized with alcohol, the inflammatory round-cell infiltration is not 
seen, but it was slight. 
The organisms were present in larger numbers, both in inflamed and normal tissue, 
and were especially to be observed in the corium, occupying the lymph spaces and 
extending by traveling through these channels. In Fig. 17 is shown large masses in 
these lymph channels, the immediately surrounding connective tissue appearing normal. 
In Fig. 18 organisms from the same patient as those of Fig. 17 are shown, under a 
higher power. The number of the organisms and their grouping are marked. Their 
presence around blood vessels is also shown in Fig. 3 and Fig. 16. SECTION XIV DERMATOLOGY AND SYPHILOGRAPHY. 
263 
In the two cases of several years' duration they were also found, but in much less 
number. In the most severe case of all I did not examine for them, as the specimen 
had been hardened in Muller's liquid, and, consequently, was unfit for such studies. 
The specimens of the other ones had been hardened with alcohol alone. 
I have already given you the histological characters of the skin, and endeavored to 
explain the cause of the falling out of the hair, the depression in the skin at the affected 
part, etc. Now, I wish to inquire if these organisms are accidental, or essential to the 
anatomical changes described. You will note the large number present in the tissues, 
Fig. 17. 
Micrococci in the lymph vessels, a. micrococci; &. connective tissue of corium 
the almost, if not entirely, normal condition of the skin in many places, and the 
inflammatory changes in other parts-a condition suggestive of a local agent acting in 
different places. Organisms in such quantity, and with such anatomical characters of 
the habitation, do not, I believe, occur in any other condition, as far as known at 
present. 
Their number and situation explain, without argument, the condition of the lymph 
vessels, and also of the blood vessels. It is true that micrococci are present in other 
pathological conditions, but then the tissues show marked changes in nutrition in such 
Fig. 18. 
Micrococci in lymph vessels, a. micrococci. 
cases, while in alopecia the changes are slight at first, or perhaps not appreciable, 
although organisms are present. 
The manner of spreading of the disease is furthermore easily comprehended when 
we consider how these organisms travel in the lymph vessels, just as in erysipelas, and 
in no other way, do I think, can we explain satisfactorily the manner in which the bald 
patches spread. 
The deep seat of the organisms also explains why contagion occurs so rarely, if ever 
it occurs, and the absence of marked contagious power is no longer an argument against 
the parasitic nature of the disease. 264 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Finally, the frequent failure of anti-parasiticides in the treatment of the disease is 
easily understood ; for the organisms are too deeply seated to be destroyed with ordi- 
nary anti-parasitic remedies. To insure success a remedy must be chosen that will 
penetrate deeply from without, or the organisms must be destroyed by internally acting 
agents, as white blood corpuscles, or the ground must be made unfavorable for their 
growth and multiplication. 
Treatment.-As alopecia areata is a disease which generally tends to disappear spon- 
taneously and at no definite period of existence, sometimes after having existed only a 
few weeks, and, again, only after many months, or even years, it is very difficult to 
judge of the positive results of any special method of treatment, even when a consider- 
able number of cases have been under observation, and it is absolutely impossible if 
only two or three have been treated. 
I have treated about thirty cases during the last eight years, and, in a number of 
these cases, have experimented with different remedies upon the same person, either 
upon a single patch at different times, or, when the patient had more than one bald 
spot, upon the different ones at the same time, using different substances on different 
places, with the object of observing their comparative value. I have used electricity, 
stimulating or irritating applications, as capsicum, cantharides, etc., different mercurial 
preparations, chrysarobin and croton oil. The sulphur preparations were not made use 
of, as the observations of Dr. Thin on fifteen cases made any experiment on my part 
unnecessary for the present study. 
Unna reports a case cured by electricity, that had resisted all the usual methods of 
treatment, but this must have been a case of long standing, and the result due to the 
effect of the agent producing the changes, for I have never seen any benefit whatever 
from its use, in any form, upon recent cases of the disease. That it can be of benefit in 
restoring the part to a normal condition after the active (progressive) stage is passed, is 
not difficult to understand, and it could or should be used in chronic cases. Stimu- 
lating or mildly irritating (inflammation-producing) preparations, as capsicum, ammonia, 
cantharides, etc., I have not found to be of any value, if their action is limited to the pro- 
duction of hyperæmia or slight superficial catarrhal condition of the skin ; but if their 
application be prolonged or sufficiently often repeated to produce a deeper dermatitis, 
and this inflammation be kept in existence for a length of time, and in a somewhat 
intense form, in order that emigration of corpuscles be greater than takes place in a 
simple serous inflammation, then I think we are generally, if not always, able to con- 
trol the spreading of the disease. The explanation I have for this result will appear 
directly. Of the mercurial preparations, I have used the oleate in two, four, six and 
ten per cent, solutions, and while some cases have been cured rapidly by this remedy, 
others have not been benefited. A four or six per cent, solution is strong enough, 
unless the object be to inflame the skin, and this can be better accomplished by other 
means. The cases which have been most benefited have been recent ones, but the 
remedy is an unreliable one. not only in this disease, but in those which all admit to be 
parasitic, as ringworm, for instance ; consequently the failure to cure every case of 
alopecia areata with it is no argument against the parasitic nature of the disease, while 
its prompt cure of some cases of recent origin favors the parasitic theory. White pre- 
cipitate ointment has never seemed to me to be of any value, although I have made 
frequent use of it. The same unfavorable results were observed when the mercurial 
preparation was mixed with lanolin or agnine. The bichloride of mercury was of value 
in some cases, and in others no beneficial effect was observed. As I did not follow the 
method for its application recommended by Lassar, that is, perhaps, the reason for the 
difference in the results obtained by us. My own observations from the use of the 
mercurial preparations, especially of the bichloride, lead me to the conviction that any 
organisms existing on the surface of the skin are not the cause of the disease. SECTION XIV DERMATOLOGY AND SYPHILOGRAPHY. 
265 
Chrysarobin of the strength of 15 to 20 grains to an ounce of lanolin has given me 
the best results among the remedies properly called directly anti-parasitic. It will not 
cure every case ; but I have often seen spots rapidly cured and the spreading process 
stopped, by the use of this remedy. As an example of its comparative value, I treated 
a boy last year who had several large areas of alopecia areata of over one year's duration, 
with either oleate of mercury, bichloride of mercury, white precipitate ointment or 
chrysarobin applied to the spots, the chrysarobin being applied to the largest of the 
bald areas. Within two weeks' time an increase in the growth of the hair in the area 
treated by the chrysarobin was observed, with subsequent rapid return to a normal 
condition, while the other places remained unchanged. 
The results obtained by the mercurial preparations and chrysarobin, point to the 
disease being parasitic in its origin, for surely these remedies can have no beneficial 
effect in neurotic conditions, unless their action be traced to a stimulating effect, a view 
hardly correct, at least as regards chrysarobin. If to these results we add those obtained 
by Dr. Thin with sulphur ointment, and by Lassar with corrosive sublimate, I do not 
see how any one can doubt the parasitic origin, unless they doubt the results obtained, 
or at least described. The failure of the anti-parasitic remedies in some cases, can be 
best explained by the view of the deep seat of the organisms, as I have already 
pointed out, comparing the results with those obtained in lupus vulgaris when treated 
by anti-parasitic agents. 
Croton oil has given the best results in the treatment of this disease, when used in 
the proper strength to accomplish the object in view viz : the production of a dermatitis 
in which the exudation or rather infiltration will contain a considerable number of 
white blood corpuscles. If pure croton oil is used a very intense inflammation of a 
suppurative character is almost certain to be produced around the hair follicles, a 
suppurative perifolliculitis by which there is danger of destruction of the hair follicle. 
A fifty per cent, preparation, the croton oil being mixed with olive oil or some other 
suitable substance, should be used at first, and this made stronger or weaker afterward, 
according to the vulnerability of the tissue, that is, according to the intensity of the 
inflammation produced. As intensity of inflammation in any case depends upon 
the vulnerability of the tissue being acted upon, upon the agent acting, and the 
duration of action of the agent, so we can with a weak preparation of the croton oil 
accomplish, by frequent application or long duration of action, without danger, the 
same results as by a stronger preparation. An inflammation of the character I have 
described should be produced and maintained for perhaps a few weeks, and the result 
studied, observing whether the disease is spreading or the alopecia disappearing. The 
application should be made not only to the bald area but also to the hairy margin. 
With this agent I have often seen the disease stop spreading in the region treated 
while it spread at öther parts. If it was a neurosis surely such an effect would not be 
produced, nay, I would say could not be produced. The result is the same as can be 
obtained in treating a portion of a serpiginous syphilide by a mercurial ointment ; the 
part treated becomes free of the disease while the remainder of the lesion continues to 
spread; and syphilis is an infectious disease, with organisms, no doubt, in the corium, 
even if they have not been cultivated or successfully inoculated in the lower animals. 
The beneficial results of the croton oil depend, I believe, upon the inflammation 
produced ; the white blood corpuscles passing out of the vessels into the lymph channels, 
the situation of the microccoci already described, act as anti-parasiticides, and destroying 
the organisms remove the agent producing the disease. As this emigration of corpus- 
cles occurs especially in chronic inflammations of some intensity, the necessity of main- 
taining for some time the dermatitis produced by the action of the croton oil is apparent. 
Any agent, of course which will produce such a dermatitis, will act as well as croton 266 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
oil; the reason I recommend this substance is because as yet it has given me the best 
results.* 
From what we have already learned of the histological characters of alopecia, it is 
evident that there are some cases in which treatment cannot be of any service what- 
ever. When the hair follicles are destroyed the alopecia must be permanent, and there 
are some cases where lanugo hairs are still being produced, but the blood vessel walls 
are too much changed to admit of restoration to a normal condition. If, however, we 
treat recent cases in the manner I have described, regarding the disease as parasitic and 
the location of the organisms as seated in the corium, I believe the results will be 
entirely different from the treatment based on the neurotic theory. 
As the nature of the ground is an important factor, perhaps the most important, in 
most parasitic diseases, it follows that everything should be done that is necessary to bring 
the general system into a normal physiological condition. It is not necessary to enter 
into a discussion of this subject, for each case must be treated according to the special 
condition present. A cure of the alopecia by internal medication which corrects the 
nutrition of the tissues, is no proof that the disease is not parasitic, for the changes 
produced in the skin about the period of puberty, for instance, will usually cause a 
ringworm to disappear without local treatment. 
As an additional argument for the parasitic theory I might mention the tendency to 
invasion of certain tissues, viz., those parts specially provided with well developed hair, 
as scalp, beard, axilla, etc., the capillary production being the result not of the nervous 
system but of hereditary influences. The selection of certain tissues by certain organ- 
isms is a well established fact, and should be considered in a discussion of the aetiology 
of alopecia. If the disease were a neurosis this selection of certain areas covered with 
hair would not occur. 
The results of my observations would tend to show, then, that alopecia areata is a 
parasitic disease; that the organisms are microccoci and have their seat specially in the 
lymph vessels; that they give rise to inflammatory changes in the corium, and frequent 
coagulation of fibrine in the lymph and blood vessels; that the depression of bald areas, 
in recent cases, depends upon the loss of hair and diminished blood supply in the part, 
and in old cases, in addition to these changes, the destruction of the sebaceous glands 
and an atrophy of the corium and epidermis; and finally that in anti-parasitic remedies, 
in the widest sense of that term, we have the only means which have any effect upon 
recent cases of the disease. 
I have further endeavored to show, by the clinical symptoms, the histological 
changes and the effects of certain local agents to the parts, that ordinary alopecia areata 
cannot depend upon a disturbance of the nervous system for its cause. 
DISCUSSION. 
In the discussion, Dr. Unna said that just as summer changes to winter and 
back again, so do the views upon the aetiology of alopecia first favor the neurotic then 
the parasitic theory. 
He himself might be said to hold both views. One must, however, have his mind 
directed to the possibility of a parasitic origin when one sees, as he has, a father and 
daughters in one family simultaneously affected. On the other hand, an alopecia 
following an injury to the scalp, as from a needle broken off in the tissues, rather 
favors the opposite view, and one must recognize a neurotic origin for cases of general 
alopecia following shock, etc. He could only offer his congratulations to Dr. Robin- 
son on the scrupulous original work which he had done, and the admirable manner 
in which he had presented the result of his investigations. The two theories rise 
* Since reading this paper I have used Chrysarobin in several cases, with excellent results. SECTION XIV-DERMATOLOGY AND SYPHILOGRAPHY. 
267 
side by side, each having points of strength and weakness. He thought it would be 
a long time before either became the recognized one for all cases of alopecia areata. 
To prove the parasitic theory, isolation, cultivation, and transmission were neces- 
sary. 
Dr. Thin, after a careful examination of Dr. Robinson's specimens, satisfied 
himself as to the undoubted presence of cocci, as described by Dr. Robinson, in the 
lymphatic vessels and in the arteries, and of the presence of fibrinous coagula in the 
vessels. He considered that these cocci were identical in form and size with the 
cocci described by himself some years ago as being present in the hairs in alopecia 
areata, and named by him bacterium decalvans. 
Dr. Thin had, by repeated investigations, after the publication of Von Sehlen's 
paper, confirmed his previous views as to the presence of these cocci in the interior 
of the hairs, but the demonstration was by no means easy. The same aniline dyes 
that are used in staining cocci also stain the hair substance proper. In the various 
manipulations that are necessary to differentiate the hair and the cocci, as recom- 
mended by Von Sehlen, the cocci that are lying free on the split surfaces are very 
apt to be washed away. The more manipulation the hair undergoes in staining the 
less chance of the cocci being left. Still, if these manipulations are carefully per- 
formed, cocci can be found lying on the surface of the fibres which are formed by 
the splitting of the hair. 
As regards the pathogenic value of this bacterium, Dr. Thin considered himself 
entitled to criticise with severity some of the German writers, particularly Dr. Michel- 
son, the author of the chapter on Alopecia areata in Von Ziemssen's "Handbook." 
He considered it somewhat remarkable that the editors of the book allowed an obser- 
vation of Dr. Michelson's to appear in which that gentleman expresses his belief that 
the objects described by Dr. Thin, and figured by him in a paper accepted for publi- 
cation in the Royal Society, were only air bubbles. 
As regards the value of Dr. Michelson's opinion Dr. Thin is ignorant, but in 
regard to the German criticisms on recent researches on alopecia areata, he would 
remark that the same gentleman, who, when his paper appeared, could not accept 
the fact that bacteria were present in alopecia areata, as soon as Von Sehlen's paper 
appeared, jumped incontinently to the other extreme and said that bacteria were pre- 
sent in all hairs. 
In regard to the existence of organisms in healthy hairs, Dr. Thin differs from 
the German critics. He has made many observations (which he hopes shortly to be 
able to publish) which show that no such organisms are present in ordinary hairs as 
he has described in hairs in alopecia areata. If proper precautions are taken in 
purifying the scalp and in extracting the hairs, it can be shown, he believes, that 
normal hairs are free from bacteria in that part of the shaft which is in the corium. 
As regards the value of Dr. Robinson's observations, which Dr. Thin believes 
constitute a great discovery as regards this disease, opinions will vary according to 
the bias of different observers on the important point of what constitutes sufficient 
evidence that an organism is pathogenic. Those who hold that we are not entitled 
to consider an organism pathogenic until we have reproduced the disease by cul- 
tivated organisms will consider that the point is not proven as regards this organism, 
but he would call to mind the fact that this canon is not held in universal respect. 
Many observers, like himself, have no doubt that the bacillus of leprosy is a patho- 
genic organism, although not only has the disease not been produced by the cul- 
tivated organism, but the organism has not yet been cultivated. 
He would remind them that for more than forty years trichophyton tonsurans was 268 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
almost universally accepted as the cause of Ringworm, although the fungus had never 
been cultivated at all. Even now he is not aware that authentic observations are to 
be found in literature that show that ringworm of the head or of the body has been 
produced by cultivations of trichophyton. No one doubts that tinea versicolor is pro- 
duced by the fungus that is always found among the scales of that eruption, but the 
fungus has never been cultivated, far less has the disease been reproduced by the 
cultivated fungus. 
Dr. Robinson has shown that, in a series of cases, in the diseased areas of alo- 
pecia areata one and the same coccus is always present, leading to obstruction of the 
lymphatic vessels and blood vessels, and causing changes which explain hitherto 
unexplained features of the disease. Those who believe that the bacillus of leprosy 
is pathogenic, and that the fungi of favus, ringworm and tinea versicolor are respec- 
tively pathogenic in these diseases, are, he contended, logically bound to accept Dr. 
Robinson's conclusions. 
The paper he considered to be one of enormous interest, and to mark the begin- 
ning of a new epoch in the study of this important malady, and he congratulated the 
author and the Section on the fact that they had had a paper of such great value 
brought before them. 
Dr. Zeisler, of Chicago, agreed with Dr. Unna that it would take a long time 
to bring about a union of the two opinions regarding the cause of alopecia areata, as, 
so far, there are strong proofs in both directions. When microorganisms are found 
after such careful methods of investigation as Dr. Robinson has made, one must 
believe in the causal relation of the same to the disease. It is only natural that 
every observer will form an opinion for himself from the nature of the majority of 
cases which he has observed. He related two cases in which the neurotic origin 
appeared unmistakable. One was in a case of exophthalmic goitre (Basedow's dis- 
ease) ; the other followed a stroke upon the head. 
Dr. Henry J. Reynolds regarded the paper as a most admirable one, but said 
that, while the résumé of the arguments that had been previously advanced for and 
against the parasitic theory were essential and ably presented by the essayist, they 
did not decide anything positively, either in favor of the neurotic or the parasitic ori- 
gin of the disease. In fact, to his mind, he thought the balance of evidence thus 
afforded was rather in favor of the tropho-neurotic origin. The pathological con- 
dition shown by Dr. Robinson was, however, conclusive, certainly, so far as the cases 
embraced under his investigations. Then granting that the pathological conditions 
thus shown be established, the final question as to the cause of that condition remains 
yet to be settled. Could that condition be produced by a neurotic trouble ? That it 
is produced by the microorganisms seen is not proven, as it was still a question with 
many whether those bodies are the cause or the consequence of the disease. Cer- 
tainly the almost established non-contagious character of the disease would be 
opposed to the parasitic theory ; and until the disease be reproduced by culture and 
inoculation it could not be conclusive. The arguments rehearsed by the essayist, 
however, certainly show this much, that the parasitic trouble or origin, if at all, is 
confined to the interstices of the true skin rather than to the hair structure or fol- 
licles as has been claimed by other supporters of the parasitic theory. 
In regard to treatment, if the disease be the result of a parasite within the struc- 
ture of the true skin, he would very strongly urge a trial of the treatment which he 
proposed for favus, etc. in his paper read the day previous, viz., the application of 
the parasiticide with the positive electrode of a galvanic battery. There can be no SECTION XIV DERMATOLOGY AND SYPHILOGRAPHY. 
269 
possible doubt but that a medicinal substance applied in this way will permeate all 
the structures for a considerable distance beneath the surface. The procedure would 
not only be beneficial by possibly curing the disease, but would tend, if successful, to 
show a parasite to be the true cause rather than a tropho-neurosis. 
Dr. Ravogli said he had found small corpuscles resembling microorganisms in 
the epidermis, around the hairs, and in the hair follicles and hair shaft. He related 
the case of a lady who complained of an itching in a circumscribed spot, shortly after 
which a spot of alopecia areata occurred at this point. He related the clinical his- 
tories of several other cases. 
Dr. Knaggs related a case of general alopecia following a severe dental neuralgia. 
The perchloride of mercury, pilocarpine in large doses, the extraction of the teeth, 
were without avail. Faradism finally resulted in a cure. After this the patient had 
marked anæsthesia of the whole body, especially of the scalp. A strong current was 
necessary to make him feel the application. Afterward he suffered intense agony 
when the electricity was given, even in weak current. In other cases he had used 
twenty per cent, oleate of mercury with benefit. 
Dr. Robinson, in closing the discussion, regretted that more attention had not 
been directed to the anatomical changes in the skin in considering the question of 
etiology. Such conditions as are present could not be the result of a tropho-neurosis. 
He admitted an alopecia from neurotic disturbance, but not the usual alopecia areata. 
Inoculation with negative results could lead to false conclusions, as shown in many 
undoubted parasitic diseases. 
A UNIQUE CASE OF MELANOSIS OF THE SKIN. 
UN CAS UNIQUE DE MELANOSE DE LA PEAU. 
BY A. R. ROBINSON, M.D., 
Of New York, N. Y. 
The patient, a lady, twenty-one years of age, a resident of the South, came to me 
■with the following history :- 
When about two or three years of age, there appeared a faintly visible, dark spot on 
the lid of her right eye. No pain or sickness attended the appearance of this discolora- 
tion, but ever since first noticed, it has been slowly and gradually spreading. It was 
especially noticeable on the face at eight years of age. 
At no time has she suffered from pain, numbness or tingling in the affected parts. 
A few months ago she had an attack of measles, and had chicken-pox when an infant, 
but never had scarlatina. She has lived in a malarious district, and has suffered from 
chills and fever for ten years, although her general health and nutrition are good. 
On examination I found that the lesion consisted primarily of pin-point, non-ele- 
vated, dark spots of a bluish-black color, which did not disappear on pressure. They 
were not covered by scales, and resembled little freckle spots; being irregular in shape 
and widely separated at the periphery of the patch, approaching each other more and 
more closely toward the centre, until, finally, an area of general complete pigmenta- 
tion was formed, in which no spots were observable, only a bluish discoloration with a 
tinge of black. 
EIN EIGENARTIGER FALL VON MELANOSIS DER HAUT. 270 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
The entire right upper eyelid was occupied by a diffuse, non-scaling patch, which 
appeared perfectly normal to the touch and exhibited no atrophy, no dilated blood 
vessels, or anything abnormal, except the pigmentation. The lid was not retracted. 
The pigmentation was also present below the eye and on the right side of the fore- 
head, not extending to the median line, and passing two inches into the hairy scalp ; 
another patch was found at the right angle of the mouth. Besides this external dis- 
coloration, there was also a darkening of the inner side of the right cheek and traces on 
the mucous membrane of the left, while the roof of the mouth presented one dark 
spot the size of a pea. It appeared as if about to commence on the conjunctiva of the 
left eye. 
All the parts thus affected are merely discolored, and display no excrescences, nor 
prominences, nor anything otherwise abnormal. The case was submitted to Professors 
Webster and Starr, of the New York Polyclinic, for an examination of the eye and 
nervous apparatus. 
The following is Dr. Webster's report:- 
" Both eyes are ophthalmoscopically normal. Vision = Hm. Both ears 
are normal as far as inspection goes. The hearing of the left is normal (f§), and, as 
nearly as I can determine, the right is totally deaf. There are no evidences of aural 
catarrh, and all the symptoms, as well as the history, point to nervous deafness. The 
deafness was first noticed when she was six or eight years of age, and may have existed 
from birth." 
Dr. Starr's examination showed " that the tactile, pain and faradic sensibility was 
normal and equal on both sides over the temple and eyelids, at which points the pig- 
mentation was most intense. There was a very slight difference perceived between the 
two sides to the temperature tests, both hot and cold sensations being very slightly 
more acute on the pigmented side." 
Microscopical examination of the sections of the skin was made by Dr. Louis Heitz- 
man, who made the following report : " The epithelial layer is of normal thickness, 
covered with a thin epidermal layer which is not pigmented, while all the layers of the 
rete mucosum are made up of epithelia filled with dark brown pigment granules. 
This feature is different from the pigmentation observed in Addison's disease, where 
the pigment granules are seen only in the lower row of the columnar epithelia. The 
pigmentation involves also the epithelia of the outer root sheath of the hair, wherè it 
is lighter than on the surface of the skin. The papillary layer is unchanged and its 
fibrous connective tissue free from pigmentation. A short distance beneath the rete 
mucosum, however, a large number of pigmented corpuscles are seen, which, with 
higher powers, are seen to be protoplasmic bodies beneath the bundles of the derma, 
more or less crowded with or transformed into a dark, brown-red pigment. In some 
places nearly all the protoplasmic tracts are pigmented, in other parts only a limited 
part of the protoplasma. In the former instance there is a dark, red-brown reticulum, 
in the latter instance, dark, red-brown, star-shaped formations. Both features are due 
to the pigment forming only in the protoplasma between the bundles of connective 
tissue. The epithelia of sweat glands and their ducts are also pigmented, though 
lighter than the outer root sheath of the hair, and diffused without a marked disposition 
of pigment granules. The same is the case with the epithelia of the sebaceous glands 
when they are not transformed into fat. The pigmentation invades the whole derma 
into the subcutaneous tissue. The fat tissue of the latter is free from pigmentation." 
The case is reported, as I believe there is not a similar case on record. The situa- 
tion of the pigment, the manner of spreading of the disease and the macroscopically 
normal character of the skin in all respects, except the pigmentation, furnish a clinical 
picture not met with in any form of melanosis hitherto described. SECTION XIV-DERMATOLOGY AND SYPHILOGRAPHY. 
271 
DE L'ELEPHANTIASIS DES ARABES CHEZ LES ENFANTS. 
ELEPHANTIASIS ARABUM AMONG CHILDREN. 
ÜBER ELEPHANTIASIS ARABUM BEI KINDERN. 
PAR LE DR. MONCORVO, 
Rio de Janeiro, Brazil. 
Malgré tous les travaux publiés jusqu'à présent sur l'éléphantiasis des Arabes, 
affection prédominante dans les climats tropicaux, plusieurs points de son histoire 
demandent encore de nouvelles recherches. 
Nous n'avons en ce moment en vue que d'éclairer une question de l'étiologie de la 
maladie, celle qui se rapporte à sa fréquence pendant les premières époques de la vie. 
La presque totalité des observateurs qui ont travaillé à l'étude de l'éléphancie ont 
eu à constater dans leurs recherches des cas plus ou moins avancés dans leur évolution, 
c'est-à-dire qu'il s'agissait de malades ayant déjà dépassé l'époque de la puberté, ou du 
moins l'ayant déjà atteinte. 
D'une façon générale on peut affirmer que les faits recueillis par ces observateurs se 
rapportaient à des individus arrivés à l'âge adulte. 
Eléphantiasis des Arabes congénitale. 
Ils se bornaient, pour ainsi dire, à l'examen des cas les plus frappants, tantôt par 
leur développement considérable, tantôt par l'étendue du mal. 
Il parait que ces médecins s'inquiétaient fort peu de l'époque de l'invasion de la 
maladie, ne prêtant d'attention qu'aux caractères et au siège de l'affection. 
Cela nous explique peut-être le silence gardé jusqu'à une certaine époque par les 
auteurs qui ont écrit sur ce sujet, et l'avis émis plus tard par d'autres sur la rareté d'une 
telle affection avant la puberté. 
C'est ainsi que Ernest Godard, qui a eu l'occasion d'étudier largement cette maladie 
pendant son voyage à travers l'Egypte et la Palestine, a écrit que "jamais la maladie 
n'arrive avant l'âge adulte," en ajoutant plus loin qu'il n'existe pas un seul cas obser- 
vé chez V enfant. 
Le Dr. Mohamed-Aly-Bey, qui a fait une excellente thèse sur ce sujet, s'est exprimé 
comme il suit, par rapport à l'époque de la vie dans laquelle la maladie se présente : 
" L'éléphantiasis peut se développer dès l'âge de 15 ans chez les garçons et de 12 chez 
les filles ; il peut se rencontrer, mais très rarement, avant cette époque, ainsi à l'âge de 
huit ans, (Dr. Mohamed-Aly-Bey) à l'âge de 10 ou 12 ans. 
On peut dire d'une manière générale que l'âge le plus propice pour le développe- 
ment de cette maladie est entre 15 et 20 ans, époque à laquelle s'accomplit un révolu- 
tion générale dans l'organisme chez l'homme et chez la femme. 272 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Hebra affirme que cette maladie est très rare avant la puberté. D'après Duchas- 
saing la maladie ne se développerait jamais avant l'âge de 8 à 10 ans, ajoutant même 
que c'était une exception. 
Cloquet, Gibert, Alfonseca, Broquère considèrent, pour leur part, la maladie comme 
une curieuse exception avant la puberté Duhring partage tout-à-fait cette manière de 
voir. 
Nous pourrions ajouter bien d'autres citations à l'appui de cette conclusion acceptée 
par la presque totalité des observateurs, que l'éléphantiasis inconnu chez les enfants du 
premier âge, est extrêmement rare avant l'âge de la puberté. 
C'est à cette opinion, passée comme une vérité absolue au milieu de tant de travaux 
publiés sur cette terrible affection, que nous prétendons nous opposer, en nous appuyant 
sur une période d'observation de plus de 200 cas. 
Après être arrivé à la conviction formelle de la présence de l'éléphantiasis, même 
chez les plus jeunes enfants, nons avons procédé à de nouvelles recherches bibliogra- 
phiques à ce sujet, et nous avons retrouvé quelques faits épars dans les archives de la 
science, qui viennent corroborer les résultats de notre observation personnelle. Tels 
sont ceux appartenant à Léon Labbé (13 mois), Guéniot (2 ans), Lannelongue, Th. 
Beck (14 ans), Bardeleben, Demme Weber, V. Ruge (9 ans). 
Waring, sur un total de 945 cas d'éléphantiasis recueillis par lui dans les archives, 
rencontra 729 cas observés entre 26 et 60 ans, 139 entre 5 et 25 ans, et 77 après la 60e 
année. 
En recherchant l'époque de l'apparition de la maladie il trouva 16 cas chez de tout 
jeunes enfants, 7 cas avant la 5e année et 133 entre 6 et 10 ans. 
Cela donne donc un total de 156 cas observés chez la première et la deuxième en- 
fance soit 16 pour 100. 
Nous avons été à même de recueillir 45 cas d'éléphantiasis dont 28 furent rencon- 
trés chez des jeunes sujets, et 17 observés chez des adultes qui avaient été affectés dans 
leur enfance. 
Au milieu de ceux du premier groupe nous ferons mention toute particulière de 
quelques faits fort dignes d'être relevés par la précocité exceptionnelle de l'invasion du 
mal. 
Observation i.-Dans ce cas il s'agissait d'un nouveau-né de 15 jours, à peine 
présenté dans notre service le 23 Septembre, 1884. Ce garçon, pésant 3 kil. 500, por- 
tait sur la région hypogastrique et pubienne les signes très caractéristiques de l'élé- 
phantiasis à son début, la maladie étant survenue à une lymphangite péri-ombélicale 
apparue vers le quatrième jour de la naissance. 
Nous osons croire qu'aucun cas pareil ne fut jamais publié pour ce qui touche l'é- 
poque de l'apparition de l'éléphantiasis. 
Observation ii.-Ce fait est relatif à un garçon âgé à peine de quatre mois qui 
fut amené à notre service le 11 Juin, 1883. 
Il avait été vacciné le 5 Juin, et quatre jours après il lui était survenu une lym- 
phangite aux deux bras. 
Celle du bras gauche termina vite par la résolution, mais le bras et l'avant-bras 
droits devinrent éléphantiasiques. Ce garçon fut guéri au bout d'un mois au moyen 
de la compression élastique. 
Observation iii. -Il s'agit d'une fillette, âgée de 9 mois, portant des manifestations 
très accusées de la syphilis héréditaire. 
Un mois avant l'admission de cette enfant, elle avait été atteinte d'une lymphangite 
à la jambe gauche. 
Cette lymphangite avait été la conséquence de l'rritation que l'enfant avait déter- 
minée au pourtour d'une pustule siégeant à la malléole interne de la jambe gauche en 
s'y grattant fortement. SECTION XIV DERMATOLOGY AND SYPHILOGRAPHY. 
273 
L'œdème envahit la jambe jusqu'à la région inguinale ; elle devint douloureuse 
dans toute son étendue, la peau se montra chaude et rougeâtre. 
Elle a eu en même temps une réaction fébrile qui dura trois jours. Au bout de 
quelques jours les phénomènes de réaction locale s'amendèrent, et ensuite le tissu 
sous-cutané de la totalité de ce membre fut envahi par le processus éléphantiasique. 
Observation iv.-Le premier Mai, 1886, on nous amena à la Polyclinique une 
fillete de 13 mois, laquelle à partir du septième mois, avait été atteinte de lymphan- 
gites à la jambe gauche. 
Aussi il lui survinrent des accès de fièvre intermittente répétés. 
Quatre mois après la première crise de lymphangite la jambe gauche commença à 
être envahie par le processus éléphantiasique. 
Les dimensions des deux jambes étaient celles-ci :- 
Jambe Droite. Jambe Gauche. 
Au tiers sup. 16J cent. Au tiers sup. 18 cent. ■ 
Au tiers moyen. 17 cent. Au tiers moyen. 19 cent. 
Au tiers inf. 12| cent. Au tiers inf. 13J cent. 
En résumé le relevé d'après l'âge des cas appartenant au premier groupe est le sui- 
vant :- 
A l'âge de 15 jours, 1 cas. 
" " 4 mois, 1 " 
ii it g 11 4 ii 
h 11 13 11 j 11 
" " 2 ans, 2 " 
" " 3 " 2 " 
II II y II I II 
Total 9 
9 cas. 
A l'âge de 8 ans, 3 " 
" " 9 " 2 " 
" " 10 " 2 " 
« " 11 " 4 « 
" « 12 « 2 " 
« « 13 ii 3 « 
" " 14 " 3 " 
Total 28 cas. 
Au point de vue du sexe, 13 appartenaient au sexe masculin et 15 au féminin. 
Quant à la race : 23 blancs et 5 métis. 
D'après le siège de l'affection :- 
10 cas. 
Jambe droite, 13 " 
Les deux jambes, 4 " 
Région hypogastrique et pubienne, 1 " 
Total 28 cas. 
Bras droit, 1 cas. 
Jambe gauche, 7 " 
Jambe et main gauches, 1 " 
Face 1 " 
Total 10 
En procédant de la sorte pour les cas compris dans le deuxième groupe, nous aurons: 
D'après l'âge des malades à l'époque du premier examen :- 
A l'âge de 15 ans, 3 cas. 
" •' 16 " 3 " 
« « << 2 " 
" " 18 " 2 " 
" " 19 " 1 " 
Total 11 
11 cas. 
A l'âge de 20 ans, 1 " 
" " 22 " 2 " 
" " 28 " 1 " 
" « 29 " 1 " 
« u 44. « j 11 
Total 17 cas. 
D'après le sexe :- 
Masculin, 12 cas. 
Feminin, 5 " 
Total 17 cas. 
Quant à la race :- 
Blancs, 14 cas. 
Métis, 3 " 
Total 17 cas. 
Par rapport au siège : 
Jambe droite, 5 cas. 
Jambe gauche 2 " 
Les deux jambes, 5 " 
Total 12 
12 cas. 
Jambe et cuisse droites, 2 " 
Jambe et cuisse gauches, 1 " 
Les deux membres thoraciques et les deux jambes, 1 " 
Scrotum, fourreau de la verge et jambe gauche, 1 " 
Total 17 cas. 
Vol. IV-18 274 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
En les groupant d'après l'âge auquel l'éléphantiasis a fait son apparition, nous avons 
le tableau ci-dessous. 
A l'âge de 2 ans, 1 cas. 
« « 3 « 2 " 
<< § << J « 
Total 4 
4 cas. 
A l'âge de 6 ans, 2 cas. 
" " 8 " 5 " 
" " 11 " 3 " 
" " 12 " 3 " 
Total 17 cas. 
Enfin, si nous réunissons les deux groupes en les classant selon l'âge où. l'affection a 
fait son apparition, nous aurons le résultat suivant :- 
14 cas. 
A l'âge de 15 jours, 1 cas. 
" " 4 mois, 1 " 
a « 9 « 1 « 
" a 13 « ! « 
" " 2 ans, 3 " 
te a ß cc cc 
cc cc cc j " 
« " 6 " 2 " 
Total 14 
A l'âge de 7 ans, 1 " 
« " 8 " 8 " 
« a g <t 2 « 
« " 10 " 2 " 
« « « y « 
" " 12 " 5 " 
" a 13 u 3 « 
" u u « g « 
Total 45 cas. 
Ce chiffre fut retrouvé sur un total de 157 cas d'éléphantiasis ce qui donne une pro- 
portion de 28 pour 100. 
En ajoutant aux cas ci-dessus ceux recueillis à la littérature étrangère, nous aurons 
un total de 1110 parmi lesquels 209 survenus pendant l'enfance, soit une proportion de 
18 pour 100. 
Mais le trait le plus intéressant de cette communication c'est le fait tout dernière- 
ment recueilli dans notre service et que nous signalerons à part à cause de sa singularité, 
car il s'agit d'un cas d'éléphantiasis développée pendant la vie intra-utérine. 
Or, aucun fait analogue n'existe dans les archives de la science, que nous le sa- 
chions. 
Le 20 Septembre de 1886, on nous amena à notre service à la Polyclinique une fil- 
lette, âgée de quatre mois, et issue de parents italiens. 
La mère accusait des accidents vénériens et disait avoir eu des accès de fièvre palus- 
tre pendant la gestation de cette enfant qui était la deuxième. 
Elle n'avait pourtant subi aucune contusion, ni avait fait aucune chute pendant ce 
temps-là. 
Le père bien constitué, avait été atteint, vers Janvier, 1886, par une crise de lym- 
phangite aux deux jambes accompagnée d'une réaction fébrile intense. 
L'enfant jouissant d'une santé générale très régulière avait le poids de 6 kilogram- 
mes et mesurait 56 cents, d'extention. La mère nous la présenta dans le but de la 
faire soigner d'une malformation des deux pieds et de la main gauche qu'elle avait con- 
statée quelques moments après son accouchement. 
Par l'examen nous avons reconnu une augmentation considérable du volume des 
deux pieds, cette augmentation étant dûe au processus éléphantiasique, développé tant 
sur la région dorsale que sur la plantaire, depuis la racine des orteils jusqu'à la région 
malléolaire. 
Les tissus de la région affectée offraient assez de résistance à la pression en ayant la 
consistance du caoutchouc. 
La peau qui la recouvrait était lisse, parsemée de petites vésicules et de papules ; 
sa coloration était normale- sur la face dorsale et un peu rougeâtre à la face plantaire. 
La partie dorsale était séparée de la plantaire par un sillon partant du talon jusqu'au 
niveau des articulations métatarso-phalangiennes. 
Il n'y avait à constater aucune modification par rapport à la sensibilité ni par rap- 
port à la température. SECTION XIV DERMATOLOGY AND SYPHILOGRAPHY. 
275 
Le pied gauche était plus volumineux que celui du côté droit, comme on voit 
d'après les dimenssions suivantes :- 
Hauteur de la partie moyenne du pied droit, 4J cents. ; et celle du pied gauche, 5 
cents.; circonférence du pied droit à ce niveau, 15 cents; et celle du côté gauche, 16 
cents; l'axe antéro-postérieur du pied droit 10 cents.; et celui du pied gauche, 10J 
cents.; circonférence de la région plantaire du pieds droit 24 cents.; et celle du pied 
gauche 25 cents. 
A la main gauche l'éléphantiasis avait envahi presque exclusivement les doigts et y 
était peu accusée. 
L'enfant fut soumise à l'usage de l'iodure de potassium ainsi qu'à la compression 
élastique et à l'électrothérapie. 
Ce cas est, à notre avis, unique dans la science, car nous n'avons pu trouver d'autre 
analogue publié jusqu'ici. 
De tout ce qui précède nous devons conclure : 
1. Que l'éléphantiasis des Arabes peut se développer même pendant la vie intra- 
utérine. 
2. Que cette affection peut être retrouvée dans toute le période de l'enfance au con- 
traire de ce qu'on avait cru jusqu'ici. 
FOUR RECENT CASES OF MYCOSIS FUNGOIDES OF ALIBERT, 
WITH AN EXAMINATION AS REGARDS THE EXISTENCE OF 
PARASITES. 
QUATRE CAS RECENTS DE MYCOSE FONGOÏDE D'ALIBERT AVEC UN EXAMEN 
CONCERNANT L'EXISTENCE DES PARASITES. 
VIER NEUE FÄLLE DER MYCOSIS FUNGOIDES ALIBERTS, NEBST UNTERSUCHUNGEN ÜBER 
DIE ANWESENHEIT VON PARASITEN. 
BY PROF. THOMAS DE AMICIS, 
Of Naples. 
In the year 1882, under the title of " Dermo-lympho-adenoma-fungoides, " I pub- 
lished two cases of that malady, which had been described under the name of ' ' My- 
cosis fungoides of Alibert." In the following years the scientific literature has been 
enriched with other valuable works on the same subject,* and there has been much 
debate both as to the nomenclature to be adopted for this malady and as to the anatomo- 
pathologie nature of the process and the relation which it might bear to other neo- 
plastic forms. 
In these last few years I have had the rare opportunity of studying four new cases 
of this affection ; and I think it proper to place my observations before the enlightened 
judgment of my learned colleagues in the Section of Dermatology and Syphilography 
of the International Medical Congress of Washington. 
® "A Treatise on the Diseases of the Skin," published by Ziemssen, with articles by Aus- 
pitz, Neisser and Babés (1883-1884). "A Contribution to the Knowledge of the Tumors of In- 
flammatory Granulations (granuloma sarcomatode of the skin)," by R. Naether, Deutches Arch, 
f. Klin. Med., 1883. " On the Mycosis Fungoides," by P. Fabre, Gaz.-méd. de Paris, Nos. 5, 
6, 7, 35, 36, 1884. E. Besnier, Ann. de Dermat. et de syphiliy." p, 37, 1884. "On a New 276 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
CASE I.-MYCOSIS FUNGOIDES OF ALIBERT. 
Diagnosis.-Julius Romualdo, of Roccapiemonte, aged sixty-nine years, a priest. 
He does not present anything remarkable in his antecedents, and assures us that for 
the last fourteen years he has always enjoyed perfect health. His actual cutaneous 
disease began about two years ago, after a feeling of pain in different parts of his body, 
beginning in his feet ; and also by an intense itching, together with an almost contem- 
poraneous appearance of erythematous stains on the trunk and on the extremities. 
These stains, gradually coming up to the level of the healthy skin, assumed, after the 
lapse of two months, in some places particularly, the appearance of real tuberous excres- 
cences. Some of them disappeared spontaneously, while others remained there, after- 
ward becoming ulcerated. 
Examination of the Cutaneous Surface.-(See Figs. 1, 2.) The affection is spread over 
the trunk and the extremities, in the shape of deep-seated, reddish stains, of varying 
thickness, of noduli and tubera ; some reddish and some of a bright red color ; partly 
ulcerated (superficial ulceration on a white-grayish ground). 
In some points can be observed an abundant sero-lymphatic exudation. On the 
posterior part of the trunk the middle portion is sound, the affection being on the sides 
and on the base of the thorax, and spreading over the scapular region and over the 
deltoid externus. It extends over the anterior parts of the trunk and over the surface 
of the abdomen. It is less developed over the lateral regions of the trunk on the 
right side. On all these points are to be seen erythematous stains, diffused and a little 
elevated (on the posterior cervical region and on the shoulders), excrescences in the 
shape of tubera, some of which are oblong (3 to 4 by 2 cent. ), some circular. Some 
of these tubera are sound, some excoriated and others deeply ulcerated, with a white- 
grayish base. The excoriations result partly from the infiltration proper, and partly 
from the scratching caused by the great itching which torments the patient ; so much 
so, that excoriations on sound tissue may also be seen on him, covered with small blood 
crusts. On the anterior part of the abdomen, at the sides and on the sacral region, the 
affection is diffused and of a macular and infiltrated form, with tuberous ovoidal eleva- 
tions scattered over it. 
The Superior Extremities.-On the internal surface of the right forearm, down to its 
inferior third, there are some simple macular patches, in discrete form, while on the 
inferior portion of the left arm, from the armpit down, besides some erythematous spots 
and flat elevations, there are also to be seen real tuberous excrescences, three to four 
centimetres long, by two to three centimetres broad, as well as larger ones, some of 
which are ulcerated, as on the scapular and axillary regions. 
The Inferior Extremities.-These are less affected by the disease than the superior 
ones. The right thigh is affected over a very large extent of its internal surface, while 
the left one only shows the disease on its superior fourth. In the legs the disease is less 
advanced, the macular form, lightly infiltrated, being there prevalent. Ichthyotic, 
whitish scales are to be noticed on the elbows and knees, as well as xeroderma on the 
legs. 
The face is altogether free from the affection. 
The enlargement of the inguinal lymphatic glands is remarkable. The latero-cer- 
vical ones, too, are greatly swollen, especially on the supra-clavicular regions. 
Form of a Malady of the Skin, the Pernicious Lymphodermy," by M. Kaposi, Medic. Jahrb. 
der k. Gesellschaft der Aerzte, Wien, 1885. " A Case of Granuloma Fungoides," by Auspitz, 
Vierteljahrsch. f. Dermat. und Syph., 1885. "A Study on the Mycosis Fungoides," by Vidal 
and Brocq, France Médicale, Nos. 79 and 85, 1884. " Mycosis Fungoides," by Rindfleisch, 
Deutsche med. Wochensch., 1885. "Mycosis Fungoides," by Tilden, Amer. Dermatol. Assoc., 
August 26th, 1885. Fiéi 
Micosi fnngoide Tav. I . 
Clinica Dermo-sifilopatica della R.Université di Napoli . 
T.De Aiïûcis 
T.SINÇLAIR ». SON. UTW.PHILA. Fig II. 
Micosi fungoide Tav. IL 
Clmica Dermo - sifilopatic a della R. Université di Napoli 
T.De Amicis . 
I.StNCVAIR fc SO", LITH. PHILA SECTION XIV DERMATOLOGY AND SYPHILOGRAPHY. 
277 
The patient complains of a very violent itcfiing and of a sensation of heat. His 
sensibility is somewhat exaggerated. His nutrition is, generally speaking, in a very 
depreciated state. He has undergone a course of iodide of potassium and of liquor 
arsenicalis, but without profit. I cut two small tumors from his skin. 
April 12th, 1885. I again visited the patient. He is in the same condition of 
health ; nay, the affection has even progressed. Many of the excrescences have increased 
remarkably; several ulcerations have extended still further; some tuberous elevations 
appear to have become fungoid, and resemble in size the small berries of the solanum 
lycopersicum. The sero-lymphatic secretion is more abundant. The patient com- 
plains continually of a very tormenting itching, principally early in the morning. The 
analysis of the urine did not present anything worthy of notice. That of the blood 
did not show any increase in the quantity of the white globules. 
May 15th. The patient appears in the following state of health :- 
The Trunk (a)-the posterior part.-In the left scapulo-humeral region almost all the 
largest nodules, which, so far, were sound, are now ulcerated and flattened, the bases 
of the ulcers consisting of purulent matter, very thick and of a yellowish-black color, 
similar to caseous substance. Other smaller nodules are fused together, so as to form 
an elevated surface, which looks like a single flat and reddish stain, about six centi- 
metres distant from the vertebral column, where it ends with a raised and convex 
margin. It is spread all over with small nodules and granular excrescences. 
In the homologous region nothing else is to be observed but some reddish stains of 
little account. 
Along the median line, beginning at the middle of the vertebral column, a very 
large reddish stain is to be seen, which, as it descends, becomes broader, till it reaches 
the loins, the buttocks and the lateral region of the abdomen, over which it extends. 
On this large surface there appear some nodules, rather flat and not ulcerated, having 
the diameter of 5 to 20 mm. They cause insupportable itching to the patient. 
(5) The anterior part.-The whole anterior part of the trunk, some points excepted, 
is altogether hypersemie, and presents, besides, the following appearances:- 
On the left mammillary region the eruption has joined with that of the left humero- 
scapular region; although it is now in a remarkable state of involution, for the existing 
nodules are ulcerated, some having nearly disappeared and some being very much 
diminished in size and flat, with a very limited or insignificant amount of exudation. 
In the left axillary region the nodules, which at first reached the volume of an hazel nut, 
are now smaller, with less extended ulcerations and with diminished secretion. A 
large knot existing in the right thoracic region, corresponding with the parasternal line 
of that side, has also become flat, and the adjoining ulcerations are in a state of retro- 
gression. This also is the case with the ulcerated nodule to the left of the ensiform 
appendix. 
It can be generally said that in the anterior region of the trunk, while the affection 
is in an involutive stage where it had reached its greatest development, it has now 
spread to points where it did not exist before, under the form of hyperæmic stains, some 
of which are also somewhat elevated. 
The neck and the nape are covered with large reddish stains, having margins little 
or not at all elevated, the redness of which disappears under the pressure of the finger. 
An ulcerated tubercle existing on the nape is healing ; its base, at first excavated, is 
now getting smoother, the edges are less elevated; its secretion has nearly disappeared. 
At about six cent, downward from the middle of the inferior maxilla, at the left side, 
is to be seen a tubercular elevation of the diameter of two cent., which, as the patient 
relates, had disappeared about fifteen days before. It is now gradually increasing in 
size, being covered all over with a gray-brownish crust, that conceals an ulceration 
secreting a small quantity of purulent fluid. 278 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
The Face.-On the right mastoid region is to be seen an infiltrated wiacwZa, causing 
much itching. Its diameter is about 31 cent, and surrounds a central fovea resulting 
from a preexisting ulceration of an old tubercular knot. 
May 21st. The patient is again seen. The following modifications in his condition 
are to be noticed:- 
In the left scapulo-humeral region the largest nodules remain nearly in the same condi- 
tions as before observed, while the single pimples of the elevated margin of that large 
stain, of the size of a linseed to a small pea, have likewise undergone an ulcerative pro- 
cess, getting a crateriform appearance, with a lard-like bottom and with a very scanty exu- 
dation. From the apex of some of them there exudes a small drop of a very trans- 
parent liquid. 
The ulcerations of the left mammillary region are reduced to simple erosions with a 
scanty, serous exudation. The nodule on the left side of the ensiform appendix is 
remarkably smooth, and the neighboring ulcerations are nearly altogether healed. On 
the contrary, those of the right thoracic region, near the parasternal line of that side, 
appear still ulcerated ; there are two points with little secretion and some epithelial 
erosion in the proximity. 
Starting from the base of the ensiform appendix at the right side, and going downward 
obliquely as far as the right mammillary line, along the curvature of the eighth, ninth 
and tenth costal cartilages, there are some depressed nodules, each nearly the size of 
an hazel nut, arranged in groups and having nearly all ulcerations with irregular mar- 
gins in their centre. The one placed more on the outside is deeper than the others and 
has a more abundant purulent exudation, of a yellow-greenish color. 
On the whole abdominal surface there are here and there elevated stains of different 
dimensions-from 15 to 25 mm. diameter. They are separated one from the other by 
portions of skin far less hyperæmic than was the case a week before ; nay, with a nearly 
normal color. The umbilical fossa is flat, and in its place there is a yellowish crust, a 
little elevated, which covers a superficially ulcerated surface. By pressing the cuta- 
neous tissue between the fingers at that point one has the sensation, as it were, of a car- 
tilaginous tissue. Moreover, at the distance of about six centimetres from the umbili- 
cus there appears a large nodule, very much flattened, of three centimetres diameter, 
ulcerated and covered over with a very thin stratum of a dense sero-purulent exuda- 
tion. The skin of the lateral regions of the abdomen (more especially at the right side), 
the skin of the pubes, that of the anterior and internal region of the thighs, is all uni- 
formly hyperæmic and dry. On the contrary, the skin of the scrotum, the inguinal 
one, that of the scrotal surface of the perineum, and, finally, that of the fissure of the 
buttocks, as well as of the anal region, is hyperæmic and exudating. 
The Superior Extremities.-On the superior extremity at the right side there are two 
infiltrated stains. The first occupies a larger extent of tissue than the other, and goes 
from the inferior third of the arm to the superior third of the forearm, taking up the 
whole curvature of the elbow. It has an ulcerated tubercle in its centre. The other 
stain is to be found on the superior portion of the lateral external radial region, and is 
equally ulcerated in the middle. 
In the inferior third of the palmar side of the left forearm there is a stain, nearly 
round, little or not at all elevated, and of the diameter of three centimetres. It is a 
darker red color on the periphery and more whitish in the centre. This stain existed 
from the very first day of my observation of the patient. 
The Inferior Extremities-The Right Leg.-In the superior and anterior region of the 
right thigh, very near the inguinal fold, there is a large nodular excrescence of about 
27 millimetres diameter, with a central pit, which indicates a preexisting ulceration 
which has spontaneously healed, covered over with a very thin blood crust. This 
excrescence is not pruriginous. On the right leg the affection is more noticeable on SECTION XIY-DERMATOLOGY AND SYPHILOGRAPHY. 
279 
the antero-external region, from the calf to the popliteal space. A reddish stain is seen 
there, covered with small nodules of various sizes; some being ulcerated and covered with 
a yellowish-green crust. On the internal lateral region there is also a small elevated 
stain of about 3 cent, diameter. The whole leg is also somewhat more voluminous than 
the left one, apd its skin appears stretched and dry, being also very pruriginous. 
The Left Extremity.-The skin of the left leg is nearly entirely normal, except some 
small stains, a little elevated toward the margins, which are placed especially on the 
lateral internal region. It has also a more remarkable infiltration, nearly 8 cent, in 
breadth, at the bend of the knee. This is a little ulcerated in some points, but causes 
very little itching. 
June 10th. Another examination of the patient gives the following facts :- 
In the left scapulo-humeral region there are no remarkable modifications. The ulcer- 
ated tubercles before observed remain there yet, just as does the yellow-greenish sub- 
stance which constitutes their base and which cannot be removed even with the for- 
ceps. On the contrary, the sero-lymphatic exudation is here very scanty. The 
different infiltrated stains already existing on the cervical region have now acquired a 
greater extension on the right shoulder also, without, however, papular or tubercular 
excrescences appearing. These stains are exceedingly pruriginous, not allowing the 
patient to sleep at night more than a couple of hours. 
From the left axillary region, at the left and posterior side of the trunk, to the angle of 
the scapula, there are many new tubercles, not yet ulcerated, from 5 to 15 millimetres in 
diameter. The same can be said of the anterior thoracic region. 
The only portion of the trunk perfectly sound is limited to one-half of the dorsal 
region at the right side and a small extent on the left. For the rest the skin is here 
more or less taken up by the tubercular maculo-papular infiltration, which, while 
growing in one place, is absorbed and disappears in another. The existing ulceration 
corresponding to the umbilical fossa is now entirely healed. 
The whole right leg is swollen and œdematous ; its skin is reddish, very much 
stretched, so that it cannot be taken up between the fingers. This leg presents on the 
superior portion of the antero-external region three or four superficial ulcerations. The 
itching that it produces is really insupportable. 
Nothing remarkable is to be seen on the left leg. 
COMPABATIVE MEASUBES OF THE CIBCUMFEBENCE 
OF BOTH LEGS. 
The right leg. 
The left leg. 
At the knee, flexed, 
.... 37 cent. 
34 cent. 
Under the knee cap, 
. ... 35 " 
32 " 
At the calf, .... 
. ... 38 " 
35 " 
At the ankle, . . . 
. . . . 25 " 
23 " 
The patient complains of a feeling of oppression, especially after meals ; and more 
so if he takes heavy food. This oppression ceases altogether when he lays in bed. 
June 17th. The left scapulo-humeral region is somewhat better. 
The tubercles already existing on the nape are no longer ulcerated and are consider- 
ably flattened. 
In the right sub-axillary region, where the two lines meet, one of which separates in 
two the axillary fossa, and the other proceeding from the nipple falls perpendicularly 
upon it, there is a nodule as large as a hazel nut, much ulcerated at several points. 
The right leg is getting better ; its redness is diminished very much, but the itching 
still persists. 
July 1st. The ulcerations of the tubercles on the left scapulo-humeral region are 
improving, and the yellow-greenish substance before mentioned can be now detached 
from it. 280 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
About eight cent, under the last dorsal vertebra, at the left side, there appear 
two new tubercles, each as large as a hazel nut, distant from each other nearly one 
cent., and both placed on a small portion of infiltrated skin. Likewise on the region 
of the left gluteus some more small tubercles have appeared, which are placed on a red- 
dish infiltration connected with that of the left lateral abdominal and sacro-lumbar 
regions. 
On the right leg there only remain some thin yellowish crusts that cover superficial 
ulcerations, pouring out a very fluid serous liquid. 
It is worth noticing that for the last two months the inguinal glands are becoming 
considerably tumefied, and now appear as a large tumor, the size of a fist. It is very 
hard, insensible, and almost immovable. 
July 16th. The left scapulo-humeral region is slowly improving. 
Likewise in the other regions it seems that the alteration does not progress. But on 
the thoracic and abdominal regions there are a large number of small papular excres- 
cences, of the size of a lentil : more numerous on the forearms and back of the hand 
than on the parts ; and more abundant on the thighs than on the legs. These cause the 
patient dreadful itching. Several of them are surmounted on the apex by a small blood 
crust. Among them, moreover, are to be noticed some small vesicles containing a serous 
or sero-purulent liquid. Besides, the left inferior extremity, especially the leg, is some- 
what swollen and œdematous, principally on the anterior region, where the pressure of 
the finger leaves a sensible depression. 
August 7th. The patient, for nearly a week, has been tormented by a fever, which 
comes on daily on his rising from bed, at about six o'clock. This fever goes down at 
about two o'clock, p.m. of the day. He had this same complaint last year also, without, 
however, having any chills beforehand. 
On the deltoid and external scapular region, on the right side, the affection has increased. 
Here we notice numerous hemispherical prominences, some of which are superficially 
ulcerated and of a yellowish-gray color, and exuding a lemon-yellow serous liquid. One 
of these prominences reaches the size of a large almond. I have cut a piece out of this 
tumor, in order to subject it to microscopic examination. Only on one point of this same 
left scapular region the affection has undergone such an involutive phase that a large 
stain is to be observed there. 
The retro-cervical and supra-scapular regions are getting to be of a red-orange color, 
without exudation. 
The dorsal region, principally at the right side and on the median line, is almost 
entirely round. On the contrary, the lumbar and sacral regions are becoming of a red- 
brownish color, and are covered with numerous protuberances, more or less large, all 
appearing broken down on the surface and bleeding at the least touch. 
The anterior thoracic region and the abdominal region can be said to be entirely affected 
over their whole surface ; for only a small portion of the skin is here yet healthy. 
The glandular tumefaction still continues in the right inguino-crural region, and 
with the same characters. In the left inguinal region, also, the glands are smaller, but 
they are less conglobate and movable. 
The œdematous tumefaction of the legs also goes on ; it extends a little upward to 
the thighs, and downward to the feet. The skin of the legs, however, appears to be 
affected by eczema rubrum. The right leg, at the calf, measures 41 cent., the left 37. 
The itching on the whole cutaneous surface is indescribable. The patient scratches 
himself all over till he bleeds. 
The patient got worse toward the middle of August. 
The fever became continuous, and, according to the local medical reports, a broncho- 
pulmonary disease was added to it, with profuse diarrhoea of very pestiferous character, Fig III 
Micosi FunjäjoicLe Tav. III. 
Clinica Dermo sifilopatica della R.Université di Napoli 
T.De Amicis . 
V.SINOLAIR A »ON, LI TH. PH ILA SECTION XIV DERMATOLOGY AND SYPHILOGRAPHY. 
281 
during which, as I was told, the stains got gradually paler ; their secretion ceased, 
tumors on the skin remaining only. 
This patient died on the 17th of August, 1885, preserving to the last his mental 
faculties intact. 
CASE II.-MYCOSIS FUNGOID ES OF ALIBERT (PSORIASIS PRÆGRESSA). 
Diagnosis.-Francis Rocco, of Afragola, aged sixty-five years, a wool carder ; is mar- 
ried, and has at present six children, all living and in good health. But about twenty 
years ago he lost four other children when young ; their malady he cannot now exactly 
remember. Both his parents died of old age, two of his sisters of cholera morbus, and 
a brother of a chronic bronchial catarrh. One of his sisters is living still and enjoys 
good health. 
He has always been well, nor has he suffered from any disease worth noticing, 
except an affection, probably of a typhoid character, at the age of twenty, and scabies, 
which he got fifteen years ago. 
His actual cutaneous malady began two years ago, without any cause known to the 
patient, unless it be his affliction when, about five years ago, his three nephews were 
killed by a house falling upon them. His disease first appeared on his back, under the 
form of efflorescenses of various dimensions, lightly pruriginous, covered over with sil- 
ver-white scales, to which he, at the beginning, did not pay much attention, but which, 
after the lapse of two months, spread all over the chest, and later gradually covered his 
superior extremities and the internal surface of his right thigh. Last year, in the 
month of February, he presented himself at the dispensary belonging to the Clinic of 
this city, where his disease was pronounced to be psoriasis. Consequently, he was given 
pills of chrysophanic acid. He bore them well ; so much so that he used to take thirty- 
two of them daily, although they each contained two centigrams of acid. He followed 
this treatment without any profit for fully five months ; for the affection persisted with 
a surprising tenacity; nay, the stains of the affected skin seemed every day of more bril- 
liant red color. They were considerably infiltrated and slightly exudating ; so that 
they were no longer seen covered with a mass of dry, lucid and silvery scales, but 
rather with crusts, more or less elevated and of a whitish-yellow color. The itching 
became ever more intolerable. The baths at Telese and the arsenical liquor, taken per- 
severingly, did not give any satisfactory results. ' 
At this time (not determined with precision by the patient) there began to appear, 
on various portions of the diseased skin, several small, reddish tumors, with a surface 
more or less exudating ; while at other points there came out superficial ulcerations. 
The affection has been always accompanied by a very violent itching. 
Actual State of the Patient.-He is an old man, of normal bodily constitution ; his 
skeleton is well developed, but his muscular system not so much so. Panniculus 
adiposus is rather deficient. 
Examination of the Cutaneous Surface.-(See Figs. 3 and 4.) The affection is spread 
all over the trunk, from the neck to the umbilical line ; more, however, on the anterior 
and lateral surfaces, than on the posterior ones. Besides this it covers part of the forearms 
and the upper third of the internal surface of the right thigh. In all these places there 
are several stains of various dimensions (from about 2 to 3} cent, diameter, and 
larger too) ; some of which are more or less round, some ovoidal and others of a very 
irregular form; all of a reddish color and more or less infiltrated, so as to be in some 
places several millimetres elevated over the surrounding cutaneous surface. Several of 
these stains are covered with a stratum of scales of a whitish-gray color, having in some 
points a silvery glance. The scales are clustered together, so as to form a crust more 
or less adherent, that, on being detached, leaves a red surface, sometimes bleeding, 282 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
behind ; while others are covered with regular crusts of a whitish-gray tint, conceal- 
ing superficial ulcerations on a grayish ground, and with a rather abundant sero-puru- 
lent exudation. 
In some places the tissue is elevated, forming real tumors, the largest of which is to 
be found on the lower fourth of the internal surface of the right arm. It reaches the 
volume of half a pigeon's egg, having a red ulcerated surface. Some smaller ones are to 
be seen on the internal surface of the left arm, and on the back, principally at the left 
side. It is necessary to observe that in some places there are some achromic maculae, 
instead of which there were before efflorescences similar to those above noticed and 
which have disappeared spontaneously. 
Topographical Description-The Trunk. It is affected by the disease on the anterior 
surface, from the insertion of the neck to the horizontal umbilical line, and on the 
lateral surfaces from the axillary fossa to the aforesaid line. On the dorsal portion, on 
the contrary, the affection begins at a level with the sixth dorsal vertebra, and goes on 
to the base of the sacrum. Half the skin on the right side is more extensively affected 
than on the left side, where the efflorescences, although less numerous, are still more or 
less elevated, all appearing under the form of small tumors of the size of an almond, 
and sometimes still larger. 
The Neck.-Here only an infiltrated skin is to be seen, at the base of the right latero- 
cervical region. On the cephalic extremity nothing is to be observed. 
The Inferior Extremities.-The part more affected here is the upper third of the 
internal surface of the right thigh. On the remaining portions some isolated reddish 
stains are to be noticed, lightly infiltrated. 
The Superior Extremities.-The arms are affected almost exclusively and nearly 
totally, from the deltoid region to the elbow. Here there are two or three small tumors, 
having the characters above described, in the upper fourth of the internal surface of the 
left arm; and likewise another tumor, somewhat larger (as big as a small pigeon's egg, 
as I said before), on the lower fourth of the internal surface of the right arm. On the 
forearms there are only some few stains, lightly infiltrated, especially at the bend (i. e. 
on the upper half). 
The lymphatic glands are slightly enlarged. 
The patient complains of a very tormenting itching. 
Nothing worthy of notice is to be remarked in the internal organs. 
Analysis of the Urine.-March 24th. C. G. 700. P. S. 1019. Albumen and all 
other chemico-pathological principles are absent. The microscopical analysis, too, did 
not show anything abnormal. 
Weight of the Body.-The patient on his entering the clinic weighed 56,700 kilos. 
Clinical Diaby, from March 23d to June 19th. 
Modifications of the Lesions.-March 24th. On account of the violent itching the 
patient takes daily one gram of potassium. Temperature normal. 
March 27th. No change worthy of notice. Temperature normal. 
March 31st. Some old ulcerations, especially on the arms, seem to have a tendency 
to spread. The substance too, which they secrete, is somewhat abundant. The arms 
are daily washed with warm water (100°). Temperature normal. 
April 5th. The patient complains continually of an insufferable itching. The ulcer- 
ations on the arms do not appear to have made much progress ; on the contrary, some 
of these begin to come out, very superficially, however, on the chest. Ointment of 
borax is used. Temperature normal. 
April 8th. The ulcerations on the anterior surface of the thorax, and above all on 
its upper portion, increase, both in surface and depth; their bottom is of a dirty grayish 
color with a scanty sero-purulent secretion. Continued ungt. borax. Temperature normal. Fig IV. 
Micosi Tav. IV. 
Clinic a Dermo - sifilopatic a della R .Université. di Napol i . 
T.De Amicis . 
T.SINCLAIR «. SO N, LITH. PHILA SECTION XIV-DERMATOLOGY AND SYPHILOGRAPHY. 
283 
April 12th. Nothing remarkable is noticed. The itching is always insupportable. 
Two and a half grains of bromide of potassium are daily given to the patient. Tem- 
perature normal. 
April 16th. The ulcerations still extend, while in some points of the trunk, both 
anteriorly and posteriorly, some stains, till now but little infiltrated, become more 
prominent. The patient is still treated with borax ointment. I tried carefully to detach 
some of the less adherent crusts that cover the arms and trunk. Temperature normal. 
April 19th. On the legs of the patient is to be noticed the appearance of some red- 
dish maculae, of various size, from about fifteen to twenty-five mm. in diameter. Tem- 
perature normal. 
April 1st. The maculae observed on the legs have considerably increased in num- 
ber; some of them reach the diameter of three cent. The affection has the general 
appearance of an erythema maculosum. Temperature normal. 
April 22d. A small tumor already existing on the inferior fourth of the internal 
surface of the right arm, is cut out and the wound is dressed with ferric wadding and 
iodoform powder. Temperature normal. 
April 24th. The ulcerations above noticed on the trunk and arms show no change. 
No remarkable modification till now on the affected portion of the right thigh. The 
erythema on the legs remains as before. The trunk and the arms are dressed with 
pyrogallic acid ointment 2} per cent. Temperature normal. 
April 25th. Some erythematous stains appear also on the trunk and on the scalp, 
especially on the forehead. Temperature normal. 
April 27th. The erythema is very much increased in those regions where it appeared 
last. The dressing with pyrogallic acid is suspended and the use of the borax ointment 
resumed. Temperature normal. 
April 29th. The erythema on the legs enters an involutive phase. The stains are 
already getting very pale. Temperature normal. 
May 1st. It can be said that the erythema has disappeared from the legs. On the 
trunk and on the scalp it begins likewise to go away. Temperature normal. 
May 3d. The itching still continues violent. It torments the patient so much 
as to allow him to sleep only very little at night. He takes daily one grain of bromide 
of potassium and one of sodium. Temperature normal. 
May 5th. The wound resulting from the cutting away of the knot on the arm, 
before mentioned, is getting on well toward cicatrization. It is cauterized with a weak 
solution of nitrate of silver. Temperature normal. 
May 8th. Those stains that were beginning to become more prominent on the 
trunk, both anteriorly and posteriorly, have undergone gradual increase, and some of 
them have turned into regular small tumors. The dressing with borax is continued. 
Temperature normal. 
May 12th. The ulcerations in some points show a tendency to heal; while in some 
others they spread. Temperature normal. 
May 18th. Some erythematous stains begin to be observed on the back of the hand 
and on the scalp. A sulphuric acid lemonade is given to the patient. Temperature, 
evening 39.7° C. 
May 21st. The erythema is spreading over the forearms. Temperature, morning, 
38.5° C. ; evening, 38.6° C. 
May 24th. The erythema begins to appear also on the trunk, especially on the 
anterior region of the thorax. Temperature, morning, 38° C. ; evening, 38.5° C. 
May 27th. The erythema is in its regressive period in those points where it first 
appeared. Temperature, morning, 37.6° C. ; evening, 37.5° C. 
May 29th. A small trace of it remains on the anterior surface of the thorax. 
Temperature normal. 284 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
May 31st. The wound existing on the right arm, where the knot had been cut out 
is nearly altogether cicatrized. Temperature normal. 
The patient left the clinic on the 19th of June, to return to his native place, this 
day being the last of the scholastic year. I learned that he died some months later. 
CASE III.-MYCOSIS FUNGOIDES OF ALIBERT. 
Diagnosis.-Julia M., of Naples, aged thirty-six years, is married, and is the mother 
of seven children, five of whom are living and healthy, and two dead, from teething. 
Her father is still living, but her mother died in childbirth. Two of her three brothers 
died in their babyhood, of measles, and the last one ended his life at twenty, from a 
tuberculo-pulmonary disease. 
This patient has always been well, and menstruates regularly. She never miscar- 
ried, but brought forth always happily, nursing all her children. One of these once 
suffered a cutaneous eruption, the character of which she is not able to specify, assur- 
ing us, however, that it was in consequence of bringing that child in contact with a 
maid servant who was affected with an eruption of the skin which was thought to be 
of an infectious character. As for the rest, none of her family had had cutaneous affec- 
tions nor other maladies worthy of notice. 
The actual disease began toward the year 1880, just one year after the above-men- 
tioned eruptions on her child, and in consequence, also, of very heavy sorrow. Its 
first manifestation was an intense itching all over the cutaneous surface, which increased 
toward evening, obliging her to scratch violently, so as to producé very large excoria- 
tions on the skin. Two or three months after this terrible itching she observed that the 
skin of her extremities had become somewhat brownish and dry, particularly over the 
region of the extensors. Some time after there appeared a small tumor in the middle 
of the anterior region of the right thigh, that, little by little, grew to the size of a 
walnut. 
This tumor was indolent, of a rosy color and somewhat hard. It disappeared after 
two months, without ulceration and leaving an achromic stain. After this tumor had 
gone away, another small one came out on the interior side of the supra-orbital region, 
at the left side, which, on getting of the size of a hazel nut, became ulcerated, and 
after some months disappeared, leaving no other traces except a superficial achromic 
cicatrix. 
After that there appeared on different points of the cutaneous surface several new 
tumors of various size, some of which became ulcerated, leaving superficial cicatrices, 
sometimes hyperæmic and sometimes achromic. Others, on the contrary, ended by 
becoming superficially squamous, not leaving any modification on the skin, while there 
were others that left brownish or whitish stains, with a coloring on the surrounding 
skin. These tumors were from the size of a lentil to that of a small orange, of a rosy 
or deep red color, hard and indolent. 
Moreover, some of these tumors were isolated and some were arranged in groups, so 
as to form fungous accumulations, more or less large. After several months, together 
with the tumors, she observed that on several points of the cutaneous surface there 
appeared some stains of various size, of a rosy or deep red color, invariably accompa- 
nied by an intense itching and a superficial furfuraceous desquamation. These stains, 
on disappearing from one place, appeared in another, leaving the skin sometimes in a 
normal state and sometimes ■with an increase or diminution of color. In some places 
the stains gradually became elevated, forming flat elevations, infiltrated and of dif- 
ferent size and form, of a red or brown-red color, with a smooth surface, from two to 
five centimetres high above the skin. 
This successive appearance of tumors, of circumscribed infiltrations, and of stains 
on the skin, followed without interruption till the month of November, 1884, without SECTION XIV-DERMATOLOGY AND SYPHILOGRAPHY. 
285 
causing any inconvenience to the patient. At this time she became aware of the pres- 
ence of a small tumor on the nasal lobe, of a fleshy color, as large as a pea. This grad- 
ually reached the size of a cherry, changing to a rosy, fleshy hue, and with an infiltration 
involving the whole right side of the nose and a portion of the sub-orbital region. On 
the zygomatic region, at the same side, the infiltration assumed a special form-that of 
a semicircle, with the exterior convexity reaching from the nasal pinna to nearly the 
middle of the inferior eyelid, forming a hard, elevated margin, of a reddish color. 
It was at this time that the patient was subjected to a course of hypodermic injec- 
tions of one-half centigramme of sublimate, each time, for twenty days. At first it 
appeared that, in consequence of this treatment, the regression of the infiltrated spots, 
especially of those on the face, proceeded more rapidly. After some time, however, 
this regression remained stationary, and since the nutrition of the patient did not receive 
any great advantage from it, and, moreover, new tumors appeared on the skin, the 
treatment was suspended, and, instead of it, a restorative and tonic treatment was 
undertaken, consisting of iodide of sodium, and afterward of arsenical liquor and 
decoction of quinine. 
During the year 1885 was noticed the successive appearance of other small tumors 
on the left sub-orbital region, at the eyelids and on the chin. On the trunk and on the 
extremities there appeared several large and flat infiltrations, some circumscribed and 
others spreading. Some tumors have undergone a complete regressive phase without 
any solution of continuity, while on other points they have become ulcerated, and in 
some places they have remarkably increased their volume, as, for instance, in the right 
iliac region, one of them, that had reached the size of a walnut, by absorbing the neigh- 
boring tumors, has formed a mass as large as a fist, with cauliflower surface and ulcer- 
ated in many places. 
December, 1885. The patient for nearly three months was absent from Naples, 
residing in a provincial town, with her husband. 
She returned at thebeginning of 1886, in a very deplorable state of health and very 
much depressed in her nutrition, and feverish besides. The inguinal glands at the 
right side had become considerably larger and in the inguinal folds there was a tume- 
faction as large as an orange, very painful, both under pressure and without it. The 
skin over it was hard, stretched and red, and with a sensible fluctuation caused by 
peridermic suppuration. After a large incision was made, a very abundant quantity 
of purulent matter issued forth, and by pressing at the sides, a great deal of yellowish 
caseous matter came out. Some more of this matter was extracted by means of a 
spoon introduced into the abscess cavity. 
By using antiseptic dressing, by washing with sublimate and by powdering with 
iodoform, the locality got better, the suppuration considerably diminished, the fever 
disappeared, the patient again acquired her strength and appetite and all her conditions 
returned in their primitive state, only there remained, where the tumor had existed, a 
cavity four centimetres deep, without showing any tendency to cicatrize. The disease 
in general continued its progressive development. Here is a description of the state 
in which the patient was in May, 1886. 
Her nutrition, upon the whole, is bad, the mucosæ are bloodless and on the skin, of 
a pale tint in one place and of a brownish one in another, are spread a number of 
tumors, circumscribed infiltrations, together with stains of various size, form and color. 
The stains are of the size of a lentil to that of the palm of the hand; some are round, 
with sharp margins, others irregular; some isolated and others joined together, forming 
erythematic spots, reticulated, with lines of sound skin in the middle. Their color is 
rosy, brilliant red, brown red; the surface is smooth or lightly prominent. On some of 
them is observed a furfuraceous superficial desquamation. 
The tumors are of the size of a pea to that of a small orange ; some are isolated and 286 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
some are ranged in groups forming fungous masses of varying extent. Their color is 
rosy or brownish-red; their surface smooth, almost polished in some cases, while in 
others it is lightly squamous. Some of them are ulcerated with a broken-up surface, 
of a gray hue and giving out a sero-purulent secretion. 
Their consistency is hard and their margins either merge insensibly into the 
surrounding tissues, or are cut sharply, as isolated tumors, over the cutaneous surface. 
In order to better determine the form and position of the alteration, we will here under- 
take the examination of the single regions. 
The Scalp.-This is provided with black and coarse hair, and only toward the inferior 
extremities of the temporal region are to be seen two brownish stains with a superficial 
furfuraceous desquamation, which goes up as far as the superior massateric regions. 
The Face.-On the forehead, near the internal extremity of the left eyebrow, there is 
a superficial achromic cicatrix of two cent, diameter. Two small tumors, of the size 
of a pea, are to be seen on the superior eyelids, tending to disappear without ulceration. 
Outside of the left sub-orbital region, near the external angle of the eye, there is a small 
tumor, of the size of a hazel nut, of a red-brownish color and hard. The nose is almost 
all taken up by a tumor, that at the right side goes as far as the internal third of the 
sub-orbital region. It is of a brown-reddish color and of a hard, elastic consistency, 
with an irregular surface, in some points superficially ulcerated. It is elevated above 
the skin some few millimetres, and only on the lobe is cent. high. On the left half 
of the inferior lip and on that of the chin there is another tumor, as large as an almond, 
of a brownish color, with a smooth and desquamating surface. 
The Neck.-On tue anterior region of the neck, by the jugular fovea, there is a stain 
of the diameter of 3 J cent, somewhat elevated over the cutaneous surface, in the middle 
of which a nodular infiltration is to be seen, as large as a pea. On the lateral and pos- 
terior regions are several stains and superficial infiltrations, of various size and form, of 
a rosy or brownish color, with superficial desquamation of the epidermis. 
The Trunk.-On the anterior and lateral regions of the thorax there are large portions 
of sound skin with stains of different size, of a rosy or red-brown color, which at the 
mammary region, approaching together, assume a reticulated appearance. 
On the posterior regions too, the same changes are to be seen; the supra-spinal regions 
are taken up by a brownish stain with a superficial pityriasic desquamation ; the right 
sub-spinal region is covered with rosy and reticulated stains, and toward the inferior 
angle of the scapula, there is a tumor of the size of an egg, with smooth surface, of 
pale rosy color, somewhat hard and detachable from the subcutaneous tissue. 
In the middle of the lumbar region a large brownish stain is to be seen, of triangular 
form, with its apex upon the vertebrae, the base on the sacral region and the two other 
angles stretching toward the hips. 
On the abdomen the skin is a little more brown. On the anterior region and on a 
portion of the lateral one there are several brown stains with sharp margins, of varying 
form and size, and also some few of a deep red color, some flat and some a little 
elevated. 
In the middle of the left iliac region there are two tumors of the size of a large 
walnut, two cent, from each other, of a deep red color with a smooth and polished sur- 
face, and of hard, elastic consistency. In the proximity of these tumors, toward the 
superior and exterior portion, there are three other tumors, a little smaller, which seem 
to be in a remarkable regressive state. On the region of the right hip there exists an 
enormous fungous mass, circular in form, which anteriorly is limited by a vertical line 
starting from the anterior and superior spina iliaca and going to the last rib; and poste- 
riorly from another vertical line parallel to the first, seven cent, distant from the ver- 
tebral column ; below it connects with the crista iliaca, and above with the last rib. The 
circumference of this fungous mass is 52 cent., its vertical diameter 15 cent, and the SECTION XIV DERMATOLOGY AND SYPHILOGRAPHY. 
287 
horizontal 18 cent. The centre is elevated some three cent, and the borders, at som e points, 
one centimetre, and at others still less. The surface is rough and full of sinuosities, 
with prominences and depressions very much resembling the superior surface of the 
cerebral hemispheres. It is superficially ulcerated in some places, while in others the 
ulcerations are deep and covered over with a hard and grayish eschar, similar to that 
which is formed after the application of chloride of zinc. Large pieces of it, one cent, 
thick, can be detached from it with the forceps. The whole fungous mass has a hard 
consistency; it cause no pains to the patient, and from the ulcerated surface issues an 
abundant sero-purulent secretion. 
The Superior Extremities.-The skin on the exterior surface of the right limb is of a 
brown color, with small achromatic stains. The skin of the flexor surface, on the con- 
trary, is covered with rosy or brown-red stains of various sizes. On the elbow there 
is an infiltration of 3} cent, diameter, with ulcerated surface. On the left superior 
extremity, too, the skin presents the same modifications as on the right one. On the 
region of the deltoid there are several rosy, erythematous stains; likewise on the region 
of the extensors some stains are noticed, somewhat browner. On the superior fourth of 
the arm, in the neighborhood of the bend of the elbow, there is a limited infiltration 
of the diameter of about 3| cent., elevated two and three centimetres above the skin; 
an achromic stain of the same size and form is to be found in correspondence with the 
epitrochlea. On the palm and on the back of the hands no alteration at all is to be 
observed. 
The Inferior Extremities.-On the inferior extremities, too, the skin is brown in the 
region of the extensors and somewhat dry and rough. On the inferior fourth of the 
anterior region of the left thigh there is a tumor as large as an egg, as hard and as red 
as the others. In the right popliteal space another tumor is observed, of the size of a 
small orange, which is ulcerated, with a scanty secretion and showing a tendency to 
heal. Both on the thighs and on the legs there are stains spread all over, of various 
size and of a rosy or red-brown color, with superficial desquamation. On the sole of 
the foot there is no alteration. 
The glands of the neck and of the armpit are little enlarged. Those of the left 
inguinal region are as large as an almond; in the right inguinal region the glands are 
very much swollen both in the inguinal and in the crural portion. In the latter there 
is a fistulous opening, from which issues forth an abundant sero-purulent secretion. 
Its margins are thick and the character of the infiltration has the identical white-gray- 
ish appearance of the tumors in an ulcerative period. This infiltration goes deep in the 
iliac fossa so that its posterior limits cannot be reached. This mass on the anterior 
part, taken from one- side to the other of the fistulous opening, has the volume of a 
fist. 
In the oral cavity there is nothing abnormal ; likewise the organs contained in the 
thoracic cavity do not present any alteration. 
The Subjective Facts.-The patient suffers great itching, particularly in the evening; 
she feels no pain, but only complains of a general indisposition and debility. Her tac- 
tile as well as her thermal and dolorific sensibility are in a perfect state in all points of 
the skin, even on the single infiltrations and tumors. 
The patient undergoes a tonic and roborant treatment (quinine, iron, arsenical 
liquor). 
For the local modifications in the ulcerated parts she washes with sublimate, powders 
with the same and dresses with ferric wadding. On some small tumors has been dried, 
without success, the plaster-mull prepared with chrysophanic acid and ichthyolate of 
sodium. 
In the month of August I lost sight of this patient, for she came to the persuasion 288 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
that only from homoeopathic treatment could she hope to recover; which, to my regret, 
I could not guarantee to her. 
She died on the 13th of February, 1887. 
CASE IV. - MYCOSIS FUNGOIDES CIRCUMSCRIBED. 
Diagnosis.-Joan Della Sala, of Naples, aged thirty-three years; is married; she has 
children, three of which are living and three died of ordinary diseases. 
She does not remember having suffered, during her life, from any disease except fre- 
quent attacks of erysipelas of the face. She was in good health till July, 1886, when 
she began to observe near the region of the right hip, corresponding to the margin of 
the crista iliaca, a reddish stain of about 2| cent, diameter, very pruriginous and secret- 
ing a serous fluid. Little by little, however, this stain has become infiltrated, and 
from that time it has given no signs of regression, but, on the contrary, it has slowly 
extended its limits. 
In the month of April, 1887, the patient came to me, and here is what I could 
observe on her: She is a woman of regular skeletal conformation; in general well nour- 
ished; the color of her skin is pale rose. The objective examination of the skin does 
not present anything worthy of notice except in the region of the right hip, as above 
noted. Here there is an oblong stain, horizontally placed, of about 4 by 3 cent. It is of a 
reddish color; the skin appears infiltrated, and to the touch gives a soft elastic resist- 
ance. Its margins are sharp, but gradually descend to the level of the skin, so that it 
assumes an ellipsoid form, having in the middle the greatest thickness of infiltration. 
It is very pruriginous, and presents on the surface a superficial epidermoid erosion, from 
which issues a serous secretion. 
Treatment.-It is dressed with glycerolate of iodoform, and after some days with 
plaster-mull prepared with chrysophanic acid. 
No advantages were obtained; nay, the limits of the lesion gradually extended 
themselves, so that on May 23d, 1887, it presented a surface 7| by 41 centimetres, 
always keeping the ellipsoid form. The surface is still reddish, but it is less secreting, 
although still pruriginous. 
May 26th, 1887. With the consent of the patient, I have practiced an excision near 
the extreme limit or external side of the lesion, so as to take up the whole thickness of 
it and where the surface does not present any erosion. 
The glands of the right inguinal region are now very much swollen and ache under 
pressure. One of the glands reaches the volume of a large walnut. 
June 20th. The state of the lesion is the same. After rendering the surface aseptic, 
I made two cuts at right angles to each other and on the point of intersection, with a 
sterilized pipette. I took some blood, putting a part of it in a tube with gelatine, and 
the other portion in another tube with broth. 
July 15th. The cultures have not given any result; no germs have developed. 
REMARKS. 
The four clinical cases above described clearly show that the diagnosis which I have 
made of them corresponds to the characters which this lesion in general presents, and 
therefore it is, perhaps, not out of place to enter upon a diagnostic discussion of the 
subject. 
The first case brings to our minds the typical forms of such an affection in all its 
various stages-maculons, congestive, lichenoid, neoplastic, ulcerative, fungoid. (See 
Figs. 1 and 2. ) 
The second case is preceded by a psoriasis, and while this was in a regressive state 
the mycosis fungoides has appeared, both on the remaining anæmic stains of the psoriasis 
and on other points. A similar case has been also observed by Simon. SECTION XIV DERMATOLOGY AND SYPHILOGRAPHY. 
289 
The third case belongs to the variety that has been already studied by Bazin, in 
which neither a congestive-eczematic period is noticed nor a lichenoid-premonitory 
one; but the neoplastic-fungoid period is directly established from the very beginning. 
Consequently, this case presented in its beginning a picture not very dissimilar from 
that of the tubercular form of syphilis, or of leprosy, and that till the tumors 
reached the extraordinary volume and the configuration (massa encephalica) which is 
characteristic of this malady. It is also worthy of notice in this case that during the 
ulcerative period eschars formed, as hard and irritant as those which are obtained from 
cauterization with chloride of zinc. Here it is to be observed that the hypodermic 
mercurial treatment and the local application of a solution of sublimate had no result 
whatever. The complete evolution and the lethal issue of the disease took place, in 
the first three cases, during the space of from two to three years. 
The fourth case, on account of the circumscribed form of the affection, is yet an 
object of study and observation to me. In no one of these four cases did I meet with 
leucaemia, although in the first and third cases the glands were remarkably implicated. 
The anatomo-pathologic nature of this alteration is at present a subject of debate 
among the dermatologists. As long as the greatest importance was given to the form 
and disposition of the histological elements which constitute the structure of the neo- 
plasm, the structure of the neoplasm might well be compared to that of the lympho- 
demia ganglionaris (Ranvier), such a judgment being based principally upon the 
presence of nuclear lymphoid elements in the middle of a connective reticulum. This 
is the reason for which, in my observations, published in 1882, I thought proper to 
adopt the nomenclature "Dermo-lympllo-adenoma-fungoides.,' Further researches and 
the progress of science, however, have rightly sanctioned the view that whatever be the 
importance of the modifications that the tissues undergo in their structure, they cannot, 
for themselves alone, serve to determine the nature of a malady, and that to the mor- 
phologic product often there cannot be ascribed an absolute value if, at the same time, 
it be not considered in relation to the cause, the localization and the symptoms of the 
malady. Therefore it has been considered that the presence of the reticulated tissue 
on the tumor of the mycosis is not sufficient to establish its absolute identity with the 
lympho-adeno-ganglionaris. Anatomically considered, the mycosis fungoides presents 
one of the forms of a granuloma which has a great analogy with other granuloma of 
different origin, but of similar appearance, just because their anatomical substratum is 
the same, and the elements, in consequence of the stimulus, cannot undergo a reaction 
or alteration, except according to some determined way, while the essential difference 
between these affections follows from their different origin, so that the nature of the 
cause will in future point out the evolution and the phases of the malady that consti- 
tute the particular physiognomy and the clinical type of the lesion (granuloma leprosum, 
luposum syphiliticum and mycosis fungoides). 
At the point at which the scientific knowledge is at present the question of the 
intrinsic quality of the morbific alterations seems to be of greater importance than the 
form. Not infrequently some affections, the morphologic products of which do not 
give any anatomical difference worthy of notice, are different relatively to their origin 
and present a diverse clinical type and evolution. The scientific researches, therefore, of 
possible etiological moments of a given alteration is, at the present time, one of the 
most important questions, especially from the point of view of the existence of special 
pathogenic parasites, which could indicate their different quality. To this purpose it 
has been inquired if in the mycosis fungoides there could be found a special parasite. 
Auspitz and Rindfleisch have answered affirmatively. The former, together with 
Hochsinger, by coloring the preparations with lithio-carmine and malachite green, and 
treating them afterward with the method of Gramm, has found a parasite in the granulo- 
matous tissue, in the squamæ, in the eczematic and lichenoid eruptions, and in the 
Vol. IV-19 290 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
roots of the hair. Dr. Schiff has undertaken, with success, the culture of the micro- 
coccus. Rindfleisch, at the same time as Auspitz, announced that he had observed a 
particular parasite in mycosis fungoides. He regards it as a strepto-cocoon ; and, differ- 
ing from Auspitz, who describes it in the crevices of the tissues, he is of opinion that it 
occupies exclusively the vessels, and not the tissue, and that the colonies form agglom- 
erations obliterating the opening of the vessels. He has also employed the method of 
Gramm for colorization. 
Prof. Köbner in his late communication to the Section of Dermatology and Syphilo- 
graphy, in the 59th Congress of the German Physicians and Naturalists, in Berlin, says, 
that by using all the known methods of coloring the parasites, he has not been able to 
obtain from them any result, and thinks, therefore, the parasites found by Auspitz and 
Rindfleisch are accidental. 
Neisser admits the presence of parasites, but he is of opinion that their interpreta- 
tion is premature, for they are to be found only in the ulcerated nodosities, while they 
are wanting in those covered with epithelial strata ; a fact which might indicate the 
parasites to be of extraneous origin and not produced by the disease. 
Of all the four cases here described, I have been able to make a histological and 
bacterioscopic analysis. Simple microscopic observation has proved to me, in all the four 
cases, the identical granulomatous aspect regarding the morphology, that is to say, that 
on the skin are to be seen round nuclear elements, recalling to mind the embryo tissues, 
all homogeneous, more or less near to each other, and which little by little become 
extended into the hypoderma. The mucous body of Malpighi in the sections is to be 
seen perfectly preserved, being at some points hypertrophic with infiltration going 
deeply into the tissue. 
The bactériologie analysis made at first according to the method of Weigert, etc., 
has given constantly negative results, although it has been often repeated, using all 
possible precautions. The renewed experiments, however, for a long time unsuccessful, 
did not shake my faith, nor diminish my hope of being able, by perseverance, to reach 
finally the object in view; and my coadjutor, Dr. Melle, by changing the method of 
colorization in a thousand different ways, came at last to prepare a liquid which has 
completely answered in every case for the bacterial analysis of the mycosis fungoides. 
His composition is the following :- 
Gentian violet, cm. c. 3. 
Oil of anilin, cm. c. 3. 
Absolute alcohol at 99°, grm. 15. 
Distilled water, grm. 80. 
Method of Using it.-Let the prepared pieces lie from two to twenty-four hours in 
the solution. Put them afterward in absolute alcohol till this does not take up any 
more violet color (which happens in twenty-four hours). After having washed them in 
clove oil or in that of bergamot, they are put in xylolic balsam.* 
Having analyzed the pieces with this method, I have been able to prove the presence 
of parasites, that is to say, of micrococci, colonies of which exist in the papillary body 
of the skin, and deeper also in the hypoderma, i. e., in the interstices of the newly 
formed elements. I have found them, moreover, in the rete Malpighi. (See Fig. 5.) 
With a stronger magnifying power is to be seen that the colonies of parasites assume 
different forms, some round and some oblong, some cylindrical and some in larger accu- 
* In order to obtain a good solution of violet of gentiana, it is advisable to use the follow- 
ing method : Put first in a bottle the violet of gentiana, finely pulverized ; pour therein ani- 
line oil and afterward absolute alcohol ; shake well the bottle for several minutes ; add distilled 
water and continue to agitate the whole for twenty or thirty minutes; filter and the coloring 
liquid is ready for use. Micosi fungoide di Alibert . 
Fig. 5. Zeiss ; Oc, 3 Ob : GO ; Vubo alzato 16 . 
Fi§.6. Zeiss;0c,3 inimioin.ha tubo alzato 1.5.5. 
T.De Amicis SECTION XIV DERMATOLOGY AND SYPHILOGRAPHY. 
291 
mulations. (See Fig. 6.) The greatest quantity of them is tobe found in the papillary 
body andin the connective subcutaneous tissue, in the form of oblong ovoidal conglom- 
erations, which are afterward seen to emigrate also in the inferior part of the rete 
Malpighi. 
I have not been able to observe in the blood vessels any parasitic infiltration. The 
possibility cannot, however, be excluded, that they may be found in the lymphatic 
vessels, because the agglomerations, which are often to be seen, of a cylindric and flex- 
ible form, remind one of a vessel, although the existence of a wall can only with diffi- 
culty be proven. 
The elements of all the four preparations which I had cut out from the patients 
whose cases have been here described react alike to this method of colorization, and 
especially that of the third case, in which the tumors appeared not to have been pre- 
ceded by the eczematic and lichenoid period. 
The aforesaid method being applied to other preparations of other affections (rhino- 
scleroma, lupus, syphilis, etc)., did not give any result. 
I have, moreover, used this mode of colorization to a multiple idiopathic sarcoma, 
not pigmented, which I had the occasion of observing some few years ago, and of which 
I kept the pieces cut out and a drawing showing its alteration. The result has been 
perfectly negative. 
After having obtained these proofs, I proposed to myself to see if I could obtain the 
same result by subjecting to the described method of colorization some preparations 
that I had kept belonging to the first of the two cases which I reported in 1882 
(La Scienza), and I have found out the same elements, just as in the four cases in 
question. 
We may, therefore, conclude, from all this, that the presence of parasites, in my 
observations, is not merely accidental, but a constant fact, and belonging exclusively to 
the nature of the affection, and that these parasites exist also in places where the epi- 
thelia is perfectly preserved. 
The culture, dried with the blood taken from the tumors of the third case, gave colo.- 
nies of micrococci and streptococci, but for the fourth case the experiments had no 
result. 
It follows from what has been said: 1st, that mycosis fungoides is a morbid entity 
by itself, different from the general idiopathic cutaneous sarcomata, not pigmented. 2d, 
that the said mycosis fungoides consists of a specific cutaneous infiltration, infective 
but not contagious; similar to that of tubercular disease, of leprosy and of syphilis. 3d, 
that in this infiltration the presence of parasites is constant and not accidental, and that 
it can be observed with a special method of staining. 4th, that by means of the afore- 
said method of staining, we now possess a diagnostic criterion which enables us to dis- 
cover, in doubtful cases, the nature of the granuloma belonging to the mycosis fun- 
goides; just as it is with the bacillus of Koch in tubercular disease, and that of Hausen 
in leprosy. 5th, that it belongs to the future discoveries of science to state better the 
pathogenic value of this parasite in order to affirm with absolute certainty the parasitic 
nature of the disease. 
In conclusion, I may be allowed some few words about the nomenclature to be pre- 
ferred for this neoplastic form of disease. In my first communication (1882) I adopted 
in preference the denomination of dermo-lympho-adenoma fungoides because by it was 
better expressed its anatomo-pathologic meaning according to the views of that time, 
and also because by it a possible confusion was avoided which the word mycosis might 
cause. On account, however, of the observations made and of the constant presence of 
parasites, and considering that the existence of a reticulum containing lymphatic ele- 
ments does not constitute its special characteristic, and that the granulomatous form does 
not represent the absence of the malady, I willingly subscribe to the arguments of Bes- 292 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
nier*, accepted also by Köbner, and bold that it is more advisable to keep the old 
nomenclature given to it by Alibert, of mycosis fungoides, as a more comprehensive 
denomination, as being less exposed to the fluctuation of science, for, compromising 
nothing, it leaves all freedom to the future discoveries necessary to enlighten the obscure 
points which yet exist in the pathogenesis of this interesting malady. 
EXPLANATION OF THE FIFTH PLATE. 
Fig. 5.-A preparation (Zeiss. Oc. 3, Ob. CC., elevation of the tube 16 cent.) showing the seat and dis- 
position of the parasitic elements, both in the cutis and in the papillæ, as well as in the Malpighian 
body. 
Fig. 6-A preparation (Zeiss. Oc. 3, inniom. elevation of the tube, 15.5) representing a deeper 
point of the cutis and of the underlying tissue, which shows the various forms of agglomeration of the 
micro-cocoon. Some of these are oblong and flexuous, some circular ; some spread all over like points, 
and others as if surrounded by a granulous element, which in the middle appears more transparent.. 
Upon motion of Dr. Unna a vote of thanks to Dr. Robinson, for his zeal and 
success in behalf of the Section, was passed, and the Section closed. 
* Besnier. Annales de Dermatologie et Syphiligraphie, 1884, p. 39. SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
President: JOSEPH JONES, A.M., M. D., New Orleans, La. 
OFFICERS. 
VICE-PRESIDENTS. 
A. Nelson Bell, m.d., New York, N. Y. 
George Buchanan, m.d., b.a., f.r.s., London, 
England. 
Surgeon C. C. Byrne, m.d., Soldier's Home, 
Washington, D. C. 
Professor Corrado Tommasi Crudeli, m.d., 
Rome, Italy. 
Richard H. Day, m.d., Baton Rouge, La. 
J. W. Dupre, m.d., Baton Rouge, La. 
R. K. Fox, m.d , Jesuit's Bend, La. 
Domingos Freire, m.d., Rio de Janeiro, Brazil. 
J. A. S. Grant (Bey), m.d., ll.d., etc., Egypt. 
Professor Robert Koch, m.d., Berlin, Germany. 
John B. Lindsley, m.d., Nashville, Tenn. 
A. Magnin, m.d., Lyons, France. 
E D. Mapother, m.d., Dublin, Ireland. 
J. N. McCormack, m.d., Bowling Green, Ky. 
J. F. Y. Paine, m.d., Galveston, Texas. 
M. Louis Pasteur, Member of Academy of 
Science, Paris, France. 
P. Byrnberg Porter, m.d , New York City, N. Y. 
R. Harvey Reed, m.d., Mansfield, Ohio. 
Benjamin Ward Richardson, m.d., f.r.s., Lon- 
don, England. 
John Simon, m.d., f.r.s., London, England. 
A. K. Smith, m.d.,U. S. Army, West Point, N.Y. 
J. L. W. Thudichum, m.d., f.r.s., London, Eng- 
land. 
Professor Carmona Y Valle, m.d., City of Mexico, Mexico. 
SECRETARIES. 
J. J. Castellanos, m.d., New Orleans, La. 
Felix Formento, m.d., New Orleans, La. 
Y. R. Le Monnier, m.d., New Orleans, La. 
Wm. R. Steinmetz, m.d., Assistant Surgeon, 
U. S. Army. 
B. D. Taylor, m.d., U. S. Army, Columbus 
Barracks, Columbus, Ohio. 
Walter Wyman, m.d., U. S. Marine Hospital 
Service, New York, N. Y. 
COUNCIL. 
T. S. Antisell, m.d., Washington, D. C. 
Le Baron Botsford, m.d., St. Johns, N. B. 
Henry Carpenter, m.d., Lancaster, Pa. 
Oscar DeWolf, m.d., Chicago, Ill. 
Wm. Duncan, m.d., Savannah, Ga. 
Landon B. Edwards, m.d , Richmond, Va. 
James Finney, m.d., New Orleans, La. 
Wiley K. Fort, m.d., New Orleans, La. 
E. L. B. Godfrey, m.d., Camden, N. J. 
D. W. Hand, m.d., St. Paul, Minn. 
Chas. H. Hewitt, m.d., Red Wing, Minn. 
Thomas Hebert, m.d., New Iberia, La. 
Stanhope Jones, m.d., New Orleans, La. 
Benjamin Lee, m.d., Philadelphia, Pa. 
A. W. Leighton, m.d., New Haven, Conn, 
William R. Mandeville, m.d., New Orleans, La. 
U. R. Milner, m.d., New Orleans, La. 
H. L. Orme, m.d., Los Angeles, Cal. 
W. L. Schenck, m.d., Osage City, Kansas. 
R. M. Swearingen, m.d., Austin, Texas. 
C. M. Smith, m.d., Franklin, La. 
M. K. Taylor, m.d., U. S. Army, San Antonio, 
Texas. 
G. Troup Maxwell, M d., Ocala, Fla. 
C. B. Thornton, m.d., Memphis, Tenn. 
William W. Welch, m.d., Philadelphia, Pa. 
C. P. Wilkinson, m d., New Orleans, La. 
C. D. Owen, m.d., Eola, La. 
293 294 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
FIRST DAY. 
[note by the president of the section.] 
In the reporting of the discussions on the following papers, in the record of the minutes, and in 
the translation of French, Italian and German papers and remarks, most valuable assistance was ren- 
dered by the following gentlemen :- 
American, Walter Wyman, m. d., u. s., Marine Hospital Service, New York, N. Y.; B. D. Taylor, 
m. d., u. s. a., Columbus Barracks, Columbus, Ohio. 
French, Y. R. Le Monnier, m. d., New Orleans, La. 
Italian and German, Felix Formento, m. d., New Orleans, La. 
German, Wm. R. Steinmetz, m. d., Assistant Surgeon, u. s. a. 
The Section on Public and International Hygiene met at the Cornwell Building, 
Pennsylvania Avenue, Monday, September 5th, at 3 P. M., and was called to order 
by the President, who delivered the following address :- 
PUBLIC AND INTERNATIONAL HYGIENE. 
HYGIENE PUBLIQUE ET INTERNATIONALE. 
ÜBER ÖFFENTLICHE UND INTERNATIONALE HYGIENE. 
ADDRESS BY JOSEPH JONES, M. D., 
Of New Orleans, Louisiana. 
Gentlemen-As representatives of the science and humanity of the nineteenth 
century, you have assembled, from various civilized nations, in the capital of the 
North American Republic, to deliberate upon subjects of paramount importance to 
the welfare of mankind. 
Your deliberations will be studied with interest; and your decisions concerning 
the great issues and problems presented by the science and art of Public and Inter- 
national Hygiene should be regarded as expressing the practical results and precepts 
of scientific investigation, profound thought and wide generalization. 
To those noble and self-sacrificing men who have temporarily laid aside the daily 
discharge of the important duties assigned them by their countrymen, and crossed 
the stormy Atlantic to engage in deliberations relating to the cause and prevention of 
disease and the amelioration of human suffering, we extend a hearty welcome. 
It is not our province to recount the might and power of the great civilized 
nations of Europe, numbering over 320,000,000 of inhabitants, and covering 3,777,- 
000 square miles, which are so ably represented by the foreign members of the Ninth 
International Medical Congress; but we may be pardoned for a brief allusion to our 
North American Republic, with its 60,000,000 of inhabitants, and its domain of 
3,603,000 square miles. 
Its active, restless population is advancing all along the lines of science and art, 
converting the wilderness into cultivated fields, with their crops of golden grain; 
covering the continent with railroads, electric wires, and building great cities, and SECTION XV PUBLIC AND INTERNATIONAL HYGIENE. 
295 
founding universities, asylums, hospitals and museums of natural history and 
galleries of art. 
Her head is pillowed among the icebergs and eternal snows of the Arctic regions; 
her feet are bathed in the warm waters of the Gulf of Mexico; her right arm 
embraces the blue waters of the Pacific, and her left the rolling billows of the Atlan- 
tic ; her waist is girdled by the rich mines of gold, silver, copper, lead, iron and 
coal of California, New Mexico, Arizona, Idaho, Wyoming, Utah, Missouri, Ken- 
tucky, Tennessee and Pennsylvania; the great chain of American Lakes rest peace- 
fully on her bosom, and distill the refreshing showers which sustain her luxuriant 
corn and wheat fields; and her gigantic frame is supported by the Alleghanies on the 
East and the Rocky Mountains on the West; from her breast flows the mighty Mis- 
sissippi, watering her great interior valley, which embraces an area of 2,455,000 
square miles, more than equal in area to the whole continent of Europe, exclusive of 
Russia, Norway and Sweden, and extending through thirty degrees of latitude and 
ninety degrees of longitude. 
In such a vast empire, reaching through such zones of climate and ranging 
through such degrees of elevation, and varying to such marked extent, in its different 
regions, in soil, corresponding diversities exist in the diseases of different sections. 
The home of yellow fever lies in the West Indies and along the coast of Central 
America, and during the warm months of the year this disease constantly menaces 
the cities of the Gulf and Atlantic coasts, and this fact has modified the systems of 
quarantine adopted by the maritime States of this Republic : throughout the vast 
region of the valley of the Mississippi, every form of malarial paroxysmal fever pre- 
vails, with greater or less intensity, according to the climate and soil, the heat and 
moisture, the rainfall and peculiar climatic conditions associated with the annual 
revolutions of the seasons and the greater astronomical cycles. 
From her central position, forming the very heart of the world, from the char- 
acters of her heterogeneous population (more than one-eighth of which are descend- 
ants of the negro slaves, originally imported from Africa), and from her free and 
unrestricted intercourse with all nations of North, South, Central and Insular Amer- 
ica, of Europe, Asia and Africa, the United States of North America should, of all 
the nations of the earth, be the foremost in promoting the progress and perfection of 
Public and International Hygiene. 
The speaker hopes to be pardoned for a personal allusion, which brings in forcible 
contrast the past and the present. 
Twenty-two years ago he stood in the capital of the United States of America a 
defenceless and friendless prisoner of war, with the home of his fathers in ashes, and 
the land which he loved wet with the blood of her sons and scarred and blasted all 
over with the thunderbolts of war. 
This day, after a generation has passed away, he looks out upon fields of golden 
grain; we hear the merry song of the farmer, the hum of machinery and the laughter 
of women and children, and before us we behold the hosts of a well-disciplined army; 
but we hear no rattle of drums and no roar of cannon; the brazen trumpet is silent, 
and the gleam of the bayonet and the flash of the sword are seen no more. 
The bright banner of truth waves over these disciplined and valiant veterans ; 
their way is guided by the soft beams of the twin stars of hope and love; and as their 
serried ranks march cheerfully to mortal conflict with disease and death, each heart 
throbs with the love of humanity, and their lives are devoted, not to military fame and 
bloody conquests, but to the solution of the great problems which relate to the pre- 
servation of the lives and the healing of the diseases of the nations of the earth. 296 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
PUBLIC AND INTERNATIONAL HYGIENE. 
This branch of science may be considered under three main divisions :- 
1. Domestic Hygiene. 
2. Public and National Hygiene. 
3. International Hygiene. 
We propose to present a mere outline of this vast subject, in order to bring into 
bold relief questions of the greatest interest to mankind, which demand careful 
investigation. 
Hygiene, a word derived from the Greek, means health ; hygiene is the science, 
and practical hygiene the art, of preserving health. 
It is the province of hygiene to seek out and determine the causes of diseases 
and to formulate rules for their prevention ; it may, therefore, be called Preventive 
Medicine, although this name does not include all that must be included under this 
important branch of science. 
A knowledge of the causes and mode of propagation of diseases being necessary 
in order to formulate rules for their prevention, it is evident that hygiene is largely 
dependent for its perfection on the advances made in chemistry, physiology, pathology, 
and aetiology. Before the discovery of oxygen and the determination of the physical 
and chemical properties of the atmosphere, and its relations to plants and animals, 
during the last quarter of the eighteenth century, it was impossible to erect the 
science of hygiene upon a broad and scientific basis. 
The demonstration of the circulation of the blood, and the determination of the 
chemical changes which this fluid undergoes during respiration, and of the chemical 
properties and relations of the constituents of the blood and organs to the chemical 
elements of the atmosphere, earth, water, and food, were equally essential to the 
development of this science. All scientific determinations of the relations of health 
to the amounts and kind of mental and physical labor involved in our daily occupa- 
tions, and in the performance of certain trades and callings, must rest upon the 
determination of the equivalents of the physical and chemical forces and upon their 
mutual relations (co-relations). 
While it is true that a few of the subjects embraced under the head of practical 
hygiene have engaged the attention of some of the profoundest thinkers and most 
renowned leaders of men from an early historical age, at the same time it must be 
admitted that up to near the close of the last century it rested almost entirely upon 
an empirical basis, by reason of the imperfection of the collateral sciences, and the 
want of those physical appliances and microscopic and chemical instruments, reagents, 
and methods of analysis and investigation now made available in the nineteenth 
century for inquiries of such a difficult and recondite character. 
Within the nineteenth century, and especially during the past fifty years, it has 
been possible to investigate the problems of hygiene upon a strictly scientific basis, 
and to lay a foundation on which to build a structure which may one day enable 
hygiene to hold a place among the more exact sciences. 
It is, however, well established that, owing to the advance in knowledge and the 
improvement in the sanitary construction of dwellings, towns, and cities, more abun- 
dant supplies of cheap clothing, good water and wholesome food, the application of 
such preventive measures as vaccination against smallpox, and a more enlightened 
system of medical practice, the death rate of civilized nations has diminished. 
Two centuries ago the death rate of London was 80 per 1000 inhabitants ; at the 
present day it is under 23 per 1000 ; a century ago the navies of the world could 
hardly keep the sea, on account o'f scurvy ; now, in consequence of the discovery of SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
297 
the antiscorbutic properties of lime juice, by Captain Cook, and to the use of fresh 
canned meats, vegetables and fruit on shipboard, and to the improvement in naval 
architecture and hygiene, scurvy, ship fever, and even yellow fever are diseases of 
the past, or exist only as the results of the grossest negligence on the part of muni- 
cipal, naval and health officers. 
Jails and hospitals are no longer foul and loathsome hotbeds of infectious and 
contagious diseases ; the galling shackles have been stricken alike from the feeble 
limbs of the insane, the slave and the serf. 
Thirty years ago English troops at home died at the rate of 20 per 1000 ; now 
the death rate is less than half this. 
The extensive use of quinine in the treatment of malarial paroxysmal fever has, 
during the past forty years, greatly reduced the rate of mortality from this most 
dangerous and fatal fever in tropical and semi-tropical regions. 
By sanitary regulations and by the wise administration of quarantine, Baltimore, 
Philadelphia, New York and Boston have, for a long series of years in this century, 
banished yellow fever ; and even in our more Southern cities, as Charleston, Savan- 
nah, Mobile, New Orleans and Galveston, epidemics of yellow fever which, up to the 
year 1856, so often ravaged these cities, are recurring at much longer intervals ; and 
an extended experience and an intimate association with the sanitary affairs of our 
Southern cities have led us to the belief that it will be possible, by thorough domes- 
tic sanitation and rigid quarantine, and the proper regulation of commerce with the 
West Indies, Mexico, Central and South America, during the months of April, 
May, June, July, August, September and October, by thorough disinfection at the 
various foreign ports, by rigid inspection of crews and cargoes and the employment 
of acclimated crews, to banish this terrible scourge from the shores of the United 
States of America. 
I. DOMESTIC HYGIENE. 
The family is the unit of the village, town, city, state and nation. From the 
union of man and wife, and from the fruit resulting therefrom, the nation has its per- 
petual fountain of life and strength, from which the ravages of war and pestilence and 
the erosions of time are healed. If the fountain be impure, the stream will be foul. 
Households founded and conducted in violation of the laws of hygiene are standing 
menaces to the public health, and the danger is increased a thousandfold by con- 
gregating them into towns, villages and cities. 
The leprous father not only breeds a leprous son, but he menaces his neighbors 
with the foul contagion of a loathsome disease. 
Sanitary education and sanitary reform must begin in the household. 
The conditions for health in the household do not differ materially from those in 
the village, town and city, and may thus be formulated. 
1. Meteorological Conditions, or Climate.-The temperature and the varying 
amounts of moisture, as well as the atmospheric pressure and the character of the 
organic constituents of the air, appear to be the most important factors in the effects 
of climate on man. It must be admitted that it is difficult to separate their influence 
from those of soil and site, and much which has been attributed to climate is really 
due to other causes. 
If proper hygienic laws are carefully followed out, man may maintain his health 
in almost any climate. 
In relation to human health, climate may be considered as cold and dry, cold and 
moist, temperate and dry, temperate and moist, warm and dry, warm and moist, hot 
and dry, hot and moist, malarious and non-malarious. In hot and moist climates the 298 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
agencies of disease appear to be more easily called into action than under colder and 
drier conditions. Malarial fevers appear to require for their development conditions 
of soil, vegetation, moisture and temperature, and in their rise, spread and annual 
declension are intimately associated with the revolutions of the seasons. 
Yellow fever had its origin in the warm, moist climate of the West Indies and 
coast of Central America, and requires a certain temperature for its development 
and propagation. The epidemics of this disease which have occurred within the 
limits of the United States have most generally attained their maximum mortality 
during the heat of summer, and gradually declined in the autumn, until arrested by 
the occurrence of a decided frost. 
Enteric or typhoid fever exists under various meteorological conditions, and propa- 
gates itself under widely varying conditions of temperature. 
Asiatic cholera, although undoubtedly originating in hot and moist climates and 
countries, appears capable of being propagated through the medium of travel and 
commerce in most parts of the world. The invasions of Asiatic cholera in South 
and North America have been traced to infected vessels, and it has committed its 
ravages at every elevation above the sea and under every vicissitude of climate. 
Great heat and dryness appear to arrest certain diseases, as in Egypt, when the 
plague was said to cease after St. John's day ; and during the hot Harmattan wind 
of the west coast of Africa smallpox is arrested, and successful vaccination is 
impossible. 
Leprosy and various skin diseases appear to be characteristic of tropical regions, 
where also man is tormented by a host of venemous insects and reptiles. The dan- 
gerous Guinea worm, the Hæmatobia bilharzia, the cause of fatal disease of the 
kidneys attended with profuse hæmaturia, and the Filaria sanguinis hominis, the 
prime factor in the production of chyluria and Elephantiasis Arabum, one and all 
appear to have their home in hot, moist, tropical and semi-tropical climates. 
It must be observed, in this connection, that in a healthy body an adaptation to 
circumstances rapidly takes place, and an equilibrium is soon established. Great 
heat does not necessarily cause an elevation of the temperature of the healthy 
human body, and provided there be no excess of moisture in the surrounding hot 
air, the equilibrium is soon established and the normal temperature maintained by 
the process of transpiration ; should, however, this be arrested, then a rise of bodily 
temperature may take place, and disease of a febrile character be established. 
2. The Soil or Site of the Dwelling.-Much which has been thought to be due 
to climate, is really referable to local causes, such as the physical constitution of the 
soil, defective drainage, foul emanations land moisture exhaled under and around the 
dwelling. 
Soils may be divided into moist or dry, damp or wet, permeable or impermeable, 
and again, with reference to their composition and geological formation, as silicious, 
sand, gravel, clay, clay sand and gravel mixed, alluvium, made soil, slate, metamor- 
phic, calcareous, azoic and granite. 
Dry, permeable soils which allow of the rapid disappearance of rain water, which 
are readily drained and which are free from organic matters, may be regarded as 
suited to human habitation, especially if they be removed from all emanations from 
marsh, foul drains, canals and cesspools. 
On the other hand, soils composed of recently formed alluvium, or of the filth and 
garbage of cities, or which are flat, wet and marshy, are dangerous to human health, 
and unfit for the sites of dwellings. 
The air contained in greater or less quantities in all soils is impure, hence houses SECTION XV PUBLIC AND INTERNATIONAL HYGIENE. 
299 
should not be constructed below the surface, or immediately on the surface ; and in 
all cases the earth under the house should be covered with some impervious material, 
as asphalt, cement, or slate ; and the impervious material should, if possible, be 
laid upon a layer of gravel free from organic matter. 
The amount, character, composition, temperature and changes of the water 
naturally present in most soils is of importance to human health. Everywhere, at 
varying distances from the surface, there exists a great subterranean lake or sea, known 
as subsoil or ground water, which is continually in motion, both vertically and later- 
ally, the horizontal movement being toward the sea or nearest water-course; the 
vertical movement is chiefly determined by the rain-fall. A permanently high 
ground water, that is within five feet of the surface, and frequent fluctuations in the 
height of the ground water, are unfavorable to human health, while a permanently 
low ground water, not less than fifteen feet below the surface, is favorable to human 
health. 
Pettenkofer and his followers regard the ground water as determining the spread 
of certain diseases, as cholera and enteric fever. A previously high level succeeded 
by a fall in the ground water, with a certain height of temperature in the soil air, 
are the conditions believed to be most favorable to disease production and propa- 
gation. 
3. The Materials of Buildings.-Circumstances over which the original builder 
has no control often determine the character of the materials used. The early set- 
tlers of the forests of North America found the log cabin conducive to health, and 
at the same time capable of ready defence against the attacks of the Indians. Dwell- 
ings constructed of dry wood and well ventilated and exposed to the direct rays of the 
sun, are best for warm and moist climates, and the only objection which can be urged 
against them is their liability to destruction by fire. 
Buildings constructed of stone or well-burned brick may be regarded as healthy, 
provided proper precautions be taken to secure dryness in the foundations and walls. 
Various opinions have been expressed as to the advisability of constructing the walls 
of inhabited rooms of porous materials, or of impervious or glazed or painted surfaces. 
The latter appear to be preferable, for where air can penetrate organic matters are 
liable to form a lodgment. 
Papering may in itself contain poisonous materials, as arsenic, while the paste 
which holds it to the wall may undergo decomposition and become the source of dis- 
ease. Glazed and painted walls admit of repeated and thorough cleansings. 
The placing of a dwelling on any spot of ground tends to excite an extractive 
force on the soil, because the air of the dwelling is almost always warmer, drier and 
more rarefied than that of the soil, and there is a constant danger of the sucking up 
of the impure air into the dwelling. An impervious foundation to dwellings is there- 
fore necessaiy, to cut off this recognized source of disease, which becomes very dan- 
gerous when the soil is saturated with coal gas, carbonic acid gas, or sulphureted 
hydrogen from privies and cesspools, or by the putrefying matters and ptomaines of 
graveyards. 
4. Drainage and Sewerage.-Simple but efficient provision should be made for 
the rapid and continuous removal, not merely of rain and storm water and of that 
employed in cooking and washing, but also for the ground water. 
All excrements and garbage should be systematically and daily removed, either 
by well-constructed sewers or other well-known methods. Under certain circum- 
stances cremation offers an effective mode for the thorough disposal of garbage. 
Filth must be regarded as one of the most important factors in the development 300 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
and propagation of disease, and it is essential that it should be continuously and sys- 
tematically removed from dwellings and their surroundings. 
5. Ventilation.-Pure air should be supplied in sufficient quantity to each and 
every inhabitant of the dwelling. Proper air space is of great importance to the 
construction of habitable rooms, for upon it depends the renewal of air. The air of 
a room' can seldom be changed oftener than three times an hour; and hence the 
room should be large enough to allow of such rate of exchange providing sufficient 
air for respiratory purposes. Pure air constantly renewed is the prime necessity of 
life. We may abstain from food or water for a considerable length of time, and thus 
be enabled to replace either when impure, but we must constantly breathe the atmos- 
phere around us, whether pure or impure. 
Air is an admixture of oxygen and nitrogen, in the proportion of about 21 per 
cent, of the former to 79 per cent, of the latter, with small proportions of carbonic 
anhydride, moisture and organic matter, and microorganisms. During respiration 
atmospheric air loses oxygen, while the proportion of carbonic anhydride and of 
organic impurities is increased. 
Within certain limits, the amount of carbonic acid is not injurious to health; it is 
important as a measure of the organic matter, which is really the dangerous agent; 
air vitiated by respiration is hence more dangerous than when the increase of car- 
bonic anhydride is the result of simple combustion. 
Air is not fit for respiration when the respiratory impurity, as measured by the 
carbonic acid, much exceeds two parts in the 10,000 parts by volume. If the air of 
dwellings can be kept below this point the conditions may be regarded as satisfactory. 
The amount of impurity imparted to the respired air by living beings must vary, 
of course, with the size, weight, age, sex and work performed ; but it may be estab- 
lished that six cubic feet of carbonic acid are given off by each individual during ten 
hours. This requires an hourly supply of 3000 cubic feet per hour of fresh air, and 
this amount should be largely increased during work or sickness. 
The diseases which have been shown to be due to imperfect air supply, crowding 
and impure air, are : consumption, bronchitis, malignant sore throat, erysipelas, puer- 
peral fever, typhoid fever, pyaemia, and hospital gangrene. 
6. Water Supply.-The water used for drinking and cooking should be clear, 
tasteless, odorless, without color or deposits, and free from organic impurities, and 
should not contain more than 60 grains per gallon of such mineral salts as the car- 
bonates and sulphates of lime, magnesia, soda and potassium. Lead pipes and 
lead cisterns should be abandoned for the storage or conveyance of drinking water 
as endangering the health by inducing chronic lead poisoning, ending in cramps, 
constipation, nervous and muscular derangement, paralysis and death. 
The water should be not merely good in quality, but abundant in supply. Not 
less than from 20 to 50 gallons per head should be supplied for all purposes, including 
drinking, washing, bathing, cooking and the removal of fecal matter by sewers. 
When practicable, the supply should be continuous, and no supply pipe should com- 
municate with any pipe or main leading to a sewer or cesspool. In sparsely settled 
districts, water from wells and springs may be used, provided that care be taken to 
avoid soakage from cesspools, stables, barnyards and privies. Deep wells, including 
artesian wells, cisterns and rivers, uncontaminated by the sewage of cities, often fur- 
nish good drinking water. 
The purification of water by filtration and other measures, for drinking purposes, 
is a subject of great importance, especially when there is reason to suspect the pres- 
ence of organic matters and the microorganisms of disease. Without doubt the SECTION XV PUBLIC AND INTERNATIONAL HYGIENE. 
301 
waters of our Southern swamps and rice fields are fruitful sources of the various forms 
of malarial paroxysmal fever. The use of cistern water, boiled and filtered water, 
is essential to the preservation of health on rice fields and low, marshy localities. 
Personal cleanliness, so essential to health, depends upon a free supply of pure 
water. 
7. Heating and Lighting of Dwellings.-The open fireplace has the advantage 
of securing good ventilation, but it is inadequate as a source of heat in cold climates. 
Heating by coils of tubes or pipes, by means of hot air, hot water or steam, is prefer- 
able to heating by stoves or hot-air furnaces. 
During the winter season the temperature of sleeping, sitting and work rooms 
should not vary much-60° to 65° F. 
Sunlight is essential to health, and houses should be so constructed as to be 
open to the full rays of the sun. 
8. Clothing and Personal Cleanliness.-The clothing should be adapted to the 
temperature, and should be of such ample supply and variety of character as to 
admit of frequent change. In warm, moist climates the under clothing should be 
changed daily and the entire body bathed in water. In virtue of the increased pro- 
duction of cotton goods by machinery, the more extensive use of clothing and of 
soap, the hygienic condition of civilized nations has vastly improved during the past 
century, and various diseases, as typhus fever, the plague and Oriental leprosy, have 
ceased to commit extensive ravages. 
9. Food. 
10. Beverages: Alcohol and Alcoholic Liquors.-The effects of wine, beer, 
whisky, brandy, rum and other intoxicating drinks should not only be the subject 
of scientific investigation, but also of legislative enactment. 
11. Narcotics: Tobacco, etc. 
12. Effects of Different Trades. 
13. Work and Exercise.-The mechanical work performed by a man is usually 
reckoned as so many tons lifted through one foot, called foot tons. 
It has been calculated that a fair day's work equals 300 foot tons, a hard day's 
labor 450 foot tons, and the maximum day's labor has been fixed at 600 foot tons. 
It must be borne in mind that when the amount of work required exceeds the average 
amount of it which the human system is capable of sustaining, the strain upon the 
nervous and muscular systems, and especially upon the heart, increases in a geomet- 
rical ratio. 
Athletic and gymnastic sports are of great value to young students, and, in fact, 
to all those who have the opportunity to devote a portion of each day to physical 
training ; but if the work is excessive, or too violent and rapid, diseased action of 
the heart and other ailments may result, which may fatally diminish and impair the 
nervous, muscular and vital powers. Without doubt, the health of many robust 
young men has been sacrificed to over-exertion in the gymnasium and in the violent 
struggles for mastery in rowing, swimming and ball playing. 
14. Control and Regulation of the Sexual Appetite and Relations. 
15. The Proper Conduct of the Period of Infancy, including Food and Clothing. 
16. The Adjustment of Mental to Physical Work. 
This brief outline of this important subject, embraced under the head of 
Domestic Hygiene, is sufficient to establish its importance as a branch of human 
knowledge, and to demonstrate the fact that it underlies Public, National and 
International Hygiene. 302 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
II. PUBLIC AND NATIONAL HYGIENE. 
The principles of domestic hygiene include those of public and national hygiene. 
The recognition of hygienic laws in the conduct of the sanitary affairs of towns, 
cities, hospitals, prisons, armies and navies has been of comparatively recent date ; 
and even at the present day many cities and States in this republic are without 
efficient health organizations and intelligible and practicable health laws. 
1. Boards of Health.-It would obviously be impossible to formulate or execute 
rules for the guidance and protection of the public health without organized bodies 
charged with their execution. 
In the United States the subject of public health has been legislated by the 
people, to a certain extent, as a police question, and both local and State boards of 
health have sprung into existence. The efforts of the general government to legis- 
late on health matters have been spasmodic, and thus far have not brought forth 
the valuable fruits, either in measures or men, which the citizens of a great republic 
have a right to expect and demand. Health laws are too often ambiguous, of 
doubtful utility, and wanting in the essential elements of clearness and power of 
immediate execution. 
In many cities the powers of the municipal government and of the board of 
health are not clearly defined, leading to divided responsibility, neglect of duty, a 
lax administration of sanitary laws, and a shameful neglect of the public health. 
This condition of affairs has given rise to the formation of so-called auxiliary sani- 
tary associations, whose existence is a standing reproach to the municipal authorities 
and boards of health, and whose oft-repeated carping criticisms of the legally con- 
stituted authorities, and perpetual appeals for money, have tended to bring public 
hygiene into unmerited disrepute. 
The effects of divided authority and of the uncertain sounds of a multitude of 
councillors is shown at the present day in the deplorable condition and high death 
rate of many American cities, but most conspicuously in New Orleans, with its 
entire sewage and drainage system of canals filled with a foul mass of mud, excre- 
ment and garbage, polluting the air with their poisonous vapors, breeding diph- 
theria, diarrhoea, dysentery and malarial fever, and causing the overflow of the 
thoroughfares by every passing shower. 
The true theory of this republican form of government is that the officers who are 
elected by the votes of the people are the servants, and not the masters of the people ; 
that laws were made for the guidance of the governor as well as the governed ; that 
taxes are collected for the use of the taxpayer, and not for political parasites and 
robbers ; that an upright officer has no discretion in the execution of the law, which 
is the indestructible and inexorable guide to his acts. 
The people and their servants, the officers, cannot wisely or legally delegate the 
execution of sanitary laws to voluntary and self-appointed associations, any more 
than they can delegate the execution of judicial matters to irresponsible parties. 
Health officers and municipal officers must be held responsible for the protection 
of the public health and the preservation of the lives of the people from all prevent- 
able causes of disease and death. 
The want of uniform health laws in the States and communities of the United 
States was clearly shown in the terror, alarm, and by the untold horrors of the shot- 
gun quarantines of the yellow fever epidemic of 1878, and in the more recent Biloxi 
fever of 1886. The recent outbreak of yellow fever at Key West, Florida, revealed 
the fact that this great and fertile State, holding the nearest position to the recog- 
nized home of yellow fever, was without a well-organized central board of health. SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
303 
It is manifestly the duty of the States comprising this republic, in their sovereign 
capacity and in virtue of their inherent police powers and their rights under the 
Constitution, to meet together by their chosen representatives in general convention, 
and consult together on the subject of public and national hygiene, including quaran- 
tine, and after careful and mature deliberation to frame and adopt a uniform system 
of health and quarantine rules and laws, which shall be supreme over this entire 
republic, and apply to all emergencies and to all cases of domestic and foreign pes- 
tilence. 
The police, sanitary and quarantine powers and laws of the individual and of the 
general government should be clearly defined, and a uniform system of health and 
quarantine laws adopted by the States and national government. 
2. Vital Statistics.-The advancement of public hygiene during the past thirty 
years has been largely due to the increased attention paid by local and general boards 
of health and by civilized governments to the collection, preservation, publication 
and classification of vital statistics. Foremost in this most important work of tabu- 
lating the births, deaths and causes of death must be reckoned the Registrar Gen- 
eral of England, whose statistical work during the past forty years has influenced 
not only England and Europe, but the entire world. 
We are now able to determine the limits of mortality and its causes with some 
precision, and are obtaining correct data for the interpretation of a too high death 
rate. 
The chief vital statistics bearing upon public health are :- 
(а) Determination of the birth rate. 
(б) Determination of the general death rate. 
(c) Determination of death rate according to sex, age and disease. 
(c?) Determination of the health of classes of the community as judged of by their 
expectation of life at given ages. 
There are many other problems, but these are the most important. 
The collection of statistics of sickness, apart from mortality, has not hitherto 
been successful, on account of the difficulty of collecting the data with sufficient 
accuracy. 
The gross death rate is but an elementary expression which should be accom- 
panied by further analysis of mortality according to ages and disease, and also by 
considerations of the death rate. As far as it goes, however, the gross death rate, 
without distinction of age, sex or disease, has shown valuable uses in the institution 
of comparisons in the mortality of different localities, seasons and years. 
It has thus been assumed in England and other countries that the death rate is 
nowhere satisfactory if it exceeds 23 per annum per 1000 of population. 
In the United States, as well as in all civilized countries, the progress and per- 
fection of public and national hygiene will be advanced by the following regulations;- 
(u) Careful registration of all physicians, midwives and undertakers. 
(6) Regulation by law of the practice of the medical profession. 
(c) Scientific and uniform classification of all diseases and causes of death. 
(tZ) Forms for the systematic reports of births, giving sex, race and condition. 
(e) Forms for reports of deaths, giving age, place of death, date of death, cause 
of death, sex, occupation, condition, length of illness, birthplace, etc. 
(/) Record of marriages, giving age, race and condition. 
The system of registering vital statistics should be uniform throughout the civil- 
ized world, and should in all cases give data for the calculation of the following : 
Number of the population and of various persons of various races, ages, sexes 304 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
and occupations ; the number of deaths, the sex, ages and condition of the persons 
dying and the diseases causing the mortality. 
The national census furnishes some of these figures, and the medical profession 
furnish the rest. A very great responsibility, therefore, rests upon the medical pro- 
fession, for the proper regulation of public hygiene, by pointing out the effects of 
locality, trade, occupation, diet, water, crowding and heredity upon the mortality 
of different classes and at different ages. 
3. Relations of Race to Public Hygiene and to the National Death Rate. 
The political, social and sanitary problems presented by the negro race in the 
United States of America are of the gravest character, and remain unsolved. 
The African slave trade, established by British rulers, conducted by British slavers 
and fostered by New England merchants, New England capital and New England 
seamen, transported to the shores of the English colonies a black, barbaric race, with 
strong physical characters and race peculiarities, but destitute of learning, arts, civil- 
ization or historic fame. 
The negroes slowly but steadily gravitated to the Southern States, which were 
better adapted, by soil, climate, and peculiar productions, to slave labor. 
The concentration of the slaves in the States of Maryland, Virginia, North Caro- 
lina, South Carolina, Georgia, Florida, Alabama, Mississippi, Louisiana, Texas, 
Arkansas, Missouri, Tennessee and Kentucky, led to sectional peculiarities, senti- 
ments, prejudices and politics, which finally, through the perpetual agitation of the 
abolitionists, led to sectional hatred ; uncompromising hatred finally led to bloody, 
relentless, fratricidal warfare. If the States of this Republic had been guided by the 
counsels of great, good and wise statesmen, the bloody Civil War of 1861-65, withits 
million of slain and its billions of lost treasure, would never have taken place, but 
would have been superseded by a wisely devised system of gradual emancipation, 
which would have left these people free, happy, prosperous and united, and the soil 
of the Republic would have been unpolluted by the blood of her sons. 
Transported from slavery to freedom, not by their own power or prowess, the 
negro slaves were called upon to assume new duties and to play a new rôle in the 
march of civilization, in the heart of a great nation of white men, with different race 
peculiarities, manners, customs, traditions and moral and intellectual endowments. 
We believe it to be the duty of the stronger race to protect the weaker ; at the 
same time we do not believe that the progress of civilization on this continent will 
ever be checked by the domination of the white race by the negro or the Chinese. 
No greater crime can be conceived or perpetrated in the annals of humanity than 
the amalgamation and mongrelization of a superior with an inferior and barbaric 
race, or the political subjection of the former to the latter. 
This is not the time or the place for the discussion of political and social prob- 
lems, and we pass at once to the brief consideration of the influence of race on the 
gross mortality of this country. 
In the United States census for 1880 we find that in a population of 43,402,970 
whites there are recorded, for the year 1880, 640,191 deaths, giving a mortality of 
14.74 per 1000 inhabitants. 
In a population of 6,752,813 colored, there were recorded 116,702 deaths, giv- 
ing a mortality of 17.28 per thousand. 
Taking the States east of the Mississippi river which have the largest popula- 
tion of colored people, namely, Alabama, District of Columbia, Florida, Georgia, 
Kentucky, Maryland, Mississippi, North and South Carolina, Tennessee, Virginia 
and Louisiana (including in this latter State that part west of the river also), we find SECTION XV PUBLIC AND INTERNATIONAL HYGIENE. 
305 
that the total white population is 8,530,962, and the number of deaths of whites 
recorded 113,110, giving a death rate of 14.4 per thousand. 
The colored population of the same States was given as 5,303,267, and the num- 
ber of deaths among them reported, 91,328, giving a death rate of 17.22 per 
thousand. 
In this section of the country the deficiencies of the enumerators' returns of 
deaths are above the average, and they are greater than for the white race, so that 
the deficiencies between the mortality rates of the two races is greater than that 
indicated above. 
In the Southern States the ratio of mortality is greater among the colored people 
than among the whites, in the ratio of 17.29 colored to 14.4 white per 1000 
inhabitants. 
In the same group of Southern States referred to, over one-half the deaths 
reported, or 507.10 per thousand deaths, occur under five years of age. Of the col- 
ored females, 438.47 per thousand deaths are reported under five years of age. The 
proportion is less in the white race. 
This excess of infantile mortality in the colored race occurs in each grand group 
in which the distinction of color is made, and is the main cause of the excess of 
mortality in the colored race over the white. 
The mortality in the colored race is greatly increased in the large cities of the 
United States, as will be illustrated by the following. 
The statistics of Savannah, Georgia, as far as I have been able to examine them, 
are as follows :- 
SAVANNAH, GEORGIA: TOTAL DEATHS FROM ALL CAUSES IN WHITE AND 
BLACK RACES. 
Years. 
Total Deaths. 
White. 
Total Deaths. 
Black. 
White and Black. 
Total. 
1854 
1221 
308 
1529 
1855 
433 
292 
725 
1856 
466 
297 
763 
1857 
376 
264 
640 
1858 
592 
262 
854 
1859 
430 
273 
703 
1860 
474 
282 
756 
1861 
563 
269 
832 
1862 
555 
372 
927 
1863 
459 
389 
848 
1864 
747 
446 
1193 
1865 
1202 
819 
2021 
1866 
530 
912 
1442 
1867 
476 
594 
1070 
1868 
498 
581 
1079 
1869 
423 
429 
852 
Total deaths from 1856 to 1869, 16,234. 
The whites appear to be in excess of the colored population in Savannah, and the 
mortality is greater in proportion to the population of the latter. 
In New Orleans, Louisiana, the colored race forms a larger proportion of the pop- 
ulation than in any other American city. We have established, by carefully recorded 
statistics, now in the possession of the Board of Health of the State of Louisiana, 
that the death rate of the colored race exceeds that of the whites in the cities of the 
Vol. IV-2Ö 306 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
United States, no matter where the statistics be gathered, whether in southern or 
northern regions. As we have examined the statistics of New Orleans more fully 
than those of other American cities, we give the gross results of the investigations 
illustrating the mortality of New Orleans for a series of years in the following table, 
giving the rate of mortality per 1000 white, colored inhabitants, and total mortality. 
MORTALITY OF NEW ORLEANS, LOUISIANA-DEATH RATE PER 1000 
INHABITANTS. 
Year. 
Whiie. 
Colored. 
Total. 
1845 
25.10 
22.50 
24.32 
1847 
70.86 
37.08 
62 03 
1849 
81.92 
62.91 
77.44 
1850 
63.08 
52.10 
59.38 
1852 
67.91 
43.04 
62.90 
1853 
124.68 
48.98 
100.09 
1856 
32.98 
35.66 
33.89 
1857 
34.86 
38.07 
35.49 
1858 
69.64 
80.37 
72.70 
1859 
33.58 
86.78 
41.53 
1860 
41.99 
52.79 
43.51 
1861 
31.58 
37.16 
31.87 
1863 
37.30 
59.53 
41.35 
1864 
42.14 
81.75 
49.86 
1865 
33.32 
60.88 
38.99 
1866 
' 36.77 
65.56 
42.52 
1867 
56.79 
47.80 
54.69 
1868 
25.49 
38.97 
28.60 
1869 
27.29 
44.80 
31.75 
1870 
33.74 
52.20 
38.61 
1871 
27.26 
42.76 
31.32 
1872 
27.29 
41.93 
31.17 
1873 
32.79 
51.42 
37.73 
1874 
29.53 
43.44 
33.75 
1875 
26.28 
40.25 
30.00 
1876 
25.87 
42.50 
30.31 
1877 
25.96 
49.02 
32.11 
1878 
52.05 
39.94 
48.81 
1879 
20.85 
32.41 
23.95 
1880 
22.96 
34.38 
26.01 
1881 
25.79 
38.95 
29.31 
1882 
21.89 
39.03 
26.45 
During a period of thirty-two years embraced in the above table, with the excep- 
tion of 1879, the death rate among the whites was the lowest in 1882. The 
average death rate for the thirty-two years among the whites was about 39.6 per 
thousand, for the colored about 47.1 per thousand. 
These statistics establish the fact that the death rate among the colored popula- 
tion is heavier than among the white. 
There was a marked diminution of the death rate among the whites, and also 
among the colored during the year 1879 to 1882 inclusive; this diminution was 
largely due to the sanitary operations of the Board of Health of the State of Louisi- 
ana, and to the thorough, rigid and scientific system of quarantine established and 
maintained during the period which I held the position of President of the Board. 
The results of the rigid system of quarantine and of domestic, public and maritime SECTION XV PUBLIC AND INTERNATIONAL HYGIENE. 
307 
sanitation conducted during the years 1880-83 by the Board of Health, lead us to 
hope that foreign pestilence may be forever excluded from the valley of the 
Mississippi. 
As to the causes of the greater mortality of the colored race in Southern cities, as 
far as our observations have extended, they appear to be as follows:- 
(1) The negro has been but comparatively recently enfranchised, and is in a tran- 
sition state; freedom coming by the violent cataclasm of war and civil revolution 
found him unprepared, to a large extent, to reap its benefits. How long it will 
require the negro to obtain the necessary sanitary knowledge to reduce his death 
rate to the minimum is a question for the future. That he has not yet attained this 
knowledge is known to every careful and conscientious observer. That he has failed 
to accumulate any large amount of property, as a race, during his twenty-two years 
of freedom is well known. 
(2) Poverty and ignorance breed dissolute habits, engender imprudence, and 
directly and indirectly breed disease from poor diet, crowding, and the violation of all 
known sanitary laws. Health is incompatible with crowding and filth. The destruc- 
tive effects of poverty, poor diet, crowding, scanty clothing and filth and neglect are 
«specially manifest in the high death rate among negro children. 
(3) While the better classes of the colored people bind themselves together in 
societies for mutual aid, and employ physicians for the sick, and furnish medicine as 
well as food for the sick and destitute, large numbers, especially those crowding into 
the cities from the surrounding plantations, enjoy no advantages of this kind, and 
too frequently are crowded together in the hovels of the purlieus. 
(4) Vice and alcoholic stimulants are potent factors among the latter class, 
including the roustabouts (steamboat hands), who frequent low drinking and gam- 
bling hells and obscene dance houses in the slums of certain parts of the city. 
(5) Crowding and improper food, and in many cases absence of medical attend- 
ance and insufficiency of clothing and fuel during the winter months, without doubt 
largely increase the mortality rate, especially among the colored children. 
(6) The neglect of vaccination by the colored race makes them peculiarly liable to 
the ravages of smallpox, as I have shown by statistics collected during the last forty 
years. Owing to a large population of probably now over 60,000 colored people 
(U. S. census of 1880: white, 158,367; colored, 57,723; total, 216,090), New 
Orleans is perpetually exposed to epidemics of smallpox whenever this disease is 
introduced into the United States. The incubative period of smallpox being four- 
teen days, the negroes from the surrounding plantations who visit the city bring in 
their persons the seeds of the disease. 
(7) Statistics show that in the country outside of the city, the negro is very pro- 
lific, and that the race is increasing, notwithstanding the large death rate in the city. 
The early period at which the negro women begin to bear children, and the frequency 
with which illegal sexual intercourse takes place in this race also cause an increase 
in the birth rate in the agricultural districts of the Southern States. 
4. Location of Towns and Cities.-Dwellings should be scattered over as large an 
area as possible, for sickness and death are often in proportion to the amount of area 
per head occupied by a community. The area per head of the population of London 
is estimated as double that of Paris and many other cities, while at the same time its 
death rate is smaller than that of any other large city in Europe. 
The comparatively large rate of mortality of New York city is largely due to the 
crowded condition of its population, which appears to increase with the growth of 
the city. New Orleans, notwithstanding its situation in a low, marshy, ill-drained 308 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
basin, below the high water line of the river and lakes, and notwithstanding its hot, 
moist, semi-tropical climate and malarious surroundings, is much less unhealthy 
than could have been calculated or expected by the sanitarian ; and this comparative 
immunity from disease and death is largely due to the wide area occupied by its 
inhabitants and the large number of small wooden houses, each one of which is 
occupied by a single family. 
During the intense heat of the North American summer, the effects of lofty 
buildings and crowding of the population are shown by the frightful mortality among 
children in New York and other North American cities. Fortunately, these heated 
spells are of comparatively short duration. 
The choice of the sites of towns and cities have been unfortunately, in many cases, 
the results of causes which had no bearing on their hygienic condition ; so, also, the 
arrangement, the size and character of the houses, the width of streets, and the 
presence or absence of open areas and squares, have been regulated by the neces- 
sities of commerce and the accidents and exactions of war. 
In the United States, Savannah, Georgia, which was laid off by Oglethorpe one 
hundred and fifty-four years ago, may be regarded, with its alternate open squares, 
covered with evergreen live oaks, as presenting an admirable plan to secure the health 
and comfort of the inhabitants of a city located in a warm, moist climate. So, also, 
the plan which Mr. Jefferson proposed for the improvement of New Orleans, at the 
time of the purchase of Louisiana from the French, approached nearly to that which 
had been put in execution by Oglethorpe seventy years before in the British colony 
of Georgia. 
Cities should in all cases, where the sanitarian is consulted, occupy elevated, dry,, 
well-drained situations. The soil should be connected with large masses of water, 
as lakes, running streams and rivers, provided they are not used for drinking water, 
and in that case the drainage of the city should be discharged below the source of 
Water supply. In most cases, however, the sanitarian of the present day has no 
choice whatever in the selection of the sites of cities, and he is compelled to overcome 
by engineering skill the original defects of elevation, drainage and position. 
5. Drainage and Sewerage.-The first and prime requisite for health is the free 
and continuous removal of the subsoil water, and of rain and storm water. No 
cause of disease is more potent than the accumulation of stagnant water under human 
habitations. Without doubt, phthisis, diarrhoea, dysentery, cholera infantum, sore 
throat, diphtheria and bronchitis, hepatitis, intermittent fever and anaemia, find 
the chief conditions for their development and propagation in the foul emanations 
and poisonous moisture exhaled under, in and around houses located in depressions 
which receive the leakage of the surrounding filthy yards and privies. If we could 
suddenly uncover one of our modern cities, we would be appalled by the low depres- 
sions filled with a solution of human excrements and filth, and the yawning privies 
groaning under their load of putrid faeces. 
Thorough drainage is the only mode of permanently drying the soil. Paving the 
soil with slate or asphalt, without doubt, excludes a certain portion of moisture and 
exhalations from the portions paved, but this measure does not prevent the exhala- 
tion of the moisture and foul ground air in unpaved localities. 
The relations offilth to the public health may be thus classified :- 
(a) Relative merits of the various plans of sewerage and the disposal of garbage 
and fecal matter. 
(/>) Organization of the scavenger force. 
(c) Best method of disposing of the dead. SECTION XV PUBLIC AND INTERNATIONAL HYGIENE. 
309 
(</) The effects of putrefaction in the dissemination of the germs of contagious 
and infectious diseases, such as cholera, yellow fever, smallpox, measles, 
scarlet fever, etc. 
(e) Cremation. 
Sewers may be so arranged as to serve for drainage, for the removal of house 
water, as well as for the removal of ground water. 
Each town should have a system of sewers or a system of deep drainage of some 
kind; there should be no cesspools, middens, manure piles, or accumulations of fæces 
or filth of any kind within the limits of any city. Every refuse of garbage and 
fecal matter, and filth of all kinds, should be constantly removed, and should never 
be allowed to soak into the ground, which should be secured against every source of 
contamination. The careful and thorough paving of all streets, courts, and of the 
soil underneath all houses, so as to prevent surface impurities from soaking in, and 
the construction of the public sewers so as to allow of no overflow, will preserve the 
soil of cities free from those impurities which, under the influence of heat, air and 
water, generate injurious effluvia that may be sucked into houses. 
Great care should be exercised in filling up depressions and in raising the low 
lots in cities. It is too often the case, as in New Orleans and other American cities, 
that the rakings of gutters, the foul, stinking mud of canals which receive the sewage 
of the city, are employed for making and repairing streets and filling lots. 
The fearful epidemic yellow fever of 1878 was supposed to have been aggravated 
in its symptoms and accelerated in its march by the utter disregard of the public health 
by the municipal authorities of New Orleans, in dumping large masses of garbage 
and filth in various localities within the limits of the city. 
The conditions of effective drainage and sewerage are greatly complicated when, 
as in the case of New Orleans, the site of the city is below the level of the high 
water in the lake and Mississippi river, thus necessitating the lifting up of the drain- 
age and storm water over the levee surrounding the city by strong machinery. 
In made ground at least three years are required for the disappearance of the 
more easily decomposed animal and vegetable matters. In other soils it may be 
longer, as in the impure soil of old graveyards. 
We have clearly demonstrated, in our reports to the Board of Health of the State 
of Louisiana, 1880-1884, that at least one-half the deaths occurring in New Orleans 
may be traced to preventable causes, such as- 
(1) Imperfect drainage. 
(2) Imperfect sewerage, or, more correctly, no sewerage at all. 
(3) Ill-constructed, ill-ventilated brick buildings, the floors of which rest upon a 
tenacious clay saturated with the soakings from privies. 
(4) Accumulation of fecal matters, garbage and filth of all descriptions in the 
drainage canals, as well as within the habitable limits of the city and in the vast 
network of foul gutters. 
(5) Neglect of vaccination on the part of large masses of the population. 
(6) Imported pestilence : yellow fever and Asiatic cholera. 
It is true that other American cities will fall within the preceding indictment ; 
and it must also be admitted that greater attention has been paid to sanitary affairs 
in New Orleans, since the publication of the report of the New Orleans Sanitary 
Commission of 1853. A careful and impartial examination of the drainage system 
and canals of New Orleans, for the year 1887, shows that in this respect the drainage 
of the city is more imperfect, and the canals are in a more neglected and filthy con- 
dition, than ever before in the history of the city 310 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
The vast importance of this subject to our American cities is shown by the 
following facts and figures relative to the diseases which cause the chief mortality in 
New Orleans. 
During the past 55 years, in the great Charity Hospital of New Orleans, there 
have been admitted 476,188 patients, of which number 355,996 have been discharged, 
with a mortality of 62,380, or 14.7 per cent. The mortuary record of New Orleans 
during 34 years (1844-1880), with the exception of two years (records incomplete), 
shows that the total deaths were 242,426, and of this number phthisis pulmonalis 
occasioned 24,071. During the period just specified (1844-1880), 34 years, the prin- 
cipal diseases occasioned the number of deaths shown by the following table :- 
Deaths in New Orleans, Louisiana, from Some of the Principal Causes, 
During a Period of Thirty-four Years, 1844-1880. 
Cholera (Asiatic)11,847 
Cholera Morbus 889 
Cholera Infantum 2,408 
Total15,144 
Enteritis 6,915 
Diarrhoea 8,289 
Dysentery 7,097 
Total22,301 
Phthisis Pulmonalis24,071 
Smallpox, Scarlet Fever and Measles 9,381 
Dengue, Typhoid, Typhus Fever, Cerebro-Spinal Fever and 
simple Continued Fever 5,932 
Yellow Fever28,739 
Various forms of Malarial Fever12,416 
Total56,468 
While fevers of all varieties destroyed in the city of New Orleans 56,478 citizens 
in 34 years, yellow fever destroyed only one-half of that number, namely, 28,739; 
and notwithstanding the fact that only about one-half of the mortality from fever 
in New Orleans, during the period specified, was due to yellow fever, the attention 
of the citizens of the entire Mississippi valley has been and is directed to this disease. 
Congestive fever alone occasioned in New Orleans, during 34 years, 6337 deaths. 
Phthisis pulmonalis destroyed nearly as many citizens as yellow fever, namely, 24,071 ; 
enteritis, dysentery and diarrhoea, 22,301, and cholera, cholera morbus and cholera 
infantum, 15,144. Total deaths from phthisis pulmonalis and bo we 1 affections, 61,516. 
These diseases, which are common to the entire valley, caused 61,516 deaths, 
exceeding those caused by fevers, which were 56,478. Fevers, bowel affections and 
phthisis pulmonalis alone caused in New Orleans 117,994 deaths in 34 years, out of 
a total of deaths from all causes of 242,426. 
6. Structure, Hygienic Arrangements and Ventilation of Buildings. 
(а) Proper condition of the soil for the location of buildings. 
(б) Size and arrangement of streets, squares, courts, etc. 
(c) Relations of building materials to moisture, heat and cold. 
(<Z) Public buildings, legislative halls, depots, churches. 
(e) Schoolhouses and colleges. 
(/) Factories. 
(g) Dwellings. SECTION XV PUBLIC AND INTERNATIONAL HYGIENE. 
311 
All streets, sidewalks and courts should be paved with brick, granite, slate, asphalt, 
limestone or other impervious and hard material. Wooden pavements have proved 
useless ana dangerous to health in New Orleans and Memphis. Wooden pavements 
in warm, moist climates undergo gradual but steady decay, and absorb the urine and 
liquid excreta of man and animals. The square block, New England granite, has 
proved the most useful and durable pavement in New Orleans. 
In such large cities as New Orleans, excellent streets may be constructed of the 
hard, silicious, coarse, concrete gravel of the hills of Louisiana and Mississippi. This 
gravel, free from organic matter, also forms an admirable material for the filling and 
elevation of lots. For roadways it appears to be superior to the oyster and lake 
shell, in that it creates less dust, is more indestructible and forms a harder and 
smoother road. 
Streets should be at least twice as wide as the height of the tallest houses, and 
should allow of a free passage of air to all parts of towns and cities ; vacant squares 
and courts add to the air space and prove of great value for the dilution and purifi- 
cation of the air. There should be open spaces at the back of the houses, and back 
to back buildings should be absolutely prohibited; upon any given square of ground 
the vacant spaces should exceed those occupied by the houses. 
It is difficult to determine the exact number of people who can be crowded upon 
any given space of ground, as an acre or square mile. The degree of crowding which 
may be compatible with the public health will be largely determined by the struc- 
ture, height and arrangement of the individual houses, and the peculiarities of 
climate. All houses should be ventilated, both vertically and laterally, and no room 
should have a borrowed light, but each room should have windows open directly 
upon the exterior for light and fresh air. Rooms should be of sufficient height, from 
ten to twelve feet, and of sufficient size, from fifteen to eighteen feet square. Great 
attention should be paid to the ventilation of the closets, which should be, as far as 
possible, detached from the main building and furnished with their own arrangements 
for ventilation. 
Without doubt certain contagious and infectious diseases, as Asiatic cholera, 
scarlet fever and diphtheria, have been communicated by means of the foul air of 
badly constructed sewers, from house to house. 
7. Water Supply-Relations of Water to the Public Health. 
(a) Properties of wholesome potable water. 
(&) Water supply of cities. 
(c) Proper supply of water for each inhabitant. 
(cZ) Filtration and purification of water. 
(e) Transmission of disease germs through the medium of water. 
In towns with sewers and water closets, it has been reckoned by sanitarians that 
the supply of water daily, per head, should not be less than twenty-five gallons, and 
if there are trades using water, from five to fifteen gallons more additional to each 
inhabitant. If there are no water closets, from fifteen to twenty gallons are com- 
monly deemed necessary. 
(/) An accurate chemical analysis should be made of all waters used for drinking 
in each and every town or city. 
(g) A careful determination should be made of the relations of the water to lead, 
iron, tin and terra-cotta pipes. 
(Ji) The supply of water should be abundant, and sufficient for all emergencies of 
drought or fire. 
(i) The water supply should not be liable to any contamination whatever. 312 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
(J) The water should be clear, colorless, odorless and tasteless. It should contain 
no injurious amount of organic matter, not exceeding two or three grains 
per gallon ; and the mineral constituents should not exceed fifty grains 
per gallon, and should be composed chiefly of chlorides and sulphates of 
the alkalies and alkaline earths, which are not injurious. 
It is not so much the amount of organic matters present in drinking water, as the 
presence or absence of disease germs and of the products of the putrefaction of vege- 
table and animal matters. The sources of supply of the water, whether springs, 
wells, streams, lakes or gathering grounds, should be carefully investigated. 
In towns of any size all superficial wells are dangerous sources of drinking 
water, in that they are largely supplied with water drawn from the surface and con- 
taminated with filth from privies, garbage and the streets, gutters or manufactories 
of cities. 
Questions relative to filtration, and with reference to the continuous or intermit- 
tent supply of water, should be considered with the greatest care. 
8. Food and its Adulterations-Food Supply-Markets-Slaughter Houses, Meat 
and Sausage Factories-Bread and Bakeries-Confectionery-Canned Food and 
Canned Vegetables-Canned Milk-Milk and its Adulterations. 
(а) Diseased meat as a medium of propagating certain contagious, infectious and 
parasitic diseases. 
(б) Methods of inspecting live animals designed for human food. 
(c) Inspection of the meat of slaughtered animals, including the use of the 
microscope. 
(cZ) Inspection of milk and its products. Milk as a medium of the transmission 
of various diseases, as diphtheria, scarlet fever, etc. 
(e) Influence of different methods of preserving food on the public health. 
(/) Influence of canned food upon the public health. 
(</) The injurious effects of lead, copper, tin, zinc and antimony upon food, said 
metals being used for culinary vessels, dishes, receptacles, cans and solder. 
Each town or city should have one or more competent medical and chemical 
officers, who should be charged with the continuous and careful inspection and 
examination of all markets, all articles of food, including meats, the products of 
grain, fruits, milk, canned vegetables, and preserves. These officers should be com- 
pelled to condemn all adulterated articles of food, and to punish offenders. 
Each civilized nation should establish a thorough system of inspection of the 
manufactories and the products of canned goods. Every can of vegetables, fruit or 
meat should have the precise date of the manufacture stamped upon it. At the 
periodical inspection of canned goods, all imperfect goods should be destroyed. It is 
a question to be determined whether the alleged increase of Bright's disease and of 
certain forms of paralysis has been caused by the extensive use of canned goods, and 
of syrup manufactured from cellulose by the action of sulphuric acid. 
All coloring matters used in the preparation of certain kinds of food and pre- 
serves, and in the manufacture of wines and beverages, should be the subject of care- 
ful scientific investigation at the hands of competent medical officers and chemists. 
9. The Influence of Alcohol on the Public Health. 
(а) Wine. 
(б) Malt liquors. 
(c) Distilled liquors. 
(fl) The relations of alcohol to muscular and intellectual work. 
(e) The value of alcohol in the treatment of disease. SECTION XV PUBLIC AND INTERNATIONAL HYGIENE. 
313 
(/) The adulteration of wine, malt liquors and distilled liquors. 
(</) Inspection and analysis of liquors. 
(A) The relations of alcohol to crime. 
(Ï) The relations of alcohol to the production and increase of insanity. 
10. The Influence of Narcotics on the Public Health-The Unrestrained Sale of 
Poisons and Patent Secret Medicines. 
(а) Tobacco. 
(б) Cannabis Indica, etc. 
(c) Opium and its preparations. 
(fl) Chloral hydrate ; chloroform and ether ; cocaine, etc. 
(e) Patent medicines whose composition is kept secret. 
(/) The unrestricted sale of poisons and patent and proprietary medicines by 
druggists. 
In this republic the unrestrained sale of poisons, poisonous drugs, and of secret 
patent and proprietary compounds is a great and growing evil, which should be sum- 
marily suppressed by carefully enacted laws on the part of the State and general 
governments. The manufacturers of patent and proprietary medicines, and of 
various elixirs (more or less strong compounds of alcohol), and sugar-coated pills 
(the composition and strength of which depend entirely upon the will and honesty 
of the manufacturer), have attained sufficient power, not merely to control the local 
druggists, but even to subsidize a considerable portion of the medical press. It is at 
this day by no means uncommon to observe the advertisements of proprietary medi- 
cines sandwiched between the pages of articles on medical subjects in American 
medical journals. 
It is well known that numerous cases of fatal poisoning have been traced to the 
unrestrained sale of poisons by druggists. 
11. Effects of Trades and Manufactures on the Public Health. 
(а) Relative effects of agriculture and of trades on the longevity and health of 
the people. 
(б) Detailed statement of the effects of various trades on the health. 
(c) Effects of the introduction of machinery upon the longevity and health of the 
people. 
(fl) Effects of manufactures upon the atmosphere and waters of towns, villages 
and cities. 
(e) Effects of various manufactures upon the public health. 
(/) Influence of coal gas upon the public health. 
(g) Influence of the electric light on the public health. 
12. Structure and Arrangement of Prisons and the Treatment of Prisoners. 
(a) Treatment of prisoners ; food, clothing and occupation. 
(b) Sanitary regulations of prisons, jails. 
(c) The relations of prison labor to free labor. 
(fl) Has the State the right to work prisoners in swamps and marshes and to cause 
the destruction of human life by the neglect of all the laws of hygiene ? 
(e) Are not deaths occasioned by cruelty, overwork, scant clothing, poor food and 
exposure, directly chargeable against the officials composing the govern- 
ment, whether acting in behalf of a city, county, State or nation ? 
13. Influence of the Modern Style of Travel on the Public Health. 
(a) Effects of railroad travel in inducing paralysis. 
(b) Hygienic structure and conduct of railroad trains, so as to avoid the intro- 
duction and dissemination of infectious and contagious diseases. 314 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
(c) Conduct of railroad trains and travel during epidemics of yellow fever, small- 
pox, and Asiatic cholera. 
(tZ) Structure and arrangement of sailing and steamships. 
(e) Hygienic regulations of officers, crews and passengers. 
(/) The sanitation of ships so as to avoid the introduction of contagious and 
infectious diseases. 
(</) Methods of disinfection best adapted to purify railroad cars and ships. 
(A) Disinfection of infected cargoes and clothing. 
14. Influence of Agriculture on the Public Health. 
(a) Influence of overflows on the public health. 
(A) Importance of drainage ; drainage of swamps, marshes, and land generally. 
(c) Influence of the cultivation of rice on the public health. 
(cZ) Influence of cotton, tobacco, sugar and the indigo cultures on the public 
health. 
15. Relation of Disease Germs to the Origin and Spread of Contagious and 
Infectious Diseases, and to Endemic and Epidemic Diseases. 
(a) Relations of malaria to the public health. 
(Z>) Nature of the malarial poison. 
(c) Physical, chemical and microscopical characters of the poisons or causes of the 
following diseases :- 
Yellow fever, Relapsing fever, Oriental leprosy, 
Typhoid fever, Erysipelas, Oriental plague, 
Typhus fever, Syphilis, Elephantiasis, 
Measles, Phthisis, Smallpox. 
(tZ) Relations of phthisis to the public health. 
(e) Relations of syphilis to the public health. 
(/) Measures for the arrest of smallpox. 
(g) Value of cowpox inoculation (vaccination). 
(A) Accidents attending vaccination ; transmission of the syphilitic virus through 
the medium of the vaccine virus. 
Smallpox and Vaccination.-If the great work of public and international 
hygiene be the preservation of the human race from disease, then to the immortal 
Jenner be awarded the highest place in this branch of human knowledge. 
Before the discovery of the protective power of cowpox by Edward Jenner, one 
in fourteen of all persons born died of smallpox, even after inoculation had been 
introduced ; and of persons of all ages taken ill of the smallpox in the natural way, 
one in four or six died ; and in addition to this frightful mortality, alike observable 
in all the different regions of the globe, many of those who recovered were perma- 
nently disfigured or deprived of sight, or left with shattered constitutions, the prey 
to pulmonary consumption, chronic ophthalmia and scrofula. 
Before the introduction of vaccination, smallpox was infinitely more destructive 
to human life than the plague itself ; it has swept away whole tribes of savage and 
half-civilized people, and its miserable victims have been abandoned by their nearest 
relatives and friends as persons destined by divine wrath to irrevocable death. It 
was calculated that 210,000 fell victims to it annually in Europe, and that not less 
than 15,000,000 of human beings were destroyed by smallpox every twenty-five 
years, that is, 600,000 annually; and the loathsome disease was not only universal 
in its ravages, but was so subtle in its influence and insidious in its attack that all 
efforts to stay its violence or to prevent its approach were futile. 
Even inoculation, while it was far less severe, violent and fatal than the natural SECTION XV PUBLIC AND INTERNATIONAL HYGIENE. 
315 
smallpox, tended, nevertheless, to increase the spread of the disease, and the exten- 
sive adoption of inoculation was attended by a most marked increase of smallpox in 
the human race. 
By the unaided efforts of a man, emulous not of distinction, but desirous of 
advancing truth and promoting the happiness and well-being of his fellow-creatures, 
and distinguished as much for his humility, long-suffering and perseverance, as for 
his unsurpassed powers of practical observation, the world has been furnished with 
the means of completely eradicating this terrible scourge, by substituting the same 
disease in a mild, modified form, non-communicable by effluvia, and capable of 
effecting complete immunity from the smallpox. 
If the medical profession had uniformly adhered to the advice and to the rules 
established by Jenner, the human race would have been spared the vast majority of 
those unfortunate accidents which tend to bring into disrepute the only safeguard 
against smallpox. 
During the recent American civil war, the investigation of the causes of the 
various deviations of the vaccine disease from its normal course, as well as the danger 
of the introduction of other diseases into the organism-as syphilis-by vaccination, 
engaged the earnest attention of the speaker. 
After an extended series of investigations, the accidents following vaccination 
were referred to the following causes :- 
(1) Modification, alteration and degeneration of the vaccine vesicle, dependent 
upon depressed and deranged forces, resulting from fatigue, exposure and poor diet, 
and upon an impoverished, vitiated and scorbutic condition of the blood of the patient 
vaccinated and yielding vaccine matter. 
In scorbutic patients, all injuries of the skin tend to form ulcers of an unhealthy, 
sluggish, spreading character. 
(2) The employment of matter from pustules or ulcers which had deviated from 
the regular and normal course of development in the vaccine vesicle, such deviation 
or imperfection in the vaccine disease and pustule being due mainly to previous 
vaccination, and the existence of some eruptive disease at the time of vaccination ; 
or, in other words, the employment of matter from patients who had been previously 
vaccinated, and who were partially protected, or who were affected with some skin 
disease at the time of the insertion of the vaccine virus. 
(3) Dried vaccine lymph or scabs, in which decomposition had been excited by 
carrying the matter about the person for a length of time, and thus subjecting it to 
a warm, moist atmosphere. 
(4) The mingling of the vaccine virus with that of the smallpox matter taken 
from those who were vaccinated while they were laboring under the action of the 
poison of smallpox, was capable of producing a modified variola and comparatively 
mild disease in the inoculated, and which was capable of communicating, by effluvia, 
smallpox of the worst character to the unprotected. 
(5) Dried lymph or vaccine scabs from patients who had suffered with erysipelas 
during the process of the vaccine disease, or whose systems were in a depressed state 
from imperfect food, impure ventilation and the exhalations from typhoid fever, 
erysipelas, hospital gangrene, pyaemia and offensive, suppurating wounds. 
(6) Fresh and dried vaccine lymph or scabs from patients suffering with secondary 
or constitutional syphilis at the time of vaccination and during the progress of the 
vaccine disease-vaccino-syphilis. 
The subject of vaccination, and the continued renewal of the vaccine virus in its 316 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
original purity and potency, is of vast importance to the human race, and should 
command not merely national, but international investigation and action. 
There should be established in each nation and kept in perfect working order 
and in perpetual action- 
(1) A medical commission composed of three or more competent medical men, of 
undoubted integrity and capacity for observation and scientific investigation, who 
shall be charged with the preservation and distribution of pure vaccine and cow-pox 
virus. Every spontaneous outbreak of cow-pox should be carefully observed, recorded 
and reported for the information and use of the medical profession. 
(2) Cow-pox or vaccine farms for the propagation and preservation of the cow-pox. 
(3) An international commission composed of not less than twelve learned, com- 
petent and trustworthy medical men, skilled in the modern methods of chemical, 
microscopic, physiological and pathological research, whose duty it shall be to observe 
and report, at stated intervals, the progress of smallpox in the various nations 
of the earth. All matters touching the relations of smallpox to other dis- 
eases, and of vaccinia and cow-pox to allied diseases and to syphilis, as well as all 
deteriorations of the vaccine virus, should be carefully investigated by this com- 
mission. 
(/) Value of inoculation or vaccination of healthy persons exposed to the yellow 
fever atmosphere in preventing or modifying this disease. 
(J) Relative value of employing the virus, microbe or cultivated and attenuated 
virus of yellow fever. 
Cordial invitations have been extended by the President of the XVth Section, 
Public and International Hygiene, Ninth International Medical Congress, to Dr. 
Domingos Freire, of Rio de Janeiro, Brazil, and Dr. Manuel Carmona y Valle, of 
the city of Mexico, not only to occupy the positions of Vice-Presidents of the Section 
on Public and International Hygiene, but also to demonstrate their methods of 
yellow fever inoculation before its officers and members of council. 
I have received assurances that these distinguished physicians will be present, and 
give full demonstrations and explanations of the nature of the microbe of yellow 
fever and of their method of inoculation against this disease. 
The cause of science demands that these questions should not be disposed of by 
the criticisms and lucubrations of theorists ; the profession demands demonstration. 
A feeble effort has recently been made by the United States to investigate, by 
means of one or more experts, the method of inoculation against yellow fever per- 
formed by Professor Freire in Brazil ; but whatever the results of the expedition 
may be, the sum appropriated by Congress for the work was insignificant. 
The confusion and uproar arising in the public mind, and the reliance of the 
populace, in epidemics of yellow fever, upon the " shot-gun' ' quarantines of barbarism 
and brute force, as manifested in the occurrences in and around Biloxi, Mississippi, 
in 1886, would indicate that the American mind is not yet ready for the trial of 
inoculation against yellow fever. 
(&) Value of inoculation against Asiatic cholera, charbon and other diseases. 
(?) Value of inoculation with attenuated virus from the spinal cord of animals 
suffering with hydrophobia, for the modification or prevention of this 
disease. 
The President of the XVth Section, Public and International Hygiene, addressed 
an earnest request to M. Pasteur, of Paris, to preside as a Vice-President in this 
Section, and to demonstrate to the medical profession the great and remarkable dis- SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
317 
coveries which have thus far crowned his labors with reference to charbon and 
hydrophobia. The distinguished investigator has declined, on account of ill health, 
from overwork. 
M. Pasteur, in his investigations on hydrophobia, claims that he has established 
the following:- 
(1) M. Pasteur has discovered a method of protection from rabies, which may be 
compared with that which vaccination affords against smallpox. 
(2) M. Pasteur has discovered a treatment capable of preventing the development 
of the disease in persons bitten by rabid dogs. 
(3) M. Pasteur has shown that the virus of hydrophobia is located in the medulla 
and spinal cord of the affected animal ; that inoculation of this virus in healthy 
animals is, as well as the bite of rabid animals, capable of producing the disease, the 
only difference being that in the former case the stage of inoculation is shorter. 
(4) The virus located in the medulla and spinal cord is attenuated by exposure 
of the organs in dry air, and inoculation with this attenuated virus is capable of pre- 
venting the development of hydrophobia, provided this protective inoculation be 
begun during the period of incubation. 
In this connection, it is worthy of note that in the early history of vaccination 
protective powers against certain diseases were attributed to cow-pox inoculation. 
Soon after the world was informed that the vaccine poison was preventive of the 
smallpox, a disposition was shown by physicians and speculative men to extend its 
influence and prophylactic powers to other diseases. The idea was advanced that the 
morbid'action excited by the virus from the cow could as well prevent other con- 
tagious distempers as that one for which it was particularly employed ; and if it was 
capable of doing such good in the human constitution, it would be no less operative 
in the bodies of brutes. Accordingly, it was said that the plague of Syria could be 
prevented by previous vaccination, but Mr. Valli, who made the experiment on him- 
self, was afterward seized with the plague. 
This alleged power of vaccination in controlling the plague attracted, at an early 
period, a considerable degree of attention, and Dr. Jenner received letters on this 
subject from many quarters. The circumstances having been made known to the 
Spanish Consul at Morocco, a communication was transmitted to Sir Joseph Banks 
on that subject, and from him to Jenner. 
The opinion of Jenner on this point was thus expressed :- 
" I never was so sanguine in my hopes of seeing the plague extinguished by 
vaccine inoculation as some of my friends were, as you may have seen from a few 
introductory lines which Dr. Carré cites in the public papers. I will just drop a hint; 
the vaccine disease, in my opinion, is not a preventive of the smallpox, but the 
smallpox itself ; that is, the horrible form under which it appears in its contagious 
state is (as I conceive) a malignant variety. Now, if it should ever be discovered 
that the plague is a variety of some milder disease, generated in a way that may 
even elude our researches, and the source should be discovered whence it sprang, this 
may be applied to a great and grand purpose. The phenomena of the cow-pox open 
many paths for special action, every one of which I hope may be explored." 
The prophetic hope of Jenner, breathed more than half a century ago, is being 
realized in our day by the investigations of Pasteur, Koch and others. 
Dr. Jenner proposed vaccination against hydrophobia. Thus, in a letter to Rev. 
Dr. Worthington, dated London, Flading's Hotel, Oxford Street, 1811, he says r 
" Yesterday I dined with Professor Davy. I wish you had been with us. His mind 
is all in a blaze. He seems to be one of those rare productions which nature allows 
us to see in a score of centuries. He touched on hydrophobia. He started an 318 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
ingenious idea, that of counteracting the effect of one morbid poison with another. 
What think you of a viper ? Not its broth but its fangs, as soon as the first symp- 
tom of the disease appears, from canination. If this should succeed, we must 
domiciliate vipers, as we have leeches. But from this hint I should be disposed to 
try, under such an event, vaccination ; as it can almost always be made to act quickly 
on the system, whether a person has previously felt its influence or not, or that of 
smallpox." John Archer, M.D., of Harford County, Maryland, had previously, in 
1808, recommended vaccination for the arrest of pertussis. 
Establishment of National Laboratories for the Chemical and Microscopical 
Investigation of the Causes and Prevention of Endemic and Epidemic Diseases. 
-Laboratories for the thorough and continuous investigation of the causes and 
pathology and modes of modification, prevention and arrest of such diseases as 
smallpox, yellow fever, Oriental plague, Oriental leprosy, typhoid fever, typhus and 
malarial fever, should be established and maintained by national aid in all the im- 
portant centres of population. 
In the United States, laboratories for the thorough microscopical and chemical 
investigation of disease, and for the performance of carefully devised physiological 
and pathological experiments, should be established and maintained by law, in Boston, 
New York, Philadelphia, Washington, D. C., Baltimore, Charleston, S. C., New 
Orleans, Louisiana, Cincinnati, Chicago, St. Louis and San Francisco. 
If the discoveries of Pasteur with reference to charbon and hydrophobia, and of 
other observers with reference to phthisis and yellow fever, are to be utilized in a uni- 
form and scientific manner for the prevention of disease by the inoculation of 
altered, attenuated or modified virus, such results must be accomplished through the 
medium of well-endowed and perpetually active laboratories, under the direction of 
learned and expert observers and well-trained and skillful experimenters. 
16. Structure, Hygienic Arrangements and Sanitary Conduct of Hospitals. 
(а) Structure, ventilation, disinfection and conduct of hospitals for the treatment 
of infectious and contagious diseases. 
(б) Smallpox hospitals. 
(c) Yellow fever hospitals. 
(cZ) Cholera hospitals. 
(e) Hospitals for the isolation and care of Oriental leprosy. 
Unless hospitals devoted to the treatment and isolation of contagious and infec- 
tious diseases be properly located, guarded and disinfected, they become dangerous 
mediums for the propagation and spread of contagion. 
In the case of smallpox, vaccination furnishes a ready method of preventing the 
spread to the patients, operatives and nurses; but, unless the most stringent measures 
be taken, of cleanliness and disinfection, the disease will spread beyond the limits of 
the pest-house. 
The foul air of the hospital should be so arranged as to pass upward through 
openings supplied with burning gas jets or the electric light, so that the contagious 
organic matters may be destroyed. All infected clothing and bedding should be 
either destroyed by fire or else subjected to the action of boiling water and superheated 
steam. Heat applied through the medium of boiling water and steam has been found 
by practical sanitarians the most efficient and easily applied of all disinfecting agents, 
and possesses the advantage, also, of purifying, coagulating and washing away the 
contagious organic matters. Solutions of carbolic acid (five per cent.), of corrosive 
sublimate (one per cent, and less), as well as other antiseptics and disinfectants, may 
be employed. For the purification of the air of wards and of sick rooms and dead 
houses, burning sulphur furnishes in sulphurous anhydride the most effective disin- 319 
SECTION XV PUBLIC AND INTERNATIONAL HYGIENE. 
fectant and antiseptic. As contagious diseases are propagated by particulate conta- 
gious particles, their removal from any given space or from porous materials is best 
accomplished by such gaseous bodies as sulphurous anhydride and chlorine. If the 
attempt is made to disinfect any given space by subjecting it to the fumes of heated 
corrosive sublimate (bichloride of mercury), it will be found that the particles of cor- 
rosive sublimate, volatilized by heat, quickly congeal and fall as a fine powder in the 
immediate vicinity of the source of heat. 
From practical experience, it is found that fumigation with sulphurous anhydride 
and washing the walls, floor and furniture with a one per cent, solution of corrosive 
sublimate or a five per cent, of carbolic acid, and then whitewashing the walls with 
lime, are sufficient to eradicate the poisons of smallpox, yellow fever, Asiatic cholera, 
and of other contagious and infectious diseases. 
It is essential that hospitals should be furnished with educated, well-fed, healthy 
and properly paid nurses. 
The plan adopted in the Charity Hospital of New Orleans andin other hospitals, 
of employing the convalescents, without pay, to nurse their sick companions, cannot 
be too strongly condemned. 
No matter how clean and pleasant the wards of a hospital may appear, if the 
system of alimentation and nursing be defective, the results of medical and surgical 
treatment must necessarily be unsatisfactory. 
17. Measures for the Arrest of Contagious and Infectious Diseases. 
(а) Measures for the arrest of smallpox. Vaccination and revaccination. 
It is possible to prevent the spread of smallpox by the prompt vaccination of all 
persons exposed to this contagion, as I have repeatedly demonstrated in New Orleans, 
and upon shipboard at the Mississippi Quarantine station, during my term of ser- 
vice as President of the Board of Health of the State of Louisiana, 1880-1884. 
All houses occupied by smallpox patients should be thoroughly disinfected. 
(б) Measures for the arrest of yellow fever. 
(1) The exclusion of passengers from the infected ports of Central, South and 
Insular America during those periods of the year in which this disease is liable to 
make a lodgment in the seaport cities of the United States. 
(2) The conduct of the commerce with infected ports, as Vera Cruz, Havana and 
Rio de Janeiro, by means of acclimated crews. 
(3) The fumigation of the ship and cargo at the point of departure. 
(4) Rigid quarantine, including careful inspection and thorough cleansing and 
disinfection of all ships and their cargoes from infected ports. 
(5) In the event of the appearance of a case of yellow fever on shipboard in the 
harbor of New Orleans, or of any other city, the immediate isolation of the ship and 
crew, and their return to the quarantine station. The prompt execution of such mea- 
sures in 1880, in the case of the bark Excelsior, preserved the city of New Orleans, 
and probably the Mississippi Valley, from an epidemic of yellow fever. 
(6) When a case of yellow fever occurs in a town or city, it should immediately 
be isolated, and if practicable transferred to a hospital devoted especially to the treat- 
ment of this disease. The immediate premises as well as the surrounding blocks, 
covering an area the diameter of which shall not be less than 1500 feet, or in small 
places the entire village, to be thoroughly cleansed and disinfected. The buildings 
must be systematically fumigated with burning sulphur (sulphurous anhydride) as 
far as practicable ; all woodwork whitewashed ; all foul drains and alleys disinfected 
with carbolic acid, copperas and solutions of mercuric chloride. All privies disinfected 
with solutions of copperas and carbolic acid, and mercuric chloride. 320 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
(7) In the event of death, the bedding and bed-clothing and soiled clothing of the 
deceased should be promptly burned in a properly constructed stove. The body 
should be wrapped in cloth saturated with solutions of carbolic acid and bichloride 
and transferred to the coffin and buried at the earliest practicable moment. All 
gatherings around the corpse should be prohibited. 
By such measures the yellow fever was arrested in New Orleans in 1882; the first 
case (Henry Forbes) occurring as early as June 25th, only three other cases of yellow 
fever were reported during the remainder of this season. 
(8) All excreta, in smallpox, yellow fever and Asiatic cholera, should be promptly 
and thoroughly disinfected and destroyed. 
III. INTERNATIONAL HYGIENE. 
International hygiene is based on public and national hygiene, and differs in scope 
rather than in any essential differences, and it must be admitted that our divisions of 
this subject are, to a certain extent, arbitrary. 
Thus we have placed under this division, International Hygiene, the consid- 
eration of those subjects which should be regarded of prime importance to each and 
every nation in times of health, and in periods of pestilential invasion, in peace and 
in war. 
At the present day the great nations of Europe are in a strained and artificial 
condition. One-half the fighting males are standing guard, fully armed, carefully 
watching their antagonists, and ready on a moment's warning to engage in battle. 
It would be needless for us to inquire whether this armed state and this withdrawal 
of the energies of the young men from the productive capital of mankind is best for 
the advancement of civilization, and whether it be necessary thus to bind down the 
explosive forces of the race; we must deal with things as they exist, and endeavor to 
form a correct estimate of this new branch of knowledge which relates to the preserva- 
tion of the national forces in the highest degree of health and efficiency. 
The most important subjects of International Hygiene which are of paramount 
interest to all civilized nations are :- 
1. Military hygiene. 
2. Naval hygiene. 
3. Quarantine. 
1. Military hygiene. 
(а) Food of the soldier. 
(б) Clothing of the soldier. 
(c) Exercise and rest; effect of infantry, cavalry, artillery and bicycle exercise on 
the soldier. 
(d) Shelter-barracks, their structure, location and ventilation; tents, their 
structure. 
(e) Water supply of armies; method of testing and improving; injurious effects 
of stagnant water, of marshes, swamps and rice fields, on armies. 
(/) Military prisons and military prisoners. 
(g} The establishment of uniform rules, to be recognized by all civilized nations, 
for the treatment, food and clothing of military prisoners, and for the 
regular and continuous exchange of all military prisoners. 
If one-half the male fighting population of the great nations of Europe be always 
subject to military orders and to rapid mobilization, it is evident that the science of 
military hygiene should take rank as of the greatest interest and importance to man- 
kind. SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
321 
It has been sought to make this an addendum to medicine and surgery. 
The amputating knife, saw, trephine, antiseptic bandage, opium, chloroform, qui- 
nine and calomel are all most valuable when the men are wounded and sick; but the 
enlightened military surgeon of this age conceives it to be his highest duty to remove 
every preventable cause of disease, and to preserve the health and vigor of the men 
entrusted to his care by the rigid execution of hygienic laws, not merely by the selec- 
tion of the site of the camp and the enforcement of sanitary legislation, but by atten- 
tion to the food, water, clothing and exercise of the soldiers. 
The grand work of the military surgeon should be to prevent disease, and preserve 
his command in the highest degree of strength. 
The value of hygienic measures and the destructive effects of disease were clearly 
shown in the American war of 1861-65, when the casualties of battle were exceeded 
fourfold by the deaths caused by diseases, the most important and fatal of which 
were pneumonia, typhoid fever, diarrhoea and dysentery. 
During this war the gigantic mass of suffering, disease and death engendered 
among the unfortunate, dejected and hopeless captives in the military prisons of the 
North and South, rendered it evident that the hygiene of military prisons and mili- 
tary prisoners had received no practical recognition. 
It was also shown that the stronger power was capable of finally overthrowing the 
weaker by retaining all prisoners of war in an indefinite captivity by practically discon- 
tinuing all exchanges. 
Definite rules for the guidance of military prisoners and prisons, and for the con- 
tinuous exchange of prisoners of war during periods of war, should be formulated 
and adopted by the representatives of those civilized nations who may be willing to 
accord to this class of the unfortunate victims of the accidents of war the essential 
conditions of the preservation of health and life. 
2. Naval Hygiene.-By naval hygiene we mean to include all that relates to 
maritime life, whether relating to commerce or war. All maritime nations are inter- 
ested in the construction of vessels, so as to secure strength, swiftness, capacity, sea- 
worthiness and freedom from all preventable causes of disease. Naval hygiene, 
although relating chiefly to the sanitary condition of ships, seamen and naval estab- 
lishments, illustrates to a marked degree the general results of the doctrine of the 
prevention of disease. Such demonstration of the prevention and arrest of disease 
by hygienic measures is especially adapted to the isolated community of the ship. 
It is possible at the present day to preserve the crews of ships from cholera and 
yellow fever when lying in harbors where these diseases are prevailing, and to arrest 
the effects of the deadly malaria of the African coast, by hygienic and prophylactic 
measures. Scurvy, ship fever and malignant dysentery, which formerly decimated 
crews, now only occur as the result of sanitary neglect. 
It is now recognized that the true duty of the naval officer is to preserve the men 
confided to his care in the highest state of health, and the most effective mode of 
banishing infectious and contagious diseases from the high seas is to establish uni- 
versal sanitary rules and regulations for the guidance of the merchant marine as well 
as vessels of war. The poor emigrant and wealthy passenger, the common sailor and 
marine, as well as the highest civil and military officer, should all alike be subject to 
the inexorable rules of naval hygiene. 
Even with our best exertions it must be admitted that it is difficult, if not impos- 
sible, to make the ship as comfortable and as healthy as the home on shore. The 
ship is practically a floating box, sealed against the admission of water, and neces- 
sarily also to the admission of air, except in a few places above the water line. At 
Vol. iv-21 322 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
sea, and especially in stormy weather, many of the openings for air have to be closed. 
The subject of ventilation, therefore, has been one of the most important problems 
in naval hygiene. 
The air space on shipboard being necessarily limited, the average per individual 
can only be indirectly increased by reducing the crew to the smallest possible number 
of effective men, by distributing them as equally as may be, and by removing all but 
absolutely indispensable impediments. 
When such diseases as typhus fever, smallpox or yellow fever break out on board 
an emigrant ship, military transports or men-of-war, the conditions are more serious 
than in the most crowded city. 
Naval hygiene should embrace the following considerations and subjects of inquiry 
and discussion :- 
(а) The structure of the ship ; materials used-wood, iron or steel ; size of ship ; 
arrangement of cabins, compartments, decks, bulkheads, sleeping apart- 
ments, forecastle, latrines, hold, machinery, etc. 
(б) Ventilation of the ship; discussion of the best methods of ventilating the 
various compartments of the ship. 
(c) Cleansing of the ship. 
Moisture must be regarded as the most potent cause of disease in ships, and 
frequent ablutions of the decks and sides with water are to be condemned, and should 
be replace by large volumes of dry air, introduced by steam fans to all parts of the 
ship: Thorough ventilation of all parts of the ship at all times, by means of strong, 
well-constructed steam fans, should be urged as of the highest value for the preser- 
vation of the health of crew and passengers. 
(cZ) Arrangement of the cabins, sleeping apartments, hospitals and store rooms, 
so as to secure the greatest air space and the freest ventilation. 
(e) Treatment of the sick on shipboard. 
Whenever practicable, the sick should at the earliest possible moment be removed 
to the marine hospital on shore. 
(/) Water supply. 
(ff) Food. 
(A) Clothing. 
(i ) Conduct of officers, crew and passengers on shipboard, on the voyage and in port. 
When visiting ports in which infectious and contagious diseases are prevailing, 
the vessel should anchor at least one thousand feet from the shore, and the crew and 
passengers should not be allowed to visit infected localities or to remain on shore at 
night. While lying in harbors and rivers surrounded by extensive marshes and 
swamps, as on the coast of Africa and of the Southern States, three grains of the 
sulphate of quinia, in a glass of sherry, or port wine, or water, should be administered 
daily to each passenger and member of the crew. 
(J) The appointment by each government of a reliable, practical representative 
in the various commercial ports of the world, whose duty it shall be to 
superintend the sanitary condition of every ship and crew, and the loading 
of cargoes and the issuance of correct bills of health. 
The following measures should be instituted in each important port subject to 
infectious and contagious diseases :- 
(1) Thorough inspection of the ship and cargo. 
(2) When yellow fever, cholera or smallpox are prevalent, the thorough fumigation 
of the ship and cargo should be conducted ; also cleansing of hold, deck and latrines, 
forecastle, -cabins and berths, with solutions of four per cent, carbolic acid and one SECTION XV PUBLIC AND INTERNATIONAL HYGIENE. 
323 
per cent, solution or less of bichloride of mercury. The ordinary solution of one of 
the mercuric chloride to one thousand of water is practically of little value for the 
destruction of diseased germs and the thorough disinfection of bilge water. The 
bichloride of mercury is immediately decomposed, and the metallic mercury and 
mercuric oxide precipitated by all metals and by alkalies and lime rock in ballast. 
(3) Subjection of all articles of clothing or merchandise which may have come in 
contact with the poisons of Asiatic cholera or yellow fever to the disinfectant action 
of heat (hot air and steam), in properly constructed apparatus, so constructed as to 
allow of a continuous current of hot air through the chambers. 
(4) Careful inspection of officers, crew and passengers, and the exclusion of all 
individuals who may be suspected of having been exposed to infection. 
(5) The bill of health issued by the medical officer to the ship should give the 
mortality and prevailing diseases of the port for at least thirty days, and also a full 
and accurate detail of the sanitary condition of the ship, crew and passengers and 
cargo. A thorough system of inspection thus executed would do much to prevent 
the spread of contagious and infectious diseases, and also to mitigate the hardships 
and arbitrary usages of quarantine. 
The advances made in naval hygiene, and the additions to the appliances of the 
sanitarian for the arrest of contagious and infectious diseases, have been of great 
value during the past century, and the foundation of this important branch of science 
was laid by the labors of such men as Sir John Pringle, 1750 (Note 1) ; Stephen 
Hales, 1755 (Note 2); John Huxham, 1757 (Note 3); Daniel McBride, 1764 (Note 
4); John Howard, 1789 (Note 5); Angus Smith, 1767 (Note 6); Guyton-Morveau, 
1773 (Note 7); Carmichael Smith, 1785-1795 (Note 9); Cruickshank, 1797 (Note 
10) ; and others (Note 11).* 
3. Quarantine. 
(a) The history of quarantine. 
(6) Maritime quarantine. 
(c) Land quarantine. 
(cZ) Conduct of quarantine stations. 
(e) Sanitation of ships. 
(/) Sanitation of quarantine ports. 
(</) Methods of eradicating infectious and contagious diseases from infected ports. 
(A) Sanitation of railroad stations and cars. 
(7) Land quarantine; its objects, value and mode of conduction. The proper 
construction, ventilation and conduct of railroad cars, sleeping coaches, 
warehouses, depots, so as to prevent the dissemination of contagious and 
infectious diseases. 
(J) Methods of isolation and disinfection adapted especially to land travel. 
(k) Regulation and control, on sea and land, of such diseases as yellow fever, 
Asiatic cholera, Oriental plague, Oriental leprosy, typhus and typhoid 
fevers, smallpox, scarlatina and measles. 
(Z) The relations of the duration of quarantine as determined by the natural 
history of various diseases, or more especially by the period of the incu- 
bation of their specific poisons. 
* In a brief address, covering a vast number of important subjects, we could only allude to 
the important subject of the history of Maritime hygiene and the progress of discovery with 
reference to disinfectants and disinfection, and the perfection of measures for the arrest of infec- 
tious and contagious diseases. We have collected the notes, presenting the results of our inves- 
tigations, into the form of an Appendix. (See p. 330, et seq.) 324 
324 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
(m.) Value of heat (dry heat, steam, superheated steam) in the disinfection and 
cleansing of infected vessels, clothing, houses and furniture. 
(n) Relative value of sulphurous anhydride and other antiseptics and disinfect- 
ants, as bichloride of mercury (corrosive sublimate), carbolic acid, ferruginous 
and plumbic salts, chlorine, bromine and iodine, and biniodide of mercury. 
(o) Apparatus for the application of various kinds of antiseptics, germicides and 
disinfectants. 
(p) Relative germicidal and antiseptic powers of various disinfectants. 
(g) Structure and conduct of quarantine hospitals. 
(r) Quarantine should embrace not merely detention, but also thorough disin- 
fection of ship and cargo, and thorough disinfection and cleansing of all 
wearing apparel and bedding of passengers and crew ; and when necessary 
the cargo should be discharged and thoroughly aired and disinfected. The 
ballast of infected ships should also be carefully and thoroughly disinfected. 
(s) Quarantine should be effectively and intelligently conducted so as to impose 
the least possible restrictions on commerce ; at the same time the public 
health should never be sacrificed to the insatiate and brutal greed of gain. 
Quarantine (from the Italian, quarantina, forty) has at the present day lost its 
ancient meaning of forced detention of ships, goods and passengers for forty days, 
and may be thus defined. 
Quarantine : The enforced isolation of individuals and certain objects, whether 
coming by sea or land from a place where dangerous communicable disease is pre- 
sumably or actually present, with a view of limiting the spread of the malady. The 
objects liable to quarantine include, on the assumption of their being apt to carry the 
contagion or infection of the disease, the luggage and personal effects of the individ- 
ual isolated, certain articles of merchandise and ships, and in land quarantine car- 
riages and other vehicles. Sometimes entire communities and districts are subjected 
to quarantine. According to systematic writers quarantine had its origin in the 
Fourteenth century, when the principle of isolation, applied from a much earlier 
period to leprosy, began to be extended to pestilential diseases, and leper hospitals 
(lazarets), then falling into disuse from the decline of the disease, were converted 
to quarantine uses, and to this day quarantine establishments retain the name sig- 
nificant of their original purposes, namely, lazarets. 
It has been suggested that the period of forty days, during which it was custom- 
ary formerly to enforce isolation and from which the designation quarantine is derived, 
had its source in the teachings of Hippocrates, who, according to Pythagoras, attrib- 
uted especial virtue, for the completion of many things, to that period of time. 
The methodical establishment of quarantine dates from the Sixteenth century, 
when the earliest doctrines of contagion were also formulated, and which still domi- 
nate to a greater or less extent the practice of quarantine. The plague was the dis- 
ease against which quarantine was chiefly directed up to the beginning of the present 
century, and the system is so imbued with the notions formerly held as to plague, 
that it has been found exceedingly difficult, if not impossible, to disembarrass it 
from them in endeavoring to apply quarantine to other forms of disease. It is 
worthy of note that as the plague declined in western Europe, and the area of its 
prevalence in the Levant became more restricted, the system of quarantine seems to 
have become more elaborate. Speculative notions contributed by experience applied 
to the system caused it to be overlaid by grotesque and unnecessary details. And 
notwithstanding these drawbacks, the arbitrariness of the system and the losses it 
inflicted on commerce, without obvious proportionate gains ; the advantages offered SECTION XV PUBLIC AND INTERNATIONAL HYGIENE. 
325 
by quarantine in the protection of a country from pestilential disease appeared 
theoretically so great, that neither administrative follies, nor the lessons as to its fal- 
lacy derived from experience, nor its general futility, availed to bring about a more 
rational system of protection. 
Quarantine remained substantially unmodified from the termination of the last 
century until the middle of the Nineteenth century, since which time it has under- 
gone great changes in rendering the practice more consistent with present knowledge 
of the diseases to which it is applied, and freeing it from the now useless detentions 
and preposterous practices. 
The study of the geographical distribution and natural history of diseases has 
led to important modifications of the systems of quarantine practiced in various 
countries. 
Thus in Great Britain and Ireland, quarantine, which is carried out under an act 
of Parliament passed in the reign of George IV, has no longer a medical significa- 
tion, and is practiced solely with a view of relieving British maritime commerce 
from disabilities which could else be imposed upon it by other countries in which 
quarantine is regarded as an essential part of the public health administration. 
England, from her climate and isolated situation, is peculiarly favored for the 
exclusion of foreign pestilence. Thus her temperature is such that yellow fever is 
not liable to gain a serious or protracted lodgment in her maritime cities. 
The regulation of quarantine in Great Britain is not a function of a department 
of the government which is concerned with the sanitary administration of the king- 
dom (the local government board), but of the Privy Council aided by the Board of 
Trade, the subject being dealt with as an International Commercial Question. 
The quarantine act provides for land quarantine and the quarantine of inland 
waters, as well as for maritime quarantine, internal and external quarantine. It does 
not appear that internal quarantine has been practiced in Great Britain since the act 
was passed ; maritime quarantine alone has been practiced, and this has been applied 
to three diseases only, all of them infectious diseases of foreign origin, namely, 
plague, cholera and yellow fever. 
Of plague there has been no occurrence in English ports for the last 30 years, 
except a slight alarm in 1879, consequent upon an outbreak in southeastern Russia, 
province of Astrakhan. Against cholera, quarantine has not been enforced since 
1858, its futility as a precautionary measure in England having then been manifested. 
Yellow fever is the sole disease at present subjected to quarantine in English ports, 
and this not from medical necessity, but from commercial exigencies. 
The only quarantine station now remaining in England, that of the Motherbank, 
is maintained in respect of yellow fever. Infectious diseases habitually current in Eng- 
land, such as smallpox, scarlet fever, etc., notwithstanding that the phraseology of the 
quarantine act covers any infectious disease or distemper, have always been, in prac- 
tice, exempt from quarantine, and dealt with under the general sanitary law of the 
kingdom. Measures which, in England, have been substituted for quarantine against 
cholera, consist of a system of medical inspection, the details of which are set forth 
in an order of the Local Government Board, dated 17th July, 1873. This plan differs 
from quarantine in the following essential respects :- 
(а) It affects only such ships as have been ascertained to be, or as there is reason- 
able ground to suspect of being, infected with cholera or choleraic diarrhoea ; no 
vessel being deemed infected unless there has been actual occurrence of cholera or 
choleraic diarrhoea in the course of the voyage. 
(б) It provides for the detention of the vessel only so long as is necessary for the 326 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
requirements of a medical inspection ; for treatment of the sick, if any, in the man- 
ner it prescribes, and for carrying out the processes of disinfection. 
(c) It subjects the healthy on board to detention only for such length of time as 
admits of their state of health being determined by medical examination. 
The measures for dealing with the sick under this order are but an adaptation to 
a particular exigency of the principles of sanitary administration with regard to 
infectious diseases which are in force under the general sanitary laws of the kingdom. 
The relative advantages of a system of medical inspection and of quarantine 
as against cholera in the ports of Europe underwent thorough discussion at the Inter- 
national Sanitary Conference which was held in Vienna in 1874. A large majority 
of the delegates, including those from every State of the first rank, except France, 
declared in favor of the former system. The minority, while adhering to quarantine, 
agreed to a system which would considerably diminish its stringency as heretofore 
practiced. 
These methods of inspection and disinfection and removal of the sick to hospital 
Were adopted with success in the case of some arrivals from Baltic and North Sea 
ports, with cholera on board, in 1873, no extension of the disease on shore ensuing ; 
and again, in 1884, in the case of a troop-ship, arrived at Portsmouth direct from 
Bombay, and at least two arrivals, at Liverpool and Cardiff, from Marseilles, in 1884, 
with cholera on board. 
The last importation of yellow fever into the United Kingdom was at Swansea, 
in September, 1865, by a wooden vessel with copper ore from St. J ago de Cuba. There 
had been cases of yellow fever on board during the voyage, but at Swansea, as in 
many other instances, the infection spread rather from the ship's hull and tho 
unloaded cargo than from the crew or their effects, and some fifteen deaths ensued. 
This yellow fever incident of 1865 is the last occasion in which the sanction of the 
quarantine act has been appealed to. The quarantine acts are still unrepealed, 
but they may be said to have become practically obsolete in the United Kingdom 
during the past twenty years. 
The principle of inspection and isolation of the sick adopted by the Sanitary Con- 
ference at Vienna in 1874, is now more or less consistently acted upon by all the 
larger European maritime States, except Spain and Portugal. 
In times of cholera panic, quarantine of the original kind has been imposed 
against all arrivals from infected countries by ports of the Levant and Black Sea and 
by several Mediterranean States besides Spain, but it is only in the ports of the Iberian 
peninsula that the old quarantine traditions remain in force from year to year. 
The principal occupation of the quarantine establishment of Lisbon, Portugal, all 
the year round, is with arrivals from Brazil, where yellow fever is endemic. The 
Lazaretto of Lisbon, which is probably the largest and in ordinary times the busiest 
in the world, was erected by the Portuguese Government at the cost of over one 
million dollars, and consists of seven distinct pavilions standing radially in a semicircle 
with the convexity of the sea, and is managed by an inspector, who is under the 
Minister of the Interior. Quarantine is imposed as a matter of fact on all ships, 
passengers, luggage and cargoes coming from the Brazils, the term ranging from five to 
seven days, according as the Brazilian port is considered as infected or suspected. A 
bill of health is issued to the captain by the Portuguese consul at the port of sailing, 
which usually bears on it so many deaths from yellow fever have occurred during the 
previous eight or ten days. If clean bills of health were issued the quarantine would 
be raised, and this has happened at short periods at rare intervals. During the 
winter months, when the cold makes the development of the yellow-fever viras SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
327 
improbable in Lisbon, if not impossible, the baggage and cargo only are subjected to 
quarantine, the passengers being allowed to go ashore at once with their hand baggage. 
Throughout the rest of the year all passengers from the Brazils have to go to the 
Lazaretto and stay there the allotted time, their effects being fumigated or disin- 
fected. 
This rigorous treatment is a concession to the popular recollection of the terrible 
yellow fever of 1857, when there were 19,000 cases of yellow fever in and around 
Lisbon, with about 6000 deaths, the largest proportion being among the better class of 
the population. The importation was traced to a tainted ship and cargo from Rio. 
For many years no cases of yellow fever have developed among the suspected 
passengers, and in only two or three instances have there been cases of yellow fever 
among the employes. 
The Chamber of Commerce of Lisbon is said to be now in favor of a modification 
of the quarantine law, and of regulating the process in conformity with the promi- 
nent facts of experience, namely :- 
(а) That the fever is not started on shore by personal contact, but solely by 
emanations from a ship's hull, ballast, cargo, or passengers' effects. 
(б) High-class iron steamships are not, in the nature of things, under the same 
suspicion as old wooden sailing vessels. 
These quarantine practices of Lisbon are faithfully copied at the Azores, Madeira 
and Cape Verde Islands. 
For Spain there are two chief quarantine stations and four lazarettoes: one for the 
Atlantic seaboard at Vigo, and another for the Mediterranean coast at Port Mahon, 
(Island of Minorca). 
Vessels arriving at Spanish ports with foul bills of health from Havana and other 
West Indian ports (yellow fever) in ordinary times, and from many ports in cholera 
times, must proceed to one or other of these appointed stations to perform their 
quarantine. A quarantine of observation, which is usually from six to three days 
and is imposed upon vessels with clean bills, may be performed at any port. 
It is a standard maxim with the Madrid Board of Health, that any country, as 
the United Kingdom, which does not practice quarantine, is, ipso facto, suspected, 
when a foreign epidemic is in any part of Europe with which its vessels trade, and 
all arrivals from its ports may be subjected to a quarantine of observation. 
Next to Spain, Portugal, Turkey and Greece are the countries in Europe where 
the old quarantine traditions have the most vitality, owing, doubtless, to their near- 
ness to the former seats of plague in the Levant. The Lazarettoes of the Pyræus and 
Dardanelles are considerable establishments, used mostly in times of cholera. There 
are many other lazarettoes in Mediterranean ports, as Malta and Gibraltar, called into 
requisition during cholera epidemics. 
For the whole of the northern European seaboard quarantine is practically obso- 
lete. By Holland quarantine was never seriously practiced, even for the plague, 
and by the States bordering on the Baltic it was given up about the same time that 
it fell into disuse in Great Britain. In Norwegian ports, subsequent to 1866, there 
were 3128 arrivals from countries infected with cholera, on board which 25 cases of 
cholera and 29 cases of cholerine were found, but the malady obtained no footing on 
shore, although quarantine was not enforced. 
In 1873, when cholera was prevalent in some ports of the Baltic and North Seas, 
there were 550 vessels at Norwegian ports from infected countries, among which were 
twelve cases of cholera, but importation of the epidemic to the shore was prevented 
simply by inspection and isolation of the sick. 328 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
In Italian ports 800 vessels were quarantined in 1872, in only one of which was 
any case of cholera found. 
In the Mexican Republic, in the Central and South American Republics, in the 
Rrazilian Empire, in Peru, Chili and other South American States, and in the West 
Indian colonies and cities, quarantine is to a large extent empirical, inadequate and 
valueless. 
In the North American Republic no uniform system prevails among the indi- 
vidual States, and in times of epidemic visitation, as in the case of yellow fever and 
cholera, the people become the prey of unreasoning panic and cowardly fear. 
It is true that New York, which gathers within her limits the largest population 
of any North or South American city of past or present times, has been foremost in 
enlightened quarantine reform and advancement, and she has been first to adopt 
an enlightened and liberal system, based upon the following important facts :- 
(а) Mere detention, without careful medical inspection, isolation of the sick and 
thorough ventilation, fumigation, cleansing and disinfection of the ship, cargo, ballast 
and clothing and baggage of the passengers, is valueless. 
(б) The chief danger with reference to the spread of yellow fever lies in the hold 
of the ship, in her foul bilge water and infected cargo, ballast and baggage of her 
crew and passengers. 
(c) Each ship should be judged upon her own merits, her own sanitary history 
and condition after through inspection. 
(c?) First-class iron and steel steam vessels should not be placed upon the same 
footing as old wooden sailing vessels. 
(e) Those unacclimated persons who work on board infected vessels are liable to 
contract yellow fever. 
Ry an enlightened system of quarantine, the health authorities of New York 
have not merely removed many useless and onerous restrictions from commerce, 
but they have also protected this great city, for more than half a century, from the 
invasions of yellow fever, which had been so frequent during the preceding century. 
Louisiana, who lost nearly 50,000 of her citizens during the first seventy-eight years 
of the Nineteenth century, has been steadily perfecting her quarantine system since 
the year 1855, and her chief city, holding the key to the Mississippi Valley, has, by 
her enlightened and rigid quarantine, excluded yellow fever during the past decade. 
On the other hand, the great State of Texas is without a rational system of 
quarantine, and the quarantine establishments and systems of Mississippi, Alabama, 
Florida, Georgia and South Carolina need revision and reconstruction. As far as 
this North American Republic is concerned in the perfection and conduct of quar- 
antine, we would respectfully suggest the careful consideration of the following 
questions :- 
(а) Shall the general governments of the civilized world assume control of all the 
quarantine systems, and by mutual consent reduce the entire subject of quarantine 
to order, and apply the most improved methods of sanitation and disinfection? 
(б) Shall the Government of the United States assume charge of the entire sub- 
ject of quarantine within her borders, and relieve the individual States of all further 
responsibility of regulating not merely foreign, but also interstate quarantine ? 
The object in propounding questions a and L is for the purpose of bringing about 
a grand union of action on the part of all civilized nations on the subject of quaran- 
tine, so as to advance the cause of medical science and humanity. As matters now 
stand, commerce is made to bear the brunt of quarantine. The unfortunate ship 
stricken by pestilence suffers delay, and in some cases immense expense. The unfor- SECTION XV PUBLIC AND INTERNATIONAL HYGIENE 
329 
tunate crew and passengers, who have committed no crime, are treated like outcasts 
and outlaws ; they appear to have no rights which humanity is supposed to respect. 
Commerce bears in its bosom the germs of civilization ; commerce establishes 
and sustains the markets of the world ; commerce is the agent for the dissemination 
of all that is grand and noble in the life and development of our common humanity ; 
and the brave and hardy sons of commerce have, in all ages and in all times, rallied 
to the defence of their native lands. 
Is it just, is it right, that the pestilence-stricken ship should bear all her expenses, 
and suffer all that the safety of man may demand, and that avarice and cowardice 
may suggest? Has not civilization advanced to that stage, and are not the great 
civilized and Christian powers of the world (the United States of America, the British 
Empire, France, Germany, Austria, Russia, Denmark, Norway, Sweden, Italy, Spain 
and Portugal) sufficiently strong, wealthy and enlightened to establish a uniform 
system of quarantine, which shall embrace- 
1st. A system of mutual confidence ; a uniform system of registration of diseases 
and deaths. 
2d. A system of regular health reports, giving detailed statements at regular 
intervals-daily, weekly, monthly and annually-of all matters relating to the public 
health, to the sanitary welfare of nations. 
By the use of the telegraph, all civilized nations could be kept informed of the 
appearance, spread and arrest of any contagious or infectious disease, as smallpox, 
cholera and yellow fever. 
3d. A uniform system of quarantine adapted to the climate, latitude and endemic 
and epidemic diseases of each nation. By a uniform system, we mean uniformity in 
the construction of quarantines and their administration, and the uniform assumption 
by the great Powers of the world of all quarantine expenses of cleansing, discharge 
of cargo, disinfection and fumigation, and of the care and treatment of the sick. 
The only expense necessarily borne by the pestilence-stricken ship, or suspected ship, 
detained in quarantine, would be the loss of time, and the necessary expense for food, 
etc., of the crew and passengers. 
As quarantine is now conducted, the owners of ships, as well as their passengers 
and crews, suffer often unequally and unjustly for the public good. 
The two questions are complementary the one to the other ; b flows necessarily 
from a ; to be of any practical value, the discussion of a must precede that of b ; a 
cannot be construed as relating to any government but the United States of America 
and its individual States, and does not refer to foreign States, only so far as that the 
United States may become one of the contracting parties under proposition a. 
The high purpose of this discussion is clear ; it is designed for the benefit of all 
civilized nations ; it is designed to lead ultimately to the establishment of uniform 
national and international quarantine laws, quarantine methods, and quarantine 
administration and charges. 
We will conclude this branch of our subject by the following recommendations 
for the advancement of international hygiene :- 
1. The appointment of one or more competent medical men, thoroughly informed 
with reference to questions relating to public and international hygiene, including all 
that relates to quarantine by the individual States of the United States of North 
America. 
Said representatives shall be regularly commissioned by the governors of the 
respective States, and shall be empowered to deliberate upon all questions relating 
to quarantine, and to formulate a uniform system of hygienic rules adapted to the 330 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
differences of climate, location, natural products and commercial and agricultural 
relations of the various sections of this Union, which shall govern the foreign and 
interstate trade and commerce and intercourse at all times of health and of pesti- 
lential visitation. 
2. The appointment of a representative or representatives by the United States 
of America, by the Mexican Republic, and by each of the Central and South 
American Republics, by all the governments of the West India Islands, and by 
the Brazilian Empire, to investigate the sanitary condition of all the chief seaports of 
North and South America. 
The duty of this international hygienic congress shall be to formulate suggestions 
for the sanitary improvement and quarantine regulation of all the important com- 
mercial centres of North, South, Central and insular America. 
If any effort is to be made by the nations to eradicate the cause of yellow fever, 
and to free commerce from the restrictions which its dread imposes, this effort must 
commence with the sanitary improvement of such cities as Vera Cruz, Havana, 
Panama and Rio de Janeiro. 
When we consider the vast importance of Hygiene to the welfare of the human race, and the 
value of correct systems of disinfection and sanitation, the history of the gradual development of 
this science in its application to the arrest of contagious and infectious diseases possesses peculiar 
interest. 
It would be foreign to the present discussion to enter into any extended review of the great 
advances which have been made in sanitary science, but we may be permitted to allude to certain 
well-established facts. 
Thus, during the Middle Ages the characters of the epidemic fevers were modified, and 
their destructive tendencies intensified, and their external manifestations rendered more marked, 
by the neglect of all sanitary regulations in cities and private houses, and by the filthy habits 
and salt diet of the people. Every town was a fortress, and every house a castle, and the inhabit- 
ants, like the soldiers of a garrison, worked and slept with their arms, and always held them- 
selves ready to resist attacks. Bands of robbers defied the power of the rulers, openly encamped 
upon the public roads, and plundered and murdered all who were not able to protect themselves 
by the force of arms. The country was covered with forests and undrained swamps and marshes, 
and the best lands were uncultivated. The walled towns were encompassed by large, stagnant 
ditches, which were the receptacle for refuse and all sorts of decomposing filth ; the streets were 
narrow, unpaved, undrained, uncleaned and unlighted ; there was no provision for the removal 
of the town refuse, which was thrown into the gutters and streets, forming, in dry weather, a 
semi-fluid mass of corrupting animal and vegetable matter, and, in wet weather, noxious bogs of 
filth. The houses were described as mean and squalid, without chimneys, the windows without 
glass, and the floors without boards. The floors, says Erasmus, " generally are made of nothing 
but loam, and are strewed with rushes, which being constantly put in fresh, without the removal 
of the old, remain lying there, in some cases for twenty years, with fish bones, broken victuals, 
the dregs of tankards, and impregnated with other filth underneath, from dogs and men." 
From the absence of cotton and linen goods, and the scarcity of woolen garments, resulting 
from the slow production of cloths by the hand-loom, the personal habits of the people were filthy 
in the extreme. Combined with this there existed ignorance as to the mode of raising and pre- 
serving vegetables, and improvidence and intemperance of living. For many centuries no more 
subsistence was produced in Europe than was barely sufficient for the necessities of the people. 
Consequently, every year of scarcity became a year of famine. The malarious, undrained state of 
APPENDIX. SECTION XV PUBLIC AND INTERNATIONAL HYGIENE. 
331 
the country, the crowded, filthy condition of the towns, and the filthy, degraded habits of the 
people, formed the necessary conditions for the origin and spread of contagious diseases, which 
almost annually desolated the more thickly populated cities and countries. 
During the past two centuries, the great revolution wrought by changes of diet, dress and habits, 
and the great advance of the arts of civilization, and the application, in public and private build- 
ings, and in cities and towns, of correct sanitary regulations, have banished many destructive 
diseases and mitigated the severity of others. 
The plague, which ravaged Europe for more than two thousand years, disappeared two cen- 
turies ago, and now only lingers in the more ancient and filthy Eastern cities. The labors of the 
agriculturists have banished malarial fever from large portions of the European and American 
continents; typhus or jail fever, the fatal scourge of the unfortunate prisoner, of the sailor and 
soldier, or of the inmates of the crowded hospital, and which in many of its visitations was 
scarcely less terrible than the plague, is now confined to the hovels of the poor in certain 
oppressed and suffering countries, and is almost unknown among the better classes. Many pain- 
ful and fatal forms of disease which formerly swelled the bills of mortality in the large European 
cities have so completely disappeared that their names even are no longer in use; and smallpox, 
which before the discovery of vaccination by Jenner was infinitely more destructive than the 
plague itself, sweeping off whole tribes of savage and half civilized people, and destroying not less 
than fifteen millions of human beings every twenty-five years, exists only because of our neglect 
and folly. 
It is the duty of the physician to prevent, as well as to cure disease, and all questions relating 
to sanitary science should be discussed with calmness, deliberation and justice. In the discussion 
of any and every measure which relates to the prevention and control of these pestilences, and 
especially of yellow fever, which have at various times inflicted incalculable injury upon the 
maritime cities of Insular, Central and North and South America, it would be well for the guar- 
dians of the public health to consider the advice of a noble Roman to the Senate : " AH who 
deliberate upon doubtful matters ought to be uninfluenced by hatred, affection, anger or pity. 
When we are animated by these sentiments it is hard to unravel the truth, and no one has been 
able to serve at once his passions and his interests." All facts relating to the origin, cause and 
means of prevention of yellow fever, are of vital importance to the inhabitants of southern cities. 
A correct knowledge of the laws which govern yellow fever can be obtained only by the accumu- 
lation of a large number of well-observed and undoubted facts, and the medical profession will 
sustain and encourage legitimate and efficient measures designed to limit or prevent the spread 
of this disease. 
Whoever may be instrumental in the discovery and establishment of the laws which govern 
the origin and spread of this great scourge, will certainly be entitled to the gratitude of the 
inhabitants of insular, tropical and sub-tropical America. 
If it be true that the localizing causes of yellow fever, and the high death rate of certain 
cities in insular, tropical and sub-tropical America, be preventable in New Orleans and other 
cities, then it is of prime importance to the public welfare that the medical profession should 
calmly discuss every experimental procedure directed to the control or removal of the local 
causes of disease and death. 
DISINFECTION PRACTICED BY THE ANCIENTS, BUT ITS SCIENTIFIC INVESTIGATION OF 
MODERN ORIGIN. 
The word disinfection is applied to the removal of all disagreeable gases and odors, as well as 
to the decomposition which produces them, and, therefore, includes deodorizing ; and the use of 
the word in this sense is in accordance with the opinion held from the earliest ages, that the 
infection of fever or plague was either the same as, or distinctly allied to, these gases. 
The preservation of meats by smoking, drying and pickling with salt, and of vegetables and 
fruits, by means of honey and sugar, is a kind of disinfection which was practiced from time 
immemorial; Moses, the lawgiver, established specific hygienic rules for camps and cities; 
described with great care the modes of disinfecting vessels, clothing and houses contaminated with 
putrid or infectious matter; pleasant scents were used not merely for pleasure, but during aH 
epidemics, perfumes and substances with decided odors, were everywhere employed as disinfectants 
or guards against infection and contagion. The use of such antiseptics as resins, pitch or tar, 332 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
bitumen, aromatics, natron or nitre and cedar oil, in the process of embalming the dead bodies of 
man and animals was known to the Egyptians before any authentic history which books have 
handed down. The Greeks and Romans, at an early day, directed their attention to the evil 
effects of crowding, and enacted laws for the proper construction of houses. In Rome the houses 
were ordered to be at least five feet apart, and not more than nine stories high. Augustus com- 
manded that they should not exceed seventy feet in height. Trajan made the limit seventy. 
Zeno, of Constantinople, ordered all houses tobe twelve feet apart all the way up, and the projec- 
tions which caused the houses to meet above were disallowed. The disinfection and cleansing of 
the streets and sewers was the duty of a high officer in Rome. " The Prætor took care that all 
sewers should be cleansed and repaired, for the health of the citizens, because uncleaned or unre- 
paired sewers threaten a pestilential atmosphere, and are dangerous." And finally, from the days 
of Homer and Hippocrates, of the great plague of Athens to the present moment, the burning 
of sulphur and tar have been practiced for the arrest of pestilence. 
As the art of disinfection borrows its knowledge from chemistry, it has advanced in accord- 
ance with the general advances of this science, which is, to a large extent, of modern creation, 
and it may at some future day attain the rank of a science, when the nature of contagious and 
infectious matters have been fully revealed, and the direct chemical and physical actions of 
disinfectants established. 
Much ingenuity and force of argument have been exerted by some authors, to show that con- 
tagion is the mere result of putrefaction, but though many circumstances serve to prove that 
they are intimately connected, and capable of being destroyed by similar agents, sufficient evi- 
dence has not hitherto been adduced to warrant the positive conclusion that contagious effluvia 
are essentially the same with the miasmata exhaled from putrid substances. Whatever difference 
of opinion may, however, prevail respecting the nature and origin of febrile contagions, accurate 
observations have fully proved that, in whatever way generated, they may all be propagated, 
either by actual contact with infected persons or things, or by breathing air charged with effluvia, 
whether proceeding from substances imbued with contagious virus, or from patients laboring 
under pestilential disease. 
Since all contagious effluvia act only when near to the sources whence they arise, and since, 
when diffused in the air, or chemically united with it by solution, they unquestionably lose their 
deleterious qualities, it must be obvious that, by a proper attention to ventilation and cleanliness, 
the influence of infection may be generally avoided ; but although both reason and experience 
confirm the efficacy of such measures in preventing or controlling the destructive agency of con- 
tagion, yet, as the time requisite thus to dilute or diffuse the poison is uncertain, and as this mode 
of purification is not universally applicable, recourse has been had to the more easy and expedi- 
tious means which chemistry affords. 
While the modern history of disinfectants began in the Seventeenth century, it was not until 
near the close of the Eighteenth century that the nature and agencies of oxygen and chlorine 
were explained by the discoveries of Priestley, Scheie, Cavendish, Lavoisier, and other chemists. 
The investigations of Boyle, showing the influence of air and heat and cold upon putrefaction, 
were followed by the experiments of Dr. Petit, in 1732, on the effects of antiseptics in the preser- 
vation of flesh. Petit came to the conclusion that astringents were the best preservatives of 
fresh meats, and that their action was similar to drying. Lord Bacon had long before observed 
that the inducing or accelerating putrefaction was a subject of very universal inquiry, and says 
that "it is of an excellent use to inquire into the means of preventing or staying putrefaction, 
which makes a great part of physic and surgery." * 
• 
NOTE 1. EXPERIMENTS OF SIR JOHN PRINGLE, 1750. 
In 1750, Sir John Pringle read before the Royal Society his "Experiments upon Septic and 
Antiseptic substances, with remarks relating to their use in the Theory of Medicine," f for which 
he was honored with the Copleian Medal. Sir John Pringle was led to make some experiments 
into the manner in which bodies are resolved by putrefaction, with the means of accelerating, or 
* Nat, History, Cent. iv. 
+ Philosophical Transactions, 1750, Vol. xlvi, No. 495, p.481 ; No. 49G, p. 525, p. 550. "Observations on 
Diseases of the Army," by Sir John Pringle. Appendix. SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
333 
preventing that process, by his having had " an uncommon number of putrid distempers " under 
his care in the hospitals of the Army. 
From the first series of experiments he concluded that acids by themselves were among the 
most powerful antiseptics, and that the alkaline salts were likewise of that class. Sir John 
Pringle thus rates the comparative powers of salts in resisting putrefaction : sea salt, 1 ; sal 
gemmæ, 1; Tartarus vitriolatus, 2; Spiritus minderer!, 2; Tartarus solubilis, 2; Sal diureticus, 2; 
Sal ammoniacus, 3; Saline mixture, 3; Nitre, 4; Salt of hartshorne, 4; Salt of wormwood, 4; 
Borax, 12; Salt of amber, 20; Alum, 30. According to this table the antiseptic power of alum 
is thirty times as great as that of common salt. He experimented also upon the antiseptic prop- 
erties of Myrrh, Aloe, Asafcetidæ, Terra japonica, Gum ammoniacum, Opium and Camphor. 
Of all resinous substances, he found camphor to be the strongest "resister of putrefaction." Ex- 
periments with infusions of Virginia snake root, Peruvian bark, pepper, ginger, saffron, contra- 
erva root, galls, dried sage, rhubarb, root of wild valerian, leaves of mint, angelica, ground ivy, 
senna, green tea, red roses, wormwood, mustard seed and horse-radish root, proved that they were 
powerful "resisters of putrefaction." 
After detailing various experiments illustrating the power of a decoction of Peruvian bark to 
arrest putrefaction, Sir John Pringle makes the following practical applications :- 
"Now, since the bark parts with so much virtue in water, is it not reasonable to suppose that 
it may yield still more in the body, when opened by the saliva and the bile, and therefore that 
in some measure it operates by this antiseptic virtue ? From this principle we may, perhaps, 
account for its success in gangrene, and in the low state of malignant fevers when the humours 
are apparently corrupted. And as to intermitting fevers, in which the bark is most specific, 
were we to judge of their nature from the circumstances attending them, in climates and in 
seasons most liable to this distemper, we should assign putrefaction as one of the principal causes. 
They are the great epidemics of marshy countries, and prevail most after hot summers, with a 
close and moist state of the air. They begin about the end of summer and continue throughout 
autumn, being at the worst when the atmosphere is most loaded with the effluvia of stagnating 
water, rendered more putrid by vegetables and animals dying and rotting in it. At such times 
all meats are quickly tainted, and dysenteries, with other putrid disorders, coincide with these 
fevers. The heats dispose the blood to acrimony, the putrid effluvia are a ferment, and the fogs 
and dews, so common in such situations, stopping perspiration, shut up the corrupted humours 
and bring on a fever. The more these causes prevail, the easier is it to trace this putrefaction. 
The nausea, thirst, bitter taste in the mouth and frequent evacuations of corrupted bile, are 
common symptoms and arguments for what is advanced. We shall add that in moist coun- 
tries and in bad seasons, the intermittents not only begin with symptoms of a putrid fever, but if 
unduly treated, are easily changed into a malignant fever with livid spots or blotches on the 
skin or a mortification of the bowels. At the same time it must be acknowledged that such is the 
quick action of the bark in removing these fevers that its febrifuge quality must be something 
different from its antiseptic : and yet we may remark that whatever medicines (besides evacua- 
tions and the bark) have been found useful in the cure of intermittents, they are mostly, so far as 
I know, powerful correctors of putrefaction, such as myrrh, camomile-flowers, wormwood, 
tincture of roses, alum with nutmeg, the vitriolic or other strong mineral acids, with aromatics." 
NOTE 2. VENTILATION OF SHIPS IN 1755. BY DR. STEPHEN HALES. 
In 1755, Dr. Stephen Hales* published in the Transactions of the Royal Society of London, 
an article "On the Great benefits of Ventilators in many instances, in preserving the health and 
lives of people in slave and other transport ships." 
Captain Thomson, of the "Success " frigate, in a letter to Dr. Hales dated London, Sept. 25th, 
1749, states that he "found this good effect from ventilation, that though there were near 200 
men on board for almost a year, yet he landed them all well in Georgia, notwithstanding they 
were pressed men and drawn out of jails with distempers upon them." 
He states also that all kinds of provisions in the ship kept better, from the coolness and fresh- 
ness of the air in the ships, caused by ventilation. Mr. Crammond and Captain Ellis testified to 
the value of free ventilation in preserving the lives of the crew and slaves during the voyages from 
* Philosophical Transactions, 1755, Vol. XLIX, p. 332. 334 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Africa to America. Also the Earl of Halifax, often informed Dr. Hales of the great benefit they 
found by the use of ventilators in several Nova Scotia transport ships, twelve to one more having 
been found to die in unventilated than in ventilated ships. 
In view of such facts, Dr. Hales affirmed that " It is indeed a self-evident thing that this chang- 
ing the foul air frequently in ships in which there are many persons, will be a means of keeping 
them in better health than not doing it. It is the high degree of putrefaction (that most subtle 
dissolvent in nature), which a foul air acquires in long stagnating, which gives it that pestilential 
quality which causes what is called the jail distemper. And a very small quantity, or even 
vapor of this highly attenuated venom, like the infection or inoculation for the smallpox, soon 
spreads its deadly infection." 
NOTE 3. 
Dr. John Huxham, in his Essay on Fevers, * in the Appendix, details a method of pre- 
serving the health of seamen in long cruises and voyages, and advises that " Every sailor 
should have at least a pint of cider a day, besides beer and water. And I would advise, also, a 
frequent and free use of vinegar in the seaman's diet ; especially when the provisions begin to 
grow rancid. Besides this, the decks, etc., should be frequently washed or sprinkled with vinegar; 
after having drawn the gross and foul air out of the ship by Mr. Sutton's contrivance, or by Dr. 
Hales' ventilators, which should be done once, at least, every day." 
NOTE 4. EXPERIMENTS OF DR. DAVID MACBRIDE, IN 1764, ON ANTISEPTICS. 
Surgeon David Macbride published, in 1764, his Five Experimental Essays on the Fermenta- 
tion of Alimentary Mixtures, Fixed Air, Antiseptics, Scurvy and the Resolvent Power of Quick- 
lime. f 
The old chemists believed that all the true spontaneous changes or transmutations of bodies 
were the effects of fermentation ; but Boerhaave, disliking so enormous an extension of terms, 
restricted it within very narrow limits, and would suffer nothing to be called fermentation which 
did not produce either an ardent spirit or an acid, thus entirely confining it to what are usually 
called the vinous and acetous stages, and altogether rejecting the putrefactive, as looking on putre- 
faction to be quite a different process, and no way allied to fermentation. But this restriction, 
which was merely for the sake of clearness and precision, introduced confusion with regard to the 
word putrefaction. This word, in its common acceptance, was always understood to imply a plain 
tendency to destruction in bodies, accompanied with every sign of rottenness and offensiveness; 
and, accordingly, it was often met with in cotemporary writers with Macbride, in this sense, when 
perhaps, on the very same page, the statement is made that the aliment is prepared for nourishing 
the human body by putrefaction ; that motion, life and heat are communicated to the fluids by 
putrefaction. 
The later chemists, therefore, who reduced this branch of chemistry to a-more intelligible and 
methodical system than Boerhaave, approached more nearly to the ancient opinion, and with 
Macquer, defined fermentation to be an intestine motion, which, arising spontaneously among the 
insensible parts of a body, produceth a new disposition and a different combination of the parts. 
Macbride, accepting this definition, held that a great number of the natural changes which 
daily take place in the animal and vegetable kingdoms should be looked on as so many modes of 
fermentation, and that, in particular, the digestion of our food should be looked on as a fermenta- 
tory process. 
Macbride held that "the experiments already made by the very learned and ingenious Dr. 
Pringle, seem sufficient to convince every unbiased reader of the truth of this theory, which, 
if we consider the matter with any degree of attention, we must find to be absolutely necessary 
in order to bring about that new disposition and that different combination of the insensible parts 
of the alimentary substances which enable the immense variety of discordant mixtures that enter 
the composition of our food to depart so far from their original natures as to become one mild, 
sweet and nutritious fluid ; for this demands a great deal more than mere mechanical mixture and 
dissolution, which is the most that the common theories of digestion lead to, since they do not 
seem expressly to require, nor indeed suppose, such an absolute change to be wrought, in the first 
* Third Ed., London, 1757, page 262. 
f London, 1764. SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
335 
passages, on the nature of the different kinds of food, as would render them susceptible of that 
firm union and that strong attraction by the means of which they become so soon one and the same 
substance with the body into which they are received. 
It also appears pretty plain, from Dr. Pringle's experiments, that there is something gener- 
ated or set free during the first stage of the fermentation of animal and vegetable mixtures, 
which hath a power of correcting putrefaction." * 
Hoffman, however, previous to Macbride, had insisted much on the complete change that the 
aliment undergoes in the first passages, and niakes digestion a mere fermentatory process, as may 
be seen at large in his chapter de Alimentorum Solutione and Solutione Usu, and the three suc- 
ceeding ones. 
The labors of Hoffman, Pringle and Macbride were of the highest importance, in that they 
referred putrefaction, fermentation and digestion to the same general causes. 
Macbride repeated and extended the experiments of Pringle, and confirmed his conclusions, 
that combinations, as the mineral acids, aromatic gums and Peruvian bark, possess powerful anti- 
septic virtues, resisting and correcting putrefaction. He also established the fact that fixed air 
(carbonic acid) tended to retard fermentation. 
Macbride threw out the following suggestions with reference to the treatment of yellow fever :- 
"However, I will, in the meantime, recommend the trial of an experiment in that very 
destructive disease, the putrid yellow fever of the West Indies. It is to give the patients repeated 
doses of the alkaline salts, in fresh lime juice, or the like, and let it always be swallowed during 
the act of effervescence; and let the patient's drink be somewhat of the highly fermentable kind; 
I would even propose the juice of the green sugar cane, diluted, and acidulated with some of the 
recent sour juices." 
" I find that Dr. Lind often prevents the fits of an ague by giving these mixtures in the 
manner above mentioned. And Riverius used to check vomitings therewith in an infant." 
"A surgeon who was some time at Goru, on the coast of Africa, tells me that the natives use 
in these fevers, with very good success, a drink prepared by macerating in water a fruit of the 
plum kind, that grows there in great plenty."f 
Lime was found by Macbride to prevent but not remove putrefaction. Animal fluids, he 
observes, will remain for a long time without putridity if kept from the air. He says that astrin- 
gent mineral acids and ardent spirits "not only absorb the matter from the putrescent substance, 
but, likewise, crisp up its fibres, and thereby render it so hard and durable that no change of 
combination will take place for years." 
NOTE 5. DISINFECTION AS PRACTICED IN THE HOSPITALS OF MALTA, AND IN THE 
LEVANTINE LAZARETTOES. 
Disinfection has been practiced in the hospitals of Malta and in the Levantine lazarettoes 
from an early and, as far as my information extends, for an indefinite period. 
The plague was first noticed in the "Maltese Annals" in 1549, a.d.; in 1593 it again 
appeared ; in 1623 forty-six persons died of it, and in 1663, it reappeared, when only twenty 
persons fell victims to it. But its advent in 1675 was dreadful, for 11,300 persons died of this 
dreadful malady. For one hundred and thirty years Malta was free from plague, when it broke 
out with fearful violence in 1813 ; from its commencement in April, 1813, to its termination in 
September of the same year, 4486 deaths took place in the island, of which 1223 occurred in 
Valetta, the mortality being about 80 in the 100 attacked. J The monthly progress is shown by the 
deaths from April to November, viz. ; April, 3 cases ; May, 110 ; June, 800; July, 1595 ; August, 
1042; September, 674; October, 211; November, 53. Maximum of the thermometer during 
these months was 71°, 82°, 84°, 88°, 86°, 88°, 83°, 72°, F. Strong winds blew during part of 
the period, particularly in July. 
The progress of this mortality resembled that of the yellow fever in America. 
* "Essay on the Fermentation of Alimentary Mixtures," pp. 1-4. 
f " Essay on the Respective Powers and Manner of Acting of the Different Kinds of Antiseptics," 
pp. 165-166. 
t" History of the British Colonies," by R. Montgomery Martin, Vol. v. Possessions in Europe. 
London, 1835, p. 192. 336 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
The process of expurgation, at Malta, during the plague or other pestilential diseases, con- 
sisted of the free and continual admission of air to all parts of the house and furniture ; the 
removal of filth of every species; ablution of all woodwork by a strong lye of soap water and the 
application of hot lime wash to all the walls, from the cellar to the garret; taking care to remove 
and repair all loose or decayed pieces of plastering; all the drains, etc., completely emptied of 
their contents and thoroughly cleansed ; the clothing and furniture most minutely cleansed, and 
such parts as are not susceptible of damage from water submitted to copious effusions, and even 
boiled in a strong lye when practicable ; books and all other similar articles placed in the open 
air, on terraces, etc., and every decayed, superfluous, or useless article, particularly in the form of 
bags, cordage, paper, clothes, hangings, etc., destroyed. 
To these precautions were added fumigations of various kinds, mineral and vegetable; those 
from the mineral acids were very frequency used in the public hospitals. The smoke of straw, 
dampened with water, and the fumes of vinegar were a'so very frequent means of fumigation ; 
but the great officinal formula of the Levantine lazarettoes is as follows (it, however, was princi- 
pally applied to goods, letters, etc.) :- 
Sulphur, six pounds. 
Orpiment, crude antimony, litharge, cumin seed, euphorbium, black 
pepper, ginger, of each, four pounds. 
Asafœtida, cinnabar, sal ammoniac, of each, three pounds. 
Arsenic, one pound. 
All reduced to a fine powder, to which is added- 
Raspings or sawdust of pine wood six pounds. 
Bran, fifty pounds. 
This most offensive and penetrating compound and efficient antiseptic and disinfectant 
appears to have been long in use, for it is noticed by Dr. Russell, in his history of Aleppo.*' 
In the burning of such a compound sulphurous acid and arsenious acid would necessarily be 
evolved, as well as some of the compounds of mercury, and it is, perhaps, true that modern sani- 
tary science has failed to discover a more effective and, at the same time, a more offensive disin- 
fectant. The fumes of this compound must have been, if inhaled to any great extent, destructive 
to all animal life, even that of man. The exposure of the clothing to the night air was sup- 
posed by many to be the most effectual of all means of purification, and the Turks and other 
inhabitants of the Levant place the most implicit confidence in its efficacy, which they attribute 
principally to the operation of the dew. 
Coins and other articles were purified by passing them through vinegar, and the free use of 
oil in anointing the body has prevailed from time immemorial, in the Levant and East, as a 
means of protection against the plague. 
The method of disinfection practiced in the quarantine stations and lazarettoes of the South of 
Europe and the Levant was investigated by the celebrated John Howardf and Dr. Charles 
Maclean,J who voluntarily subjected themselves to the barbarous restrictions of the odious quar- 
antine, and the barbarous method of confinement in damp, ill-ventilated and filthy rooms of the 
lazarettoes, and the more important facts relating to disinfection recorded by these authors are 
embraced in the preceding observations. 
In order to obtain the best information, by performing the strictest quarantine, John Howard 
took passage for Venice, from Smyrna, in a ship with a foul bill. He thus records his 
experience:- 
" Contrary winds and other causes made this a tedious and dangerous voyage, and it was sixty 
days from the time of leaving Smyrna before I arrived at Venice." 
"Here, after our ship had been conducted by a pilot-boat to her proper moorings, a messenger 
came from the health office for the captain ; and I went with him in his boat to see the manner in 
which his report was made, his letters delivered, and his examination conducted. The following 
*" History of the British Colonies," by R. Montgomery Martin. Vol. v, pp. 194, 195. 
f " An account of the principal Lazarettoes in Europe ; with various papers relating to the Plague, 
together with further observations on some Foreign Prisons and Hospitals, etc." By John Howard, 
D. R.s., Warrington, 1789. 
t"Results of an Investigation respecting Epidemic and Pestilential Diseases; including Researches 
in the Levant concerning the Plague." By Charles Maclean, m.d. London, 1817 ; 2 vols. 337 
morning a messenger came in a gondola to conduct me to the new lazaretto. I was placed, with 
my baggage, in a boat fastened by a cord ten feet long to another boat in which were six rowers. 
When I came near the landing place, the cord was loosed, and my boat was pushed with a pole to 
the shore, when a person met me, who said he had been ordered by the magistrates to be my 
guard. Soon after unloading the boat, the sub-prior came and showed me my lodging, which was 
a very dirty room, full of vermin, and without table, chair or bed. That day and the next morn- 
ing I employed a person to wash my room ; but this did not remove the offensiveness of it, or 
prevent that constant headache which I had been used to feel in visiting other lazarettoes, and 
some of the hospitals in Turkey. This lazaretto is chiefly assigned to Turks and soldiers, and the 
crews of those ships which have the plague on board. In one of the enclosures was the crew of 
a Ragusian ship, which had arrived a few days before me, after being driven from Ancona and 
Trieste. My guard sent a report of my health to the office, and on the representation of our 
consul, I was conducted to the old lazaretto, which is nearer the city. Having brought a letter 
to the Prior from the Venetian ambassador at Constantinople, I hoped now to have had a comfortable 
lodging. But I was not so happy. The apartments appointed me (consisting of an upper and a 
lower room) were no less disagreeable and offensive than the former. I preferred lying in the 
lower room, on a brick floor, where I was almost surrounded with water. After six days, however, 
the Prior removed me to an apartment in some respects better, and consisting of four rooms. 
Here I had a pleasant view; but the rooms were without furniture, very dirty, and no less offen- 
sive than the sick wards of the worst hospital. The walls of my chamber, not having been 
cleansed probably for half a century, were saturated with infection. I got them washed repeatedly 
with boiling water, to remove the offensive smell, but without effect. My appetite failed, and I 
concluded I was in danger of the slow hospital fever. I proposed whitewashing my room with 
lime slaked in boiling water, but was opposed by strong prejudices. I got, however, this done one 
morning, through the assistance of the British Consul, who was so good as to supply me with a 
quarter of a bushel of fresh lime for the purpose. And the consequence was, that my room was 
immediately rendered so sweet and fresh that I was able to drink tea in the afternoon, and to lie in 
it the following night. On the next day the walls were dry as well as sweet, and in a few days I 
recovered my appetite. Thus, at a small expense, and to the admiration of the other inhabitants 
of this lazaretto, I provided myself and successors an agreeable and wholesome room, instead of 
a nasty and contagious one. 
" Over the gateways of two large rooms or warehouses was carved in stone the images of three 
saints {San Sebastiano, San Marco, and San Rocco), reckoned the patrons of this lazaretto. 
Formerly, when persons who had the plague were brought from the city, they were put into one 
of these rooms for forty days, and afterward into the other for the same time, before they were 
discharged." John Howard adds, in a note : " Many of the windows in these rooms, and also 
in some other ancient pest-houses which I have seen, are now bricked up. This shows that in 
the last century physicians were sensible of the importance of fresh air and a free circulation of 
it in sick wards. A different practice, particularly in the smallpox and the gaol-fever, was after- 
ward adopted by medical gentlemen ; but we seem now to be returning to the ancient and more 
salutary practice. Formerly, also, it seems probable that men did not entertain these absurd 
prejudices against the free use of water in washing themselves and their rooms, which are now 
prevalent; for in several of the old pest-houses I have observed the marks of a greater attention 
to the means of gaining plenty of water than has been thought necessary in many of the hospitals 
built within these fifty years." * 
The health office of Venice was instituted by decree of the Senate, in the year 1448, in the 
midst of a very destructive pestilence, and afterward confirmed and regulated by subsequent 
decrees, till reduced to the order in which it stood at the time of the visit of John Howard, in 178Ö. 
NOTE B. HYDROCHLORIC ACID (MURIATIC ACID), NITROUS ACID, NITRIC ACID, PEROX- 
IDE OF NITROGEN, BINOXIDE OF NITROGEN AND CHLORINE AS DISINFECTANTS. 
An essay recommending nitrate of potash in ventilation received the recommendation of the 
Academy of Dijon in 1767. Dr. Robert Angus Smith suggests that when this substance was used 
in ventilation the saltpetre was heated, in which case it would give off oxygen gas, which at first 
SECTION XV PUBLIC AND INTERNATIONAL HYGIENE. 
* An account of the Principal Lazarettoes in Europe, etc., pp. 10-12. 
Vol. IV-22 338 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
is very pure ; afterward nitrogen conies off, and then the salt itself, or, at least, the base, is car- 
ried into the air, causing a very stifling sensation. The oxygen, however, would be valuable. 
This plan was remarkable as having been tried before the discovery of oxygen, which was in 
1774. 
Guyton-Morveau * made a valuable and practical advance in 1773, when he proposed fumiga- 
tion with muriatic acid vapors as a mode of disinfecting hospitals; but the acid fumes of burning 
sulphur had been used in Greece and Rome, for the arrest of pestilence, two thousand years 
before, and this latter agent is far superior to muriatic acid as a disinfectant. The Chancellor of 
the Legion of Honor, writing to him in the name of the Emperor Napoleon, in 1805, says: 
" Europe and America know that since 1773 you have employed your discovery of the applica- 
tion of muriatic acid fumes to arrest the effects of contagious and direful diseases." He obtained 
for it the brevet of an officer of the Legion of Honor. 
The Danish method of fumigation is by the use of muriatic acid ; common salt may be used 
by pouring sulphuric acid on it, without heat, and nitric acid may be used, but the products are 
different. 
The use of muriatic acid by Guyton-Morveau, in 1773, has justly been regarded as the begin- 
ning of acid fumigation, leaving out the ancient use of vinegar and of sulphurous acid. 
Chlorine gas was discovered by Scheele, in 1774, and while we cannot go to the ancients for 
its history, it has, nevertheless, been supposed that the ancient Egyptians used it, as they evi- 
dently obtained nitric acid from the saltpetre, and this must have, in their experiments, been 
mixed with common salt, thus giving nitrous gases and chlorine. 
NOTE 7. EXPERIMENTS AND INVESTIGATIONS ON THE MEANS OF PURIFYING INFECTED 
AIR, OF PREVENTING CONTAGION AND ARRESTING ITS PROGRESS BY FUMIGATION 
WITH THE MURIATIC ACID, INSTITUTED BY L. B. GUYTON-MORVEAU, 1773. 
The employment of muriatic acid for the purification of vitiated air seems first to have been 
suggested by Dr. James Johnstone, of Worcester, so early as 1758, in a Treatise, entitled "An 
Historical Dissertation on the Malignant and Epidemical Fever which prevailed at Kidder- 
minster in 1756 ; " but it is, indisputably, to M. Morveau that the medical profession is indebted 
for having fully established its efficacy by a variety of well-conducted and decisive experiments. 
These and other instances, in which acid fumigations were employed with the greatest success, 
seem evidently to have suggested the experiments of Dr. Smith with the nitric acid vapor, on 
board the Union Hospital ship at Sheerness, in the year 1795. 
The questions which prompted his experiments have thus been stated by Guyton-Morveau : 
" The most mournful events incessantly recall to our attention the effect of contagion. The bare 
mention of this word presents the image of the most dreadful of all the evils which afflict 
humanity. The sword blunts its edge in the body which it pierces; poison remains inactive in 
the organ which it has deprived of sensation ; fire, removed from its aliment, dies of itself; but 
contagion derives additional force from the number of its victims. 
" What, then, is the nature of those invisible corpuscles which, like organic beings, possess the 
power of reproduction, and of assimilating to their own essence everything with which they come 
in contact, and which seem to assume life but for the purpose of propagating death ? Is their 
composition sufficiently powerful to resist the force of the chemical agents which destroy almost 
simultaneously the equilibrium of the elements in animate as well as inanimate matter ? " 
The sepulchral vaults of the principal church at Dijon having been entirely filled, in conse- 
quence of the winter of 1773, which froze the ground of the common cemetery to such a depth 
that it could not be opened, orders were given to remove the bodies from the subterranean 
repositories. It was conceived that sufficient precaution had been taken by throwing in some 
quicklime, without even furnishing a vent for the putrid effluvia, or suspecting, what ought to 
have been anticipated from the experiments of Macbride, that lime, though it prevents the 
process of putrefaction, tends only, when employed at a certain stage of that process, to accelerate 
the evolution of its products. The infection of the air soon became so insupportable that it 
was found necessary to shut up the church. 
* " Traité des Moyens de Désinfecter l'Air, de prévenir la Contagion, et d'en arrêter le Progrès," 
1805. SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
339 
Unsuccessful attempts had been made to purify the air by the detonation of nitre; by fumiga- 
tions of vinegar; by burning a variety of perfumes and odoriferous herbs, storax, benzoin, etc., 
and by sprinkling the pavements with a large quantity of anti-pestilential vinegar, known under 
the name of " the vinegar of the four thieves." The odor of the putrid effluvia was merely 
masked for a moment by these operations, and soon reappeared with its former activity, spreading 
to the neighborhood, when the symptoms of a contagious fever began to appear. At this period 
Guyton-Morveau was consulted on the means of destroying the source of the distemper. 
Guyton-Morveau at once directed his attention to the muriatic acid, the very diffusible 
vapors of which might seize the ammonia, which he regarded as the vehicle of the fetid mias- 
mata, and thus leave the latter to subside by their own gravity. He proposed, therefore, to make 
trial of fumigation with the muriatic acid, as a means of purification. It was accordingly exe- 
cuted in the evening of the 6th of March, 1773, with six pounds of common salt, and two pounds 
of concentrated sulphuric acid. The whole was put into a capacious bell-glass, inverted and 
placed on a bath of cold ashes, which were gradually heated by means of a large chafing dish.* 
The next day, the church being wholly thrown open for admission of fresh air, not the slight- 
est vestige of any offensive odor remained. Four days after service was performed in it as usual, 
without any danger, or even the least apprehension. 
Another event furnished occasion to Guyton-Morveau for a second trial of this process: 
Toward the end of the same year, 1773, the jail-fever, which is known to be of the same nature 
with the hospital fever, had been carried into the jails of Dijon by some prisoners removed from 
another part of the country. Thirty-one persons had already sunk under it, and the contagion 
continued to make the most alarming progress. The effect of the fumigation practiced a few 
months before, in the church of St. Stephen, was recollected, and Guyton-Morveau was requested 
to superintend the execution of a similar process, which was accordingly performed, with the 
greatest success. M. Maret, secretary of the late Academy of Sciences at Dijon, inserted an 
account of it in the Journal de Physique, of January, 1774, p. 73. A singular circumstance 
occurred in this instance, which served to undeceive those who regarded fire as the most effectual 
purifier. Such was the virulence of the infection in a particular cell, that no person could 
approach the entrance without suspecting that one of the dead bodies had been left behind. 
This was the unanimous opinion of all who were present when Guyton-Morveau first visited it : 
and it was generally known that even subsequently to that time three bundles of straw had been 
burnt in it, the traces of which were visible on the walls, the archway and the gate, which was 
of iron. The day after the fumigation, in which he employed about fifteen decagrammes only of 
common salt, and five of sulphuric acid, the putrid odor was so completely removed that a student 
of surgery offered to stop in it for the night. 
In 1774, an almost general epizootic distemper ravaged the South of France. M. Vicq-d' 
Azyr circulated some directions with respect to the manner of purifying the villages and stables; 
among these he takes notice of fumigation with the muriatic acid. " The object to be proposed," 
says, M. Vicq-d' Azyr, " is to destroy the miasmata with which the atmosphere and the walls are 
impregnated, and to admit a free circulation of air into the stables. Those who wish to effect 
these purposes must begin with putting a quantity of ashes, or sand, into an earthen pan. In 
the midst of this bath should be placed a glass vessel filled with culinary salt; and the whole 
must then be heated. A quantity of vitriolic (sulphuric acid), must be gradually poured upon 
the salt. The same process should be performed at both ends of the stable, if it be somewhat 
large. The white fumes which ascend will then become very active." 
With reference to aromatic substances, M. d' Azyr says, " in burning, only an agreeable is 
substituted for a fetid odor. They merely deceive the organ of smell, but do not destroy the 
putrid miasmata. The saline vapors possess the latter advantage, and on that account ought to 
be preferred." 
In the following year, two productions by M. de Montigny, which had the approbation of the 
Academy of Sciences, were published together in the same volume, by order of the Government. 
The one of them was entitled, " Instructions and advice to the inhabitants of the Southern 
* The details of the process of Guyton-Morveau were described with considerable accuracy in the 
Journal de Physique of that year, Vol. I, p. 436, under the title of "A new method of purifying com- 
pletely, and in a very short space of time, a mass of contaminated air." 340 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Provinces respecting the putrid and pestilential malady which proves so destructive to cattle ; " 
the other "Advice to the people of the provinces into which the contagion has penetrated." Both 
of them equally recommend the method of M. de Morveau, of destroying infection. 
In 1780, the Academy of Sciences was consulted by the Government on the means of correct- 
ing the insalubrity of prisons, and appointed a committee to investigate the matter, composed 
of MM. Duhamel, De Montiguz, Leroi, Tenon, Tillet, and Lavoisier. One of their objects was 
to compare and appreciate the different known methods of purifying infected air. In the report 
of this Commission, on the 17th of March, 1780, printed in the volume of memoirs for that year, 
they express the opinion that " Another precaution which we think it our duty to recommend, and 
which will contribute more than anything to the salubrity of prisons, is once a year to destroy 
contagion by the method successfully employed by M. de Morveau. It consists in disengaging 
in those places which it is proposed to purify a considerable quantity of marine acid in a state of 
vapour, etc. The vitriolic acid disengages that of the sea salts, which last, rising in the form of 
a white vapour, diffuses itself over the chamber and neutralizes the putrid miasmata." * 
It might have been supposed that, supported by such respectable authorities, this method would 
have been practiced when the first symptoms of contagion rendered it necessary ; but during the 
twelve subsequent years it was wholly neglected ; the lazarettoes were abandoned to the usual 
routine of aromatic fumigations, and the hospitals and prisons to the most deplorable neglect, at 
the time when the crowd of patients augmented the ordinary contagion, which began to prove 
fatal in many instances, even to the attendants of the sick. 
In the second year of the Republic, 1794, in consequence of the multitude of persons infected 
with fever, and of the wounded which it was necessary to receive into the military hospitals of the 
interior, hospital fever prevailed to a great and alarming extent, and many eminent physicians 
fell victims to the contagion. M. Guyton-Morveau therefore proposed to the Convention that 
instructions should be drawn up and published respecting the means of arresting the progress of 
the contagion. They therefore passed the following decree : " The Executive Council shall cause 
to be drawn up, without delay, by the Board of Health, detailed instructions respecting the me- 
chanical and chemical means of preventing the progress of infection in the hospitals, and of purify- 
ing the air from the mephitic vapors or putrid miasmata, with which it may be charged. These 
instructions shall be printed and sent by the Minister of War to all the military hospitals, by 
the Minister of Marine to the naval, and by the Minister of the Interior to the civil hospitals. 
Guyton-Morveau is charged with the superintendence of the matter." 
The Board of Health, after a series of experiments, conducted by a committee of its members, 
at the hospitals of St. Cyr, Franciade and Gros Caillon, reported:- 
"The results of these experiments incontestably proves that the proposed method of purifying 
hospitals by the muriatic acid gas, may be practiced without inconvenience, and with the greatest 
advantages, in full as well as in empty wards ; observing always to disengage in the former a 
smaller proportion of gas." 
This conclusion of the Board of Health, delivered in the instructions approved by the 
Provisional Executive Council on the seventh ventose, year two, was sent by the Minister of War 
to the military commissaries, to the officers of health, and those employed in the military hospi- 
tals, with injunctions to carry into execution the processes prescribed. 
That these recommendations by the Board of Health and Provisional Executive Council pro- 
duced but imperfect and unsatisfactory results, is evident from the following statement of Guyton- 
Morveau, the discoverer of the method of fumigation by muriatic acid :- 
"What was the result of opinions so decisive, and orders so precise? It is with regret L 
observe that occasions on which the process might have been employed have repeatedly occurred, 
of a nature to arouse the attention of the officers of health to their own safety ; yet most of them 
remain ignorant both of the process of fumigation and of its salutary effects. Citizen Chaussier, 
indeed, Professor of Anatomy in the Medical School, practiced it with success in one of the mili- 
tary hospitals at Dijon, of which he had the direction. It was also employed, when I was in the 
army of the Saome and Meuse, in purifying some hospitals in Belgium, which the Austrians 
had left in a very foul state. But these were the only instances of the execution of the instruc- 
tions which have come to my knowledge, when I very recently learned from the reports made by 
* Memoir of the Koval Academy of Sciences for 1780, p. 421. SECTION XV PUBLIC AND INTERNATIONAL HYGIENE. 
341 
the Board of Health to the Minister at War that the process prescribed in the instructions was 
practiced in the course of the epidemic disease with which the Army of the Western Pyrenees 
had been attacked, in the year three. It is also in consequence of the solicitude which the minister 
has felt on this subject, that I have learned that the process was recommended and followed in the 
destructive disorder which last year (year seven) made such ravages in the army of Italy, and 
the Southern department. Thus we have received not one attestation, not one relation, no official 
publication, and not even a simple notice respecting the practice of acid fumigation and its results 
in different circumstances." 
The mortality occasioned at Genoa by the contagious malady which raged in that city in 
1800, as well as the disposition on the part of the French Government to enforce by its authority 
the introduction of acid fumigations into the military hospitals, afforded new motives to M. Guy- 
ton-Morveau for resuming his inquiries on this subject, and gave rise to an important publica- 
tion, in which he gives a history of acid fumigations, the results obtained, and the experiments 
illustrating their effects and modes of application. 
At the time when the epidemic disease of Genoa raged in its utmost violence, a malady, differ- 
ent in character, but not less dreadful, broke out at Cadiz, and spread with such rapidity as to 
threaten the whole of Andalusia. 
The account of the epidemic disease of Genoa, published by Doctor Rasori,f in which he 
regarded the disease as true hospital feuer,\ appeared to Guyton-Morveau important conclusions 
in favor of anti-contagious fumigations. 
Although Rasori held that the cause of the malady of Genoa, as well as that which preceded it 
at Nizza, was some foreign matter introduced into the system in an unknown manner, and that 
it originated in the hospitals, and from the exhalations from a number of dead bodies improperly 
interred, he does not indicate any measures for the destruction of the putrid and contagious 
effluvia. In fact, he states that one of the conclusions arrived at by the Conference of the Board of 
Health and Physicians of Genoa was that, " instead of applying ourselves to indicate the ordinary 
and commonly ineffectual preventatives, it was necessary to think at first of deciding upon a 
general method of cure." The measures recommended by the physicians of Cadizg consisted 
simply in cleansing the sewers, the interment of the dead without the precincts of the city, 
watering the streets, lighting in the streets and squares large fires of green fir, explosions of 
small quantities of gunpowder, and the sprinkling of the inside of the houses with vinegar and 
aromatic plants. 
This was not the case at Seville, to which place the yellow fever had extended, and where it 
made the most alarming progress. Acid fumigations were there employed with success. M. Ch. 
Gimbernat, in a letter addressed to Guyton-Morveau, on the 18th of January, 1801, says : "The 
instructions which I communicated respecting the manner of performing fumigations with the 
muriatic and nitric acids, have produced the happiest effects in stopping the progress of the con- 
tagion in Andalusia. 
" Unfortunately, prejudices for some time retarded the application of this powerful remedy. 
But at length the zeal and information of two medical men, Queralto and Sarrais, sent by the 
Government to Seville with the necessary orders and authority to practice the acid fumigations 
as profusely and generally as the extent of the contagion required, produced the most prompt 
and fortunate success. Commissary Sarrais, one of the ablest physicians of Spain, was seized 
with the contagion on the very day of his arrival at Seville, and died on the following day. 
"The reports made by Queralto to the Government attest that it is to the acid fumigations we 
owe the extinction of a malady which threatened to throw the whole nation into mourning." 
It is evident, from the preceding facts, that fumigations with muriatic and nitric acids were 
employed for the arrest of yellow fever in Spain as early as 1800. 
The following directions were given by Guyton-Morveau for the performance of his method 
of fumigation with muriatic acid :- 
* " A Treatise on the Means of Purifying Infected Air, of Preventing Contagion and Arresting its 
Progress." By L. B. Guyton-Morveau, Member of the National Institute of France, etc. 
f"Storia della Febre Epidemica di Genova negli anni, 1799-1800." Milan, 9th year; in 8vo, 222 pages. 
I " La Nostra Fébre Epidemica e della Stessa Indole della vera Nosocomiale." Storia, etc., p. 91. 
g " An Account of the Epidemic Diseases of Cadiz." Translated into French, from the Spanish, by 
F. F. Bliss, etc., p. 10. 342 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
" When it is intended to purify the air in the chambers of infirmaries, the wards of hospitals, 
in close places after exhumations, where animal matters have been allowed to putrefy, or where 
some individuals have died of epidemic or contagious maladies, and which are not inhabited, we 
place a chafing-dish in the centre, and on it an iron pot ha'f filled with silicious sand or ashes. 
On this bath must then be placed a large glass vessel containing muriate of soda (common salt), 
and when this begins to be heated sulphuric acid (oil of vitriol of commerce) should be poured on 
the salt ; after which the doors and windows should be kept as closely shut as possible for seven 
or eight hours. 
" To determine the quantity of materials necessary for the intended purpose, let us suppose, 
for example, a lofty ward or apartment containing twenty beds ; it would require of common 
salt thirty decagrammes (about nine ounces six drachms), sulphuric acid, twenty-four deca- 
grammes (about seven ounces seven drachms). These quantities must be augmented or dimin- 
ished in proportion to the space in which they are intended to act. Experiments have demon- 
strated that three kilogrammes of salt are sufficient to completely purify, and by a single fumiga- 
tion, the air in a church the capacity of which is about 15,000 cubic metres,* or about 2023 cubic 
toises. A chamber of the size of between twenty-five and thirty square metres will require no 
more than ten decagrammes of salt and eight of acid. 
" Such is the method in which fumigations may be practiced when no particular considera- 
tion renders it necessary to restrain either their duration or intensity, and where it is intended 
they should at once produce a complete purification. They must, however, be conducted in a very 
different manner in places which are inhabited, where it is often necessary to carry them near 
to the beds of the sick, and where they must be repeated at certain intervals in proportion to the 
more or less rapid reproduction of the contagious emanations. 
" In very extensive wards, instead of a large apparatus, several small ones should be employed 
at different points, each containing four or five decagrammes of salt, upon which may be poured 
two-thirds of the weight of sulphuric acid ; since it would be altogether useless to effect the entire 
decomposition of the salt, the vapors which are first disengaged being sufficient for our purpose. 
In this case, the method employed by Citizen Chaussier in a large military hospital, which we 
have already mentioned, is very advantageous. He causes the apparatus containing the salt to 
be carried round the apartment, upon which the acid is poured by degrees, so that the extrication 
of the vapors may be made to take place at any point and in any quantity that is judged neces- 
sary, without the smallest inconvenience to the sick. " f 
NOTE 8. METHOD OF FUMIGATION ADOPTED IN SPAIN. 
The mode of fumigation practiced in Spain near the close of the last century, for correcting 
the insalubrity of the air, consisted in disengaging muriatic acid gas, by means of sulphuric acid, 
in the manner directed by Guyton-Morveau in 1773. In the Journal of Agriculture and Arts 
(Semanario de Agricultura y Arte» dirigido a los Parvoos), for 1797, a description is given of 
this method, under the article " Domestic Medicine." 
It is stated that it continued to be used with success at Madrid ; and further, that experience 
had proved that it might be employed in wards when persons were present, even without any 
inconvenience or danger to the sick, performing it with small quantities at a time and frequently 
repeating the process. This method of fumigation is recommended as very beneficial in all cases 
of pestilential fevers, epidemic and epizootic distempers. The process even appears to have 
become so common that it was considered of importance to derive some advantage from the salt 
remaining in the vessels. 
In the Dutch receipts, used not much after the time of the discovery of chlorine gas, the acid 
fumigation was obtained by pouring sulphuric or nitric acid on common salt ; the first gives 
muriatic acid and the second chlorine. 
Muriatic acid destroys vegetation and attacks with violence metallic substances, and is irri- 
tating to the lungs of animals and poisonous when inhaled in any considerable quantities ; it is 
not a good practical antiseptic, and is inferior in its disinfecting properties to chlorine and nitrous 
acid. 
* A metre is 3 feet, 11 lines, of the old French measure. 
t " Treatise on the Means of Purifying Infected Air, etc.," pp. 234-237. SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
343 
Dr. Carmichael Smith used nitrous fumes at Winchester, in 1780, and afterward in the Fleet, 
and in 1802 the British Parliament voted him £5000 for his method of acid fumigation. 
The nitrous acid fumes were tried very largely, toward the close of the last century and the 
beginning of this, in the hulks and prisons where Spanish, French and Russian prisoners of war 
were confined. * At that time, so rapidly did the disease (typhus fever) spread in the confined 
spaces where so many men were kept, that the efficacy even of ventilation was doubted, though 
there can be no question that the amount of ventilation which was necessary was very much 
underrated. Both at Winchester and Sheerness the circumstances were most difficult. At the 
latter place (in 1795), in the hulk, 200 men, 150 of whom had typhus, were closely crowded 
together; ten females and 24 men of the crew were attacked; three medical officers had died 
when the experiment commenced. After the fumigations, one attendant only was attacked, and 
it appeared as if the disease in those already suffering became milder. In 1797 it was again tried 
with success." Many reports were made on the subject by army and navy surgeons. It was 
subsequently largely employed on the continent, f and everywhere seems to have been useful in 
typhus exanthematicus. 
NOTE 9. EXPERIMENTS ON THE PURIFICATION OF AIR BY FUMIGATIONS WITH NITROUS 
ACID (NITRIC ACID), ACCORDING TO THE METHOD OF DR. CARMICHAEL SMITH, 1780-1795. 
Dr. Smith first used nitrous acid fumigation at Winchester in 1780, and published several 
accounts. From a publication entitled " An Account of the Experiments made at the Desire of 
the Lords Commissioners of the Admiralty, on board the 'Union ' Hospital Ship, to Determine the 
Effect of the Nitrous Acid in Destroying Contagion, and the Safety with which it may be 
Employed, etc.," London, 1796, 8vo, 73 pages, we extract the following, illustrating his method 
of disinfection :- 
The Lords of the Admiralty being desirous that Dr. Smith should send some person on board 
the hospital ship " Union " to make trial of fumigation with Nitrous Acid, the Doctor intrusted the 
direction of the experiment to Mr. Menzies, a surgeon in the Royal Navy, so that the report 
which he presented is an exact copy of the journal of the means employed by him to arrest the 
progress of the contagion. 
Mr. Menzies set out from London, November 24th, 1795, and arrived the same day at Sheer- 
ness. On his first visit to this hospital, he judged that it would be difficult to obtain conclusive 
results from his experiments, because new contagion was every day conveyed from the Russian 
vessels. Their lower and middle gun-decks were divided into wards by cross partitions, with a 
free communication between each. The sick were much crowded and placed without order, to 
the number of nearly 200, of whom about 150 were in different stages of a malignant fever, 
extremely contagious, as appeared evident from its rapid progress and fatal effects. From the 
month of September, when the Russian sick were first admitted, eight nurses and two washer- 
women had been attacked with this fever, and of these three had died. About twenty-four of 
the ship's company had likewise been ill of the same disorder, and of these a surgeon's mate and 
two marines had died. In short, there could be no doubt, from the evident malignity of the 
fever, that, without the incessant attention and activity of Mr. Bassan, to whose care they were 
intrusted, it would have proved still more fatal. 
Mr. Menzies caused to be brought on board the necessary apparatus and material for fumiga- 
tion. These consisted of a sufficient quantity of fine sand, two dozen quart earthen pipkins, as 
many common teacups, together with some slips of glass to be used as spatulas, and a quantity 
of concentrated sulphuric acid and pure, pulverized nitre. 
On the 26th of November he began his operations by causing the ports and scuttles to be shut. 
The sand, which had been previously heated in iron pots, was then scooped into the pipkins by 
means of an iron ladle, and in this heated sand, in each pipkin, a small teacup was immersed, 
containing half an ounce of concentrated sulphuric acid. To this, after it had acquired a proper 
degree of heat, an equal quantity of nitre in powder was gradually added, and the mixture 
stirred with a glass spatula till the vapor was disengaged in considerable quantity. The pipkins 
were then carried through the wards by the nurses and convalescents, who kept walking about 
* "An Account of the Experiments made at the desire of the Lord Commissioners of the Admiralty." 
By J. C. Smith, 1796. t Chevallier. Traité des Désinfectants, pp. 39, 40. 344 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
with them in their hands, and occasionally putting them under the cradles of the sick, and 
in every corner where foul air was expected to lodge. In this manner the fumigation was 
continued till the whole space between decks was filled with the vapor, which appeared like 
a thick haze. 
" I, however, proceeded," says Mr. Menzies, " in this first trial, slowly and cautiously, follow- 
ing with my eyes the pipkins in every direction, to watch the effect of the vapor on the sick, and 
observed that it at first excited a good deal of coughing, but which gradually ceased in propor- 
tion as it became more generally diffused through the wards. This effect appeared, indeed, to be 
chiefly occasioned by the ignorance of those who carried the pipkins, in putting them sometimes 
too near to the faces of the sick, by which means they suddenly inhaled the strong vapor as it 
immediately issued from the cups. 
" In compliance with Dr. Smith's request, the body clothes and bed clothes of the sick were, 
as much as possible, exposed to the nitrous vapor during the fumigation; and all the dirty linen 
removed from them was immediately immersed in a tub of cold water, afterward carried on deck, 
rinsed out and hung up till nearly dry, and then fumigated before it was taken to the wash house, 
a precaution extremely necessary in every infectious disorder. Due attention was also paid to 
cleanliness and ventilation. As the people were at first very awkward and slow, it took us about 
three hours to fumigate the ship. In about an hour after, the vapor having entirely subsided, 
the ports and scuttles were thrown open for the admission of fresh air. I then walked through 
the wards and plainly perceived that the air of the hospital was greatly sweetened, even by this 
first fumigation." Next morning the ship was again fumigated, and the operation was performed 
in the course of an hour. The sand being more heated, the vapor disengaged itself more speedily, 
while the patients suffered no other inconvenience but a slight coughing, which was less general 
than on the preceding day. 
Twelve pipkins were found sufficient for fumigating the lower deck, ten for the middle gun- 
deck, two for the ship's company's bedroom, two for the marine's bedroom, and one for the 
washing place, in all twenty-seven pipkins; consequently about fourteen ounces of the sulphuric 
acid, and as much nitre, was expended in the forenoon. 
In the evening, as every place was so close, and the fresh air could not afterward be so freely 
admitted, it was not thought necessary to employ so many pipkins, so that little more than half 
the quantity of the fumigating materials used in the morning was generally found sufficient for 
the evening's fumigation. 
The immediate effect of this process in destroying the offensive smell arising from so many 
sick crowded together was now very perceptible even to the nurses and attendants, who were no 
longer afraid of approaching the cradles of the infected, so that the latter were better attended, 
while a pleasing gleam of hope cast its cheering influence over that general despondence which 
was before evidently pictured on every countenance, from the constant dread each individual 
naturally entertained of being perhaps the next victim to the contagion. 
Mr. Menzies caused these fumigations to be repeated for eight days, with equal success; not 
only was there no inconvenience felt, but he observed that while the danger of infection was 
removed, the malignity of the disorder was diminished. He also proposed a useful alteration in 
the position of the necessaries, of which it was not possible to banish the putrid effluvia without 
perpetual washings, which endangered the life of those who were charged with the troublesome 
office. He took care that the beds of those who were discharged from the hospital should be 
washed with the diluted muriatic acid, in pursuance of the instructions of Dr. Smith. 
On the seventh of December, Mr. Menzies resigned to Mr. Bassan the care of continuing the 
experiments. Since their commencement none of the attendants or ship's company had been 
seized with this fever, with the exception of one nurse, who suffered a slight relapse from some 
imprudence; and none of the patients had died. It was therefore manifest that the process had 
produced the happiest effects, and that it might be employed with particular advantage, and with- 
out any inconvenience or danger of fire, in ships where many people were crowded together within 
a narrow compass. 
Annexed to this journal of Mr. Menzies are extracts from the correspondence of Mr. Bassan 
with Dr. Smith and Mr. Menzies concerning the effects of the operations which the Doctor had 
intrusted to his care; in these it is noticed that only one sick Russian had died since the 
commencement of the fumigations up to the latter part of December, and only one nurse and SECTION XV PUBLIC AND INTERNATIONAL HYGIENE. 
345 
one marine had been taken ill of the fever, although the symptoms were much milder than 
formerly. 
On the third of February, Mr. Bassan writes that the contagious fever had entirely ceased, 
and that no person had been seized since the 26th of December, though during the intermediate space 
they had been daily receiving patients laboring under the same putrid petechial fever from the 
Russian ships. In short, he regarded the experiment as decisive, and proposed continuing to 
employ the same acid fumigation for the purpose of destroying the alkaline miasmata, and of 
purifying the air. He also informed Dr. Smith that Captain Senevin, of the " Pamet Eustaphia," 
of 74 guns, had assured him that having continued the fumigation every day since the departure 
of Mr. Menzies, he had no longer any sick on board. 
Next follows a second journal of Mr. Menzies, relating some new trials of this fumigating 
process, made on board some ships of the Russian squadron at the request of Admiral Hannicoff. 
The " Pamet Eustaphia " was first pitched upon for this fumigation, because that ship had sent 
moresick with malignant fever to the hospital than all the rest of the squadron. Notwithstanding 
numerous disadvantages from the nature of the ballast, composed of sand and rock earth, the nature 
of the clothing of the Russian sailors, consisting in part of a sheepskin great coat with the woolly 
side inward, and from the crowded condition of the ship, the effect of the first fumigations was so 
perceptible that the Russian surgeons were inclined to continue them. Fumigations were also 
instituted on the 16th of December on board the " Pimen," of 66 guns, Captain Colokolsoff, when 
the infection had reached such a height that communication with the other ships was forbidden ; 
also in the ship " Katvezan," and the frigate " Revel," where a malignant fever had discovered 
itself. 
The acid fumigations arrested the disease on these ships. 
The following is the " Certificate of Captain Chichagoff, Commanding Officer of the Russian 
Fleet, in the absence of His Excellency, Admiral Hannicoff, dated Chatham, March 9th, 1796. 
" It has been observed that the fumigation with the nitrous (nitric) acid, introduced by M. 
Menzies on board the ship " Pamet Eustaphia " has produced in a short time the best effect in 
stopping the progress of the fever and other evils, which were then evidently increasing, for which 
reason it was not only regularly continued on board of that ship, even after M. Menzies' departure, 
but adopted on board of others, and always found useful. It is, therefore, my duty to certify by 
this, not only the good consequences that have been observed from that useful contrivance, but 
even the advantage that arises from its easy and sure execution in comparison with other means 
of fumigating the ships, which requires greater attention from the fire that must be made use of, 
and therefore cannot be effectual in all parts of the ship." 
Those writers, as Dr. Parkes, are in error who refer the experiments of Mr. Menzies, at 
Sheerness, with nitrous acid fumigations, according to the method of Dr. Smith, to the year 1785. 
England was at peace with other nations from 1783 to 1793. In the year specified in the "Accounts 
of the Experiments made at the Desire of the Lords Commissioners of the Admiralty," namely, in 
1795, England was in alliance with Russia, and the fleets of the two nations were acting in con- 
junction. 
Fumigations of nitrous acid were employed by Ramon da Luna,* in yellow fever, and it is 
asserted that no agent was so effectual in arresting the spread of the disease.")" 
I have shown by numerous experiments upon living animals with the binoxide and peroxide 
of nitrogen, liberated by the action of nitric acid on copper filings, that these gases are powerful 
poisons, exciting the muscular, nervous, respiratory and circulatory systems, and, finally, pro- 
ducing pulmonary congestion and inflammation, coma, convulsions and death. The blood in all the 
vessels and organs of the body presents a brownish, bleached appearance after poisoning by this 
gas. I also employed both nitric acid and chlorine in disinfecting wards of Confederate hospitals 
crowded with sufferers from typhoid fever, measles and mumps during the civil war, 1861-65. 
Chlorine, regarded by many as a much more powerful disinfectant, before which muriatic 
acid, nitric and nitrous acids were destined to give way, was introduced as a fumigating agent 
by Fourcroy in 1791-2 ; and the gas was subsequently introduced into England as a disinfecting 
agent by Dr. Cruikshank. 
* Ann. d'Hygiene, Avril, 1861. 
t" Medical and Surgical Memoirs," Vol. I, pp. 298, 327, 512. 346 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
NOTE 10. ACID FUMIGATIONS ACCORDING TO THE PROCESS OF MR. CRUICKSHANK. 
This process is described in a work by Dr. Rollo, on the diabetes mellitus, published at 
London in 1797. The substance which is the active agent in this process is really chlorine, but 
designated by Cruickshank as the oxygenated muriatic acid gas. 
Dr. Rollo says : " It is observed that the oxygenated muriatic acid gas was found to destroy 
the offensive smell of sores, that it destroyed specific contagion, and could be easily obtained, and 
very safely used. We had, therefore, given it a preference to other things ; and in order that it 
may be more generally tried, we must insist on Mr. Cruickshank's manner of procuring and using 
it in the wards of this hospital. 
" This consists in intimately mixing two parts of common salt and one of crystallized man- 
ganese previously reduced to powder. Two ounces of this compound are introduced into a small 
basin ; about an ounce of water is then added, and afterward an ounce and a half of the concen- 
trated vitriolic or sulphuric acid, at different times, so as to preserve a gradual discharge of the 
oxygenated muriatic gas. One of these basins is sufficient for a ward or room containing five or 
six beds, and more must be employed according to the size of the apartment." 
As long ago as 1807 fumigations of chlorine were used by Mojon* to destroy the emanations 
from the stools of dysentery, with the best effects ; and this gas has also been employed as a dis- 
infectant in typhus exanthemicus. Many experiments made in Austria and Hungary, in 1832, 
seem to prove that chlorine diffused in the air has no action on the spread of cholera. Mr. 
Herapath, of Bristol, asserted, in 1849, that it was a complete preservative, and an opinion partly 
to the same effect was expressed in Paris in 1865 ; but the Hungarian experiments are much 
more conclusive, inasmuch as they were positive, and not negative, results-that is to say, chlor- 
ine did not prevent the outbreak of cholera. Charcoal also, so far, appears inert, as in the 
Crimean war cholera prevailed severely on board a ship loaded with charcoal. 
On the other hand, Ramon da Luna has asserted that nitrous acid has really a preservative 
effect against cholera, and that no one was attacked in Madrid who used fumigations of nitrous 
acid. But negative evidence of this kind requires to be on a very large basis to prove such an 
action. At the same time, the facts should certainly lead to a fair trial of nitrous acid fumes in 
all cholera epidemics. In none of the trials, however, were the substances added to the stools ; 
they were merely diffused in the air.f 
The testimony of Mojon, in 1807, as to the value of chlorine fumigations in dysentery is posi- 
tive. Thus he says :- • 
" The dysentery became contagious in the hospital at Gdnoa ; almost all the sick of my divi- 
sion, nearly two hundred, were attacked. And, as we know that this disease, when contagious, 
is communicated ordinarily from one person to another by the abuse, which exists in all hospitals, 
of making the same latrines serve for all the sick of a ward, I wished to see if fumigations of 
chlorine had the power of destroying these contagious exhalations. I therefore caused fumiga- 
tions to be used twice daily in the latrines, and in a few days I was able to destroy that terrible 
scourge which already had made some victims." 
It appears that the chlorine was therefore in the air, and not added to the stools. 
Chlorine, although widely diffused through nature in combination with metals, and especially 
with sodium, was not known in the uncombined state until 1774, when it was discovered by 
Scheele, and its elementary nature was first established by Davy in 1810. In order to understand 
the terms used by those who first employed chlorine as a disinfectant, it is important to note the 
following facts : Chlorine was originally regarded as a compound body, namely, Oxygenized 
muriatic acid, or oo-ymuriaitc acid. Muriatic acid was supposed to be a compound of oxygen 
with the unknown radicle muriaticum, or mwtm, and chlorine or oxygenized muriatic acid, was 
supposed to contain the same radicle united with a larger quantity of oxygen. 
Chlorine owes its disinfecting properties to the following well-established facts :- 
Chlorine is one of the heaviest substances that are gaseous at common temperatures, being 35J 
times heavier than hydrogen, and 2| times heavier than atmospheric air, and hence the hold of 
a ship, or any confined space, may be readily filled with this gas by simple displacement of the 
atmospheric air and foul gases. 
* Chevallier. "Traité des Désinfectants." 
t" A Manual of Practical Hygiene, etc." By Edmund A. Parkes, m.d. Sec. Ed. London, 1886. p. 85. SECTION XV PUBLIC AND INTERNATIONAL HYGIENE. 
347 
It has a pungent, irritating smell, and is irrespirable unless very much diluted. I have in the 
first volume of my Medical and Surgical Memoirs (pp. 297, 303, 304, 314), by a series of experi- 
ments, illustrated the action of chlorine upon living animals, and demonstrated that, when 
largely diluted with atmospheric air, or with water, this gas acts as a powerful cardiac stimulant, 
increasing both the force and frequency of the heart's action ; and that when inhaled in large 
quantities, it acts as a powerful irritant upon the mucous surfaces of the throat and lungs, 
inducing pulmonary congestion, pneumonia, convulsions and death. When absorbed it combines 
with certain constituents of the blood, and chiefly with the coloring matter of the colored corpus- 
cles. After death caused by the inhalation of chlorine, the blood from all parts of the body, as 
well as the muscles of the heart and of voluntary motion, presents a brown and bleached appear- 
ance. Chlorine is in like manner destructive of plants. 
If certain diseases, as the various forms of malarial fever and yellow fever, he propagated by 
animalcules or fungi, or by living germinal matter, or by organic compounds having an analogous 
composition and acting in an analogous manner to ferments, chlorine disinfects, by destroying 
life, and chemically altering the organic compounds subjected to its action. 
It is well established that chlorine possesses very active chemical properties, and gives origin 
to many phenomena of combination, substitution and indirect oxidation. It is moreover non- 
inflammable, and does not unite directly with oxygen under any circumstances. At ordinary 
temperatures, chlorine combines directly with all the metals, with many metalloids, such as hydro- 
gen and phosphorus, and many compound bodies, as sulphurous anhydride, olefiant gas, ben- 
zine and carbonic oxide. Paper dipped in oil of turpentine, and plunged in a vessel of chlorine 
gas, takes fire spontaneously, yielding abundance of hydrochloric acid and carbon. Chlorine 
displaces bromine, iodine and fluorine from their combinations, by equivalent substitution. 
Chlorine also displaces hydrogen by equivalent substitution, one-half of the chlorine taking the 
place of an equivalent quantity of hydrogen, while the other half unites with the hydrogen 
eliminated. Chlorine, by combining with hydrogen or a metal, acts indirectly as an oxidizing 
agent. Chlorine destroys the color of most organic pigments, and this bleaching action is usually 
accompanied by oxidation and substitution. 
Chlorine also destroys odors of various kinds, and possibly infectious miasmata, and poisonous 
organic compounds, by abstracting hydrogen, with or without substitution, or by indirectly 
oxidizing. 
Chlorine, therefore, acts upon organic compounds, and alters their chemical and physical 
properties, in four distinct modes. 
1. It may enter into direct combination. 
2. It may simply remove hydrogen, as in the conversion of alcohol into aldehyd. 
3. It may act as an oxidizing agent, by liberating oxygen from water. 
4. It may produce compounds by substitution, in which hydrogen is diplaced atom for atom 
by chlorine, and hydrochloric acid escapes. 
This kind of substitution is of frequent occurrence, and some of the most instructive instances are 
offered by the action of chlorine upon ether and other derivatives of alcohol. By attention to a num- 
ber of precautions, a succession of compounds is furnished in which, atom for atom, the hydrogen 
is displaced by chlorine, until at length the last product obtained is the solid chloride of carbon. 
The discovery that the substitution of chlorine for hydrogen was practicable, at first excited 
the greatest astonishment among chemists, since, owing to the powerful attraction of chlorine, 
particularly when its electrical opposition to hydrogen is borne in mind, the possibility of such 
an occurrence was never suspected. The displacement of oxygen by chlorine was familiar to the 
mind of the chemist, but the displacement of hydrogen by chlorine was a circumstance in oppo- 
sition to the doctrines of chemical attraction then prevalent. The discovery of this remarkable 
fact has led to the production, by substitution, of an immense number of analogous compounds in 
other groups of organic bodies. 
It is evident, from the preceding facts, that the discovery of chlorine, and its application to 
the destruction (disinfection) or chemical alteration of putrefying and fermenting organic com- 
pounds and animal poisons, were most important advances in sanitary science. 
As we have seen, the application of the so-called oxygenated muriatic gas (chlorine) was 
employed at the close of the last century an 1 in the beginning of the present, with success, both 
in France and in England, in the destruction of contagion or infection. 348 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
METHODS OF FUMIGATION PRACTICED IN THE BRITISH NAVY DURING THE EIGHTEENTH AND 
NINETEENTH CENTURIES. 
The following method of extricating chlorine (oxygenated muriatic gas), for the fumigation 
of ships, was recommended to Dr. C. Chisholm* by Mr. Cruickshank, Chemist to the British 
Board of Ordnance :- 
"Let four pounds of common salt be intimately mixed with a pound and a half of manganese 
reduced to a fine powder. Introduce them into a leaden vessel, with a cover, and add about two 
pounds of water through a hole in the cover. By means of a glass funnel introduce, by degrees 
and at different times, three and a half pounds of vitriolic acid. In every addition of the 
vitriolic acid the oxygenated gas will escape, in great abundance, through a tube connected with 
the vessel, and may be directed to any place and in any quantity we please. By the application 
of a moderate heat to the vessel a very considerable quantity of gas may be obtained from the 
same materials, after they have ceased to give out any in the cold." 
Dr. Chisholm affirmed that : " This acid, in moderate quantities, may be employed to correct 
putrid and offensive smells in any particular ward, without removing the patients, and this it 
effects more completely than vinegar or any other means usually employed." 
Dr. Thomas Trotter,f Dr. C. ChisholmJ and Dr. Samuel L. opposed the method of 
Dr. Carmichael Smyth, for preventing or stopping contagious diseases on shipboard by nitrous 
fumigation ; \yat this discussion is not worthy of further consideration, as the writings of Drs. 
Trotter, Mitchell and Chisholm on this subject are singularly wanting in accurate details of 
experiments illustrating the exact value of the so-called nitrous fumigations, although these 
authors possessed superior advantages for a thorough and scientific investigation of the subject. 
Dr. Trotter justly lays great stress upon the value of free ventilation in ships; Dr. Mitchell 
advocated strenuously the use of lime for the destruction of septic poison, and Dr. Chisholm, while 
admitting the value of free ventilation, advocated the use of vinegar as a disinfectant in ships 
and hospitals. 
Dr. Lind,|| one of the highest authorities of his day in all that relates to the hygiene of ships 
and seamen, in speaking of certain contagious diseases, says :- 
"The clearest idea we can conceive of the manner in which this infection is communicated is 
to suppose there is, in all infected places, adhering to certain substances an envenomed nidus, or 
source of effluvia corpuscles, or whatsoever infection may be supposed to consist, and that, as the 
air is more or less confined, becomes more or less strongly impregnated with them." 
In some parts of his valuable papers on fever and infection, Dr. Lind appears to be satisfied that 
animalcule had nothing to do with the propagation of contagion ; but in the preceding quotation 
he modifies the old doctrine and expresses it in terms closely allied to those used by some modern 
writers. Dr. Lind looked upon infected clothing as the envenomed nidus, where a new genera- 
tion of corpuscles were multiplied, which gave to the noxious matter an increased virulence, and 
became more certainly productive of the disease than when it first diffused itself from the body. 
That this was his meaning is abundantly confirmed by his rules for expelling and purifying 
contagion. Every substance which he prescribes is with the direct intention to destroy animal 
life; hence, the heat of an oven, fumigations with sulphur (brimstone), gunpowder, tobacco 
smoke, boiling vinegar, etc., are his main agents. 
It was not merely to purify clothes, bedding, and other substances, that Dr. Lind applied 
fumigations with these substances, but the wards of the sick in hospitals and the decks and holds 
of ships became also subject to the process. 
The population of a British ship of war before the application of steam to navigation was 
more dense than that of the most crowded city ; and hence, from the earliest history of the navy 
*"An Essay on the Malignant Pestilential Fever introduced into the West India Islands from 
Boullam, on the Coast of Guinea, as it appeared in 1793, 1794, 1795 and 1796, etc." By C. Chisholm, m.d. 
2d Ed. London, 1801. p. 30. 
j-" Medicin a Nautica ; an Essay on the Diseases of Seamen." 3 Vols. 2d Ed. London, 1804. Vol. I, 
pp. 171-251, pp. 302-362, pp. 431-457; Vol. II, pp. 32-78, pp. 274-436; Vol. in, pp. 144-298. 
J "An Essay on Malignant Pestilential Fever, introduced into the West India Islands, 1793, 1794, 
1795 and 1796." 2d Ed. London, 1801. Vol. n, pp. 25-36. 
§ The Medical Repository. Conducted by Samuel L. Mitchell, m.d., Edward Miller, m.d. and Elisha 
Smith. New York. Vols. I, it, in and IV. || Papers on Infection. SECTION XV PUBLIC AND INTERNATIONAL HYGIENE. 
349 
of this great and conquering nation we find that minute attention was paid to the health of the 
seamen ; and measures were adopted at an early day for the arrest of those contagious diseases,, 
as typhus and yellow fever, which were prone to spread with great rapidity, and to commit fear- 
ful ravages in fleets. And it is but strict justice to say" that, while the world is indebted to Eng- 
land for the discovery of the means of arresting smallpox and preventing the fearful ravages of 
scurvy in navies and armies, we are also indebted to the same country for the first and most thor- 
ough system of fumigating and disinfecting ships affected with contagious diseases. 
In proof of this assertion, we select the following account of " The Means used to eradicate 
a Malignant Fever which raged on hoard His Majesty's ship 'Brunswick,' at Spithead, in the 
spring of the year 1791 ; with some short observations on the most probable Means of preserving 
the Health of a Ship's Company : by Sir Roger Curtis,* the captain of the 'Brunswick.' " 
" The health of the crews of His Majesty's ships is a consideration of so important a nature 
that whatever may contribute to its preservation, or to the removal of contagion when it unhappily 
exists among them, are circumstances which merit the serious attention of every officer. Those 
who are conversant with our maritime history must have regarded with horror the dreadful havoc 
which disease, for a long continued series of years, made among the seamen of this country. They 
will have observed that disease carried off a hundred times more than fell by the hands of the 
enemy. During these unhappy periods it is true that medical skill had not reached the degree 
of perfection it now possesses; but the- chief cause of the dreadful calamities which befell our 
fleets was the want of that order, cleanliness, and internal economy which is now more generally 
observed. It is now proved that a due attention to these circumstances operates most powerfully, 
in all situations, toward the preservation of health. But, notwithstanding the strictest adherence 
to the wisest precautions, disease but too often finds its way among us. Fevers of the most infec- 
tious and dangerous kind frequently rage in our ships. They are sometimes generated there, 
by a want of cleanliness in the ships and in the people ; but they are more generally propagated 
by the introduction of infected persons. 
" When contagion has once taken root in a ship the different parts of it, as well as the per- 
sons and clothes of the crew, become highly infected, and it cannot be removed without great 
labor and perseverance. Under circumstances where neither the stores nor the crew can be 
removed from the ship the difficulty of eradicating infection is greatly augmented ; but even thus 
situated it is possible to be effected. It requires, however, great and unremitting pains. The 
slight and ordinary modes of fumigation, by correcting the air, are serviceable in the prevention 
of sickness ; but when contagion is established a more powerful application of it, and other 
means, must be adopted. 
" The ' Brunswick ' was afflicted with a putrid and highly infectious fever, when lying at Spit- 
head, in the spring of 1791, which raged so violently that frequently ten or fifteen men would 
fall down in it in a day, and more than one hundred and fifty were in the hospital at Haslar at 
one time. 
" Its progress in the ship was, however, at last arrested, and the means made use of as here- 
after related, that they may be followed by others under similar circumstances, if they are 
deemed to be deserving of notice. 
" As seamen have great reluctance in complaining when they find themselves but slightly 
indisposed, and it being very material that infected persons should, as speedily as possible, be 
removed from the body of the ship's company, to impede further communication of the disease 
as well as to facilitate the care of those attacked by an early application of medicine, great 
attention was observed by all the officers in immediately reporting every man who appeared to 
have the smallest indisposition, whether it was discovered by day or by night. The whole space 
under the forecastle, on the larboard side, including the round house, was appropriated to the sick, 
and the obtrusion of any other person absolutely prevented. To this place every person was 
removed the moment it was discovered that the disease had seized him, and the primary remedies 
toward cure immediately applied, from whence, as speedily as could be, he was carried to the 
hospital, care being had that everything belonging to him was sent with him. 
"Moisture operating more powerfully than any other cause in the production of disease, as 
* Captain of the Fleet of Lord Howe. "Medicina Nautica." An Essay on the Diseases of Seamen, by 
Thomas Trotter, m.d., etc., Vol. I, pp. 431-139. 350 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
well as in the propagation of it, the first care was the endeavor to remove all humidity and foul- 
ness of air. 
" The well was bailed out, scraped and swabbed till entirely dry, and then a large fire was kept 
burning in it for several hours every day, so that the smallest dampness therein was not suffered 
to remain. The hold had the upper tier of casks removed from it and sent on shore. Three 
fires were then kindled in it and kept burning for many hours every day, confining the smoke as 
much as possible and occasionally shifting the fires from place to place; and in the fuel made 
use of as many empty tar barrels were consumed as could be collected for the purpose ; at other 
times, wood, and occasionally coal, intermixed with shavings of tarred ropes, every precaution 
being constantly taken to prevent accident. When the fires were extinguished, the gratings of 
the hold were removed and the wind-sail let down. The orlop was constantly kept as clear as 
possible of everything that prevented a free circulation of air, and a fire placed sometimes in one 
part of it and sometimes in another. The cockpit, steward room and bread room were treated in 
the same manner. The doors of all the store rooms were occasionally thrown open and the 
ventilators worked unremittingly day and night. 
" Three fires on each side the 'tween decks were kept burning almost the whole day, and these 
were, from time to time, shifted to every part of it. The manger was cleared of all manner of 
lumber and a fire occasionally placed therein. The deck was seldom washed and never but when 
the weather was such that the people could remain upon the upper deck until it was perfectly 
dried by the fires and the natural current of the air. Nor was any person permitted to go below, 
under any manner of pretence, until the general permission for it was given. When the deck 
was not washed it was kept perfectly clean by other means, and slops about the decks, and every 
sort of dampness, was especially guarded against. The sides, beams, carlings, the deck overhead 
and every part of the 'tween decks were whitewashed twice or thrice during the course of the 
disorder. 
"Fumigation in the hold was thus conducted: four half tubs with stands in them were dis- 
posed therein. In each of the tubs was placed an iron pot into which was put almost two pounds 
of brimstone tied up in a piece of canvas. The gratings were laid and so closely covered with 
tarpaulins, old hammocks, swabs, etc., that none of the smoke might escape. When everything 
was prepared, a red-hot loggerhead, or iron lid, was put into each of the iron pots, which set fire 
to the brimstone; and the men performing this service immediately leaving the hold, by a grat- 
ing of the main hatchway being kept open for the purpose, the hatches were entirely closed. 
" It was the custom to fumigate the hold, orlop and 'tween decks at the same time, but as we 
could not be furnished with a sufficient quantity of brimstone to make use of it in all the dif- 
ferent parts of the ship at the same period, it was usual, therefore, to use the brimstone in the 
hold, orlop and between decks in rotation; and when the brimstone was not applied, there were 
substituted what are called devils, made of powder wetted with vinegar. In those parts of the 
'tween decks least accessible to air, and where, consequently, there is a greater degree of con- 
tagion, the flashing of powder from pistols is attended with very good effect, for the shock of the 
explosion assists very powerfully in dispersing the infectious matter attached to the timber of 
the ship. 
" During the fumigation, the men's hammocks were all hung up in their places, with their 
mattresses and blankets spread over them, and all their spare apparel was so disposed of upon 
the guns, etc., as to receive the full effects of the fumigation ; and the clothes which the men wore 
upon deck during the time of one fumigation, were changed upon the next and placed below, 
that all their things might receive equal purification. 
" The gratings on the main deck were laid and covered with such care that no smoke could 
escape, and the pots were carefully barred in. The brimstone in tubs, or the devils, with other 
safe precautions, were dispersed about the decks and then lighted, the persons who did it escap- 
ing upon deck and closing the hatchway after them ; the operation was completed. 
"The smallest crevices of the ship were pervaded by the smoke and effluvia of the brimstone 
and affected every part of her in a powerful and astonishing manner. 
" Three hours were generally suffered to elapse before the gratings were uncovered and the 
ports opened, and a free circulation of the air for a very considerable time was afterward necessary 
before a person could remain below without inconvenience. The whole of the hull of the ship 
and everything therein, animate and inanimate, were strongly impregnated with the fumes of SECTION XV PUBLIC AND INTERNATIONAL HYGIENE. 
351 
brimstone, and to such a degree that it was perceptible when to leeward of the ship, at a con- 
siderable distance from her. 
" In damp weather these fumigations were practiced every day, and never less than three 
times a week. The fires were continued daily. 
" The sick berths were attended to with the same solicitude, to impede and eradicate infection, 
as has been described in respect to other parts of the ship. Nor were the persons and apparel of 
the men disregarded. Every man in the ship was washed from head to foot with warm water and 
soap, and more than even our usual pains were taken that they should be cleanly in all respects. 
If any old and useless clothes were found, they were thrown overboard. Such serviceable apparel 
as was discovered the least filthy was washed and fumigated, and the men were forbidden to wear 
woolen trowsers. On fine days the whole of their bedding was hung upon lines between all the 
masts and in the rigging, and exposed thus to a free ventilation for many hours, and the clothes 
of every kind were treated in the same manner. 
" The recovered men, returned from the hospital, were treated, upon their coming back to the 
ship, with great precaution. Having received, at the hospital, notice of their recovery and the 
intention of their return, a careful officer was sent thither to see all their clothes and bedding 
well aired, by being spread abroad for two days, and well beaten and cleaned, previous to their 
coming to the ship. Upon their arrival on board, every man was washed in warm water and 
with soap, and an entire change of clothes was then put upon him; all the rest of his apparel 
and his bedding were immediately fumigated with brimstone, which was performed by suspend- 
ing it over the fumes issuing from an iron pot, placed in a half tub, in a convenient place under 
the forecastle. 
" Such were the means made use of with punctual and unceasing perseverance. They cer- 
tainly were attended with no little labor, but the fever with which they were afflicted having been 
entirely subdued, the gratification arising from the reflection that our endeavors were crowned 
with success was the most ample recompense for all our trouble." 
OBSERVATIONS OF JOHN HUNTER * M.D., ON THE " PRECAUTIONS TO BE TAKEN IN SENDING 
TROOPS TO THE WEST INDIES; AND OF THE MEANS OF PRESERVING THEIR HEALTH 
IN THAT CLIMATE, 1781-1788." 
The following observations were made, while Dr. John Hunter had the care and superintend- 
ence of the Military Hospitals, in the island of Jamaica, from the beginning of the year 1781 
till the month of May 1783. The first edition of his work was published in 1788, and contained 
certain suggestions for the preservation of the health of the British troops, which were not modi- 
fied in the succeeding editions, and from which we have condensed the following analysis. 
From the first discovery of the West Indies, all expeditions and immigrations to that part of 
the world have been attended with great mortality. Columbus and his companions suffered 
severely, and succeeding adventurers have not been more fortunate. The first British Military 
expedition of any consequence to the West Indies, was sent against Hispaniola, by Oliver Crom- 
well; but failing in an attempt upon that Island, they attacked Jamaica, with better success. 
The far greater part of the troops perished by sickness in a short time. The unfortunate expedi- 
tion of the English against Carthagena is memorable, not less from the mortality that attended it, 
than from its failure ; and though England in a subsequent war, was more fortunate in her 
attempts upon Martinique, Guadaloupe, and the Havannah, yet it is a melancholy truth that 
there were few of the conquering troops alive six months after their victories. Great losses were 
sustained in the war which closed in 1783, particularly at St. Lucia, Jamaica, and on the Spanish 
Main. Four regiments were sent from England, in 1780, to Jamaica; they arrived there on the 
11th of August, and before the end of January ensuing, not quite six months, nearly one half of 
them were dead, and a considerable part of the remainder were unfit for service. Notwithstanding 
these repeated losses, and the West Indies having been a principal seat of war between France 
and England, no steps adequate to the importance of the object had been taken to guard against 
the mortality. 
* "Observations on the Diseases of the Army in Jamaica, and on the best means of preserving the 
health of Europeans in that climate; also observations on the Hepatitis of the East Indies." By John 
Hunter, m.d.f.r.s., etc., Physician to the Army. 3d edition, London 1808. pp. 10-31. 2d edition, 1795, 
pp. 10-31. 352 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
The disorders that prove fatal to soldiers and Europeans in general in the West Indies are of 
two kinds, namely, fevers and fluxes. They are the concomitants of armies in all parts of the 
world, but in tropical countries they rage with peculiar violence. The means recommended by 
Dr, John Hunter, of preserving the health and lives of soldiers in the West Indies were briefly 
as follows. 
1. The troops to be sent should consist of well disciplined, and not new-raised men; for the 
latter being less orderly, and not accustomed to the life of a soldier, are more liable to disease, 
from the necessary confinement on board the transports on their passage, and suffer greatly more 
from the climate than men habituated to discipline. 
2. The men should be embarked at a proper time of the year, that is, about the end of Sep- 
tember, in order that they may arrive in the West Indies both at the coolest and most healthy 
season of the year. They should proceed directly to the place of destination, without touching 
at any of the islands, where they seldom fail to contract much sickness. If, however, it be abso- 
lutely necessary to stop at one or other of the islands, to be supplied with laboring negroes, or for 
other purposes that the service may require, the troops should be kept on board the transports; 
and the transports should be anchored in a healthy station, at a distance from and not to the 
leeward of marshy ground. 
3. When the troops are embarked, which they should be on board roomy transports, the utmost 
attention ought to be paid by the officers to keep the men clean, both in their persons and berths. 
This is done by dividing them into two or more watches ; and making them come regularly upon 
deck every day with their bedding; also by scraping, smoking, and cleaning between decks daily, 
and by washing their clothes once or twice a week. 
4. When the troops arrive in the West Indies, they should be quartered in barracks erected in 
healthy situations; and when the accommodations on land, in houses, are insufficient, they should 
remain on board the transports till the buildings are erected, for the air at sea is pure and 
healthy, and productive of none of the diseases of the country. It has always been found most 
fatal to encamp troops in the West Indies, and it should never be done except on actual service. 
In regard to healthy situations for barracks, there are two kinds; namely, dry, sandy peninsu- 
las or islands near the shore, and elevated situations in the mountains. Elevated and mountain- 
ous situations, are more uniformly healthy than dry and sandy places on the coast; for the 
neighborhood of marshy ground, or accidental inundations may render these last unhealthy. 
5. When the troops are properly disposed of as to barracks, there should be a certain number 
of negroes attached to each regiment, to do whatever duty or hard work is to be done in the 
heat of the day, from which they do not suffer, though it is fatal to Europeans. 
6. The soldiers should be supplied with provisions from the government. 
7. The men should be frequently out at exercise; and if it be in the morning, and not con- 
tinued too long, it will contribute to their health. The evenings are also cool, but motion, even 
the most moderate, is attended with profuse perspiration, in which situation the men exposing 
themselves to the cool air of the night, with wet shirts upon their backs, become liable to colds, 
rheumatism, and other complaints. But after the morning exercise the heat of the day follows 
and prevents any evils of that kind. 
OBSERVATIONS OF SIR GILBERT BLANK, M. D., ON THE CAUSE OF SICKNESS IN FLEETS AND THE 
MEANS OF PREVENTION, 1780-1799. 
In the year 1780 Sir Gilbert Blane printed a treatise for the use of the British fleet, contain- 
ing general rules for the prevention of sickness, and reproduced it, with some additions, in his 
Observations on the Diseases of Seamen, the third edition of which was published in London in 
1799. 
The work of Sir Gilbert Blane was the result of several years of labor employed in the Public 
service, chiefly under Admiral Lord Rodney, in a series of naval operations which were produc- 
tive of events more glorious than any before recorded in the annals of Britain. His opportunities 
of experience were sufficiently extensive to entitle his observations to a permanent place in the 
annals of medical science. 
The following outline will be confined chiefly to an analysis of those portions of the labors of 
Sir Gilbert Blane which relate to the hygiene and disinfection of ships. 
It would be useless to enumerate the accounts furnished by history of the losses and disap- SECTION XV PUBLIC AND INTERNATIONAL HYGIENE. 
353 
pointments to the public service from the prevalence of disease in fleets. Sir Richard Hawkins, 
who lived in the beginning of the last century, mentions that in twenty years he had known of 
ten thousand men who had perished by the scurvy. Commodore Ansen, in the course of his 
voyage of circumnavigation, lost more than four-fifths of his men, chiefly by that disease. History 
supplies us with many instances of naval expeditions that have been entirely frustrated by the 
force of disease alone; that under Count Mansfeldt in 1624; that under the Duke of Buckingham 
the year after ; that under Sir Francis Wheeler in 1693 ; that to Carthagena in 1741 ; that of the 
French under D'Auville in 1746 ; that of the same nation to Louisbourg in 1737. When Henry 
V was about to invade France, he had an army of fifty thousand men ; but owing to sickness 
which arose in the army in consequence of some delay in the embarkation, their number was 
reduced to ten thousand at the battle of Agincourt. The disease of which they died was chiefly 
the dysentery. 
That the health of a ship's company depends in a greater measure upon the institution of 
measures within the power of the officers than upon mere medical care and treatment, is strongly 
evinced by the fact that different ships in the same situation of service enjoy very different 
degrees of health ; and it has been frequently observed in great fleets that out of ships with the 
same complement of men, who have been the same length of time at sea, and have been victualed 
and watered in the same manner, some are extremely sick while others are free from disease. 
The diseases most prevalent among seamen are fevers, fluxes and the scurvy ; while on the 
other hand they are to a great extent exempt from such diseases as the gout, gastric complaints, 
hypochondriac and nervous disorders, to which the indolent and luxurious are subject. 
Man being formed by nature for active life, it is necessary to his enjoying health that his 
muscular powers should be exercised and that his senses should be habituated to a certain strength 
of impression. It is to be remarked, however, that exercise and temperance may be carried to 
excess, and that in these there is a certain salutary medium ; for when labor and abstinence 
amount to hardship they are equally pernicious as indulgence and indolence. This is strongly 
exemplified in seamen ; for, in consequence of what they undergo, they are generally short-lived, 
and have their constitutions worn out ten years before the rest of the laborious part of mankind. 
A seaman at the age of forty-five, if shown to a person not accustomed to be among them, would 
be taken by his looks to be fifty-five, or even on the borders of sixty. The most common chronic 
complaints which a long course of fatigue, exposure to the weather and other hardships, tend to 
bring on are pulmonary consumption, rheumatism and dropsies. It is also to be considered that 
these complaints, particularly the last, are further fomented by hard drinking, which is a common 
vice among this class of men, and they are led to indulge in it by the rigorous and irregular course 
of duty incident to their mode of life. To these complaints should be added those foul and 
incurable ulcers which are so apt to arise at sea, particularly in a hot climate. The slightest 
scratch or the smallest pimple, more especially on the lower extremities, is apt to spread and to 
become an incurable ulcer, so as to end in the loss of a limb. The nature of the diet and the 
malignant influence of tropical climates both conspire in producing them. 
Though the venerea! disease is less frequent in the sea service than in other situations, 
owing to the opportunities of infection being more rare, yet there is reason to think that it. 
may have owed its origin to a sea life. It is now agreed by those who have fully considered 
the subject, that this disease was not found among the natives of the New World at its dis- 
covery, for no such fact is mentioned in the narrative of Columbus or his son. But it seems 
that Europeans, after making longer voyages than they had ever before been accustomed to, and 
living long upon corrupted and unnatural food, might under such a peculiar concurrence of cir- 
cumstances, engender a new disease when they return into port, more especially when they come 
to be connected with the females of a new race of people, so different in their constitutions and 
mode of life. This is corroborated by what happened in our own times in the islands of the South 
Sea, in which this disease was not known before they were discovered, but appeared upon the 
arrival of the Europeans, though the ship's crew were declared by the surgeons to be free from it. 
The diseases most frequent and prevalent at sea have this advantage, that they are more the 
subjects of prevention than most others, because they depend upon remote causes that are assign- 
able, and which increase and diminish according to certain circumstances which are, in a great 
measure, within our power. 
The prevention of diseases is an object as much deserving our attention as their cure, for 
Vol. IV-23 354 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
the art of physic is at best but fallible, and sickness, under the best medical management, is 
productive of great inconvenience, and is attended with more or less mortality. The means of 
prevention are also more within our power than those of cure; for it is more in human art to 
remove contagion or alter a man's food and clothing, to command what exercise he is to use and 
what air he is to breathe, than it is to produce any given change in the internal operations of the 
body. What we know concerning prevention is also more certain and satisfactory, inasmuch as 
it is easier to investigate the external causes that affect health, than to develop the secret springs 
of the animal economy. 
The prevention of disease has relation only to external causes that affect health, and are 
considered by Sir Gilbert Blane under the four heads of 1. Air; 2. Aliment; 3. Exercise; 4. 
Clothing. Sir Gilbert Blane also devotes a section to the consideration of the regulation of heat 
and cold, and observes that the direct rays of the sun not only produce that sudden and fatal 
affection called the Coup de Soleil, but exposure to them is one of the principal causes of the 
very fatal diseases of newly-arrived Europeans. There can be no doubt but that fatigue and 
intemperance conspire to the same effect, but these do not produce the like diseases in temperate 
or cold climates. It is evident from this why women are so much less subject to the fevers of 
tropical climates than men. That this is not merely owing to something in the constitution 
peculiar to their sex, is proven by another striking fact. The prisoners of war who were not 
under the influence of disease at their capture, were observed to remain exempt from the epi- 
demic fevers of the West Indies. This has been particularly conspicuous in the years 1794 and 
1795, during which the most deplorable ravages ever known were made in the great armaments 
sent to the West Indies, yet the prisoners of war remained exempt from it, according to the 
testimony of those who had the custody of them at Jamaica and Antigua. There can be no doubt 
that the peculiarity of situation to which this is principally imputable is shelter from the sun. 
With reference to the noxious effects of land air in particular situations, Sir Gilbert Blane 
observes :- 
"The common air of the atmosphere at sea is purer than on shore, which gives to a sea life a 
very great advantage over a life on land. This advantage is still greater in the tropical regions, 
where the foul air, especially such as proceeds from woods and marshes, is so fatal, and where 
the heat is also considerably less at sea than on shore. But this superior purity of the air at sea 
is more than counterbalanced by the artificial means of propagating diseases on board of a ship. 
All the diseases incident to a fleet, except the scurvy, are more apt to arise in a harbor than at 
sea, and particularly the violent fevers peculiar to hot climates. There are generally woods and 
marshes adjacent to the anchoring places in the West Indies, and the men are exposed to the bad 
air proceeding from thence, either in consequence of the ship's riding to leeward of them or of 
people's going on shore on the duties of wooding and watering, or on military service. Instances 
of this without number might be adduced from the accounts of voyages to all the tropical coun- 
tries. The fatal expeditions of the British to the Bastimeqtos and to Carthagena, in former wars, 
are striking proofs of it ; and the same effects, though in a less degree, were seen while the British 
fleet was at Jamaica, in 1782. Sir Gilbert Blane has known a hundred yards in a road make a 
difference in the health of a ship at anchor, by her being under the lee of marshes in one situation 
and not in the other. When people at land are so situated as not to be exposed to the air of woods 
and marshes, but only to the sea air, they are equally healthy as at'sea. There was a remarkable 
instance of this on a small island, called Pigeon Islaryl, where forty men were employed in mak- 
ing a battery, and they were there from June to December, which includes the most unhealthy 
time of the year, without a man dying, and with very little sickness among them, though they 
•worked hard, lived on salt provisions and had their habitations entirely destroyed by the hurri- 
cane. During this time, nearly one-half of the garrison of St. Lucia died, though in circum- 
stances similar in every respect, except the air of the place, which blew from woods and marshes. 
The duties of wooding and watering are so unwholesome that negroes, if possible, should be hired 
to perform them. In general, however, the employing of seamen in filling water and cutting 
wood is unavoidable, but it should be so managed as not to allow them, on any account, to stay on 
shore at night; for, beside that the air is then more unwholsome, men, when asleep, are more 
susceptible of any harm, either from the cold or the impurity of air, than when awake and 
employed. The danger of sleeping in the Campagna of Rome, and on the road from thence to 
Naples, is a fact well known in Europe." SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
355 
As the service necessarily requires that men should be on shore more or less, however unwhole- 
some the air may be, Sir Gilbert Blane recommended the following means to prevent its pernicious 
impressions on the body, the most important of which was, without doubt, the use of Peruvian 
Bark as a prophylactic. 
He says : " Certain internal medicines, such as bitters, aromatics and small quantities of vinous 
liquors, tend to preserve the body from its bad effects. Of the bitters, Peruvian bark is, perhaps, 
the best; and there is a well-attested instance of its efficacy in the account given by Mr. Robert- 
son of a voyage in the ' Rainbow,' to the coast of Africa; and by the same means Count Boneval and 
his suite escaped sickness in the camps in Hungary, while half of the army were cut off by fevers. 
In consequence of Mr. Robertson's representation of the effects of bark in curing and preventing 
the fevers of that climate, the ships of war fitted out for the coast of Guinea have been supplied 
with it gratuitously. The fever produced by the impure air of marshes may not appear for many 
days after the noxious principle, whatever it is, has been imbibed, men having been sometimes 
seized with it more than a week after they have been at sea. It naturally occurs, therefore, that 
something may be done in the intermediate time to prevent the effects of this bad air, and nothing 
is more advisable than to take some doses of Peruvian bark, after clearing the bowels by a purga- 
tive. Some facts show that an interval of ten days or a fortnight may elapse between the imbib- 
ing of the poison and its taking effect. And in order to guard against the diseases of this climate 
in general, it would be more proper to take some large doses of bark once in either of these 
periods than to make a constant practice of taking a little, as I have known some people do, by 
which they may also render their body, in some measure, insensible to its good effects. The spices 
of the country, such as capsicum and ginger, for which nature has given the inhabitants of the 
torrid zone an appetite, have also been found powerful in fortifying the body against the influ- 
ence of noxious air. Either these or the Peruvian bark, or similar substances of a bitter and 
aromatic nature, given in wine, or if there should be none, in spirits, to men going upon unwhole- 
some duty, have been found to have a powerful effect in preventing them from catching the fevers 
of the climate." 
Sir Gilbert Blane recommends that in harbors the ship should be made to ride with a spring 
■on the cable, that the side may be turned to the wind, whereby a free ventilation will be pro- 
duced, and the foul air from the head, which is the most offensive part, will not be carried all 
over the decks, as it must be when the ship rides head to wind. 
Sir Gilbert Blane referred the origin of the jail, otherwise called the ship and hospital, fever 
to the noxious air generated by men keeping the same clothes too long in contact with the body, 
while they are, at the same time, confined and crowded in small and ill-ventilated apartments. 
Dr. Cullen also ascribed the low nervous fever of Britain to a similar origin, being caused, as he 
thinks, by an infection of a milder kind arising in the clothes and houses of the poor, who from 
sloth or indifference neglect to change their linen and air their houses. The greater number of 
fevers, particularly those of the low and malignant sort, may be traced to the want of personal 
■cleanliness and defective ventilation. 
Sir Gilbert Blane discusses at length various means of preventing the introduction of infection in 
ships, the production of infection, and the means of eradicating infection. He recommends the 
most rigid examination of all recruits and the exclusion of the diseased, and also the most thor- 
ough cleanliness of all parts of the ship and of the beds and clothing of the men, and free ventila- 
tion by means of wind-sails, ventilators and fires kindled in various portions of the ship. 
When, from a neglect of the various measures to prevent the introduction and production of 
infection, an infectious fever comes actually to prevail, and the infection, perhaps, adheres obsti- 
nately to the ship in spite of cleanliness, good air, good diet, and all the other means which, if 
employed in due time, would have prevented it, Sir Gilbert Blane recommends the following 
measures for eradicating the subtle poison :- 
The first step toward this is to prevent the disease from spreading, and this is done by sepa- 
rating the sick from the healthy, and cutting off all intercourse as much as possible. For this 
end, it is necessary to appropriate a particular berth to contagious complaints, and not only to 
prevent the idle visits of men in health, but to discover and separate the persons affected with 
such complaints as soon as possible, both to prevent them from being caught by others, and 
because recent complaints are most manageable and curable. Officers might be very useful in 
making an early discovery of complaints by observing those who droop and look ill in the course 356 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
of duty ; for seamen think it unmanly to complain, and have an aversion to being put on the sick 
list. In order to prevent sickness from spreading it is not sufficient to cut off all personal inter- 
course. The clothes of men are as dangerous a vehicle of infection as their persons ; and it should, 
be a strict and invariable rule, in case of death from fever, flux, or smallpox, to throw overboard 
with the body every article of clothing and bedding belonging to it. Upon the same principle, in 
case of recovery from any contagious disease, as it would be too great a waste to destroy the 
clothes and beds, they should be smoked, and then scrubbed or washed, before the men join their 
messes and return to duty. This precaution is the more necessary, as infection in a ship is 
extremely apt to be communicated by bedding, from the custom of stowing the hammocks in the 
netting, by which they are brought into contact with each other. 
It sometimes happens that the number of sick in a ship is so great that it is not possible to 
take proper and effectual measures on board for stopping the progress of disease. But when she 
can be cleared of the sick by sending them to an hospital, no pains should be spared to extirpate 
the remaining seeds of infection. 
For this purpose let their clothing and bedding be sent along with them ; let their hammocks, 
utensils, and whatever else they leave behind, be smoked, and either scrubbed or washed before 
they are used by other men, or mixed with the ship's stores ; let the decks, sides and beams of 
their berths be well washed, scraped, smoked and dried by fire ; then let them be fumigated with 
brimstone and charcoal, and, finally, whitewashed all over with quicklime. A mode of fumiga- 
tion has been brought into use by Dr. Carmichael Smith, the peculiar advantage of which, over 
charcoal and sulphur, is that it can be put in practice in the midst of the sick. It consists in. 
pouring strong vitriolic acid on powdered nitre, whereby the latter is decomposed and the acid 
rises in the form of fumes. 
But besides these recent infections, it sometimes happens that the seeds of disease adhere to 
the timbers of a ship for months and years together, and can be eradicated only by a thorough 
cleansing and fumigation ; sweeping, washing, scraping, and airing, are not sufficient entirely ta 
remove the subtle infectious matter ; but they will assist and will prepare it to be acted upon by 
heat and the fumes of mineral acids, which are the only means to be depended upon. 
When a ship is at sea, these precautions cannot be taken so completely ; but if infection is 
present, or is suspected, then cleansing and the nitrous fumigation may be practiced. 
It will also be of great service to make the men expose their clothes to the sun and wind, in 
order to prevent or carry off mustiness or slight infection. If a strong infection be suspected, 
and it cannot be afforded to destroy the clothes, the best means of eradicating the poison at sea is 
to hang them for a length of time over pots of burning brimstone in a large cask standing end- 
ways, with small apertures to admit air enough for the brimstone to burn; or the nitrous fumiga- 
tion may be used for this purpose. 
Fire, when it can be applied sufficiently strong, is perhaps to be considered as the principal 
agent of purification, by its heat and the ventilation it occasions. Next to this may be reckoned 
the fumes of brimstone and those of nitrous acid. The smoke of certain narcotic and resinous 
bodies has also been recommended, such as tobacco and tar. The vapor of vinegar, and the 
smoke of gunpowder have also been used, but have been known to fail. 
There is reason to think that the open air very soon dissipates and renders inert all infections 
of the volatile kind, and, of course, the warmer the air is the more readily it will have this effect. 
It is accordingly observed, that infection is much less apt to be generated about the persons of 
men, and that it adheres to them for a much less space of time in a hot climate than in a cold or 
temperate one. 
Sir Gilbert Blane saw so many instances of filth and crowding in ships and hospitals in the 
West Indies, without contagion being produced, and which in Europe could hardly have failed to 
produce it, or to render it more malignant, that he was convinced that there is something in 
tropical climates unfavorable to the production and continuance of infectious fevers. The ships 
which bring this fever from Europe generally get rid of it soon after arriving in a warm climate; 
and nothing but the highest degree of neglect can continue or revive it. 
The facts above mentioned suggested to Sir Gilbert Blane " what is related of the plague at. 
Smyrna and other places, that it disappears at the hottest part of the year. The climate being 
hotter at Cairo than Aleppo, the plague ceases a month sooner at the former than the latter. It 
is also curious and important to remark that the true pestilence never has been heard of between SECTION XV PUBLIC AND INTERNATIONAL HYGIENE. 
357 
the tropics. It is not easy to assign the cause of this effect of heat upon infection, as everything 
relating to this subject is very obscure. We can conceive it to be owing to the greater degree of 
airiness which the heat of the climate makes necessary, or to the use of fewer woolen clothes. 
There may be something in the state of the body, particularly in the pores of the skin and lungs, 
which disposes them less to produce or absorb the poisonous effluvia, or, when absorbed, it may 
more readily be thrown out by perspiration, with the other acrimony of the blood ; or more 
probably, as has been hinted above, the virulent matter is of such a degree of volatility as to be 
readily dissipated in a certain degree of heat. 
" There is a fact, which, though seemingly of a contrary tendency, yet is in reality in proof of 
the same opinion. It is, that these same diseases disappear in winter ; and the same is observed 
at Moscow and other places. In this case, the infectious matter is rendered inert, but not etctinct, 
and the return of heat sets it afloat in the atmosphere, so as to expose it to human respiration. 
" Dr. Guthrie* informs us that infection is entangled and fixed by the cold of winter on the 
doors and walls of the houses of the Russian peasants, and that upon the return of the warm 
season it is let loose by the thaw, and then becoming active produces diseases." " Observations on 
the Diseases of Seamen," by Gilbert Blane, m.d., etc. Third edition, London 1799, pp. 183-337. 
Sir Gilbert Blane describes the bad effects of foul, damp air in ships, gives minute directions 
for the change of air by means of ventilators, wind-sails and fires in the orlop and hold, and 
recommends that minute attention be paid to the choice of ballast, for that which is called 
shingle, consisting all of pebbles, is far preferable to that which is sandy and earthy, as it does 
not so readily soak and retain moisture and filth, and putrid matter may readily be washed out 
of it. Sir Gilbert Blane recommended the use of spruce beer, porter, ale and wine, instead of the 
stronger alcoholic distilled liquors. 
He says " The abuse of spirituous liquors is extremely pernicious everywhere, both as an 
interruption to duty and as it is injurious to health. It is particularly so in the West Indies, both 
because the rum is of a bad and unwholesome quality and because this species of debauchery is 
more hurtful in a hot than in a cold climate, and one of the most common causes of exciting the 
malignant fevers peculiar to tropical countries. It is with reason that the new rum is accused of 
being more unwholesome than what is old; for when long kept it not only becomes weaker and 
more mellow by part of the spirit exhaling, but time is allowed for the evaporation of a certain 
nauseous, empyreumatic principle which comes over in the distillation, and which is very offensive 
io the stomach. Another objection to the rum supplied in the West Indies is the admixture of 
lead, which it acquires from the vessels employed in distilling.f It was originally the custom to 
serve seamen with their allowance of spirits undiluted. The method now in use, of adding water 
to it, was first introduced by Admiral Vernon, in the year 1740, and got the name of grog. This 
was a great improvement, for the quantity of half a pint, which is the daily allowance to each 
man, will intoxicate most people to a considerable degree, if taken at once, in a pure state. 
" The most salutary kind of drink, next to malt liquor and spruce beer, is wine. The benefit 
which the fleet derived from it at different times, and the advantages it has over spirits, have been 
often taken notice of in the former part of this work. It seems to be owing to this that the 
French fleet sometimes enjoys superior health to ours and is less subject to the scurvy. We have 
a remarkable proof of this in comparing the fleet under the command of Admiral Byron with that 
under Count d'Estaing, when they both arrived from Europe, on the coast of America, in the year 
1778, some of the British ships having been unserviceable from the uncommon prevalence of 
scurvy, while the French were not affected with it. Wine is also preferable to every other medi- 
cine in that low fever with which ships are so much infested, and there is no cordial equal to good 
wine in recruiting men who are recovering." 
In order to preserve water pure on shipboard, Sir Gilbert Blane recommended that a pint of 
quick lime be put into each butt when it is filled. He says " It has the advantage of not being 
injurious to health, but on the contrary is rather friendly to the bowels, tending to prevent and 
check fluxes. In the year 1779, several ships of the line arrived in the West Indies from England, 
and they were all afflicted with the flux except the 'Sterling Castle,' which was the only ship in 
which quicklime was put into the water for any culinary purpose. Its action in preventing 
* Philosophical Transactions, Vol. 69. 
f See a paper on this subject in the 3d vol. of the Medical Transactions, by J. Hunter, m.d. 358 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
putrefaction consists, in part at least, in destroying vegetable and animal life. An addition of 
putrescent matter is produced in water by the generation of small insects, and the glaze that 
collects on the sides of the cask and also what collects on the surface of the water, is a species of 
vegetation, of the order called by the naturalists Algee.* Quicklime is a poison to this species of 
vegetable life, as well as to insects ; but upon whatever principle it depends, the property of it in 
preserving water sweet is so well ascertained that it is inexcusable ever to neglect the use of it." 
RULES FOR THE PREVENTION OF YELLOW FEVER, PROPOSED BY SIR GILBERT BLANK IN 1798. 
On the 26th of November, 1798, Sir Gilbert Blane addressed to Rufus King, Esq., Minister 
Plenipotentiary from the States of America to the Court of London, some remarks on the natu~e 
of yellow fever and the means of preventing it, from which the following observations are 
extracted :- 
" The first question that occurs with a view to preventive measures is whether this disease be 
infectious, and under what circumstances it is so. 
"In those situations in which I observed it in the West Indies, it was evidently so. There 
was the most incontestable evidence of this, both on board of ships and in hospitals, and the doubts 
which have been started on this point seem to have arisen from the operation of infection being 
blended with that of other causes which must concur with it in order to give it effect. 
"But whatever doubts there may be on this subject in the West Indies, there can be none in 
the climate of North America. This will be best proved and illustrated by an example. 
" On the 16th of May, 1795, the ' Thetis ' and ' Hussar ' frigates captured two French armed ships 
from Guadaloupe, on the coast of America. One of these had the yellow fever on board, and out 
of fourteen men sent from the ' Hussar ' to take care of her, nine died of this fever before she reached 
Halifax, on the 28th of the same month, and the five others were sent to the hospital sick of the 
same distemper. Part of the prisoners were removed on board the ' Hussar,' and although care was 
taken to select those seemingly in perfect health, the disease spread rapidly in that ship, so that 
near one-third of the whole crew was more or less affected by it. 
" This fact carries a conviction of the reality of infection, as irresistible as volumes of argument, 
and it further affords matter of important and instructive information, by proving that the infec- 
tion may be conveyed by the persons or clothes of men in health. 
" It is a question of still more consequence, with a view to preventive measures, whether this 
epidemic has arisen in the towns of North America from internal causes, or whether it was 
imported from the West Indies. 
" In order to decide upon this, it will be necessary to go back into the origin of the disease, in 
so far as it can be ascertained. 
"After laying together and considering fully all the facts relating to this subject, it appears to 
me that the yellow fever cannot be produced but in a season in which the heat of the atmosphere 
is pretty uniformly, for a length of time, above the 80th degree of Fahrenheit's thermometer p 
that under the influence of this heat, Europeans newly arrived, and more especially in circum- 
stances of intemperance, or fatigue in the sun, may be subject to it in many instances, but that it 
has usually become general only by the previous influence of that infection which produces the 
jail, hospital or ship fever, or from the influence of putrid exhalations ; and that when so pro- 
duced it continues itself by infection. It would be too tedious to enumerate the multiplied proofs 
of this which have occurred to me in my connection with the public service. With regard to the 
effects of ship infection, it is enough to say that the seamen of ships of war from England havin g 
infectious fevers on board were observed to be most subject to the yellow fever, when they arrived 
in the West Indies, and that the troops which have been conveyed in ill-aired, crowded and 
sickly transports, are the most liable to it after disembarking ; this applies even to that part of 
them who have arrived in health. And with regard to the effect of putrid exhalations, I need 
only mention that at the time of the battle of the 12th of April, 1782, there was not a sickly ship 
in our fleet, but many of those officers and men who were sent to take care of the French prizes 
were seized with the yellow fever ; and it was observed that when, at any time, the holds of these 
ships, which were full of putrid matter, were stirred, there was an evident increase of these fevers 
soon after. 
* See an article in Rozier's Journal de Médecine, for July, 1781, by Dr. Ingenhousz. SECTION XV PUBLIC AND INTERNATIONAL HYGIENE. 
359 
" It has been alleged by some authors that the yellow fever is produced by the same marshy 
exhalations which produce the intermittent and remittent fevers, and that it is only a variety of 
the latter; but the remitting fevers differ from it in some essential symptoms, and the yellow 
fever has been known to arise, both in ships and on shore, where men were entirely out of reach 
of the vapors of marshes. 
" It may naturally be expected that this infection will not take place except in particular cir- 
cumstances. There have been physicians paradoxical enough to maintain that the plague itself 
is not infectious, and their principal argument is that numbers are exposed to it without being 
affected by it. But the same may be said of the smallpox, and it is the nature of all infection to 
require a certain concurrence of circumstances, both external and in the constitutions of those 
exposed to it, in order to its taking effect. One circumstance necessary to the operation of the 
infection of the plague is a certain range of atmospheric heat. A temperature about 80°, or 
below 60°, will soon put a stop to this epidemic, so that it was never known between the tropics 
nor within the polar circles ; and it is only at certain seasons that it appears in the temperate 
zone. The atmospheric heat necessary for the excitement of the yellow fever begins where that 
of the plague leaves off, for it has never been known to arise and prevail but when the ther- 
mometer stood for some length of time pretty uniformly above 80° as has been already stated. 
" In applying these observations to the question concerning the importation of the infection 
into Philadelphia and the other towns of America, I cannot but think that they make greatly for the 
affirmative ; for it is agreeable to the analogy of all other infection that it may be introduced so 
as to prove active in portions so minute as to escape detection, and at other times may fail of 
producing its effect, though in the most accumulated state. 
"The circumstances under which it appears in North America are, indeed, totally different 
from those in which it appears in the West Indies. This fever had not prevailed in Philadel- 
phia from 1762 till 1793; whereas it occurs, more or less, every year in the West Indies, and its 
prevalence is in proportion to the number of new comers from Europe. If this disease were the 
spontaneous production of America, how comes it that it did not destroy the British armies which 
acted in the late war in Pennsylvania, Virginia and Carolina, as it has done of late in the West 
Indies ? It is also against the laws of probability that this fever should have arisen by mere acci- 
dent in that year in which a number of French emigrants had arrived from the islands in which 
it prevailed, and in a year in which it had prevailed there to such an unexampled degree. 
" Supposing it established, therefore, as a truth, that this disease arose from imported infec- 
tion, we are next to inquire what are the precautionary measures that ought to be adopted to pre- 
vent its introduction or counteract its influence. 
"These divide themselves into three heads : first, the prevention of the importation ; secondly, 
the prevention of its spreading ; thirdly, the removal of those circumstances which predispose to 
its action. 
"Under the first head is included the regulations relating to quarantines 
" The second head is extremely important, and the neglect of it has at all times given occa- 
sion to the extensive spread of pestilential disorders. The principle of it is comprised in these 
few words : ' To discover the first beginnings of disease, and to cut off all intercourse with the 
infected.' It is at this period only that such a measure can be effectual, the number of infected 
being small 
" The third head is one which has not been commonly enumerated and treated of by those who 
have written on this subject. It is only, however, necessary to reflect on the present situation of 
London to become sensible of its great importance. It is extremely doubtful how far this city 
owes its safety to quarantines; and there is no proof of the pestilence having ever been stopped in 
England by the vigilant detection of its first invasion, and the consequent adoption of wise and 
vigorous measures to prevent intercourse. But the advantages of spacious and airy habitations, 
of personal cleanliness, of dryness and cleanliness from forming drains and common sewers, are 
undeniable. The commerce in this age so far exceeds whatever was known in former ages, that 
there is, most probably, at all times, enough of infection in the warehouses of London to kindle 
the flames of pestilence if the fuel was applied and duly prepared and disposed for its action. 
" I am not sufficiently acquainted with the towns of America to say what improvements they 
admit of in the points above mentioned. It is evident, however, that the causes of this fever are 360 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
connected with those circumstances which belong to a town ; for, if I am rightly informed, it has 
not spread into villages and single houses in the country. As the inhabitants of America possess 
habits of cleanliness in their persons and habitations, in common with the rest of the civilized 
world in our times, the amendment required is not in these points. A circumstance which you 
mentioned to me regarding New York, to wit, that the fever prevailed only in that quarter of the 
town which adjoins the East river, and had not spread to that which borders on the North river, 
seems to point out the measures that are likely to be most advisable and practicable for ameliorat- 
ing the air of the towns in the American States. Drains and common sewers, therefore, of the 
most perfect construction that can be devised for promoting dryness and sweetness, by carrying off 
all superfluous moisture, and for conveying all manner of filth and soil under ground, could not 
fail to be highly conducive to general health, and to prevent the future visitations of epidemic 
fevers. Whether the late fever has been owing to imported infection, or to the bad air of the 
place, this precaution is equally founded upon reason. I consider the drains and sewers of London 
as the most essential circumstance in promoting that decency, comfort and health enjoyed so long 
by this great metropolis, in a degree of which I believe there is no example in ancient or modern 
times." 
Sir Gilbert Blane adds, in a postscript to his letter to Minister Rufus King, that "Upon 
reviewing the preceding letter, it has occurred to me that in enumerating the different heads of 
preventive means I ought to have mentioned what is called expurgation, that is, the methods 
taken for the expulsion and destruction of infection when the disease is declining or has ceased. 
Dr. Russell is very full on this subject; but since he wrote, there is a method of fumigation intro- 
duced by Dr. Carmichael Smith, of which he has published an account; and as this has acquired 
some name from trials made in the hospitals for prisoners of war and in the navy, I should think 
it would be worth a trial in America, as one of the means for the expurgation of the infection of 
yellow fever."* 
OBSERVATIONS OF SIR WILLIAM PYM ON THE MEANS OF ARRESTING THE SPREAD OF 
YELLOW FEVER. 
The principal object which Sir William Pym had in view in publishing his "Observations 
upon the Boullam Eever, which has of late years prevailed in the West Indies, on the coast of 
America, at Gibraltar, Cadiz and other parts of Spain," was to counteract the influence which the 
opinions of Dr. Bancroft had upon the minds of the public as well as of the profession, by bring- 
ing forward evidence to prove that it is a different disease from the bilious remitting fever of warm 
climates; that it is not produced by, nor in any way connected with, marsh miasmata ; that it has 
not been a constant resident in the West Indies; that it is contagious, and capable of being 
imported to and propagated in any country enjoying a certain degree of heat; that it attacks the 
human frame but once, and attacks in a comparatively mild form, natives of a warm climate, or 
Europeans whose constitutions have been assimilated to a warm climate by a residence of three or 
four years; that it differs from all other diseases, in having its contagious powers increased by heat 
and destroyed by cold, or even by a free circulation of moderately cool air. 
The observations of Sir William Pym were commenced in the West Indies in 1794, and he was 
present also in Gibraltar during the terrible epidemic of 1804. 
The first step which Sir William Pym proposed, in 1794, for the arrest of the fever prevailing 
on the island of Martinique, among the troops under Sir Charles Grey, was the change of the 
quarters of the troops to airy, elevated ground, at Point Negro, close to the sea and almost a mile 
and a half distant from the town. The soldiers experienced an almost instantaneous change for 
the better. 
When Sir William Pym took charge of the Medical Department of Gibraltar, in 1804, during 
the indisposition of Dr. North, he drew up a code of regulations and proposed that all the men 
who had been in the West Indies, or who had recovered from the disease, should be employed in 
hospital duties, burying the dead, etc. ; that a convalescent camp should be established for the 
men discharged from the hospital, where they should have their linen and clothes washed before 
being allowed to join their regiments; that men in barracks who had not had the disease, 
* "Observations on the Diseases of Seamen." By Gilbert Blane, m. d., f. r. s., London and Edinburg, 
etc. Third Ed., Loudon, 1799, pp. 605-613. SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
361 
should be moved to camp; that whenever a soldier was taken ill he should be carried to the hos- 
pital by men who had passed the disease; his bedding and tent washed, and that his comrade and 
all other men in the same tent should be sent, for a certain time, into quarantine. 
Although these suggestions were only partially carried out, they proved so far effectual as to 
save 1200 of the soldiers from an attack of the disease, while of the civil population of Gibraltar, 
which amounted to nearly 14,000, only twenty-eight escaped an attack of yellow fever, and of 
this number, twelve had been attacked with the same fever at former periods, either in the West 
Indies, Philadelphia or Spain. 
As far as our information extends, to Sir William Pym is due the credit of having first brought 
prominently before the medical profession that yellow fever, as a general rule, attacks the same 
individual but once, and that those who have passed through the disease should alone be employed 
in nursing and attending the sick. 
The value of the suggestions of Sir Gilbert Blane and Sir William Pym, as to the immediate 
separation of the first cases of yellow fever and the establishment of a rigid quarantine between 
the sick and the infected districts in the cities in which the disease appears, received remarkable 
and unquestionable demonstration in the two largest American cities in the years 1820, 1822 and 
1819. Yellow fever appeared in Philadelphia on the 24th of July, 1820,* and caused eighty- 
three deaths. 
The deaths caused by preceding epidemics in Philadelphia were as follows. 1699,f 220 
deaths; 1741,J 250 deaths; 1793,$ 4041 deaths; 1797, || 1300 deaths; 1798,3500 deaths; 
1799,** 1000 deaths; 1802,307 deaths; 1803, 195 deaths; 1805, 3400 deaths. 
The following extract from a letter from the late Professor Samuel Jackson, m.d., of Philadel- 
phia, to the author, is important as illustrating the measures adopted by the Board of Health, for 
the limitation and arrest of the disease. 
Philadelphia, September 7th, 1867. 
Professor Joseph Jones, m.d.: 
" My Most Esteemed Friend :-I had given up all hopes of being able to again communicate 
with you ; but I have a respite, very probably a short one, and I seize the opportunity to write 
you a few lines. I received your letter of July while confined to my bed, and cannot express 
the pleasure I received from your letter ; it was most cheering to my spirits, which were begin- 
ning to fail me. But I must say it has given me considerable anxiety respecting yourself. You 
are, I fear, falling into the error I committed myself at your time of life, and to which I attribute 
so many years of suffering, and the miserable condition I am in, from worn out centres, the 
generators of motor or mechanical force. You are overtaxing your forces-vital, organic and 
physical. You are treading in my footsteps-be warned in time, and avoid the wretched, painful 
life I have endured for forty years. 
" A few facts will make the matter cleaf to you. 
"In 1820, I was President of the Board of Health. In July, yellow fever broke out; most 
of the members were politicians and the labor of combating the threatened epidemic devolved 
on me. By prompt and energetic means, and by the assumption of powers we did not possess, 
the disease was confined and suppressed in the different points in which it appeared to be gener- 
ated. One of these, at Walnut street wharf, was the centre of our commerce. The first cases 
occurred on Saturday night, and Mr. Barker, whose counting house was on the wharf, was then 
lying very ill ; he died that night. To have left it open to the public, would have exposed hun- 
dreds to the infective poison." 
"No time was to be lost. Early on Monday the streets leading to Front and Walnut were 
barricaded, and the inhabitants in Water street and Front street, from Chestnut to Dock, were 
ordered to remove." 
" This was a very arbitrary proceeding, but it proved effectual-the epidemic was arrested, but 
nearly 50 cases scattered about the city, were traced to this locality. I had the credit of having 
* S. Jackson, American Medical Record, 1821, p. 689. 
f "Yellow Fever," by R. La Roche, m.d., Vol. 1, p. 46. Charleston Medical Journal and Review, 1852, 
p. 58. I J. H. Griscom. "Visitations of Yellow Fever," p. 3. 
g Carey, Account of the Malignant Fever, p. 116. f Benjamin Rush. 
|| Benjamin Rush, Epidemic, 1797. ** Yellow Fever, R. La Roche, Vol., 1. 
ff W. Hume. Ch. M. J. and Rev., 1860, p. 24, et seq. 362 
NINTH INTERNATIONAL MEDICAL CONGRESS, 
saved the city from a general epidemic. Toward the close I was taken down with the disease, 
and treated, after the fashion of that day, with calomel." 
"I was at this time a member of the City Council, and serving on the Water Committee, 
superintending the erection of the water-works, and building the dam of the Schuylkill, at Fair- 
mount, a most arduous duty. In addition to these labors, I was one of the attending physicians 
of the Almshouse and hospital, and lecturing in Chapman's Institute, on therapeutics. At 
the same time I was harrassed by some heavy debts of a firm in which I had been concerned. 
For about ten years, almost daily, my expenditure of vital force exceeded the normal power of 
my constitution, and I was brought to the verge of the grave. It was then that I discovered 
that there was a limit to the production of the forces, which, if exceeded, caused a waste of the 
organic structures, by a slow gradual dissolution. I immediately began to economize my vital 
expenditure, and limited myself to only what was indispensable. I retired from public life, and 
contracted my social circle." 
Yellow fever appeared in New York, on the 10th of July, 1822, and ceased on the 5th of 
November, and caused 230 deaths. 
In some of the preceding epidemics, the following deaths had been caused by yellow fever ; 
1702, 570 deaths; 1743, 217 deaths; 1795, 730 deaths; 1798, 2080 deaths; 1799, 76 deaths; 1803, 
6-700 deaths ; 1805, 340 deaths. 
When the yellow fever broke out in New York in 1791, after forty years exemption from the 
pestilence, every physician then practicing, with the exception of two or three of the oldest mem- 
bers of the profession, were utter strangers to the disease. Instead of studying the characters of 
the disease with patient attention, they began first to search for evidence to prove its domestic 
origin, and that it was indigenous to the soil, and that is was not a contagious disease and could 
not be imported, and that all measures of precaution, and especially the system of quarantine 
restrictions, were a useless and degrading imposition. 
In the year 1819, the Board of Health of New York discarded the temporizing system of the 
boards of preceding years, and put in practice an entirely new system. It was resolved, although 
the disease might be introduced, to endeavor at least to stop its mortality and mitigate its horrors. 
The disease was looked upon as a contagious pestilence, and the part of the city where it was 
introduced was immediately and totally cleared of its inhabitants, and those who would not re- 
move of their own accord, were turned out of their houses by force. 
The result was that only about 150 cases and about 50 deaths from yellow fever occurred, which 
was infinitely less than the mortality of other years, especially 1797 and 1798, when the mass of 
the population remained at their homes, taught by their physicians to believe that the disease was 
some ordinary bilious fever, which would soon pass away ; or that the whole atmosphere for miles 
into the interior was so tainted that it would be folly to run from it. 
The Board of Health of New York was satisfied, from the experience of 1819, that when yel- 
low fever is once introduced there is no safety but in flight, and that all that can be done is to 
disperse the inhabitants and to remove the sick with the utmost expedition into the pure air of 
the country, and to erect an insuperable barrier between the infected and uninfected parts of the 
city. Accordingly, they forthwith began to depopulate and barricade that part of the city where 
the disease was introduced, stopping up all the streets and lanes which ran into this section of the 
town. But such were the prejudices of the community against this novel procedure, first intro- 
duced in 1819, and such the fallacious hope that the disease would not continue to spread, that 
the Board were under the necessity of adopting this measure with the greatest caution; by which 
means the disease kept the start of the barricades that had been interposed, until the general 
panic which seized all the lower part of the city, about the first of September, caused the inhabit- 
ants to abandon their homes en masse, and served to put an entire stop to the progress of the dis- 
order, except among those few who willfully exposed themselves by remaining in their houses, or 
by going too far down into the most infected streets. * 
* "An Account of the Yellow Fever as it prevailed in the city of New York in the Summer and 
Autumn of 1822," by Peter S. Townsend, m.d. New York, 1823, pp. 217, 236. SECTION XV PUBLIC AND INTERNATIONAL HYGIENE. 
363 
DISINFECTANT ACTION OF SULPHUROUS ANHYDRIDE AND SULPHUROUS ACID. 
The efficient agents in the preceding thorough system of disinfection as practiced in the 
British navy by Sir Roger Curtis and other officers during the past century, were 
Cleanliness, 
Free Ventilation, 
Heat, 
Lime, 
Sulphurous Anhydride (sulphurous acid). 
The last mentioned agent (sulphurous anhydride) appears to have been the true and essential 
disinfectant or destroyer of the organic poison inducing the contagious fever. 
Sulphur, the first disinfectant employed by the ancients, and called sacred or divine by the 
Greeks, has maintained its reputation from the time of Ulysses, who after killing the Suitors, 
fumigated the palace with burning sulphur, to the present moment, when it is chiefly relied on 
for the destruction of the poisons of contagious diseases. 
The advances of modern chemistry have enabled us to comprehend the effects of burning 
sulphur upon the organic materials causing contagious diseases. 
The dioxide of sulphur, sulphurous oxide, or sulphurous anhydride, resulting from the com- 
bustion (oxidation) of sulphur, is at ordinary temperatures a colorless, irrespirable, poisonous, 
incombustible gas. As it is more than twice as heavy as atmospheric air, it may be collected by 
displacement, and when introduced into the hold of a ship, or in any confined space, will gradu- 
ally accumulate from the bottom upward, and thus expel the atmospheric air. 
It is also important to note that sulphurous anhydride may very readily be condensed into the 
liquid state by a pressure of three atmospheres, or by a freezing mixture of ice and salt. By its 
evaporation it produces intense cold, sufficient even to freeze itself, and rapidly to freeze water in 
which it is poured. 
If sulphurous acid gas be generated by pouring muriatic acid upon the sulphite of lime, or 
soda, in a form of apparatus similar to that of Babcock'a fire engine or extinguisher, we may not 
only thus in a very short space of time evolve a large volume of gas, without the danger of fire, as 
in the burning of sulphur, but we are also able by such an arrangement to generate the gas under 
high pressure, and when it is allowed to escape into the hold of a ship, or in any confined space, 
a degree of cold may be induced which will be an important factor in the purification of the 
atmosphere. 
This plan of disinfection (the liberation of sulphurous acid in a special apparatus by the action 
of hydrochloric acid upon a sulphite) now for the first time proposed, is worthy of a careful trial 
at the quarantine stations. 
The fumes of burning sulphur, or sulphurous anhydride, when brought in contact with the 
moisture of the atmosphere or water is converted into sulphurous acid. 
Both sulphurous anhydride and sulphurous acid act as powerful reducing agents; sulphurous 
acid bleaches by forming colorless compounds with certain coloring matters, but it does not, like 
chlorine, decompose the coloring matter, for the sulphurous acid may either be expelled by a 
stronger acid, or it may be neutralized by an alkali, and the color will be restored. 
Sulphurous anhydride is a powerful antiseptic, its power of arresting fermentation having 
been recognized by the Greeks and Romans in the manufacture of wine, and it consequently has 
long been valued as a powerful disinfecting agent. 
Meat which has been exposed to the action of sulphurous anhydride gas and then sealed up in 
metallic canisters filled with nitrogen, to which nitric oxide has been added to remove the last 
traces of oxygen, may be preserved fresh for years. Ln the process proposed to Mr. Gamgee for 
the preservation of fresh meat by sulphurous acid, the animal is killed with carbonic oxide gas 
and the meat is kept in that gas and sulphurous acid. Meats may thus be kept fresh and of the 
original color for six weeks. Meat, vegetables and fruit subjected to the fumes of burning 
sulphur and charcoal and then immersed in water containing the sulphurous acid in solution, 
resist decomposition and retain their natural appearance and form for months. 
It is but just to suppose that sulphurous anhydride acts as a disinfectant in a complex man- 
ner. Thus, it arrests decay in organic matter; it deoxidizes, and afterward gives off its oxygen 
and acts as an oxidizer ; it also acts as an acid, and dissolves animal matter. 
Just as sulphurous anhydride preserves meat from putrefaction and change, in a similar man- 364 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
ner, without doubt, it acts upon animal poisons, and arrests their changes, and so alters their 
composition as to destroy their poisonous action. In like manner sulphurous anhydride and sul- 
phurous acid destroy living germs, whether animal or vegetable. 
The theory of the action of sulphurous acid held by those who regard the germs of contagious 
diseases as of parasitic and vegetable origin, has been well expressed by Dr. Dewar, of Kirkcaldy. 
He says :- 
" It may be well to premise that our adoption of such an auxiliary implies a belief that the 
enemy of which we are in pursuit lurks about indefinitely ; that its vitality can outlive ordinary 
processes of decay, and that it is transmitted, or at least located, in the atmosphere. This being 
the case, we may well assume that the germs are parasitic, most of them of vegetable origin; that 
some retain their peculiar properties independent of temperature or climate, and that some even 
can (as in cholera), in a dry climate, in the form of dust, be carried by the wind to distant points, 
where, as they absorb moisture, they retain their power of spreading devastation." 
He treated his own cattle with sulphurous anhydride gas four times a day, the sulphur for six 
cattle being about as large as a man's thumb, and burning for twenty minutes, the attendant 
being shut in along with the cattle. 
The cases of cure by this means in cattle plague are said to have been very numerous. 
Dr. James Dewar*' has also strongly recommended sulphurous acid as a topical application to 
wounds and sores, and has adduced very successful cases in which it was employed. The wounded 
surfaces should either be sponged with the acid of full strength, or the spray of the fluid acid 
should be applied by a suitable vaporizer. Cases of wounds have been recorded in which, after 
dressing in this manner, there was rapid healing, with no discharge whatever ; but the dressings 
require frequent changing, at least every thirty-six hours. 
Mr. Crooksj" says : " A mixture of sugar and yeast was kept in a warm room until it became 
in a state of active fermentation. An aqueous solution of sulphurous acid was added, when 
the fermentation instantly ceased ; when examined under the microscope, after treatment with 
sulphurous acid, no apparent change was observed in the appearance of the cells." 
In the use of sulphurous acid for the disinfection of ships, hospitals and rooms it should ever 
be remembered that it is poisonous to both vegetable and animal life, and that, even in small 
quantities, it acts as an irritant to the lungs, causing violent coughing, which becomes painful 
and dangerous, according to the amount used. Sulphurous acid fumigation is not, therefore, 
applicable to wards of hospitals, or cabins of ships, or rooms inhabited by human beings. All 
living beings should be removed from the space to be disinfected. This may readily be accom- 
plished by fumigating wards and rooms and the different portions of a ship in succession. The 
fumigation should be followed by thorough cleansing of the furniture, beds and floors, and white- 
washing in order to remove, as far as possible, those portions of contagious matter which have 
been disinfected and embalmed by the gas ; and when the poison is concentrated and virulent, 
the cleansing and whitewashing should be followed by a second fumigation. 
Chlorine is, without doubt, one of the most effective disinfectants and germicides, but it 
should not be used simultaneously with sulphurous acid. By fumigating alternately with sulphurous 
acid and with chlorine it would appear almost impossible for any disease germs to survive in 
any given space of air. 
Washing the floors and walls with a solution of chlorinated soda, or chlorinated lime, has 
proved, at the great quarantine station of Lisbon, Portugal, and in many other places, effective. 
As New Orleans is situated at the mouth of one of the largest rivers, and as it holds daily 
communication with ports infected with yellow fever, all that relates to the history of disinfec- 
tion as practiced by her sanitary officers is of interest and value, and we present the following 
facts relative to the use of sulphurous acid at this port :- 
Dr. Alfred W. Perry, who was quarantine physician to the Mississippi station from April 
11th to October 14th, 1874, invented and put to practical use a mechanical contrivance for the 
disinfection of ships' holds, by injecting, by the means of a blower, the fumes of burning sulphur. 
A similar apparatus had been used by the sugar refiners for the bleaching of brown sugar and 
syrups, and also for influencing the process of fermentation, by the injection into saccharine 
liquids of sulphurous anhydride. 
* Medical Times and Gazette, Sept. 21st, 1869, p. 318. 
f"On the Application of Disinfectants." SECTION XV PUBLIC AND INTERNATIONAL HYGIENE. 
365 
The essential part of the disinfecting process of Dr. Perry was the forcing the product of the 
combustion of burning sulphur, namely, sulphurous anhydride gas, SO2, into the hold and various 
compartments of a ship. Previous to the adoption of this method the hold of a ship, as well as 
the cargo, the cabins and forecastle, were fumigated by burning sulphur in iron pots. It had 
been well established by the experience of many sanitarians, at various quarantine establishments 
and in various hospitals for the treatment of infectious diseases, that this was an effective means 
of practicing sulphurous acid disinfection. The only point which appeared to be in favor of the 
new method was that it apparently required less time for the accomplishment of the same results. 
In the New Orleans Medical and Surgical Journal for January, 1874, is an article by Dr. 
Perry, entitled " Quarantine without Obstruction to Commerce," which had been read before the 
American Public Health Association, and from which the following is quoted:- 
"I think that time, as an element of quarantine, is the least to be depended on, the most 
oppressive to commerce, the most costly and at the same time the least effectiveThe 
disease germs may occupy any part of the vessel or cargo, and to be effective, the disinfectant 
should reach every part of the vessel, every crevice of the cargo. This can only be done in a 
cheap, quick and thorough manner by the use of gaseous or volatile disinfectants, applied by a 
special apparatus which I will describe. This method will perfectly destroy all disease germs and 
can be performed in four to six hours, and will detain infected vessels less than one day. 
" The apparatus consists of one or more force-blowing machines, put in motion by steam power, 
which are connected with a furnace for generating sulphurous acid gas, with an apparatus for 
impregnating air with carbolic acid vapor, and a furnace for producing heated air. The cost of 
the apparatus would not exceed $3000 or $4000. It could be placed either on a wharf, to which 
vessels to be disinfected could be towed, or it could be placed on a small steamboat." 
In the same journal for January, 1875, is a "Special Report of Quarantine Operations at the 
Mississippi Station, 1874," by Dr. Perry. The following is quoted:- 
" Soon after being assigned to quarantine duty, apparatus was prepared to carry out my ideas 
in regard to the disinfection of vessels. This apparatus was brought into working order June 
20th, 1874. It consisted of a sheet-iron cylinder, three feet in diameter, with numerous adjustable 
air-holes near the base; into this was put a charge of thirty to one hundred pounds of sulphur, 
which was lighted by a few burning shavings ; an eight-inch iron pipe connected the upper part of 
this sulphur burner with the entrance opening of a No. 2 Sturtevant fan blower; to the outlet was 
connected a short upright iron (eight-inch) pipe, and to this was fastened an eight-inch rubber hose. 
The fan of the blower was put in motion by three pulleys of increasing speed, and made 2500 
revolutions per minute; the main driving pulley was turned with a crank by two men. The 
whole apparatus was mounted on a small, stout flatboat, which was towed to the vessel lying at 
anchor near the quarantine station, the fire lighted and the blower started until the shavings had 
entirely burned out and the sparks had ceased ; one end of the rubber pipe was then connected 
to the lower outlet and the other end was introduced into the vessel." 
The details of Dr. Perry's contrivance and those of the apparatus now in operation at the 
Mississippi Quarantine Station, 1887, are essentially the same, with the exception of the use of 
steam for the propulsion of the wind power or blower. 
The apparatus of Dr. Perry was used up to the close of 1879, and during the period extending 
from its introduction in 1874 to this latter period, cases of yellow fever were reported in New 
Orleans in 1874, 1875 and in 1876; and in 1878 occurred the great yellow fever epidemic which 
spread such terror throughout the valley. 
It was evident from these facts that mere fumigation with sulphurous anhydride, in the 
absence of other sanitary measures and proper detention, was not sufficient to protect New Orleans 
from the introduction of yellow fever. 
Upon the reorganization of the Board of Health of the State of Louisiana in 1880, I found the 
Mississippi Quarantine Station in need of a new wharf and extensive repairs of the fever hospital, 
smallpox hospital, physicians' and boatmen's quarters, and of new boats. The apparatus of Dr. 
Perry was practically useless; the.iron cylinder burned out and the flat in a rotten and leaky 
condition. 
I caused to be constructed a disinfecting apparatus with a strong blower for propelling the 
sulphurous anhydride, and the necessary iron furnace for burning the sulphur, at an actual cost of 
$249.09 (two hundred and forty-nine dollars and nine cents). 366 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
The intention was to place this upon a steam tug and operate it, and move it from ship to ship 
by means of steam (see Report of Joseph Jones, m.d., President of the Board of Health of the 
State of Louisiana for 1880, p. 18). 
Large expenditures, over $12,000, were required for the necessary repairs, and in addition to 
this three of the most wealthy and powerful shipping corporations were in open rebellion against 
the quarantine laws of Louisiana. 
During the entire period of my term of service I was compelled to conduct a suit in court 
against Morgan's Steamship and Texas Railroad Company, which was represented during a 
considerable portion of the time, extending from April, 1880, to April, 1884, by Mr. Charles 
Whitney, President of the New Orleans Auxiliary Sanitary Association. 
The only meeting of the Louisiana State Legislature which occurred during this period was 
embraced by the enemies of quarantine, led by the friends and agents of the President of the 
New Orleans Auxiliary Sanitary Association, to array the legislature against the State Board of 
Health and defeat the quarantine laws of Louisiana, and to declare them unconstitutional, null 
and void. 
Under such circumstances, and pressed with enemies on all sides and with diminished reve- 
nues, the Board of Health was unable to command the necessary funds for the employment of 
steam tugs and crews for the rapid and thorough disinfection of vessels by the proper appa- 
ratus. 
Nevertheless it has been shown that under all these difficulties the officers of the Board in- 
spected and, whenever necessary, fumigated and disinfected ten thousand (10,000) vessels, manned 
by over 150,000 seamen, and not only effectually excluded yellow fever from New Orleans and 
the valley of the Mississippi, but finally, after a severe battle of four years' duration, vindicated 
the quarantine laws of Louisiana before the Supreme Court of the State. 
In 1884 the present mechanical service for disinfecting ships by sulphurous acid was proposed 
by the succeeding President of the Board of Health, which has been made efficient by a legisla- 
tive appropriation of $30,000. 
The principle of Dr. Perry's contrivance was precisely the same as that of the apparatus used 
at the Mississippi station in 1885 and 1886, but he was under the necessity of operating his fan 
by hand power, for want of the funds since supplied by the General Assembly of the State. 
The method practiced with infected ships, 1880-1884, consisted of the following measures :- 
1. Discharge of cargo. 
2. Thorough cleansing of the ship, including discharge of bilge-water and washing out with a 
solution composed most generally of fifty pounds of copperas and five gallons of carbolic acid 
(Calvert's No. 5), dissolved in fifty gallons of water. A similar solution was employed in the dis- 
infection of ballast and cleansing of woodwork, decks, etc. 
3. Fumigation with sulphur. Iron pots were filled with sulphur, which were lowered into 
the hold and placed in all the compartments of the ship. The pots rested in iron pans of water, 
so as to avoid all risks from fire. The sulphur was then ignited and all openings closed. The 
sulphur was allowed to burn until the oxygen was consumed and naught remained but sulphur- 
ous anhydride and nitrogen. In infected ships the fumigation was repeated during successive 
days, as often as deemed necessary. 
The following results are worthy of notice :- 
(а) All vermin were destroyed upon the ships thus treated. 
(б) No accident from fire occurred during four years. 
(c) No case of yellow fever was traced in New Orleans to the cargo of a ship thus fumigated. 
4. Coffee vessels from Rio de Janeiro, Havana and Vera Cruz, during the prevalence of yel- 
low fever, discharged their cargoes into the large brick Government warehouse at the Mississippi 
quarantine station, and were subjected to thorough fumigation by sulphurous acid gas. The dis- 
charge of the cargoes from infected vessels was made by acclimated men, who had previously 
had the yellow fever. 
5. When deemed necessary the large coffee warehouses in New Orleans were subjected to 
sulphuric acid fumigation. These stringent measures appeared to have been necessitated by 
the prevalence of yellow fever at Rio de Janeiro, Havana and Vera Cruz, and also to allay public 
alarm. The valley was still agitated by the remembrance of the terrible epidemic of 1878, which 
had carried consternation and desolation far into the interior of the continent. SECTION XV PUBLIC AND INTERNATIONAL HYGIENE. 
367 
The method invented and put into practice in 1874, by Dr. Perry, is more rapid in its action 
than the old method ; hut it is only adapted to those ports and quarantine establishments which 
are able to endure the expense of the construction of the apparatus and its operation by steam. 
Under the old method it is possible, at a small outlay and with a few men, to fumigate seve- 
ral ships or vessels at the same time. 
Any quarantine station, however small, can thoroughly and effectually disinfect vessels, how- 
ever large or small, by the old method, which is in like manner adapted to any vessel or ship, 
large or small, in any port and under any circumstances. In the present condition of commerce, 
therefore, the new method cannot wholly displace the old method of sulphurous acid fumiga- 
tion. 
GERMICIDE PROPERTIES OF SO2. 
One pound of sulphur when burned produces lira cubic feet of sulphur dioxide gas. The 
aqueous solution of this gas contains sulphurous acid. 
Baxter's experiments show that it is the most potent volatile disinfectant known, and as it is 
very soluble, and is little affected by the presence of albumen, it is also powerful in the disinfec- 
tion of liquids. It destroys sulphureted hydrogen, thus, SO2 + 2H2S = 2H2O + S3, and com- 
bines with ammonia. This disinfectant forms sulphites, and is a reducing or deoxidizing agent 
in the first place, for it unites with the oxygen of many compounds to form sulphuric acid, but it 
may give up oxygen, and when mixed with much vegetable matter the sulphur may come off as 
sulphureted hydrogen. Sulphur dioxide and sulphurous acid and chlorine and permanganate 
of potassium mutually destroy each other, and therefore should not be used together. Sulphur 
dioxide destroys the activity of dry vaccine on points very rapidly, and, even when much diluted, 
stops the amoeboid movements of living cells, kills vibrios, and acts deleteriously on vegetation. 
A virulent liquid cannot be regarded as certainly and completely disinfected by sulphur dioxide 
unless it has been rendered permanently and strongly acid. The greater solubility of this agent 
renders it, ceteris paribus, preferable to chlorine or carbolic acid for the disinfection of liquid 
media. (Baxter.) 
According to Baxter's experiments a larger percentage of sulphur dioxide than of carbolic 
acid is required for the disinfection of the virus of infective inflammation, but a smaller per- 
centage for other contagia. Sulphur dioxide preserves meat and other substances when in closed 
vessels for very long periods. 
The power of sulphurous acid gas to destroy the virulence of vaccine virus has been demon- 
strated by several experiments. Ten minutes' exposure in an atmosphere saturated with sulphur- 
ous anhydride vapor was found by both Baxter and Dougall to neutralize the virulence of vac- 
cine dried upon ivory points. Experiments made by Dr. George M. Sternberg, in 1878, showed 
that liquid vaccine is rendered inactive by exposure for four hours to sulphur dioxide in the pro- 
portion of five volumes to one thousand of air. In experiments with dried virus upon ivory 
points, made in 1880 by the same observer, it was found that virulence was destroyed by six 
hours' exposure in an atmosphere containing one per cent, of this gas. Baxter and Vallin have 
tested the disinfecting power of sulphur dioxide upon the virus of glanders. Baxter found that 
four parts to one thousand in solution destroyed the virulence of material obtained from nostrils 
Tubbed up in water from the lungs of an animal with glanders. 
Vallin experimented with virulent pus from an abscess, obtained from a patient with glanders 
in the Hospital of Val-de-gras. This pus was passed, by inoculation, into Guinea-pigs and other 
animals, to produce the characteristic lesions of glanders. Some of this pus, placed in a watch- 
glass, was exposed for twelve hours to sulphur dioxide generated by burning two grammes of 
sulphur in a box having a capacity of 100 litres (equal to 14 volumes of SO2 to 1000 volumes of 
air). Disinfection was complete, as proved by inoculation. 
Dr. Klein, in 1884, has shown that swine fever can be communicated to healthy pigs, through the 
air, by placing them in the same stable with diseased animals, but so separated from them that no 
bodily contact can take place between the diseased and healthy ; and that this could certainly be 
prevented by the presence of chlorine in the air of the stable. Dr. Klein made similar experi- 
ments with sulphurous acid gas. It was found that when an animal seriously affected with swine 
fever was used as a disease germ, healthy animals introduced into the same stable with it con- 
tracted the disease and died of it, notwithstanding that the air of the stable was impregnated 
with sulphurous acid. But when the same experiment was repeated with an animal affected in 368 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
a mild form and free from the severe pulmonary symptoms which in the other case accompanied 
it, no infection took place. 
It must therefore be determined by further experiments how far sulphurous dioxide is cap- 
able of preventing the spread of contagion among living animals. (Fourteenth Annual Report of 
the local Government Board, 1884-1885, pp. 183-187, London, 1885.) 
HEAT AS A DISINFECTING AGENT. 
It has long been known that heat acts as a powerful disinfectant by its power of destroying 
animal and vegetable life, coagulating albuminoid substances, and by its desiccating effects. 
The absorption of noxious effluvia by clothes or soft and porous articles of merchandise has 
long been recognized as a fact by men who have directed special attention to this subject. 
Many of the liquid disinfectants which have at various times been proposed are not applicable to 
articles of clothing; and the common practice of baking clothes in ovens is liable to lead to their 
destruction, owing to the impossibility of regulating the temperature to which it is necessary to 
expose them. 
The plan of Messrs. Davison and Symington combines economy with certainty of disinfection, 
and consists in exposing the articles of clothing, in a large chamber, to rapid currents of air, 
heated to a temperature insufficient to injure them, varying from 200° to 250° F. In the case of 
infected clothing, it is obvious that while a high temperature tends to destroy the animal poisons, 
a rapid current of air, constantly passing through the chamber, tends to carry them off. The 
temperature of the current of air can be so regulated that common albumen is speedily dried into 
a yellow, transparent solid, without coagulation, or, if necessary, the heat may be increased from 
400° to 500° according to the nature of the articles which are exposed. 
Dr. Copland directed the attention of the medical profession and sanitary authorities to this 
process, and observes that: "The great advantage of this method is its easy applicability to all 
kinds and to any number of objects and articles without injury to their textures or fabrics." 
Dr. A. N. Bell, Vice-President of this Section, applied steam to the disinfection of vessels of war 
in this country in 1847-1848. 
Dr. Andrew Ure,* writing in 1854, says : " From an inspection of one of these chambers when 
the temperature of the current of air was 116° F., we can state that the process of Messrs. 
Davison and Symington for the drying and disinfecting of the clothing of cholera and fever 
patients will be far more efficacious than the common plan of washing and baking. In our 
opinion, an apparatus of this kind, fitted up in large hospitals, infirmaries, prisons and work- 
houses, as well as all quarantine stations, would be admirably adapted to prevent the diffusion of 
contagious diseases." 
This method might be rendered still more efficacious by combining with the hot air or steam, 
the vapor of carbolic acid or the fumes of burning sulphur. 
It would manifestly be very difficult, if not impossible, to apply heat and hot air, or even 
steam, and the so-called superheated steam (used by the late Captain Fry, of New Orleans, for 
the seasoning and preservation of wood), to the disinfection of the holds and cabins of ships, or 
the large wards of hospitals ; and for such purposes the sulphurous acid fumigation is far more 
rapid and efficient. 
The hot air and steam process is evidently applicable chiefly to infected clothing and woolen 
and cotton goods and bedding. This process has been used with marked benefit in the disinfec- 
tion of the clothing of yellow fever and cholera patients at the quarantine station and large 
hospitals of New York and other cities. , 
As it is well established that the cause of yellow fever is arrested by cold, it has been proposed 
to subject the interior of ships and infected houses to the action of such an amount of cold as will 
condense and freeze all moisture in the air. Such a result would, without doubt, be practicable 
by means of apparatus similar to the ammonia ice-freezing machine; but aside from the difficul- 
ties and expense attending the artificial condensation and congealing of the moisture and organic 
matters in the holds and cabins of ships, it is possible that the poison inducing certain forms of 
fever, and especially yellow fever, may again be excited to renewed activity after the melting of 
the ice. If yellow fever be due to a special plant or animalcule, or to a specific form of organic 
* " A Dictionary of Arts, Manufactures and Mines." American Edition, Vol. I, p. 583. SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
369 
matter, it is possible that the active properties may survive the action of cold, as it is well known 
that many of the simple organisms of the vegetable and animal kingdoms possess the power of 
resisting great extremes of heat and cold, the action of these agents being only temporary, or 
during their immediate continuance. It would appear that in the disinfection of ships such pro- 
cesses do not reach the true source of the difficulty, and are inferior, and at the same time are 
more expensive and difficult than such processes as the sulphurous acid fumigation, which com- 
bines at once simplicity, economy, efficiency, and permanence of effects. 
The experiments of Dr. Henry Baxter, W. Roberts and others have shown the effects of heat 
on vaccine, malignant pustule, septic microzymes, scarlet fever, plague, etc. High temperature 
and length of exposure are, to a certain extent, mutually compensatory, but it appears that a 
temperature below 140° F. (60° C.) will not disinfect vaccine unless with long exposure. 
Tyndall points out that some germs seem to be in a dormant condition, in which they resist 
the action of heat unless applied very long or intermittently, so as to start their vitality into 
growth, when they are easily killed. Experimental facts show that excessive temperatures are 
as unnecessary as dangerous in practical disinfection. It is extremely improbable that any con- 
tagion can withstand a temperature of 220° F. (104.5° C.), maintained during two hours. When 
contagion is shielded by thick material into which heat penetrates slowly, the time necessary to 
reach the disinfecting temperature may be long, and hence the necessity of spreading clothing 
and opening out bedding in special hot-air chambers where the heat ought not to be less than 
220° F. (104.5° C.) nor more than 250° F. (121.1° C.). Hot-air chambers are usually built of 
brick and are furnished with wooden supports for clothing, which should not come in contact 
with metallic or brick work. Metal, being a much better conductor of heat than wood, is liable to 
become so hot as to fire the contents of the drying chamber. This accident has twice occurred 
(if the statements of the public and medical press are to be credited) at the quarantine station 
on the Mississippi river, under the charge of the Board of Health of the State of Louisiana, 
during the past eighteen months. The fire on both occasions is said to have originated in the 
drying room for the disinfection of infected clothing and goods by heat. Upon the first occasion 
the flames communicated with and destroyed the quarantine wharf. It has been estimated that 
the loss occasioned by these fires to the ships, passengers and property of the State exceeded 
ten thousand dollars. 
The proposition to substitute metallic screens for wooden partitions for the clothing and goods, 
upon the ground that under such circumstances the wire gauze would act in a manner similar 
to that employed by Sir Humphrey Davy for the prevention of explosions in mines, is unscien- 
tific and unphilosophical. Such an arrangement, unless the heat was carefully regulated, would 
tend to destroy, rather than preserve, the clothing and goods subjected to heat. 
Heat, however, is perhaps the best agent that we possess for disinfecting infected clothing and 
bedding, provided they be properly opened and spread out. 
During my term of service as President of the Board of Health of the State of Louisiana, 
1880-1884, yellow fever prevailed in the epidemic form at Rio de Janeiro, Havana and Vera 
Cruz, and at Brownsville, Texas, and Pensacola, Florida. Many vessels which had had yellow 
fever on board, and upon which deaths from the disease had occurred on the voyage, arrived at 
the Mississippi quarantine station, then under the charge of Dr. James F. Finney, assisted by 
Dr. C. P. Wilkinson. During this entire period the process relied on chiefly for the disinfection 
of the linen and clothing of the patients treated in the yellow fever hospital and smallpox hos- 
pital at the Mississippi quarantine station was the boiling and thorough washing required to 
cleanse and dress the clothing; and yet no case of yellow fever was traced to this method. 
Dr. James B. Russell, medical officer of health for Glasgow, has recorded similar experience 
as to the efficacy of boiling and washing infected clothing. Dr. Russell states that at the infec- 
tious diseases hospital of that city no further disinfection of the linen and clothing of the 
patients is carried out than is afforded by the boiling and washing, etc., required, in the judgment 
of the washerwoman, to cleanse and dress the clothing; and yet a continuous careful scrutiny has 
failed to discern a single case of disease propagated by such clothing. 
Dr. James B. Russell, m.d.c.m.-suggests that probably soda is used in the boiling, in some 
cases at least, and that the extreme softness of Glasgow water doubtless helps, by its osmotic and 
dissolving power, to cleanse the clothing. 
Vol. IV-24 370 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
In considering the applicability of heat as a means of disinfection, some distinct questions 
present themselves for solution, as- 
1. The degree of heat and the duration of exposure which are necessary under different con- 
ditions, as of moisture and dryness, in order to destroy with certainty the activity of the con- 
tagia of infectious diseases. 
2. How shall the required degree of heat be made to penetrate through bulky and badly con- 
ducting articles, namely, clothing and bedding, for the disinfection of which heat is especially 
employed ? 
3. The degree of heat to which clothing, bedding, etc., can be submitted without injury, for, 
if they are injured by heat, disinfection presents but little advantages over destruction, as has 
been recently demonstrated at the Mississippi quarantine station. 
I. THE DEGREE OF HEAT HELD TO BE NECESSARY FOR THE DESTRUCTION OF THE CONTAGIA OF 
INFECTIOUS DISEASES. 
The earliest experiments on disinfection by heat, as distinguished on the one hand from 
destruction by fire, and on the other from mere washing in boiling water, appear to be those 
made by Dr. Henry, f. r.s., of Manchester, and published in the Philosophical Magazine for 
1831. 
These experiments were made with a copper vessel surrounded by a steam jacket, the steam, 
which was used at atmospheric pressure, that is, at a temperature not exceeding 212° F., being 
admitted only into the casing, so that it did not come in contact with the objects to be disin- 
fected. 
Experiments were first made with vaccine lymph, dried on glass, at ordinary temperatures. 
It was found that exposures of four hours' duration to 180° F., four hours to 140° F., two or three 
hours to 165° F., two hours to 192° F. and two hours to 150° F., destroyed the activity of the 
vaccine lymph. 
The original activity of the lymph was proved by the subsequent successful vaccination of 
the same children with unheated portions of the same lymph. On the other hand, exposure to a 
temperature of 120° F. for three hours did not impair the activity of vaccine lymph. 
With reference to the poison of typhus, the experiments of Dr. Henry were as follows :- 
Three flannel waistcoats were worn successively, each for several hours, by a person suffering 
from contagious typhus. 
No. 1, after one and three-quarters hours' exposure to a heat of 205° F., was kept for two 
hours close under the nostrils of a person engaged in writing, who was fatigued and had fasted 
for eight hours. 
No. 2, after similar exposure to heat, was kept for twenty-six days in an air-tight canister, 
and was then placed for four hours close to the face of the same person. No injurious effects 
followed. 
It was not, however, shown that the person in question was susceptible to the disease. 
Similar experiments were made with flannel waistcoats taken from the bodies of scarlet fever 
patients, and after exposure to heat, worn by children who were known not to have previously 
suffered from the disease. None of these children contracted scarlet fever, although kept under 
careful observation, in order that no slight symptom might pass unobserved. 
The exposures in these experiments were as follows : 4| hours to 204° F., 2| hours to from 
200° F. to 204° F., 3 hours to 204° F., 2 hours to 200° F. and 1 hour to 204° F. Here again, 
however, the proof, for obvious reasons, was not completed by causing the children to contract the 
disease by wearing garments equally infected but unheated. So far as these experiments of Dr. 
Henry go, they show that the contagia of the ordinary infectious diseases are destroyed by dry 
heat at temperatures below the boiling point of water. 
A series of experiments on the degree of temperature necessary to destroy the activity of vac- 
cine lymph was made by Dr. Baxter ("Report of Medical Officer of Privy Council and Local 
Goverment Board." New series, 1875, pp. 228-229). The experiments were made with dried 
lymph on wire points. These were attached to the bulb of a thermometer which was enclosed in 
a test-tube in such a manner as not to touch the sides of the tube. The test-tube was then heated 
by being immersed in a water bath. The duration of exposure was half an hour in all cases. 
Ten experiments were made ; in each the heated point being used to inoculate three places on one SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
371 
arm of a child, while three other points charged with lymph from the same source were used to 
inoculate corresponding places on the other arm. 
One of the children so inoculated did not return for inspection ; in the other cases it was found 
that exposure for half an hour to a temperature rising, in that time,'from 167° F. to 176° F., or 
to a temperature below this, did not impair the activity of the lymph, while exposure for the same 
length of time to a temperature rising from 185° F. to 194° F., or above, destroyed its activity. 
The difference between these results and Dr. Henry's is explained by Dr. Baxter as attribut- 
able to the difference in the duration of the exposures, which, in Dr. Henry's experiments, was 
from two to four hours; in his own, only half an hour, degree of heat and length of exposure 
being mutually compensatory. 
In Holland, Drs. Carsten and Coert have made a large number of experiments on the tempera- 
ture necessary to destroy the activity of calf lymph. They find that lymph heated to the boiling 
point of water is invariably sterilized. 
They arrive at the following conclusions :- 
1. Animal vaccine heated to 148° F. for thirty minutes loses its potency. 
2. Animal vaccine heated to 125.6° F. for thirty minutes does not lose its potency. 
3. The highest heat which vaccine can support without losing its potency is probably 
between 125.6° and 129.2° F. 
The experiments of Dr. Henry upon the degree of heat necessary to destroy the contagion of 
human communicable diseases other than vaccinia do not appear to have been repeated by sub- 
sequent investigators. 
Davaine ( Comptes Rendus, September 29th, 1873) ascertained that the blood of an animal 
suffering from anthrax, even when enormously diluted with water, when inoculated into a Guinea- 
pig, caused its speedy death. Such dilutions (1 in 10,000) were exposed to heat and subsequently 
inoculated, when it was found that their virulence was destroyed by exposures of five minutes to 
131° F.; ten minutes to 122° F., or fifteen minutes to a temperature of 118.4° F. 
When the blood was not diluted, it required for complete disinfection an exposure of fifteen 
minutes to a temperature of 123.8° F. On the other hand, the blood when previously dried over 
chloride of calcium retained its virulence after an exposure to 212° F. for five minutes. Davaine 
states that the virus of septicaemia is not destroyed by a prolonged ebullition. 
In the experiments, however, of Dreyer (Archiv für Experimentelle Pathologie, 1874, p. 182), 
Tabbits inoculated with septicæmic blood which had been previously mixed with a few drops of 
water and boiled (it is not stated for how long) remained virile. 
Modern discovery, that certain communicable diseases, as anthrax, are connected with the 
presence of microbes in the blood and tissues, a proposition which, from analogy, it is thought 
may ultimately be found applicable to all diseases of the same class, has led to the inference 
that by ascertaining under what circumstances microorganisms or the more resistant among 
them are destroyed, the conditions necessary for effectual disinfection may be learned. 
Upon this basis an extensive and important series of researches has been conducted by Koch 
and his coadjutors (Mittheilungen aus dem Kaiserlichen Gesundheitsamte, Berlin, 1881). The 
organisms employed in these researches as subjects of experiment, comprise, as examples of 
organisms devoid of spores, the micrococcus prodigioses, and the bacterium of blue pus, and of 
septicaemia, and as examples of spore-bearing kinds, the bacilli of anthrax and those found in 
hay and garden earth. The samples having been exposed to processes of disinfection, the subse- 
quent capacity for the development of the organisms so treated was tested by cultivation on 
slices of potato, or on gelatin containing blood serum, and in some instances by inoculation of 
animals. Control experiments were made at the same time with portions of the material not so 
exposed. 
The general results with chemical agents was to show the comparative or entire inertness as 
germicides of most of the substances commonly received as disinfectants, as carbolic and sulphur- 
ous acids, chloride of zinc, etc. The spores of bacillus anthracis were however destroyed by 
■exposure for one day to the action of the watery solution of either of the following substances, 
namely, chlorine, bromine (2 per cent.), iodine, corrosive sublimate (1 per cent.), permanganate 
of potash (5 per cent.), and arsenic acid (1 per cent.). 
They were also destroyed after longer periods by the following, namely, ether, oil of turpen- 
tine, hydrochloric acid, chloride of iron (five per cent.), arsenious acid (one per cent.), chloride 372 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
of lime (five per cent.), sulphide of ammonium, formic acid, chloropicrin, quinine (one per cent, 
solution in water with hydrochloric acid). 
It appeared, however, that the destructive power upon spores in the form of vapor is, in 
some cases, increased by elevation of temperature. Thus, spores of the bacilli found in garden 
earth were killed in two hours by exposure at a temperature of 176° F. to the vapor of bisul- 
phide of carbon, although neither this temperature in dry air nor the vapor of bisulphide of car- 
bon in equal concentration at ordinary temperatures had any destructive action on spores. 
The experiments of Koch and his fellow-workers were in hot air, made in apparatus con- 
sisting of a cylindrical or rectangular vessel of cast iron, heated by steam at a pressure up to six 
atmospheres in a closed coil of copper pipe. The results of these experiments are thus summed 
up by the authors :- 
1. Bacteria free from spores cannot withstand an exposure of one and a half hours to a tem- 
perature a little over 212° F. in hot air. 
2. Spores of mildews require for destruction a temperature of 230° F. to 239° F., for one 
hour and a half. 
3. Spores of bacilli are only destroyed by remaining three hours in hot air at 284° F. 
4. In hot air the temperature penetrates so slowly into articles to be disinfected that, after 
three or four hours' heating to 284° F., articles of moderate dimensions, namely, small bundles of 
clothes, pillows, etc., are not disinfected. 
5. By the heating for three hours to 284° F., necessary for the disinfection of such objects, 
most materials are more or less injured.. 
The results obtained with steam were strikingly superior to those obtained with dry heat. It 
was shown that an exposure of five minutes to steam at 212° F. was sufficient to kill the spores 
of the anthrax bacillus, and one of fifteen minutes to kill those of the bacilli contained in garden 
earth. However, the penetration of heat Into articles exposed to steam took place far more 
quickly than with the same articles when exposed to dry heat. 
Edwin Waller, ph.d., of New York, has published valuable tables of the degrees which have 
been found sufficient and insufficient for the destruction of various contagia, etc. (See Buck's 
" Hygiene," Vol. II, p. 550.) 
Vallin (" Traité des désinfectants et de la désinfection," 1883, p. 238), in reproducing the 
table of Edwin Waller, remarks that many of the assertions therein contained are open to ques- 
tion. On the other hand, Panum (according to Rezl, " Prophylaxis der übertragbaren Krank- 
heiten," p. 85, Vienna, 1881) finds that septic liquids resist much higher temperatures, and a heat 
of 320° F., has not sufficed to take away their infectious properties. 
II. EXPERIMENTS ON THE DEGREE AND DURATION OF HEAT NECESSARY FOR DISINFECTION. 
Dr. Parsons and Professor E. Klein have made an elaborate series of experiments on the 
degree of heat and its duration, necessary for disinfection. 
Dr. Klein furnished the infective materials, and also, after these had been exposed to disin- 
fecting processes by Dr. Parsons, tested the results by inoculations on animals. Control inocu- 
lations with unheated portions of the same materials were also in all cases made. 
The following were the infective materials employed :- 
1. Blood of Guinea-pig, died of anthrax, containing bacillus anthracis without spores. 
2. Pure cultivation of bacillus anthracis in rabbit broth, without spores. 
3. Cultivation of bacillus anthracis in gelatin, with spores. 
4. Cultivation of bacillus of swine fever (infectious pneumo-enteritis of the pig) in pork 
broth. 
5. Tubercular pus from an abscess in a Guinea-pig which had been inoculated with tubercle. 
The results of the experiments of Drs. Parsons and Klein with dry heat, as far as regards 
anthrax, are far more favorable as to its efficacy than those of Koch. It appears that the spores 
of bacillus anthracis lose their vitality, or at any rate their pathogenic quality, after exposure 
for four hours to a temperature a little over the boiling point of water (212° to 216° F.), or for 
one hour to a temperature of 245° F. Non-spore bearing bacilli of anthrax and of swine 
fever were rendered inert by exposure for an hour to a temperature of 212° to 218° F., and 
even five minutes' exposure to this temperature sufficed to destroy the vitality of the former 
and impair that of the latter. From their experiments with boiling water, Parsons and Klein SECTION XV PUBLIC AND INTERNATIONAL HYGIENE. 
373 
conclude that the cöntagia of the ordinary infectious diseases of human beings are not likely to 
retain their activity after boiling for a brief period in water. 
The results of the experiments of Parsons and Klein are conclusive as to the destructive 
power of steam, at 212° F., upon all the contagia submitted to its action ; these results are in 
accordance with those of Koch, Gaffky and Löefler; and it may be considered as established that 
the complete penetration of an object by steam heat for more than five minutes is sufficient for 
its thorough disinfection. 
These experiments were made by Drs. Parsons and Klein in 1884 and 1885, and the valuable 
report of Dr. Parsons on " Disinfection by Heat," containing these experiments, has been pub- 
lished in the "Seventeenth Annual Report of the Local Government Board, 1884-1885." Sup- 
plement containing the Report of the Medical Officer, pp. 218-304. 
In addition to the experiments cited, this report contains experiments and observations on- 
" The penetration of heat into articles submitted to disinfection." 
" On the liability to injury of articles disinfected by heat." 
" On the practical utility of disinfection by heat." 
■" On the different forms of apparatus for disinfection by heat." 
The apparatus for disinfection by heat are thus classified :- 
(a) By hot air- 
1. Apparatus in which the heat is applied to the outside of the chamber and the products of 
combustion do not enter the interior. 
2. Apparatus in which the heated products of combustion enter the interior. 
3. Apparatus heated by steam or hot water circulating in closed pipes. 
4. Apparatus in which air previously heated is blown into the chamber. 
(5) By steam- 
5. By a current of free steam. 
6. By steam confined in a chamber at pressures above that of the atmosphere. 
The apparatus described under the first class are Nelson's, Fraser's, Dr. Heron Roger's, 
Dr. Longstaff's, Taylor's and Bradford's, also Dr. Scott's, in the form heated by coal. Under the 
second class are described Washington Lyon's Steam Disinfector, Benham à Son's Steam Dis- 
infector, Branford's Steam Disinfector. 
THE FOLLOWING IS A SUMMARY OF THE VALUABLE REPORT OF DR. PARSONS ON DISINFECTION BY 
HEAT. 
" Fourteenth Annual Report of the Local Government Board, 1884-1885. Supplement con- 
taining Report of Medical Officer for 1884, pp. 218-304." London, 1885. 
1. With the exception of spore-bearing cultivations of the bacillus of anthrax, all the infective 
materials experimented upon were destroyed by ten hours' exposure to dry heat of 220° F., or 
five minutes' exposure to steam at 212° F. Spores of bacillus anthrax required for destruction 
four hours' exposure to dry heat of 220° F., or one hour's exposure to dry heat of 245° F., but 
were destroyed by five minutes' exposure to a heat of 212° F., in steam or boiling water. It 
may be assumed that the contagia of the ordinary infectious diseases of mankind are not 
likely to withstand an exposure of an hour to dry heat of 220° F., or one of five minutes to 
boiling water or steam of 212° F. 
2. Dry heat penetrates very slowly into bulky and badly conducting articles, as of bedding and 
clothing ; the time commonly allowed for the disinfection of such articles being insufficient to 
allow an adequate degree of heat to penetrate into the interior. 
Steam penetrates far more rapidly than dry heat, and its penetration may be aided by 
employing it under pressure, the pressure being relaxed from time to time, so as to displace the 
cold air in the interstices of the material. 
In hot air the penetration of heat is aided by the admixture of steam, so as to moisten the 
air, but hot moist air did not appear to have a greater destructive effect upon spores of anthrax 
bacilli than dry heat. 
3. Scorching begins to occur at different temperatures with different materials, white wool 
being soonest affected. It is especially apt to occur where the heat is in the radiant form. To 
avoid risk of scorching, the heat should not be allowed much to exceed 250° F., and even this 
temperature is too high for white woolen articles. 374 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
4. By a heat of 212° and upward, whether dry or moist, many kinds of stains are fixed in 
fabrics so that they will not wash out. This is a serious obstacle in the way of the employment 
of heat for the disinfection previous to the washing of linen, etc., soiled by the discharges of the 
sick. 
Ö. Steam disinfection is inapplicable in the case of leather, or of articles which will not bear 
wetting. It causes a certain amount of shrinkage in textile materials, about as much as an 
ordinary washing. The wetting effect of the steam may be diminished by surrounding the 
chamber with a jacket containing steam at a higher pressure, so as to superheat the steam in the 
chamber. 
6. For articles that will stand it, washing in boiling water (with due precautions against 
re-infection) may be relied on as an efficient means of disinfection. It is necessary, however, 
that before boiling, the grosser dirt should be removed by a preliminary soaking in cold water. 
This should be done before the linen leaves the infected place. 
7. The objects for which disinfection by dry heat or steam is especially applicable are such 
as will not bear boiling in water, e.g., bedding, blankets, carpets and cloth clothes generally. 
8. The most important requisites of a good apparatus for disinfection by heat are (a) that the 
temperature in the interior shall be uniformly distributed; (&) that it shall be capable of being 
maintained constant for the time during which the operation extends; and (c) that there 
shall be some trustworthy indication to the actual temperature of the interior at any given 
moment. Unless these conditions be fulfilled, there is risk, on the one hand, that articles 
exposed to heat may be scorched, or on the other hand, that through anxiety to avoid such 
an accident the opposite error may be incurred, and that the articles may not be sufficiently 
heated to insure their disinfection. 
9. In dry-heat chambers the requirement (a) is often very far from being fulfilled, the 
temperature in different parts of the chamber varying sometimes by as much as 100°. This is 
especially the case in apparatus heated by the direct application of heat to the floor or sides of 
the chamber. The distribution of temperature is more uniform in proportion as the source of 
heat is removed from the chamber, so that the latter is heated by currents of hot air rather than 
by radiation. 
10. In chambers heated by gas, when once the required temperature has been attained, but 
little attention is necessary to maintain it uniform, and in the best made apparatus this is auto- 
matically performed by a thermo-regulator. On the other hand, in apparatus heated by coal or 
coke, the temperature continually tends to vary, and can only be maintained uniform by constant 
attention on the part of the stoker. 
11. In very few hot-air chambers did the thermometer with which the apparatus was provided 
afford a trustworthy indication of the temperature of the interior; in some instances there was an 
error of as much as 100° F. This was due to the thermometer, for reasons of safety and accessi- 
bility, being placed in the coolest part of the chamber, and to the bulb being enclosed, for protec- 
tion, in a metal tube, which screens it from the full access of heat. The difficulty may be over- 
come by using, instead of a thermometer, a pyrometer, actuated by a metal rod extending across 
the interior of the chamber. 
12. In steam apparatus the three requirements above mentioned are all satisfactorily met, and 
for this reason, as well as on account of the greater rapidity and certainty of action of steam, 
steam chambers are, in Dr. Parson's opinion, greatly preferable to those in which dry heat is 
employed. 
13. Without wishing to give the preference to one maker over another, I may mention that 
of the apparatus heated by coal, Bradford's newer machine; of those heated by gas, the Notting- 
ham self-regulating disinfecting apparatus ; and of those employing steam, Lyon's patent steam 
disinfector, in Dr. Parson's experiments, gave the best results of any in their respective classes. 
14. It is important that the arrangement of the apparatus, the method of working, and the 
mode of conveyance to and fro should be such as to obviate risk of articles which have been sub- 
mitted to disinfection coming into contact with others which are infected. 
The preceding facts present a comprehensive view of the present state of our knowledge with 
reference to heat as a disinfecting agent. 
The mode of its application, as well as the capacity and arrangement of the apparatus, will, 
of course, depend largely upon the size and resources of the quarantine station or hospital. SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
375 
The value of heat as a disinfectant is now so well understood and the facilities for its use so 
great that all quarantine stations, hospitals and inspection stations for the detention of passengers 
along lines of travel, and especially along railroads, should be supplied with the necessary appli- 
ances for the application of both dry heat and steam. 
CARBOLIC ACID : ITS ANTISEPTIC AND GERMICIDE POWERS. HISTORY OF CARBOLIC ACID DISINFEC- 
TION IN EUROPE AND AMERICA, AND MORE ESPECIALLY IN NEW ORLEANS, LOUISIANA. 
Carbolic Acid (Phenic Acid, Phenol, Phenyl Alcohol, or Coal Tar Creasote): its Antiseptic 
Properties.-An important advance in sanitary and medical science was made when the anti- 
septic and disinfectant virtues of carbolic acid were recognized and practically applied. 
Such compounds as coal, bitumen, asphalt and petroleum, which contain carbolic acid, or com- 
pounds closely allied thereto in nature and properties, are widely spread over the globe, and have 
been used for ages as antiseptics. The Egyptians employed resinous and bituminous compounds 
in embalming their mummies; resinous aromatic substances, incense and tar were burnt by the 
Greeks and Jews to arrest and remove pestilential diseases; tar and bitumen were used by the 
ancients for the preservation of wood, and especially the timbers of boats and ships, from decay 
and the ravages of insects and marine worms; and some of these compounds were employed by 
the Romans to arrest vinous and acetous fermentation in the preparation of wine. 
The Romans sometimes place ! their fermenting wine in vessels lined with pitch, or threw 
powdered pitch into the fluid, or adopted the simple expedient, the rationale of which was prob- 
ably identical, of plunging therein a blazing pine torch, and there is no doubt that in these 
operations carbolic acid, in the guise of tar, controlled the vinous and prevented the acetous fer- 
mentation. 
Wood steeped in asphalt, or coated with this substance, will last for centuries, as has been 
clearly shown by the results of the experiments of the Assyrians and Egyptians. The experi- 
ence of four thousand years has shown that asphalt is one of the most indestructible of all sub- 
stances, and at the same time that it is the most powerful of all preservers of animal and vege- 
table substances. Not only are the Egyptian mummies and burial cases, which have been steeped 
in hot asphalt, in a state of preservation at the present time, but the delicate fabrics surrounding 
the mummies have been preserved in their original strength and beauty. Asphalt has been used 
by both ancient and modern nations, from the time that Noah fulfilled the divine command to 
"pitch," the ark "within and without with pitch," for the preservation of ships and boats and 
wooden structures from decay. The first structure of any magnitude erected after the flood-the 
Temple of Relus-was cemented with bitumen ; and, according to Herodotus, asphalt was used as 
a cement for the union and preservation of the bricks composing the immense walls and temples 
of Babylon. The Spaniards discovered in the West Indies, three centuries ago, the important 
fact that the asphalt with which Cuba and Trinidad abound was the best and only preservative 
of the bottoms of their ships against decay and the destructive action of marine animals, with 
which the warm salt water abounded. The whole country around Havana is impregnated with 
bituminous matter; even the solid quartz, the serpentine rocks and the veins of chalcedony have 
cells and cavities filled with liquid pitch or asphalt. In the Bay of Havana, the shore at low 
water abounds with asphalt and bituminous shales, in suffi cient quantity for paying of vessels. It 
is stated that in buccaneering times signals used to be made by firing masses of this chapapote, 
whose dense columns of smoke could be recognized at great distances and served as signals 
to vessels at sea; and it is even a matter of history that Havana was originally named, by the 
earlier visitors and settlers, Carene, "for there we careened our ships, and we pitched them with 
the mineral tar which we found lying in abundance upon the shores of this beautiful bay." 
In 1854, I instituted an extended series of experiments upon the antiseptic properties of 
various substances, and have as opportunity served continued them up to the present moment. 
The first series of experiments related to the preservation of animal structures; the second 
related to the arrest of decomposition in gangrenous ulcers, cancers and gunshot wounds ; and 
the third series related to the preservation of wood from decay, and the destructive action of 
marine animals. A large number of the specimens thus preserved from decay are at the present 
time deposited in the Museum of the Medical Department of the Tulane University of Louisiana. 
One of the most striking specimens consists of both feet of a man whose lower extremities were 
frozen in the swamps of Louisiana. 376 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Not only was the decomposition caused by the gangrene arrested in this case, but the feet 
exhibit the black, gangrenous portions, the lines of demarkation and the sound skin. 
It was determined by these experiments, that it was possible to preserve not only limbs and 
organs, but also entire animals, by means of various antiseptics, as arsenious acid, bichloride of 
mercury, and carbolic acid. 
Wood subjected to the action of hot asphalt and carbolic acid not only resisted decay, but also, 
when immersed in the waters of the Gulf of Mexico, resisted the action of the marine worm, 
( Teredo Navalis) which destroys annually an immense amount of property in all seaports and 
along all coasts in warm climates. 
The late General Braxton Bragg, who was an engineer, took the liveliest interest in the method 
of preserving wood from decay and the action of the Teredo Navalis, carried out a careful series 
of experiments, by the aid of the United States engineers and the civil engineers of the more 
important railroads, upon the samples of wood prepared by myself; and in all cases the wood 
immersed in Mobile Bay, Pensacola Harbor, Bay St. Louis, Galveston Harbor and Matagorda 
Bay, resisted decay and the action of marine animals. 
History of the Discovery of Carbolic Acid, and its Application to Medical and Sanitary 
Science.-Carbolic acid (Phenol, hydrate of phenol, phenylic alcohol, phenic acid, coal tar, 
creasote) was discovered by Runge in 1834, who experimentally determined its disinfecting 
properties; in 1844, M. Bayard introduced a powder as a disinfector in which coal tar was an 
ingredient; in 1851, Mr. Calvert, of Manchester, made many experiments with carbolic acid, 
using it for preserving flesh from putrefaction, injecting it into the arteries of dead animals, and 
demonstrating its power to prevent putrefaction, and to cheek fermentation. 
Mr. Robert Angus Smith, in his valuable work on Disinfectants and Disinfection, published 
in 1869, says, " The use of carbolic acid on a large scale was first brought prominently forward 
by myself and Mr. McDougal, so far as I know, about fourteen years ago, but all its essential 
properties were known before. Mr. McDougal, by using it in McDougal's powder, has made it 
famous, and its fame has caused a similar powder to be made in other countries, and by other 
persons. He used it also for wounds and the destruction of insects. 
"For the preservation of manure, it is as marvelous as for the preservation of meat, while it 
does not destroy the fertilizing power, but preserves all the elements, as if frozen, from all 
change. 
" It was recommended by the author (Robert Angus Smith) for the prevention of decom- 
position in sewers and in sewer rivers, until they could be more thoroughly purified. In a 
treatise on 'Siivern's system,' by Dr. Hubert Grouven, the same mode of purifying sewers is 
recommended, and said to be on trial in Leipzig. The mixture used is a little different ; 1 pound 
of melted chloride of magnesium; 3 pounds of lemi; J pound coal tar. 
" Mr. McDougal has long used tar-oil and lime for the land at Carlisle. I still think that it 
would be better to pour this on the streets, and to let it disinfect all that is found there, running 
it then into the sewers, and preventing putrefaction there, as it is better to prevent than to 
interrupt the formation of unwholesome gases. 
" The great advantage of carbolic acid is that it is a liquid, slightly volatile; it is therefore easy 
to throw it down anywhere, and to cause it to penetrate into every corner of a building, or to fill 
the air of the neighborhood." p. 63. 
It is evident from the preceding statement that the investigations on the value of carbolic 
acid as a disinfectant were commenced by Mr. Robert Angus Smith about the year 1854. 
M. le Beuf, of Bayonne, about 1859, employed crude carbolic acid in the form of a saponaceous 
emulsion, and associated with his labors M. Lemaine, of Paris. These investigators established 
the value of the emulsion as an application to gangrenous ulcers. About the same time Küchen- 
meister, of Dresden, used carbolic acid in medical and surgical practice, and in arresting 
putrefaction and preventing the manifestation of fungi. 
In 1860 M. Lemaire established the value of coal-tar applications in the treatment of wounds, 
and demonstrated that carbolic acid was the active agent in effecting the changes ; and in an 
elaborate treatise published in 1863, he narrated a series of investigations in which carbolic acid 
was employed as a means for the destruction of low forms of animal and vegetable life, as a pre- 
ventive of fermentation and putrefaction, as an external application in cases of ulcerating and 
suppurating surfaces, as well as an internal remedy in zymotic and other diseases. SECTION XV PUBLIC AND INTERNATIONAL HYGIENE. 
377 
Coal tar was used in the treatment of gunshot wounds, to a limited extent, by the Southern 
(Confederate) surgeons during the American civil war, 1861-1865. 
The occurrence of cattle plague in England, in 1865, gave an impetus to the study of disin- 
fectants, and important additions to sanitary science were made by the investigations of Dr. 
Angus Smith and Mr. Crooks. The appendix to the " Royal Commissioners' Report " on the cattle 
plague contains the following :- 
" According to the principles laid down, the air must be treated, and where there is no disease 
there is only a secondary use in treating anything besides the air. Several cow-houses have 
been treated with carbolic acid with very excellent results. The mode has been, first, to remove 
from the floor the mass of manure which too often adheres to it ; secondly, to sprinkle the floor 
with strong carbolic or cresylic acid. Next to wash the walls, beams and rafters, and all that is 
visible in the cow-house, with lime, in which is put some carbolic acid, one to fifty of the water 
used, or with strong carbolic acid alone. Next to make a solution containing one of carbolic 
acid or cresylic acid to 100 of water, or, perhaps still better, sixty of water, and to water the yard 
and fold until the whole space smells strongly of the acid. Only a few farms have been treated 
in this way, so far as I know, but in each it has been successful. It may be well to give the cat- 
tle a little of the weak solution of carbolic acid, but this has not been so fully tried as the 
external use. The washing of the mouth and entire animal with the weak solution may be 
attended with good results, especially in the early stage of disease." 
Mr. Crooks made elaborate experiments on carbolic acid, and in his Report gives details of 
experiments in which this acid was injected directly into the.blood vessels of cattle. Although 
the experiments with the injection of carbolic acid into the blood were too few to permit of any 
practical conclusions as to its therapeutic effects when administered in this manner, nevertheless, 
Mr. Crooks demonstrated that it reduces the animal temperature, and does not necessarily prove 
fatal when injected in the amount of one part to 10,000 parts of blood. 
In 1865 Professor Lister commenced the employment of carbolic acid as an application to 
wounds and abscesses attended with suppuration, and obtained results which confirmed the 
accuracy of those previously announced by Lemaire and others. 
Mr. Lister has continued his investigations up to the present time, and by his energetic and 
intelligent advocacy of carbolic acid for the treatment of wounds in England, France, Germany 
and America, has succeeded in directing the minds of the profession to the value of this agent, 
and rendered popular the so-called antiseptic system in surgery. It would be foreign to our pur- 
pose to adduce in this connection the mass of testimony recorded by Professor Lister and others 
as to the value of carbolic acid as a local application to wounds. 
Value of Carbolic Acid as a Disinfectant and Antiseptic in Asiatic Cholera and Cattle 
Plagues.-During the outbreak of cholera in 1866, carbolic acid was put to a practical test, both 
in England and America, and the reports of the medical officers of health testifying to its efficacy 
may be found in the Registrar-General's Report on the cholera epidemic of 1866 in England. 
The intelligent and systematic use of carbolic acid and other disinfectants in North America 
for the arrest of cholera and other contagious diseases was inaugurated by the Metropolitan 
Board of Health of New York during the cholera epidemic of 1866; and the marked success 
achieved in the limitation of the ravages of the disease was largely due to the untiring labors 
of the eminent American sanitarian, Dr. Elisha Harris. 
The prevalence of cholera in various parts of Europe, and the almost absolute certainty of 
its appearance in America during the year 1866, stimulated the Metropolitan Board of Health 
to great activity, immediately upon its organization, to prepare the Metropolitan District for the 
arrival of the epidemic. Under the direction of the Board, a disinfectant depot and laboratory 
was established in a building, No. 308 Mulberry street, immediately adjacent to the central 
office, and placed under experienced and able assistants. The laboratory was constantly used for 
experiments in the use and combination of various disinfectants, and the men, for the proper and 
faithful application of the same. This duty, as the season advanced, became of a most laborious, 
and often hazardous, character. The men were constantly visiting infected districts, entering the 
houses there and handling bedding and clothes soiled by the dejections of cholera patients ; they 
were also obliged to disinfect all bodies dead of cholera, and frequently to place them in coffins 
and remove them to the morgue. 
Immediately upon the arrival of the steamship Atalanta, with its company of cholera sick, 378 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
in the Bay of New York, in November, 1865, Dr. Elisha Harris, by request of the Citizens' 
Council of Hygiene, prepared a memorandum on preventive measures against the epidemic, 
from which we extract the following paragraphs concerning cholera disinfection.* 
" Let the excrementitious matters from the sick be disinfected in the vessel as soon as voided, 
by means of carbolate of lime, su'phate or proto-chloride of iron, coal tar, carbolic acid, or per- 
manganate of potash, and let no well person directly use the privy into which such materials are 
emptied while cholera is prevailing. Whenever practicable, let the evacuated materials be 
deeply buried in the earth, and immediately covered with quicklime or coaltar and gravel. 
" Let all the vessels and clothing that are used by the patients be immediately cleansed with 
boiling water and soap, or alkaline chlorides, or permanganates. 
" Preserve the utmost degree of personal cleanliness of the sick and their attendants. 
"To absorb moisture and putrid fluids, use fresh stone lime, finely broken; sprinkle it 
abundantly on the place to be dried ; or for damp rooms place a large number of plates filled, 
with the lime powder and not with the kalsomine. 
" To absorb putrid gases use charcoal powder. The coal must be dry and fresh, and should 
be combined with lime. 
" To give off chlorine, to absorb putrid effluvia and to stop putrefaction, use chloride of lime, 
as lime is used ; and if in cellars and close rooms the chlorine gas is wanted, pour diluted sul- 
phuric acid, or muriatic acid, upon your plates of chloride of lime occasionally, and add more of 
the chloride. 
" To disinfect the discharges from cholera patients and to purify privies and drains, dissolve 
ten pounds of copperas in a pailful of water, and pour a gallon or two of this strong solution 
into the privy, and water-closet or drain, every hour, if cholera discharges have been thrown into 
these places; but for ordinary use, to keep privies from becoming offensive, pour a pint of this 
solution into every water-closet, pan or privy seat every night or morning. Bed-pans and chamber 
vessels are best disinfected in this way, by a teacupful of the copperas solution. Add the same 
quantity of carbolic fluid (diluted carbolic acid), or coal-tar powder, to insure permanent disin- 
fection ; chloride of zinc, or proto-chloride of iron, may be substituted for the sulphate of iron. 
" Permanganate of potassa may be used to disinfect clothing and towels from cholera and fever 
patients during the night, or when such articles cannot be instantly boiled. Throw the soiled 
articles immediately into a small tub of water, in which there has been dissolved an ounce of 
permanganate salt to every two gallons of water, until the clothing is boiled; and see to it that 
the permanganate salt is added in just sufficient quantity to keep up a purple or red color in the 
water that covers the clothing. A pint of Labarraque's solution of chlorinated soda may be 
used for the same purpose in the tub of water if the clothing is to be soon boiled, but must not 
be trusted for permanent disinfection. Either of these substances may bo used in cleansing the 
soiled parts of the body of the sick or dead persons, or may be used in bed-pans, etc. The 
permanganate solution will instantly disinfect and deodorize whatever it touches, but its action 
continues only while it gives a purple or reddish color. 
" Carbolic acid and the coal-tar disinfectants are the most efficient and permanent antiseptics. 
The crystallized acid (Cortly) will dissolve in one hundred times its own weight of water. A 
tablespoonful of the solution will disinfect a chamber vessel. The fluid acid (cheap), seventy 
per cent, strength of crystallized, is most valuable for common use. Dilute it in twenty-five, fifty, 
or more parts of the iron solutions for fluid use, or in fine quicklime or saw-dust for use in foul 
surfaces and heaps. 
" To disinfect discharges from cholera patients, privies, water-closets, garbage tubs and foul 
heaps, or surfaces, use the strongest of the coal-tar or carbolic powders, which are powerfully 
antiseptic. Those which contain a large amount of some proto-salt of iron, and the most 
carbolic acid, are best. For disinfecting cholera always use one of the soluble salts of iron or 
zinc, as mentioned in this memorandum, whatever else is employed." 
Never use chlorine, chlorides, or the permanganate of potash with carbolic acid disinfectants. 
Let closets and bedrooms be cleansed, dried and ventilated. Beds and bedding must be fre- 
quently ventilated in the sun. 
Whatever soiled clothing can be boiled should, if possible, as soon as removed, be thrown into 
* " Annual Report of the Metropolitan Board of Health, 1886," pp. 206-217. SECTION XV PUBLIC AND INTERNATIONAL HYGIENE. 
379 
boiling water and be kept boiling an hour or two. While waiting the boiling, keep all the 
cholera-soiled clothing covered in the disinfecting permanganate water, or, if that is not at hand, 
use the chlorinated solution. Whatever articles have received the infective matter of cholera 
and cannot be immediately disinfected by such means, or by sulphurous fumigation, should be 
destroyed by fire. 
Let it not be forgotten that all the discharges from the bowels and the stomach of the cholera 
sick must be immediately disinfected by the means specified for this purpose. 
Never cast the discharges from the sick into a privy or upon the surface of the ground, but 
into some privy or water-closet that is not, for the time being, frequented, or into a specially pre- 
pared pit. And whether cast into a privy or earth-pit, or elsewhere, the choleraic discharges, at 
every stage of the disease, from the first diarrhoea to the final collapse, must be disinfected as 
soon as voided, and be impregnated with destructive chemicals when cast away. 
Fumigation of Infected Houses.-In any room, house or ship, where the infection of cholera 
exists, or is liable to exist, after cleansing, fumigation should be practiced with sulphurous acid gas, 
by burning a few ounces of sulphur upon a dish of red-hot embers, or with nitrous acid fumes, by 
pouring three ounces of concentrated nitric acid over an ounce of fine copper shavings, or by heat- 
ing a mixture of nitrate of potassa and sulphuric acid in an iron or porcelain dish; or with chlor- 
ine gas (of little use in cholera), by mixing a quart of muriatic acid and a pint of water, and 
pouring it upon a pound of finely powdered black oxide of manganese, or by any other methods 
of evolving this gas. Sulphurous acid gas is the most effectual and the most easily applied of all 
the agents of fumigation. Before fumigation begins let all chimneys and windows be closed ; 
as soon as begun let the person on duty withdraw from the place, close all the doors, and keep 
them closed for twelve hours. Then open every window, door and aperture, and keep open for 
successive days and nights. There is no substitute for cleanliness and ventilation. To protect 
from cholera, attend to these sanitary duties, and also destroy, by chemical agents, the choleraic 
discharges. 
Quantity and Kind of Disinfectants which are Required for Common Use.-Recent reports 
from Professors Pettenkofer and Wunderlich, from Dr. Muhling, of Constantinople, and the espe- 
cially excellent ones by Dr. Angus Smith, Mr. Crookes and Professor Rolliston, as well as our own 
experience, fully confirm the confidence we have placed in the crude sulphate of iron and car- 
bolic acid, for use upon the surfaces or in the vessels that receive the cholera excrement. There 
are many other chemical agents that can control or destroy the infective property of the excre- 
mental matters, but these are the most available, because, at the same time, the cheapest and most 
effectual. 
Let it be borne in mind by all sanitary authorities that the object of all methods of cholera 
disinfection is to destroy or to hold in perpetual inactivity the excreta of the sick and the sources 
of organic putridity, wherever the excrement may be cast away. The saturated solutions of sul- 
phate of iron and carbolic acid, when employed jointly, or in the order here mentioned, most 
certainly accomplish such disinfection when properly applied. They are our best and cheapest 
antiseptics. 
Boiling and high steam heat will most speedily and effectually disinfect foul clothing. The 
floating hospital has testified to this fact these eight years past. But all kinds of clothing and 
surfaces soiled by the cholera fluids require antiseptic care until they are washed. In the English 
towns, carbolic acid is employed for this purpose, although it is apt to destroy the fabrics, as it 
is but sparingly soluble (about one per cent, only, in water). 
The permanganate of potash is, both theoretically and practically, the best and most econom- 
ical, for it does not impair the fabrics it touches, if properly diluted, while, at the same time, it 
gives a color test of its effective presence. 
Chloride of lime and chlorinated soda solutions will unquestionably hold the cholera poison in 
check for a time, but we have seen very decided proofs that their disinfecting power is transient 
and unreliable."-"Annual Report of the Metropolitan Board of Health," 1866. 
The objects of the preceding directions, as propounded by Dr. Elisha Harris, and other Ameri- 
can and European sanitarians, were :- 
1. To destroy or to neutralize the offensive gases and products of putrefaction. 
2. To prevent fermentation and putrefaction. 
3. To destroy all infection and infective processes in the specific contagions and infections. 380 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
It was not until the results of the more exact and defined experience and researches, in the 
epidemics of 1854, 1859 and 1865, in Europe, had been analyzed and compared, that the conclu- 
sion was reached- 
That the diarrhoeal excreta of the sick when impregnating the soil, the drinking water, or 
any kind of decomposing matter, especially that of privies, cesspools, sewers, drains, and the 
ground about dwelling houses, constitute the positive, the chief, and, for aught that is yet known, 
the only means of propagating and spreading Asiatic cholera. 
This proposition being granted, the conclusion is reached : That the cholera germs or infec- 
tion, by whatever means they chance to be introduced into any town or city, will be epidemically 
propagated only where and when certain conditions of putrescence in the earth, the atmosphere, 
or the potable water, are present; that where any two or more of these unhealthful circumstances 
are present, the certainty and severity of the epidemic will be greatly increased, unless the disin- 
fecting power of acid antiseptics is brought to bear at every point of infectious exposure; and, 
finally, the co-existence and co-operation of surface moisture of the ground-technically, in the 
words of Pettenkofer, the ground-water-is the most constant and essential of all the physical 
agencies that promote the propagation of cholera, after the germs of infection have been intro- 
duced. 
The view has long been held that the cause of cholera and zymotic diseases was in some 
way dependent upon cell germs and cell growth, more or less like certain ferments; and ever 
since 1838 the best microscopical students, particularly those who were familiar with the minutest 
forms of vegetable and animal parasites, have sought for the existence of some minute kind of 
cryptogamie cell growth or fungus parasite that might turn out to be found exclusively in the 
rice-water excrement of the cholera sick. 
During the year 1866, several of the ablest microscopists in Europe, independently of each 
other, reached the same results, which may be thus expressed :- 
In the rice-water excrement of cholera patients, and within the intestinal canal of such 
persons, also in the water and soil that have been in any manner made to receive or imbibe the 
rice-water excrement, is discovered a peculiar cell growth or fungus cyst, that in most respects 
resembles, in its developed state, the fungus Pénicillium and the Oïdium, that are so well known 
in connection with certain blighting diseases of cereals, as well as with the diphtheritic and other 
diseases of the human body. This new and peculiar species of fungus cell, called by Professors 
Thomé and Klobe cylindro-tænium, or zoo-glua, and considered by Professors Hallier and Simon 
as an exotic member of the family to which the urocystic and oïdium blights of cereal grain 
belong, is distinguished for its rapidity of development, strange forms of growth, and its fatal 
destruction of the epithelial tissue of the intestine. Professor Hallier has proved that from the 
Pénicillium stage of development of the cholera fungus it would grow luxuriantly in the rice- 
plant, which is a native of India. As described by Professor Ernest Hallier, of Jena, this 
cholera fungus cell growth is a Penicillium-bearing one, which is known to be a native of India 
only, and as having the following peculiarities :- 
1. As shown in all his experiments its life power of further propagation or growth is 
instantly destroyed by an acid condition of the fluid or soil in which their growth was observed. 
2. The presence of an abundance of nitrogenous matter, and the absence of acids in the soil, 
the substance or the fluid in which the propagation and development of the cholera fungus was 
being observed, experimentally, was proved to be an essential condition for such propagation and 
growth. 
3. When the fungus cells, in the course of their development upon a piece of intestinal mem- 
brane (in a bottle) reached a certain stage, they rapidly increased, and the epithelium as rapidly 
wasted away. 
It is evident, therefore, that the investigations of 1865, and 1866, and the sanitary measures 
instituted in Europe and America, constituted a new and important era in sanitary and medical 
science ; and in the latter country, the first and greatest advances were made by the Board of 
Health of New York, and especially by its Registrar of Vital Statistics, Dr. Elisha Harris. 
In the Gardener's Chronicle, November 9th, 1867, a description is given, by the Hon. W. Hope, 
of experiments made in diseased cattle at his farm, near Barking. He says " I thought that 
while there was life there was hope, and I determined to do more than any one had done before. 
Where one man had used a hundredweight of lime I determined to use a ton, and where one man SECTION XV PUBLIC AND INTERNATIONAL HYGIENE. 
381 
had used a pint of carbolic acid I determined to use a gallon. . . The dry substance I had at 
hand to deal with in large quantities was lime. This I slaked in small pyramids in the centre of 
the sheds. I also laid trains of it outside the sheds, underneath the ventilators, and then slaked it. 
I also smothered the roads and paths at different points in layers of quicklime three or four 
inches deep, so that every man and animal would be compelled to pass it. After scouring out the 
sheds, every cow's tail was dipped into a bucket of carbolic acid and water. Their heads and 
noses were dabbed over with it, also their sides and flanks. All the manure and litter from the 
cow's stall, as well as from the adjoining ones, was taken out at once and the floor thoroughly 
cleansed and saturated with carbolic acid, and, on the suggestion of Professor Brown, I had four 
days previously commenced the use of sawdust saturated with carbolic acid, one or two shovelsful 
of which were placed every day under the cow's head. This operation was also repeated in every 
stall and the cows were then drenched with gruel and sulphite of soda. Of the 58 cows in shed 
D, and 53 in shed E, that I took the entire charge of and treated as described, I did not lose 
one." 
The rinderpest having broken out in a herd of upward of 260 cows, in its virulent form, Mr. 
Hope undertook the treatment of one-half the number by the carbolic acid plan. " The result 
was," says Mr. Hope, " that while every single animal that I did not take charge of either died or 
was slaughtered, I succeeded in saving every single animal that I did take charge of."* 
Dr. Edmund A. Parkesf has expressed his conviction that carbolic acid deserves the foremost 
place as a means of limiting the spread of infectious diseases. Dr. Parkes inhaled, for the 
purpose of testing their morbid effects, the exhalations from sewers. The first effects were a nasal 
catarrh and an irritation of the mucous membrane of the throat ; hyper-salivation followed, and 
subsequently, after an interval of 30 to 50 minutes, nausea. In a few hours occurred chilliness, 
headache and fever, lasting from 20 to 24 hours. None of these effects were observed when 
the sewage matters had been previously treated with a sufficiency of carbolic acid. 
Dr. Wm. Budd, of Bristol, has stated that by the employment of disinfectant agents, ''the 
contagion of scarlet fever, of whooping cough, of diphtheria, and many others of the same family 
may be in great degree, if not wholly, disarmed." There is also, he says, every reason to believe 
that the contagion of typhus may be thus limited. 
We have thus brought the history of disinfectants down to the period in which they were first 
used systematically for the arrest of yellow fever by Dr. S. A. Smith, President of the Board of 
Health of New Orleans, during the yellow fever epidemic of 1867, during which 3107 inhabitants 
of this city fell victims to this disease. 
The result of these efforts to limit and control yellow fever by means of sanitary measures and 
certain disinfectants, as carbolic acid and sulphurous acid, will receive careful consideration in 
the division of our researches especially devoted to this subject. 
We will endeavor to examine, in the next place, those facts which illustrate the chemical 
properties and mode of action of carbolic acid as an antiseptic and disinfectant. 
Chemical Properties and Relations of Carbolic Acid.-Phenic, or carbolic acid, phenyl 
hydrate, phenol (C6H«0, or H.C6H60), the most abundant acid product of the distillation of pit- 
coal, and produced also by the distillation of the salicylates, of the alkalies, and of the earths, and 
found also among the products of the distillation of gum benzoin and of the resin of the 
Xanthorrhœa hastilis, is classed under the secondary aromatic alcohols, and in this connection is 
termed phenol; and while giving no reaction to test paper, forms with bases distinct and definite 
salts. The crystals of phenic acid melt at a temperature of about 105.8° F. (41° C.), and the liquid 
enters ihto ebullition between 369° and 370° F. Phenic acid requires 25 to 30 parts of water for 
solution, but is dissolved by alcohol, ether and concentrated acetic acid in all proportions. When 
agitated with solution of caustic potash of sp. gr. 1060, the carbolic acid mixes freely with the 
alkaline ley, but a large portion of the acid separates on dilution. Phenic acid has a burning 
taste and an odor of wood smoke, resembling that of creasote; its vapor strongly attacks the skin 
of the lips and gums, and it possesses antiseptic properties similar to those of creasote, and 
indeed, much of the commercial creasote consists solely of phenic acid. Phenic acid, when 
heated with ammonia in a sealed tube, becomes partially converted into water and aniline. The 
acid combines with potash, and forms with it a crystalline compound, though it may be distilled, 
* Chemical News, October 21st, 1870, p. 196. 
f Lancet, November 21st, 1868. 382 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
unchanged, from caustic potash, or from quicklime, or caustic baryta in excess. Phenates of these 
bases may be obtained, but they are easily decomposed ; with oxide of lead an insoluble compound 
may be obtained. It combines with sulphuric acid, with which it forms a conjugated acid. 
Phenic acid is accompanied in coal tar by other homologous bodies which greatly resemble it. 
By subjecting commercial coal tar creasote to fractional distillation, Williamson obtained a liquid 
which boils at 397.4° F., and which is nearly insoluble in solution of ammonia. 
Kresylic acid, kresol, or methyl-phenol, is soluble in oil of vitriol, producing a violet color 
and forming a compound acid. This substance is metameric with anisol, and with benzyl alco- 
hol; it is the phenol of the toluric series. When treated with fuming nitric acid it is oxidized 
with almost explosive violence, and trinitro-kresylic acid, homologous with carbazotic acid, is 
produced. A third homologue, xylyl-phenol, also occurs in coal tar in small proportions. It is 
probably dymethyl-phenol, but it has not been accurately investigated. Isomeric with this body 
is phlorol, obtained by distilling calcic phlorotate with lime. It is a colorless, highly refractive 
oil, with a burning taste, and an odor recalling that of carbolic acid. Thymol also, according to 
Kekulé, is a homologue of carbolic acid; but this appears to be doubtful. 
Phenic acid may be caused to furnish ethers with alcohol radicles by a process of double 
decomposition, which consists in distilling potassic methylsulphate, ethylsulphate, or anlylsulphate 
with potassic phenate. These ethers may likewise be procured by heating potassic phenate with 
the iodide of methyl, of ethyl, or of amyl ; they are also produced by the distillation of the sali- 
cylic ethers with caustic baryta. 
Phenic acid gives rise, by substitution, to an unusual number of acid compounds, formed upon 
the type of phenic acid itself. All these acids are monobasic and form definite salts, many of 
which crystallize very beautifully. 
A mixture of potassic chlorate and hydrochloric acid converts phenic acid into trichloro- 
phenic acid, and by prolonged action chloronil is produced. 
Oil of vitriol dissolves phenic acid without change of color, and produces a compound mono- 
basic acid, termed sulphophenic acid ; it forms with barium a soluble salt, which crystallizes in 
tufts of needles. If phenic acid be allowed to fall, drop by drop, into fuming nitric acid, it is 
attacked with great violence ; each drop produces a hissing like that which accompanies the 
quenching of a hot iron ; and upon boiling the mixture carbazotic (trinitrophenic) acid is 
obtained. If the acid be more dilute, nitrophenic acid, or dinitrophenic acid, is produced. Both 
these acids may readily be obtained in crystals. Most of these salts crystallize with facility ; they 
greatly resemble the carbazotates. 
Antiseptic Action of Carbolic Acid on Vegetable and Animal Substances. Poisonous Effects 
of Carbolic Acid.-The aqueous solution of carbolic acid coagulates albumen ; it unites with cer- 
tain animal substances and preserves them from decomposition, even removing the fetid odor 
from meat and other substances already in a state of decomposition. Fish and leeches die when 
immersed in the aqueous solution, and their bodies subsequently dry up on exposure to the air, 
without putrefying. 
M. Méhu- and Dr. Meymott Tidy have recommended carbolic acid, dissolved in acetic acid, 
as a delicate test for albumen in the urine. The process, however, does not appear to be more 
delicate, or as reliable, as the long-established test of nitric acid and heat. 
We have seen that carbolic acid enters into union with inorganic bases, forming definite com- 
pounds, and that it may be readily displaced from its combinations. M. Roméif considers the 
compounds merely juxtapositions of the molecules, each constituent preserving unchanged its 
inherent character. 
It is important to know whether, in the case of the organic bodies with which the agent may 
come in contact, it may form compounds which may modify the original properties. 
This question has been carefully considered by Dr. Arthur Ernest Sansom, in his elaborate 
and valuable treatise on "The Antiseptic System."! 
While carbolic acid has a certain affinity for albumen, Dr. Sansom has shown that the pres- 
ence of this substance, or of potash, in small quantities, does not impair its power of arresting 
fermentation. 
* Journal de Pharmacie et de Chimie, February, 1869. 
f Bulletin de la Société Chimique, February, 1869. 
î Page 17. SECTION XV PUBLIC AND INTERNATIONAL HYGIENE. 
383 
Dr. Sansom has shown that a mixture of glycerine and carbolic acid acts upon the sensitive sur- 
face of the skin in a far less energetic manner than the aqueous solution ; the presence of glyce- 
rine impairs in a very obvious manner the power to arrest saccharine fermentation ; carbolic 
acid appears to unite chemically with glycerine. In like manner, when united with olive oil, the 
energy of its action on the skin is diminished, and its power of arresting fermentation and putre- 
faction is impaired. A five per cent, solution of carbolic acid in olive oil fails to prevent the 
putrefaction of flesh, though a one per cent, watery solution will entirely prevent such decompo- 
sition; it appears, therefore, to enter into combination with fatty matters. Alcohol also lessens its 
power over fermentation. 
Dr. Sansom concludes that these considerations are sufficient to show that carbolic acid readily 
enters into combination with the organic bodies with which it comes into relation, and that 
these are prone to mutual variations, and that then the original properties of the agent become 
modified. 
The chief value of carbolic acid, and the compounds associated with it, is its property of 
destroying vegetable and animal organisms, and its antiseptic property of preventing fermenta- 
tion and putrefaction. 
Carbolic acid not only prevents fermentation, but it also arrests it, when it has once com- 
menced ; although, on the other hand, it does not prevent the conversion of starch into dextrine, 
or the fermentation of the essential oil of almonds when amygdalin is mixed with synaptose. 
Dr. Sansom has shown that the following quantities of various agents will wholly arrest the 
fermentation of twenty-five grains of cane sugar : Perchloride of mercury, grain 0.03; hydrated 
sulphuric acid, grain, 0.10 ; carbolic acid, grains 2.00 ; perchloride of iron, grains 3.90 ; car- 
bonate of potash, grains 4.00 ; sulphite of soda, grains 5.00 ; sulphocarbolate of soda, grains, 20.00. 
Mr. Crooks, in his Report to the Cattle Plague Commissioners, related an experiment which 
tended to show that the action of carbolic acid in restraining fermentation was directed upon the 
yeast, and that the power of yeast to induce fermentation was wholly destroyed by feeble solu- 
tions of carbolic acid. Mr. Crooks washed yeast with a one per cent, aqueous solution of carbolic 
acid, and then washed away with water, as far as possible, the carbolic acid. The experiment 
several times repeated always showed that the power of exciting fermentation was wholly 
destroyed. This conclusion, however, was contested by Pettenkofer, who says that though car- 
bolic acid preserves ferment cells in an inert state, yet when the volatile acid has become dissi- 
pated these resume their activity. Dr. Sansom, who submitted this question to experimental 
demonstration, concludes that :- 
"Without as yet hazarding any hypothesis as to the nature of fermentation, our data show 
that the yeast is the element which is acted upon, and there is no sign that this is chemically 
altered." 
The action upon the yeast would appear to be not temporary, but permanent. Dr. Angus 
Smith* remarks upon the same subject, that his experiments led him to believe that Pettenkofer 
must have used very weak acid. 
Abundant experimentation has proved that carbolic acid prevents the putrefaction of organic 
substances ; that in small quantities it prevents the germination of the spores of the yeast plant and 
various seeds, as lentils, kidney beans, barley and oats ; that an infinitesimal quantity instantly 
kills bacteria, vibrios, spirilla, amœbæ, monads, eugliniæ, paramaciæ, rotifera, and vorticellæ; 
that it destroys ascarides, the ova of ants, earwigs, and butterflies ; that it kills lumbrici, cater- 
pillars, bulles, crickets, fleas, moths, fish, frogs, leeches, birds and animals. 
The multitude of observations which have been made, and the experience of every day, leave 
no room to doubt that carbolic acid has a great power in arresting both fermentation and putre- 
faction ; and, at the same time, accumulated observations by Crooks, Roberts, Angus Smith, 
Dougal, Sansom, and many others, show that it does not exert any appreciable influence on 
oxidation. Oxidation of potassium, sodium, iron, copper, lead, manganese and phosphorus have 
been observed to take place as readily in aerial or aqueous atmospheres, impregnated with car- 
bolic acid, as in cases when the latter is entirely absent. 
That carbolic acid has an action over and above its faculty of coagulating albumen, and does 
not prevent or arrest fermentation or putrefaction solely in virtue of its power of coagulating 
*" Disinfectants and Disinfection,'' p. 63. 384 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
albumen, is shown conclusively by the fact that if a solution of albumen be precipitated in one 
case by heat or by an ordinary chemical agent, and in the other by a solution of carbolic acid, 
the resultant precipitate, if kept in contact with the air, will in the first case be decomposed in the 
ordinary manner, while that precipitated by the carbolic acid entirely resists putrefactive change. 
The conclusion has been drawn from the preceding facts, that carbolic acid does not operate in 
any manner obviously chemical, but that it has a manifest effect upon vitality, and that it has the 
power of killing, in feeble doses and in a marked manner, the lower manifestations of animal and 
vegetable life, which are intimately associated with the processes of fermentation and putre- 
faction. 
When carbolic acid is added to a solution susceptible of putrefaction, and before the com- 
mencement of any putrefactive decomposition, no organisms are developed ; and when added to a 
putrefying solution, all the infusoria present in that solution instantly die, and the cessation of 
putrefactive change is coincident with their death ; there is, therefore, a direct connection 
between the manifestation of living things and the occurrence and progress of putrefaction, and 
it is in virtue of its power of suppressing vitality that carbolic acid acts as an antiseptic. 
It would be foreign to our purpose to examine the testimony accumulated from the time of the 
experiments of Redi, in Florence in 16.18, to the present moment, including the observations of 
Needham, Bonnet, Spallanzani, Lamarck, Cabanis, Bory, St. Vincent, Bremser, Tiedemann, I. 
Mtiller, Dumas, Dujardin, Burdach, Gay Lussac, Schwann, Schröder, Dusch, Pouchet, Pasteur, 
Rallier of Jena, Bastian, Huxley, Owen and others, which hare led to the promulgation of the 
two rival theories of the heterogenists and pan-spermatists with regard to putrefaction. 
According to the heterogeniete, "putrefaction is a chemical change which moist organic mat- 
ter is prone to undergo under certain influences. It is a slow process of oxidation. Its primum 
movens is an albuminous body (the putrescible matter itself), whose particles are in a condition of 
motion, which motion is capable of communicating by catalysis to contiguous organic matter. 
The initial changes are chemical changes ; these chemical changes place the organic matter in 
such conditions as favor its transformation, under ordinary physical forces, into organisms pos- 
sessing vitality. Hence, these arise de novo from the dead material ; their occurrence is non- 
essential to the process ; either they are entirely adventitious, or they are only intermediary 
means of transformation." 
According to the theory held by the Pan-spermatists, " Putrefaction is a transformation of 
organic matter entirely effected by the influence of vitally endowed organisms. The chemical 
changes in putrefaction are the sum of the products and the acts of living beings. The first 
cause is a multitude of minute particles of vitally endowed matter derived from the pre-existing 
living beings, contained in the air, permeating all substances which air itself permeates, wafted 
from place to place, finding in the putrescible fluid a suitable soil or pabulum, in which, in various 
forms, to live, grow and multiply. The universally present living particles are essential to the 
process of putrefaction, and when they are destroyed, putrefaction cannot take place." 
The force of the evidence with reference to carbolic acid sustains the theory of fermentation 
and putrefaction held by the Pan-spermatists, and it owes its antiseptic power to its poisonous 
effects upon those organisms which are so uniformly distributed upon the surface of the earth, 
and throughout the atmosphere, upon which the processes of fermentation and putrefaction 
depend. 
When we endeavor to apply the preceding facts to the explanation of the mode in which 
certain chemical compounds, as sulphurous acid, chlorine and carbolic acid, arrest contagious 
and infectious diseases, the following facts should be considered:- 
1. All disinfectants and antiseptics possess the power of arresting fermentation and putrefac- 
tion, and consequently alter the chemical and physical constitution and properties, or embalm 
and preserve from further change organic substances. 
2. All disinfectants and antiseptics are destructive of those forms of plants and animals upon 
which fermentation and putrefaction depend. 
3. Carbolic acid especially arrests the chemical changes of germinal matter, and of individual 
cells, and of the lower organisms ; it is destructive of life. 
4. Diseases may be caused by chemical and physical changes of the atmosphere ; by the 
presence of certain gases, some of which may be evolved from the bowels of the earth and others 
from decomposition and putrefaction of vegetable and animal matters upon the surface of the SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
385 
earth ; by alternations of heat, cold and moisture ; by variations in the amount and mode of 
action of the terrestrial electricity ; by changes of diet, habits of life and occupation ; by foul 
gases, volatile animal matters and putrefying secretions and excretions, resulting from crowding 
in ill-ventilated and filthy ships, camps, hospitals and houses; by tangible organic poisons propa- 
gated in and through the human system, as of syphilis and smallpox; by vegetable or animal 
matters, or living germs, which may assume new forms and develop new products in accordance 
with the soil in which they are grown, extremely minute living organisms, having the character- 
istic endowments of vegetable growths, analogous to the minute particles of vegetable protoplasm 
whose function it is to disintegrate and convert complex organic products, owing their specific 
properties in special diseases, not to any botanical characters, but to the characters implanted in them 
from the soil in which they sprang from innocuous parents, and from which they are transmitted, 
and this soil, except in the case of their earliest origin, being the fluids of the animal body ; by 
minute living organisms, fungi and animalculæ, possessing inherent poisonous properties, and 
capable of inducing specific diseases according to their species and genera, and being dependent 
for their existence and propagation upon special climatic conditions of heat, moisture and animal 
and vegetable matters. 
5. The ancient belief that decomposing animal and vegetable substances produce disease, 
and are ultimately connected with contagion and infection, has been revived in modern times; 
and it might be said that up to the middle of the present century this crude and gross result of 
sanitary investigation summed up all that had been done by boards of health and sanitary com- 
missions; while the decomposition of organized beings after death, and of organic matters 
generally, both vegetable and animal, may produce gases and vapors that are injurious to 
health, and which may favor the spread of certain diseases, as cholera, plague and yellow fever, 
they are incapable of originating these diseases. While it is difficult to determine the place and 
mode of origin of these diseases in the warm climates where they appear to be indigenous, when 
imported into more temperate latitudes they prevail with most destructive effects in crowded and 
filthy localities and habitations, where decomposing animal and vegetable matters pollute the air. 
The fostering effect of decomposing organic matter on disease has been likened to the rapid 
growth of seeds planted in the rich, fertile soil of decomposing matter, or to the action of the 
yeast plant, "as if the putrid matter itself took the disease and transformed it to the living." 
6. When the effort is made to determine the nature of the substance which forms the seed or 
germ of the disease, not merely the decomposing substance, but the resulting gases, and the various 
organisms existing in the air and water and on the surface of the earth, demand investigation. 
If the labors of chemists who have examined the gaseous compounds resulting from the decompo- 
sition of organic substances, such as sulphureted hydrogen, sulphuret of ammonium, carbonic 
acid, nitrogen, carbonic oxide, carbureted hydrogen, phosphoreted hydrogen, ammonia, acetic 
acid and alcohol, be carefully examined, it will be found that while it has been established that 
certain of these gases, as sulphureted hydrogen, are destructive of life when concentrated, no 
combination of these gases in the laboratory and in experiments has ever produced a contagious, 
infectious or specific disease, capable of propagation. While these gases, which are easily diffused 
into air, and are more or less soluble in water are, in certain proportions, injurious to human 
beings, their action even in the most rapid decompositions on the surface of the earth are wholly 
different from those of the organic contagious matters; and in like manner we must conceive that 
their action is different from those vapors in which may be concentrated the organic impurities 
of the atmosphere, or of putrid decomposing substances and organized bodies, animalculæ, 
fungi, etc., mechanically suspended in the atmosphere. 
7. However disease may be produced, by specific, organized germs, or contagious combinations 
of germinal organic matter, originally developed in the human constitution, and propagated 
through succeeding generations ; or by well known gases, as sulphureted hydrogen, phosphoreted 
hydrogen, carbureted hydrogen, or hydrocyanic acid, easily diffused in the air ; or by heavy 
vapors, enclosing the products of the decomposition of marshes; or by putrid decomposing sub- 
stances, mechanically diffused ; or by organized living bodies, acting as ferments, or as carriers of 
the contagious putrid matter: the true remedy is disinfection, chemical alteration of the 
poisonous matters, arrest of all life action, arrest of all fermentation and putrefaction. 
By means of such agents as chlorine and sulphurous acid we destroy sulphureted hydrogen, 
sulphuret of ammonium, phosphoreted hydrogen, hydrocyanic acid, and the various combina- 
Vol. IV-25 386 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
tions of hydrogen and carbon, and alter the constitution of those organic substances, whether 
living or dead, which are supposed to induce disease ; and in like manner carbolic acid destroys 
living germs, arrests fermentation and putrefaction, and thus embalms the active agents in the 
propagation of contagious diseases. 
8. A thorough system of disinfection should embrace - 
(a) The immediate isolation and disinfection of the first case or cases of any contagious 
disease. 
(5) Free ventilation and absolute cleanliness. 
(c) The disinfection of surrounding streets and houses by means of lime, sulphurous acid, car- 
bolic acid, sulphate of iron and corrosive sublimate. 
(d) Thorough cleansing and disinfecting of the bed ling, clothes, rooms and premises of the 
various outbreaks of yellow fever, cholera and other zymotic diseases, by means of such 
agents as chlorine, sulphurous acid, permanganate of potash, carbolic acid and corrosive 
sublimate. 
These notes on the history of naval hygiene and the history of disinfection and disinfectants 
will, without doubt, be rendered far more valuable to those students of public and international 
hygiene who are charged with the responsible duty of protecting cities and States from the rav- 
ages of endemic, epidemic and contagious diseases, if the practical results of actual experiments, 
during a series of years, in a large city which had frequently suffered with the ravages of disease, 
be carefully and methodically unfolded. 
We have selected for the illustration of the practical results achieved by sanitarians in their 
experiments with disinfectants, the salient facts in the medical and hygienic history of New 
Orleans, from the close of the American civil war, in 1865, up to the present time. 
No city within the bounds of the United States of America has suffered more repeatedly or 
more severely, during the past century, from yellow fever, than New Orleans, as will be seen from 
the following record :- 
NUMBER OF DEATHS IN NEW ORLEANS, LOUISIANA, DURING THE YEARS SPECIFIED. 
Deaths from 
Year. Yellow Fever. 
Year. 
Deaths from 
Yellow Fever. 
Year. 
Deaths from 
Yellow Fever. 
1847, 2306 
1860, 
15 
1872, 
39 
1848, 808 
1861, 
1873, 
226 
1849, 769 
1862, 
2 
1874, 
11 
1850, 107 
1863, 
2 
1875, 
61 
1851, 17 
1864, 
6 
1876, 
42 
1852, 456 
1865, 
1 
1877, 
1 
1853, 7849 
1866, 
192 
1878, 
4056 
1854, 2425 
1867, 
3107 
1879, 
19 
1855, 2670 
1868, 
5 
1880, 
2 
1856, 74 
1869, 
3 
1881, 
0 
1857, 200 
1870, 
588 
1882, 
4 
1858, 4845 
1871, 
54 
1883, 
1 
1859, 91 
Deaths from yellow fever for 1847-1856,17,481 ; 1857-1866 (ten years), 5354; 1867-1876 (ten 
years), 4136; 1877-1883 (seven years), 4082. Total (thirty-two years), 1857-1878, inclusive, 
31,028; total deaths (thirty-seven years), 1847-1883, 31,051. 
Carbolic acid disinfection was first proposed and practiced in New Orleans in 1866, for the 
arrest of contagious and infectious diseases, and more especially for the arrest of yellow fever ; 
and up to the close of the year 1879 it was used in the most lavish manner in the gutters and in 
the streets, and in and around all infected localities. 
During eleven years in which carbolic acid was used upon a larger scale than ever before in 
the history of sanitary science, to arrest yellow fever by the creation of a special atmosphere, 
namely, 1867-1878, inclusive, there occurred in the city of New Orleans 8193 deaths from yellow 
fever. During four years, 1880, 1881, 1882 and 1883, in which not one gallon of carbolic acid 
was poured in the gutters or in the streets in the localities where yellow fever cases were reported, 
there were but six deaths attributed to yellow fever. The subject is of such importance to public 
hygiene that we give a full outline of the main facts of the medical history of New Orleans, 
1866-1883. SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
387 
HISTORY OF DISINFECTION' AND OTHER SANITARY MEASURES IN NEW ORLEANS, LOUISIANA. 
Guyton Morveau's method of fumigation was practiced in New Orleans* during the yellow 
fever of 1820, by Dr. Forsyth, with beneficial results, in the family of a German, usually called 
" Dutch Joseph," who had contracted yellow fever on board of a German vessel in the Mississippi 
river infected with this disease. But systematic efforts to limit and eradicate yellow fever were 
not instituted in this city until after the civil war of 1861-1865, and New Orleans had existed for 
a century and a half, and been ravaged by no less than a score of severe epidemics, before the 
resources of chemistry were invoked for the arrest of its great scourge. 
Dr. E. H. Barton, in his elaborate report on the sanitary condition of New Orleans, in 1853, 
prophesied that "upon the broad foundation of sanitary measures, we can erect a monument of 
public health, and that if a beacon light be erected on its top, and kept alive by proper attention, 
this city will be second to none in this first of earthly blessings." 
In this account the facts shall be drawn from the Official Reports of the Board of Health. 
Carbolic acid appears to have been first used for the " arrest of yellow fever," as a " disinfect- 
ant," during the comparative recent and memorable epidemic of 1867, under the direction of 
S. A. Smith, m.d., President of the Board of Health. 
In the preceding year-1866-yellow fever had prevailed to a limited extent : the deaths from 
this disease neve" rose above seven per day, very rarely above three. Five deaths occurred in 
August, 56 in September, 89 in October, 31 in November and four in December; total, 185. In 
1866, the mortality was almost entirely confined to persons unacclimated, and recently from foreign 
countries or Northern States. The first case known to have occurred was that of a Frenchman, 
who died with black vomit at the Hotel Dieu, under the care of Dr. Boyer, on the 10th of August. 
This man had not been out of the city for several months, save to hunt and fish. On the Sunday 
prior to his attack he had been on one of these excursions, and complained, on his return, of fatigue 
and weariness. It was a month before any other fatal case was reported. The Board of Health 
was unable to trace the introduction of the disease through the quarantine. 
During the months of June, July, August, September, October, November and December, the 
deaths caused by the various classes of fever were recorded by the Board of Health as follows: 
Fever, 7; bilious fever, 59; congestive fever, 175; continued fever, 5; gastric fever, 2; pernicious, 
132; intermittent, 56; brain, 27 ; nervous, 3; Panama, 1; puerperal, 8; remittent, 46; scarlet, 17: 
typhoid, 77; typhus, 12 ; yellow, 185 ; total by fevers, 712. It is worthy of note that bilious, con- 
gestive, pernicious and intermittent fevers caused 422 deaths, or more than one-half of all the 
deaths caused by fevers, yellow fever included. Of the 185 deaths by yellow fever, 93 occurred in 
the Charity Hospital, out of 130 cases. The first case of yellow fever, or rather the first case that 
terminated fatally with black vomit, that of the Frenchman, was employed by Mr. Griswold, on 
Canal street, and boarded at the Orleans Hotel, on Charles street. 
On the 14th of July, a case on Hercules street, attended by Dr. Thierry, died with Asiatic 
cholera. Dr. Ball afterward reported that he had prescribed for other suspicious cases in the same 
house about the same time. The Medical Director, Col. McFarlin, reported that on the 22d a 
recruit, who had been for some time resident in New Orleans, and belonging to a detachment bil- 
leted at Holmes's foundry, near the New Basin, was taken with cholera and died in a few hours. 
Sixteen cases occurred in this detachment in the course of two weeks, five of whom died. The 
troops were removed from that locality, the sick men sent to the Sedgwick Hospital, immediate 
steps were taken to disinfect and purify the quarters and baggage, and the disease soon disap- 
peared. On the 31st of July, Dr. Henderson summoned the President of the Board of Health, 
Dr. S. A. Smith, to witness the case of a negro woman upon Race street; by the 1st of August, 
cases had occurred on Race, Robin and Felicity streets, also among the soldiers occupying a cotton 
press on Robin street. Dr. Ball, on the morning of the 1st of August, invited the President to 
see a case on Liberty, between Thalia and Erato streets. It was that of a young white woman, 
taken at 2 A.M., hopeless at 5. After seeing it, the President summoned a meeting of the Board 
of Health, and gave it as his opinion that this was an unmistakable case of cholera asphyxia. It 
was not until the 3d of August that any notice was given of its introduction into the Charity Hos- 
pital, where there had been five cases, all from the workhouse near the New Basin, and the first was 
* "An Account of the yellow fever as it prevailed in the city of New York, in the summer and autumn 
of 1822." By Peter S. Townsend, m.d. New York, 1823, p. 348. 388 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
brought in on the 1st of August. On the 3d, the first ease was reported below Canal street, and 
on the same day an officer of the Navy Department from Algiers reported a number of cases among 
his employés; on the 4th, Dr. Milum reported it in Jefferson, and in a short time the disease was 
diffused throughout the city. 
Dr. S. A. Smith, President of the Board of Health, says: "The cases of the disease which 
occurred presented characters of excessive malignity. There was little or no success in treating 
cases in collapse, yet the weight of mortality fell almost entirely upon colored people and whites 
living in poor conditions. 
" How to account for the almost entire exemption of the population living in good circum- 
stances is an interesting problem. It would seem from our experience that there is force in the 
allegation that those sleeping in second stories are less liable than those sleeping in the lower 
strata of the atmosphere. By letters addressed by the President to the mayors of the cities and 
towns on the Mississippi and Red rivers, it was ascertained that cholera appeared in St. Louis 
on the 3d of August, at Memphis on the 8th, at Baton Rouge August 1st, Natchez on the 7th, at 
Shreveport on the 12th ; at Vicksburg it had not appeared on the 13th, at Alexandria on the 
25th. The newspapers reported it at Fort Kearney on the 27th of August, all arriving on steam- 
boats from this city. Thus, it will be seen by this detail that cholera appeared in this city on 
the 22d, if not before; it was confined at first to one locality, and then for several days to two; 
that about the 5th of August it had extended itself throughout the city ; that it was carried by 
steamboats, either by means of persons or goods, to St. Louis by the time that it reached the 
lower part of this city ; that it reached there before it manifested itself in the towns below. 
In short, it would appear that an influence, or substance, or germ, was introduced into this city 
from without, that it developed itself here into epidemic dimensions, and that from this city it 
was propagated throughout the Mississippi Valley, by means of commercial 
The deaths from Asiatic cholera were as follows: July, 30; August, 569; September, 456; 
October, 166; November, 47; December, 26. Total deaths from Asiatic cholera, 1294. During 
the period extending from June 1st to Jan. 1st, 1867, cholera infantum caused 78, and cholera 
morbus 91 deaths. There were 188 deaths by variola and varioloid. The total deaths from all 
causes for the year 1866 were 7754. The highest number of deaths by cholera upon any single day 
occurred on the 15th of August, when 46 deaths were reported as due to this disease. 
YELLOW FEVER AND CHOLERA OF 1867. 
In 1867, yellow fever appeared in June; the first case died in the Charity Hospital on the 10th of 
this month. The Board of Health were unable to trace its introduction from without. The fever 
existed throughout July, in the city, and until near the middle of August, before acquiring epi- 
demic proportions. 
Every house where a case was reported as having occurred was, under the direction of the 
health officers, cleansed and fumigated with sulphurous acid gas and carbolic acid ; the premises 
likewise were subjected to the provisions of the health ordinance, and the privies purified by the 
sulphate of iron. Notwithstanding these measures the disease became epidemic, an immense 
number of cases occurred, and 3107 deaths were reported as directly caused by yellow fever, in 
addition to 990 deaths caused by the various forms of paroxysmal and continued fever. The 
President of the Board of Health, Dr. S. A. Smith, affirmed that the action of the cause of yellow 
fever was never before more general upon the population. Very few of the susceptible escaped, 
yet the mortality from it was exceedingly small, estimated as to the number of inhabitants, and 
particularly as to the number of cases. The number of susceptible subjects was larger from there 
having been no epidemic since 1858, so that all children under eight years were susceptible. Dr. 
Smith says: "The smallness of the mortality may be attributed in great part to there being little 
immigration from Europe, and from the large increase in colored people, in whom the tendency 
of the disease is to recovery." 
The first case of yellow fever died in the Charity Hospital on the 10th of June; a seaman 
who had been employed in the navigation of the lake. Three weeks before his death he had 
shipped upon the bark " Bessie," loading with staves in the Fourth District and bound for Barcelona. 
This vessel had sailed from Havana in March, arriving in New Orleans in April, laden with 
* " Report of the Board of Health to the Legislature of the State of Louisiana, 1867," p. 6. SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
389 
sugar. She was reported clean and healthy. Soon after arriving went into dry dock, in Algiers. 
Inquiries were made concerning her after her sailing. She arrived at her destination without mis- 
hap as to the lives of her crew. The second case was reported by Dr. Brickell as having been taken 
on the 13th of June, on St. Charles street, near Julia. The man recovered. The third case, 
reported by Dr. Fol well, on Julia street, between Camp and St. Charles streets, died on the 23d of 
June. The fourth case died on the 26th of June ; he arrived upon the steamer from Galveston on 
the 21st, whence he came from Indianola direct. He had a chill at Galveston on the 19th, and 
died on the 26th. The fifth case died on the 26th of June in the Charity Hospital. He came 
from 61 Girod street, and was employed on coal barges at Algiers. The sixth case was Lieut. 
Dewey, who died at the St. Charles Hotel. He came by steamer direct from Indianola, and was 
brought from the vessel to the hotel sick. 
The first vessel coming to New Orleans clearly infected was the bark " Florence Peters," which 
sailed from Havana on the 3d of June, laden with sugar. She was stopped at the quarantine 
station June 12th, where she was detained ten days, although reported clean and healthy; was 
fumigated and released. She arrived at Algiers June 22d. The wife of the captain, Mrs. 
Hooper, died of yellow fever on the 30th. This case was reported by Dr. Burns. Her sister also 
was attacked on the 25 th, but recovered. The second mate was taken July 4th, and died in the 
Charity Hospital on the 9th. The captain died on the 13th. 
The fever was not originally introduced by this vessel, as the first death occurred in the 
Charity Hospital on the 10th of June, and was probably seized with the fever about the 5th of this 
month ; notwithstanding this, it is probable that the bark " Florence Peters " was a separate centre of 
infection. Although the fever had commenced early in June, and had existed throughout July, 
it did not acquire epidemic proportions until near the middle of August ; and this slow progress 
would appear to have been highly favorable to the arrest of the disease by the early, energetic and 
thorough use of disinfectants. 
With reference to the efforts made to arrest the disease by sanitary measures, Dr. S. A. Smith, 
President of the Board of Health, says : " Every house where a case was reported as having 
occurred was, under the direction of the health officers, cleansed and fumigated with sulphurous 
acid gas and with carbolic acid. The premises likewise were subjected to the provisions of the 
health ordinance, and the privies purified by sulphate of iron." Notwithstanding the failure of 
these measures, which were subsequently, by the successors of Dr. S. A. Smith, vigorously pushed, 
the President of the Board of Health expressed the belief that- 
" The slow development of the cause of the fever, its apparent temporary suspension in par- 
ticular localities, the exceedingly mild character of the pestilence, leads to the hope that it may be 
kept in check, if not entirely eradicated in the first cases, by the prompt application of disin- 
fectants." 
The comparatively slow spread of the yellow fever of 1867 is shown by the following record of 
deaths for the respective months: June, 3; July, 11; August, 255; September, 1637; October, 
1072; November, 103; December, 23. Total, 3107. 
The highest mortality occurred on the 23d of September, when the total deaths from all causes 
amounted to 133, 82 of which were caused by yellow fever, 17 by other kinds of fever, and 41 by 
cholera. 
General reports were made by the health officers only of the Second and Third Districts. 
Dr. E. S. Lewis, Health Officer of the Third District, in his official report to Dr. S. A. Smith, 
President of the Board of Health, thus gives the results of his attempts to arrest the spread of 
cholera and yellow fever by "fumigants and disinfectants." 
" During the month of May, until about the latter part of June, my district was exempt from 
epidemic diseases, and consequently neither fumigants nor disinfectants were employed. From 
that time until August, true cholera appeared in the district; the first case, originating corner of 
Mandeville and Prosper streets, terminated fatally in the Charity Hospital. This place was not 
immediately disinfected, and soon the whole neighborhood from Elysian Fields to Mandeville, on 
Prosper, Josephine, Solidelle, Morales and Urquhart streets was thoroughly infected with cholera, 
about twenty-five eases occurring in a week. Requisitions for disinfectants were made and for- 
warded to the Street Commissioner, and about the 10th of July over thirty houses in the locality 
mentioned were thoroughly fumigated and disinfected. From that time not more than two or 
three cases originated in that part of the district. Other cases were afterward reported in various 390 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
portions of the district-on Greatman street, Congress, Cascalro and Front Levee, but the infected 
houses were promptly attended to, and the cholera was effectually checked. I have no hesitation 
in stating that it was checked, for I observed that wherever the work of purifying infected houses 
was delayed, whether from want of promptness on the part of physicians in reporting their cases, 
or from other cases occurring in the same places, the adjoining houses suffered, which did not 
prove the case when nothing interfered with or obstructed me in my duty. 
" Though I cannot assert so positively on the beneficial effects of disinfectants during the pre- 
valence of yellow fever, I firmly believe that yellow fever can be checked, but for that purpose a 
removal of the sick would be necessary, especially the first cases, and a better knowledge on the 
part of the p ractitioners of medicine generally of the disease, so that the early cases would not 
escape notice. 
" The number of houses disinfected of yellow fever from the middle of August to November 1st, 
was about three hundred. The first case died in the Hospital, but was taken there from Antonio 
Baptistella's, on Victory street, near Elysian Fields. Four days afterward there were upward of forty 
cases on Victory, from Frenchman to Elysian Fields streets. Every house is a boarding house, 
and many were filled to overflowing with strangers. These houses were not only fumigated with 
sulphur and disinfected with sulphate of iron in solution, but were pumped from top to bottom 
with carbolic acid, which impregnated the atmosphere for some distance off. This was repeated 
as often as new cases occurred. From the 1st of September to the present time there has not been 
a more healthy neighborhood, and notwithstanding new sets of boarders have taken the places of 
those who have gone away, also equally unacclimated, but very few to my knowledge have been 
sick with yellow fever."* 
During the subsequent seven years, in which carbolic acid was largely used by the Board of 
Health of New Orleans for the limitation and eradication of yellow fever, the views of Professor 
E. S. Lewis, M. n., underwent a decided and radical change. 
Thus, at a " Meeting of Physicians to Discuss Carbolic Acid," held in New Orleans, Septem- 
ber 29th, 1875, Professor Ernest S. Lewis made the following statement :f- 
"The subject under discussion, or carbolic acid disinfection as at present carried out, may be 
considered under two heads. 
"1. As to whether it destroys the germs of yellow fever and prevents its spread; and secondly, 
as to whether its use is not injurious to those sick with the fever, and to the delicate with inherited 
or natural tendencies to diseases of the brain, heart, lungs and urinary organs. 
" Taking into consideration the first division of the subject, I will state that its use, or rather 
abuse, is not of very recent date in the history of our Boards of Health; for as far back as 1867, 
at which time I was health officer, not only under my supervision were yards, privies, and gutters 
thoroughly disinfected, but by means of a pump it was thrown over the floors, walls and ceilings of 
the houses, with the hope that the germs might be destroyed and the fever arrested. It had no 
effect whatever ; the disease soon extended to every part of the city in the most rapid manner- 
under the ' genius epidemicus,' if you will-which favored the rapid propagation of the yellow 
fever germs; and if since then no epidemics have occurred, it is unquestionably because the neces- 
sary conditions have not been present. It has at no time, however, been rooted out of the city, 
and if my memory serves me right, this is the first year since the great epidemic during which I 
have not had cases under treatment. If, then, carbolic acid is such an effective agent in the sup- 
pression of yellow fever, why should the disease not stop short at the first cases, when upon its 
first appearance such extraordinary measures are adopted for its arrest ? It should not extend 
beyond the focus of infection; and yet we hear of its existence in different localities presenting 
all the requisites in the way of numerous foci of infection for its epidemic spread, excepting the 
most necessary-that which I stated was formerly designated as the ' genius epidemicus,' or 
'constitutio pestilens.' 
" I do not question the usefulness of carbolic acid as a purifying agent in arresting fermenta- 
tive processes in decomposing vegetable and animal substances, but to accomplish this there must 
be contact of the acid in a state of solution, and not in a vaporous condition . . . 
* "Annual Report of the Board of Health to the Legislature of the State of Louisiana," January, 1868, 
pages 12,13. 
f 2%« New Orleans Medical and Surgical Journal, N. S., Vol. in, No. 3, November, 1875, pages 431-434. SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
391 
"Another author, Prof. Ringer,of London, remarks as follows: 'Its destructive influence over 
the low forms of animal and vegetable life has led to its being considered a disinfectant, but no 
satisfactory proof exists of its capacity to destroy the contagious elements of disease.' 
" In my opinion, its efficacy is as questionable and as irrational as the following suggestion of 
an author of the seventeenth century, enthused with the parasitic theory of the origin of diseases, 
that the people should sally forth in the infected districts, and by sounding horns and firing can- 
non repel the invaders, which he likened to a cloud of locusts. 
" The 2d proposition, as to whether its use is injurious or not to the community, will now 
be considered. 
" In the first place, we have met together, to-night, not so much to discuss the efficacy of car- 
bolic acid in arresting the spread of yellow fever, for if that were all, we could offer no reasonable 
objections to its use as a legitimate experiment, in the interests of science, but our individual 
experience has unfortunately brought to our notice many instances of its deleterious action, when 
even life itself has paid the forfeit. Such cases have been reported in the preceding meetings, 
held in the Second District, and it cannot be wondered at that such serious opposition to its use 
should be manifested by the disinterested members of the medical profession. Numbers of persons 
living on those streets where this toxic agency was thrown, have been affected in various ways, 
with giddiness, nausea, vomiting, diarrhoea, a sense of suffocation; in other words, with manifes- 
tations of its poisonous action." 
After quoting various authors with reference to the poisonous effects produced by carbolic acid, 
Professor Ernest S. Lewis, m.d., concludes with the following observation :- 
"These few instances cited, and the many others reported in various journals, prove that this 
powerful substance is used too rashly in medicine and in surgery, and the Board of Health, no 
doubt actuated by the best of motives, would do well to bear in mind that individual susceptibili- 
ties can make of its vapor, in a state of atmospheric dilution, a fatal poison to many." 
In view of the preceding statement, it appears remarkable that when under the immediate 
supervision of Dr. E. S. Lewis, in 1867, " houses were not only fumigated with sulphur and dis- 
infected with sulphate of iron in solution, but were pumped from top to bottom with carbolic acid, 
which impregnated the atmosphere for some distance off," no injurious or pernicious effects induced 
by carbolic acid were recorded by the zealous and energetic health officer of the Third District, in 
his official report to the Board of Health. 
Dr. Alfred W. Perry, Health Officer, Second District, made the following statement on the 
3d of December, 1867, to Dr. S. A. Smith, President of the Board of Health, with reference to his 
use of disinfectants for the arrest of yellow fever, during the months of July, August, September, 
October and November :- 
" Up to the 4th of August, 1867, the amount of disinfection required was performed by police 
officer, H. Tricon, detailed from the police force of this district. The number of cases of yellow 
fever increasing, I made application to the Deputy Street Commissioner of Second and Third Dis- 
tricts, Mr L. C. de Homorgue, who supplied me with two men, who have been employed in disin- 
fecting, inspecting and serving notices. I have always found this officer ready to furnish any 
assistance in the execution of sanitary measures, and an ample supply of disinfectants was always 
kept on hand by the department. During the existence of yellow fever here, about 334 cases were 
reported to me as having died in this district. Out of this number, 293 houses had one death in 
each; 12 houses had two deaths; four houses had three; one house had five deaths. 
" The mode of disinfection was by closing the room or chamber in which the death took place, 
tightly stopping up the fireplaces and burning two to four pounds of sulphur in the apartment, 
which also was generally sprinkled with carbolic acid. Sulphate of iron was put in the privies and 
mixed with the excreta, and all bed clothes boiled or destroyed. During the period embraced by 
this report 46 deaths from cholera took place in 45 houses, only one house having had a second case. 
" I have studiously avoided, in this report, giving any opinion or theory as to the causation or 
mode of propagation of cholera or yellow fever, or of the efficiency of disinfection therein. I simply 
report the means adopted by me, and the results obtained, from which, of course, you can make 
the proper deductions." iif 
*" Annual Report of the Board of Health, January, 1868," p. 10. 392 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
During the year 1867, the following deaths were caused by the various forms of fever: Fever, 
22; bilious, 45; congestive, 278; pernicious, 255; intermittent, 51; brain, 39; nervous, 13; puer- 
peral, 11; remittent, 110; scarlet, 12; malignant, 12; gastric, 1; typhoid, 119; typhus, 23; total 
by fevers, exclusive of yellow fever, 1001 ; total deaths by yellow fever, 3107 ; total deaths from all 
fevers, 4108. Without doubt, a portion of the cases reported as congestive, pernicious, remittent 
and typhoid fevers, were in reality yellow fever. The deaths from these forms of fever numbered 
alone 762, and they occurred chiefly in those months in which yellow fever was most fatal, namely, 
deaths from these fevers, January, 14; February, 10; March, 15; April, 6; May, 13; June, 38; 
July, 53; August, 144; September, 195; October, 190; November, 57 ; December, 27. 
Smallpox and varioloid caused 47 deaths, and Asiatic cholera, 581 deaths; cholera infantum, 
100; cholera morbus, 46; congestion of bowels, 13; diarrhoea, acute and chronic, 205; dysentery, 
acute and chronic, 180; entero-colitis, 36; diphtheria, 31. Bowel affections, therefore, were 581 
deaths, or precisely the same number as Asiatic cholera ; the total deaths from all the various affec- 
tions of the bowels being 1162. 
The total deaths for the year 1867 were 10,096, and of this number 5270, or more than one-half, 
were caused by fevers and bowel affections, and the deaths caused by the two diseases generally 
regarded as exotic and of foreign origin, namely, yellow fever and Asiatic cholera, were 3688, 
or one death in 2.7 deaths from all causes. If the deaths caused by the various forms of fever as 
reported, but really caused by yellow fever, and those caused by cholera, but reported under differ- 
ent diseases of the bowels, as cholera infantum, cholera morbus and diarrhoea, are added to those 
officially charged to cholera and yellow fever, it would approximate more nearly to the truth to 
refer about one-half of the ten thousand and ninety-six deaths of 1867 to these two diseases alone. 
It cannot therefore be said that disinfection and sanitary work, as conducted by the Board of 
Health in 1867, had any recognizable effect in arresting either yellow fever or cholera. 
On the other hand, there appeared, as had been observed in this city before, some unknown 
relationship or influence between the causes inducing yellow fever and cholera. Thus, the Presi- 
dent of the Board of Health observes :- 
"The cholera introduced in 1866 maintained its existence throughout the year 1867, receding 
in its influence as the yellow fever advanced, and again exciting alarm by the number of its vic- 
tims, as the yellow fever subsided. There were reported 234 deaths from it alone in November, and 
210 in December."* 
During 1867, the cases of yellow fever admitted to the Charity Hospital f numbered 1493, and 
the deaths from this disease, 672, or one death in 2.29 cases. The following cases and deaths of 
other forms of fever occur upon the Charity Hospital Record for 1867 : Intermittent cases, 2225, 
deaths, 13; remittent cases, 296, deaths, 28; malarial cases, 298, deaths, 31; typhoid cases, 39, 
deaths, 18; congestive, 43, deaths, 35; continued cases, 11, deaths, 2 ; dengue cases, 3. Of bowel 
affections: Cholera,94 cases, 70 deaths; cholera morbus, 13 cases; cholera infantum, 1 case, 1 death; 
diarrhoea, acute, 271 cases, 23 deaths ; diarrhoea, chronic, cases, 88, deaths, 35 ; dysentery, acute, 
179 cases, 35 deaths; dysentery, chronic, 80 cases, 36 deaths. The total admissions into the 
Charity Hospital for 1867 were 8612, and the total deaths, 1438. Yellow fever and cholera alone 
caused 742 deaths, or a little more than one-half the deaths from all causes. The statistics of these 
two diseases, with reference to the total mortality, as furnished by the Charity Hospital, corres- 
ponded to a marked degree with those of the city at large. It is not known that any measures 
of disinfection were practiced in the Charity Hospital. 
YELLOW FEVER OF 1868 AND 1869. 
In the Mortuary Report of the Board of Health | for 1868, only three deaths are recorded as 
caused by yellow fever, while upon the reports of the Charity Hospital 8 cases are recorded, with 
5 deaths. We have no information as to the origin or history of these cases. During a portion of 
1868, the Board of Health appears to have been in an unsatisfactory condition, on account of the 
assumption of the offices of the State of Louisiana by the Radical party, sustained by the negro 
♦"Annual Report of the Board of Health, January, 1868," p. 4. 
f " Report of the Board of Administrators of the Charity Hospital to the Legislature of the State of 
Louisiana," July, 1868. 
J The New Orleans Journal of Medicine, Vol. xxni, No. 2, April, 1870, p. 398. SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
393 
vote under the leadership of H. C. Warmoth. In the annual report of the Board of Health, De- 
cember 31st, 1869, the following statement occurs, which explains the relations of the new (Radical) 
to the old Board of Health :- 
" The members of the Board of Health commissioned by his Excellency, Governor H. C. 
Warmoth, took their seats November 6th, 1868. To give the Common Council of New Oideans 
opportunity to fill the vacancy caused by the death of a member appointed by the city, the election 
of permanent officers was postponed to November 13th, 1868, at which time, C. B. White, M.D.,was 
elected President and S. C. Russell, m.d., Secretary. The members of the Board of Health whose 
positions were vacated by the appointment of their successors by Governor Warmoth, and the two 
members holding over by virtue of their appointment by the city, refused to give possession to the 
Board of Health, as reorganized, of either office, books, or money, encouraged the bringing of suits 
at law against the Board, injured its credit, caused much needless expense, and only yielded to the 
process of law." 
The following deaths were caused by the various forms of fever during 1868 : Fever, 109 ; bil- 
ious, 19; congestive; 105; brain, 17; intermittent, 15; malarial, 4; nervous, 7; pernicious, 67; 
puerperal, 9; remittent, 26; scarlet, 14; malignant, 1; typhoid, 58; typhus, 5; total by fevers, 
excluding yellow fever, 436 ; including all fevers, 441. 
Cholera caused 129 deaths ; cholera infantum, 85 ; cholera morbus, 22 ; diarrhœa, acute and 
chronic, 112 ; dysentery, acute and chronic, 161 ; inflammation of bowels, 30 ; total diseases of 
bowels, 419. 
The total number of deaths during 1868, as officially reported by the Board of Health, was 
5343. In 1846, the total deaths amounted to 4500, but from that period up to 1868 they had 
annually exceeded the number which was reported in the latter year. It is possible that the un- 
usual small mortality of 1868 may have been in some way associated with the heavy mortality of 
the preceding year. The difficulties in the Board of Health did not appear either to promote the 
spread of yellow fever or cause a higher death rate. 
4981 patients were admitted to the Charity Hospital, and the deaths in this institution num- 
bered 490. The fevers treated in the Charity Hospital were as follows : Intermittent cases, 995, 
deaths, 5 ; malarial cases, 410, deaths, 11 ; yellow fever cases, 8, deaths, 5 ; remittent cases, 118 ; 
congestive cases, 10, deaths, 8 ; scarlet cases, 2, deaths, 1 ; bilious case, 1 ; pernicious cases, 8, deaths, 
8 ; typhoid cases, 17, deaths, 8. Of cholera, 15 cases, 9 deaths; cholera morbus, 12 cases, 1 death; 
diarrhœa, 154 cases, 27 deaths ; dysentery, 197 cases and 48 deaths. In the city smallpox caused 
14 deaths, and diphtheria 16 deaths. 
YELLOW FEVER, 1869. 
On July 17th, Peter Tabam was taken sick with yellow fever; two days in the city,twelve days 
from Havana, eight of which he was detained at quarantine. He died with black vomit on the 
19th. The house was taken charge of by the Sanitary Police, under the supervision of Dr. Perry, 
Health Officer. The bedding and clothing of deceased were burned, the house fumigated with 
sulphurous acid, and drains and vaults disinfected with sulphate of iron and carbolic acid. 
On August 26th, a case considered by the attending physicians to be yellow fever, was reported 
on Royal street, and was removed to the Hospital of the French Benevolent Society. When seen 
by members of the Board of Health, on the eighth day of the disease, he was very yellow, had epi- 
gastric tenderness, red and spongy gums, albumen, but no bile in urine. He recovered slowly and 
with difficulty. This patient stated that he had yellow fever in 1858, at Pascagoula. 
On September 30 th, the captain of the British ship "Belgravia" was taken sick, and the next 
two days two boys belonging to the crew. The captain had a severe paroxysm of fever of twenty- 
four hours' duration, leaving him much prostrated, with conjunctivae yellow, and gums red and 
easily bleeding. He stated that he had an attack of yellow fever twenty years before, in Per- 
nambuco. 
The two boys before mentioned were taken to the Charity Hospital. One died on the fourth 
day of the disorder, the other recovered. Both had black vomit largely, and presented all the 
customary symptoms of yellow fever. They were typical cases. 
The " Belgravia " was direct from Liverpool; cargo principally salt and crates of crockery. 
Had not been within fifteen miles of land on her passage. Her previous voyage was from this 
port to Liverpool. In coming up the Mississippi river the "Belgravia" had not come in contact 
with vessels from the yellow fever ports, nor did any such crafts lie near her, before the appear- 394 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
anee of these cases of sickness. The captain of the ship had quarters in town, several blocks from 
the ship ; the boys stayed on shipboard. 
Another case of yellow fever was brought to the Charity Hospital on the 8th of October, from 
a British ship which had been lying in this port one month, and had come direct from Liverpool. 
The case was considered well marked, and resulted in recovery.* 
H. D. Baldwin, m.d., resident physician at quarantine, furnishes the following statement of cases 
of infected ships and number of cases of yellow fever which arrived from foreign ports after the 
issuing of the Executive proclamation, May 15th, 1869 :- 
The sick were taken from the vessels, placed in the hospital, and the vessels thoroughly fumi- 
gated, and only allowed to proceed after such detention and thorough cleansing as would prevent 
their carrying infection. 
Schooner "Andromeda," arrived from Havana the last week in June; one case, sailor. Recovered. 
Schooner "Jacinto," from Tampico, August 3d; three cases. Recovered. 
Schooner "Cecilia," from Tampico, August 19th; two cases. Recovered. 
Steamship "Trade Wind," from Belize, September 19th; two cases. One death. 
Bark " Aureliana," from Havana, October 30th; one case. Died. 
Forty-one vessels, arriving from ports declared infected by proclamation, were quarantined, 
thoroughly fumigated, and allowed to proceed only after detention required by law.f 
From the preceding account, as officially published by the Board of Health, we gather that dis- 
infection and destruction of clothes and bedding were practiced in the first case, but not in the 
subsequent ones. Although three cases were traced to the British ship " Belgravia," the captain and 
two boys, we have no record of any fumigation or disinfection of this vessel ; and yet the fever 
did not spread either in the port among the shipping or in the city. The cases occurring upon 
the " Belgravia " appear to have been sporadic or of local origin, and could not be traced to any for- 
eign origin. 
Upon the Mortuary Reports of the Board of Health, 1869, only three deaths were recorded as 
due to yellow fever, one in July and two in October. 
The various forms of fever caused the following deaths : Fever, 2 ; bilious, 12 ; congestive, 
118; pernicious, 110; intermittent, 32 ; brain, 26; nervous, 5; puerperal, 20 ; remittent, 36 ; 
scarlet, 13; malarial, 2-1; gastric, 3; typhoid, 63; typhus, 5; yellow, 3; total deaths from fever, 
472. Cholera infantum and cholera morbus caused only 65 deaths ; diarrhoea, 115; dysentery, 
158; inflammation of bowels, 95. Total from these bowel affections, 423. Diphtheria, 19 deaths. 
Smallpox and varioloid, 141. Smallpox caused 32 deaths in November and 88 deaths in Decem- 
ber. The total number of deaths in 1869, 6001. 
In the Charity Hospital, 6177 patients were admitted and 784 died. Three cases of yellow 
fever were reported, with one death. The admissions and deaths from the various forms of fever 
in the Charity Hospital were as follows: Intermittent, cases 1391, deaths, 7; malarial cases,291; 
congestive, 34 deaths; remittent, 48 cases, 4 deaths; typhoid, 16 deaths, 19 cases; bilious, 7 
cases; ephemeral, 1; yellow fever, 3 eases, 1 death; catarrhal, 1 case: typho-malarial, 27 deaths; 
typhus, 1 death ; puerperal, 2. With reference to the various classes of fevers, the records of the 
Charity Hospital appear to have been kept in a loose and unsatisfactory manner, and the chief 
fault appears to have rested with the time and mode of entering the diagnosis of the cases by the 
attending physicians and surgeons. These irregularities are shown thus : 13 cases of congestive 
fever are reported as admitted, with 34 deaths; 15 cases of typhoid and 16 deaths; no cases of 
typho-malarial fever and 27 deaths entered as caused by this disease. Dysentery, acute, 58 cases, 
8 deaths; dysentery, chronic, 24 eases, 49 deaths ; diarrhoea, acute, 109 eases, 5 deaths; diarrhoea, 
chronic, 17 cases and 77 deaths. 
In 1869, only a few sporadic cases of yellow fever occurred. Fevers and bowel affections 
caused a comparatively small mortality, and it cannot be claimed that disinfection prevented the 
spread of the disease. 
YELLOW FEVEK OF 1870. 
The total deaths in the city of New Orleans during 1870 were 7391, being considerably more 
numerous than in the two preceding years. Smallpox alone caused 528 deaths, while in the pre- 
♦"Annual Report of the Board of Health to the General Assembly of Louisiana," Dec. 31st, 1869, 
pp. 8, 9. t " Annual Report of the Board of Health,'' Dec. 31st, 1869, p. 10. SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
395 
ceding year this disease caused 137 deaths and varioloid, 4; total in 1869, 141. The epidemic 
of smallpox during both years appears to have been affected by the temperature; thus, in 1869, 
the monthly deaths by the disease were, January, 3; February,!; March, 1; April, 2; June, 5; 
August, 1; September,!; October, 5; November, 33; December, 89. 1870, January, 69; Feb- 
ruary, 56; March, 121; April, 122; May, 78; June, 59; July, 14; August, 4; September, 3; 
November, 1; December, 1. The deaths from bowel affections were, in 1870, cholera, 3; cholera 
infantum, 65; cholera morbus, 15; congestion of bowels, 13 ; diarrhoea, acute, 10; diarrhoea, 
chronic, 93; diarrhoea, 62; dysentery, 94; dysentery, acute, 15; dysentery, chronic, 75; inflam- 
mation of bowels, 104; total disease of bowels, 549. Consumption caused 757 deaths. The deaths 
from the various forms of fever were as follows : Fever, 1 ; bilious, 35 ; brain, 29 ; congestive, 
141; gastric, 4; intermittent, 27; malarial, 52; nervous, 4; pernicious, 100; puerperal, 17; 
remittent, 51 ; scarlet, 44; hectic, 5; typhoid, 80; typhus, 13; yellow, 587. Total deaths by 
fevers, 1189. 
The number of deaths from consumption seems to have increased during the year 1870, there 
having occurred 757 deaths from that disease, against 684 in 1869, 632 in 1868, and 671 in 1867. 
The number of deaths from measles during this year was only 23, against 217 in 1869 ; there 
were no deaths from this disease in 1868. The number of deaths from whooping cough in 1870 
was only 9, while in 1869 they numbered 121. 
The admissions into the Charity Hospital numbered 7837, and the deaths 1118; yellow fever, 
515 cases, deaths, 262. More than one-half the cases of yellow fever terminated fatally in the 
Charity Hospital, and nearly one-half of the total mortality from this disease in New Orleans 
occurred within the walls of the Charity Hospital. The deaths caused by the various forms of 
fever in this institution were as follows: Typhoid, 17; malarial, 60; typhus, 1 ; intermittent, 7; 
remittent, 6; puerperal, 1; typho-malarial, 2. Diarrhoea and dysentery caused 127 deaths, and 
phthisis pulmonalis 181 deaths. 
During the summer and autumn of 1870 the deaths from yellow fever, as reported by 
the Board of Health, numbered 587 ; but it is worthy of note that other forms of fever, chiefly 
malarial, caused 602 deaths; total from fevers in 1870, 1189. Of this number, 241 were recorded 
as due to pernicious and congestive fevers. The first death is said to have occurred on the 2d of 
June. The subject, an officer on the steamer " Agnes," had recently returned from a trip to 
Honduras, having touched last at Port Cavallo. He arrived May 16th, and died June 2d. No 
other cases of sickness occurred among the officers and men of the " Agnes." According to the 
report of the Board of Health, the premises, bedding and clothing were fumigated three times 
with chlorine, and no case occurred in that immediate vicinity in the First District during the 
remainder of the year. The next case in the First District was at 186 Dryades street, Septem- 
ber 6th, an Italian from the French Market; September 7th, two cases at 481 Rampart street, 
both Italians; September 12th, one case on Girod street, near Camp. The deaths from yellow 
fever in the First District were: June, 1; July, 0; August, 0; September, 26; October, 62; 
November, 29; December 4; total, 122. Dr. Jules A. Mathieu, Sanitary Inspector of the First 
District, states that "the premises, in each case of yellow fever, were fumigated from one to three 
times, whether the cases terminated by recovery or death, and yet the local outbreak exhibited 
the usual epidemic curve, increasing in September, reaching its maximum in October, declining 
with the cold of November, and disappearing in December. The measures instituted did not pre- 
vent the occurrence of 122 deaths in the First District." 
The first case reported in the Second District was taken ill August 14th and died August 19th. 
For a short time the disease appeared not to increase; an examination of the mortuary reports 
shows, however, that a number of Italians died soon after in the same neighborhood, but that 
the certificates state deaths to have been caused by some of the forms of malarial fever. Dr. 
White, the President of the Board of Health, affirmed that these should have been placed to the 
account of yellow fever. 
The first case of yellow fever in the Third District occurred at 155 Piety street, and the 
second at 312 Lafayette street-both Italians. 
The first case in the Fourth District was .on Ninth street, September 30th, a butcher from the 
French Market, which proved fatal; the first case in the Fifth District, September 27th; the 
first case in the Sixth District, October 4th. 
In the Second District, the disease was epidemic only in that portion included between St. 396 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Ann and Barracks streets inclusive, and the river and Rampart street. Of 252 cases in the 
Second District whose residences were recorded at the office of the Board of Health, only 12 were 
back of Rampart street, and only 17 in the street parallel with St. Ann street up to Canal street. 
The list of residences is imperfect, as in the early part of the epidemic the residences of cases 
received at the Charity Hospital, reported to the Board, were not given. Most of the mortality 
of the Charity Hospital was of sick received from this district, as above defined. Another infected 
part of the city was in the vicinity of Girod street. In the district extending from the river to 
the Girod street Cemetery, and from Poydras to Delord, 62 cases occurred out of 134 reported in 
the whole First District. 
A marked peculiarity of the disease, in its course, was the rapidity with which it increased in 
the first five weeks, showing its tendency to become epidemic, and afterward the long period in 
which there was little change in the weekly mortality from it. The weather, for a month pre- 
vious to the appearance of yellow fever in 1870, had been very warm and sultry, with daily rains, 
and close, unpleasant nights. After the disease had made some progress, the weather became 
exceedingly dry, and at the period when the disease was at its maximum, the weather became 
quite cool, steady north winds prevailing, with hot sun and increasing dryness. There was no 
rain for six weeks. It has been urged that the unusual course of the disease was due mainly to 
these climatic causes. 
According to the published statement of the President, all cases that came to the knowledge 
of the Board of Health were treated by the free use of such disinfectants as chlorine, sulphurous 
acid, carbolic acid and lime. 
Dr. F. B. Albers,* who had charge of the Second District, in which 399 deaths occurred out 
of a total in the entire city of 587, says :- 
" In every instance, when a case of yellow fever took place, the house where it occurred, also 
its immediate neighborhood and premises, were disinfected, by setting free chlorine and sulphur- 
ous acid gas in the rooms where death had taken place. The gutters of the yard were sprinkled 
freely with copperas and carbolic acid, and the carbolo-hydrochloride of iron used as a permanent 
disinfectant about the sinks, privies and vaults. The streets and gutters of that portion of the 
district where the disease prevailed were also disinfected, September 14th, by distributing five 
barrels of lime throughout that particular locality, and following it up on the 15th by distributing 
two barrels of carbolic acid, containing 100 gallons, on the same ground. As this appeared to 
have the desired effect-to check the disease from spreading-and the quantity being barely suffi- 
cient to give the infected locality a small quantity all around, 200 gallons more were applied on 
the 19th, 200 on the 20tb, and 209 on the 22d. As it evidently," continues Dr. Albers, " appeared 
to check the disease at the time and arrest its progress, the disinfection by carbolic acid was 
repeated on the 24th, 26th and 27th. The duty was invariably performed at night, to enable the 
antiseptic properties of the carbolic acid to exert its full influence before the heat of the sun 
should evaporate it." 
It is evident, from the preceding statement, that Dr. Albers used about 1300 gallons of car- 
bolic acid in this infected district in the course of twelve days, and without arresting the disease 
in the month of September, or in the succeeding months of October and November. 
According to his own statement, 210 deaths occurred from yellow fever in this " disinfected" 
district in September, 165 in October, and 20 in November. 
How much carbolic acid was used in the month of October we are not informed, but it is evi- 
dent that the disease, as usual, declined as the season progressed, and the weather became drier 
and cooler. And it is still further worthy of note that the highest mortality in the Second Dis- 
trict occurred on the 27th of September, viz., 22 deaths, immediately after the most liberal and 
energetic use of the carbolic acid. 
In the city, generally, the monthly mortality by yellow fever was as follows : August, 3 ; Sep- 
tember, 231; October, 242 ; November, 106; December, 5; total, 587. lu other words, the 
heaviest mortality occurred in the month of October, after the thorough installation of the " car- 
bolic acid disinfection." 
«"Annual Report of the Board of Health to the General Assembly of Louisiana," December 31st, 
1870, pp. 39-45. SECTION XV PUBLIC AND INTERNATIONAL HYGIENE. 
397 
TABLE SHOWING THE NATIVITIES OF PERSONS WHO DIED OF YELLOW FEVER 
DURING THE SEASON OF 1870. 
A 
© 
E 
: 
Italy 
France 
Germany 
United States 
Ireland 
Switzerland 
England 
British America 
Wales 
Scotland 
Other Countries 
Countries. 
co 
Week ending 
August 28th. 
- 
September 4th. 
© 
: : : : : : : >-*■ h* © 
September 11th. 
Oi 
tO 
■ : • : co 
cn • : co: 
September 18th. 
© 
: »- - to 
©: to h- h- >- cn o co cn 
September 25th. 
CO 
© 
mm to 
ootototococnto©ccco© 
October 2d. 
00 
4*- 
: to >-* 
© to •-* . 
October 9th. 
© 
© 
: •- to 
Ol • >-* CO ©I 00 to 4* CH 
October 16th. 
Ot 
totoh-: too5©©oioito 
October 23d. 
4* 
4* 
»-»: : »- cn to 4* to •- 4*- 
October 30th. 
CO 
00 
4*. : : : : © >- -a cn ; 
November 6th. 
CO 
00 
can-: : w' 
November 13th. 
© 
co: : »-* to ►-» to co w : »- 
November 20th. 
4- 
MS MS M! s w-MS 
November 27th. 
O< 
| 
December 4th. 
CH 
0O 
cn to »-* 4* CO bC co - 
1 ©©00 03 
Total. 
Note.-Dr. Del Orto reports, as the result of his investigation, the death of one hundred and 
twenty-eight natives of Italy by yellow fever. 
Dr. Albers says that the effect of his plan of disinfection " where it was thoroughly tried, has 
certainly been very satisfactory, and if properly brought into effect previous to the appearance of 
any disease, will probably prevent it entirely. I give the following instance as a proof of the 
value of the mode of disinfection practiced :- 
" No. 230 Chartres street is a tenement house, running through to Old Line street, containing 
thirty rooms, and it was occupied, when the fever made its appearance there, by thirty families, 
consisting of 183 persons, all natives of Italy ; of these 44 took the fever, 14 died, 26 recovered, 
4 taken to the hospital. Of the remaining 139 people that did not take the fever, 43 were here 
less than one year, 32 less than two years, 17 less than three years, 47 over three years." Dr. 
Albers estimates that 92 of the 139 people were unacclimated. " After the process of fumiga- 
tion and disinfection only two more persons were taken sick." 
Dr. Albers held that the yellow fever which prevailed during the months of September 
and October was of domestic origin, and due to the crowded and filthy condition of the city, and 
especially in the First and Second Districts, which are the largest, most populous and most 
actively engaged in commercial pursuits. It is, however, established that the first case, that of 
the officer of the steamer "Agnes," was connected with the shipping; and Dr. Albers himself 
records the fact that Robert Bell Craig, who left Havana on the 17th of August, arrived at 
Mobile on the 20th, came to New Orleans on the 21st, remained over night at a boarding house, 
corner of Old Line and Tolouse streets, went to the Charity Hospital 22d, and died of black vomit 
on the 26th. Dr. Albers says that the character of the fever was of a very malignant type, and 
the mortality was about 33 per cent. 
With reference to the contagious nature of the yellow fever of 1870, the President of the 
Board of Health says : " In the Charity Hospital, this year, the disease seemed to spread by con- 
tiguity from those sick of yellow fever to those ill of other diseases-something not known to 
have occurred previously." 
Dr. Albers says : " The contagiousness of the fever has been remarkable when no disinfection 
was resorted to, as for instance, at the Louisiana Bakery, where, as men employed there were 
taken sick and left to go to their friends or to hospitals, new men were then employed and put 
into the same beds and rooms that the others had vacated, and invariably became sick soon after. 
The same reckless disregard of all moral obligations and duties to others, and particularly to 
strangers, has furnished almost all the yellow fever patients of the Second District, which district 
supplies the hospital with fresh cases, derived invariably from the various boarding houses, prin- 
cipally in the neighborhood of the levee, where the inmates had contracted the disease previously. 398 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
These fresh cases of yellow fever were new comers, put into the same rooms and beds lately occu- 
pied by their sick predecessors." 
" To illustrate the contagiousness of the fever, I can refer to several instances that came under 
my observation. There are three establishments up town which are in close proximity to each 
other. One of them is a large corn mill and the other two are bakeries. They employ a number 
of men of various nationalities, who sleep, and generally also board, on the premises ; they were 
all there attacked by the fever about the 1st of October. Neither of the establishments was dis- 
infected at all, as the proprietors of them positively refused to have it done, and the fever con- 
tinued to linger in these places and attack new comers, as they were employed to take the places 
of their predecessors who had been carried off with the fever, until the 22d of November, when 
the last of them died, and the cold weather effectually put a stop to any further infection. 
" Another instance came also to my personal knowledge ; it was that of a lady, up town, who 
has some reputation as a ' doctoress,' and took several gentlemen into her house to ' nurse ' through 
the yellow fever. The first cases that occupied her rooms and beds yielded readily to treatment 
and were soon convalescent. When they went away and their places were taken by others, 
although they presented the same mild type of the fever as the former ones when they arrived, 
they would soon assume a more severe type, and almost invariably prove fatal. And as no 
fumigation or disinfection was resorted to, it is, without doubt, to be attributed to the influence 
of the poison that they imbibed from the immediate surroundings to which they were exposed, 
in addition to that already existing in these sections."* 
Dr. Alfred Perry states that the yellow fever made its appearance in the Fourth District "in 
the latter part of September; six weeks after its first appearance in the city, only 25 cases having 
been reported in the district. Four among the first cases gave clear evidence of having been 
communicated by infection." 
It will be observed from the preceding record that only 88 natives of the United States died 
of yellow fever in 1870, out of a total of 587 deaths from this disease. It is probable that but very 
few of these eighty-eight natives of the United States had been born in New Orleans. On the 
other hand, the total number of deaths during 1870 (7391), more than one-half, or 4753, were 
natives of the United States; 99 of England, 352 of France, 518 of Germany, 551 of Ireland, and 
199 of Italy. If we accept the estimate of Dr. Del. Orto, of the 199 deaths among Italians, 128 
were caused by yellow fever, leaving only 71 deaths from all other causes, the various forms of 
malarial fevers included. Among the Italians 1 death in 1.55 deaths from all causes were due to 
yellow fever; among the English, 1 death in 4.19; among the natives of France, 1 death in 4.09; 
among the Germans, 1 death in 4.01; among the Irish, 1 death in 11.48; among the natives of 
Switzerland (38 deaths from all causes) 1 death in 2.11; while among the natives of New Orleans 
and of Louisiana, and of all other parts of the United States, only 1 death from yellow fever in 
54.01 deaths from all causes. No data exists for the determination of the number of cases of yel- 
low fever occurring in the city, nor of the relations of these cases to the different nationalities. 
In the Charity Hospital alone, as we have seen, 515 cases (of which about one-half in 262 died), 
of yellow fever were admitted ; and as the mortality was much heavier than in private practice, 
it would be fair to estimate the deaths as about one in every four cases of yellow fever, which 
would give 587 X 4 = 2348 cases of yellow fever in the entire city of New Orleans during the 
epidemic of 1870, when carbolic acid and other agents were vigorously used to arrest and limit 
the disease. 
It is evident from the preceding facts that the natives of the United States who have 
resided in New Orleans for various periods of time suffered to a limited extent from yellow fever; 
while the disease spread among the Italians, French, Germans and Irish and natives of Switzer- 
land, occasioning the vast proportion of deaths among the unacclimated foreigners. 
The conclusion is justified, therefore, that the absence or scarcity of material among the resi- 
dent and native population, black and white, which had been recently subjected only three years 
before, in 1867, to a sweeping epidemic, was the cause of the limited nature of the epidemic 
yellow fever of 1870, rather than the action of the disinfectants used by the Board of Health. 
* " Annual Report of the Board of Health to the General Assembly of Louisiana," December 31st, 1870, 
pp. 9-12, 30, 39, 44, 52, 74, 77. SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
399 
YELLOW FEVER, 1871. 
The total deaths from all causes in 1871 numbered 6059, of which the forms of fever caused, 
respectively, fever, 2; bilious, 25; catarrhal, 1; congestive, 102; gastric, 1; hectic, 3; hemor- 
rhagic, 26; intermittent, 26; malarial, 94; nervous, 2; pernicious, 61; puerperal, 14; remittent, 
39; scarlet, 5; typhoid, 71; typhus, 4; yellow, 54; total deaths by fevers, 530. Smallpox caused 
only two deaths; measles, 12 ; while meningitis (cerebro-spinal chiefly) caused 128 deaths; cholera, 
6; cholera infantum, 84; cholera morbus, 18; diarrhoea, 185; dysentery, 155; inflammation of 
bowels, 106; total bowel affections, 544. Consumption, 780; infantile convulsions, 200. 
In the Charity Hospital, 29 cases of yellow fever were admitted, of which 20 died. 1884 
cases of intermittent and malarial fever, 53 deaths; 3 cases "typho-malarial," 3 deaths; 19 
typhoid, 14 deaths; 72 remittent, 5 deaths; 16 pernicious, 10 deaths; diarrhoea and dysentery, 
412 cases, 169 deaths; phthisis pulmonalis, 178 cases, 170 deaths. Total admissions, all diseases, 
6651 ; total deaths, all causes, 891. 
The first case of yellow fever reported died in the Charity Hospital, August 4th; the second 
case, August 20th, after five days' illness; third, September 5th, after six days' illness. In July, 
1 case, 1 death; August, 2 cases, 2 deaths; September, 37 cases, 9 deaths; October, 53 cases, 22 
deaths; November, 33 cases, 19 deaths; December, 2 cases, 2 deaths. Total cases reported, 114; 
total deaths, 54 ; the enormous mortality being reached among these sporadic and " disinfected," 
cases of 47.3 per cent., or one death in 2.1 cases. The disease was chiefly confined to the Fourth 
District, and it has been claimed that its limited spread was mainly due to the liberal use of 
carbolic acid. Sporadic cases, however, appeared in various sections of the city, and the disease, 
as in numberless other years, in this and other Southern cities, in which neither carbolic acid 
nor any other disinfectants were used, showed no disposition to spread. The fact that in certain 
Southern towns the disease exhibited a tendency to spread did not indicate anything more than 
what has often occurred before in the history of yellow fever on the Atlantic and Gulf coasts. 
The following are the facts with reference to the yellow fever of 1871, as officially reported by 
Dr. C. B. White, President of the Board of Health, and the Secretary and Sanitary Inspectors :- 
Case i.-On the 4th of August, Charles Collingberg, of Iowa, was taken to the Charity Hos- 
pital, where he died the same night of yellow fever with black vomit.* 
Investigation of the case furnished the following facts: He came to the city by way of the 
river, as flatboatman, about four weeks previously ; was homeless, without occupation ; slept about 
the elevator wharf, and drank all the liquor he could pay for or get upon credit. The night before 
being taken to the hospital he was received upon the floating elevator, as an act of charity, and 
given sleeping quarters. For not less than four nights previous he had been sleeping about the 
bark " Mary Pratt," from Cienfuegos, discharging sugar into the elevator warehouse. The " Mary 
Pratt" brought a clean bill of health to the quarantine station, and had no sickness on board. 
After her arrival in the city, the crew were discharged, the captain took rooms in the city, and 
only the mate was left on board. At this date her hatches were opened, and while discharging 
cargo Collingberg slept on board, and was taken sick. The stevedore's gang which discharged 
the cargo was found to be composed of men long residents of the city and fully acclimated. 
These facts, and the habits and condition of Collingberg, probably account for his being the only 
sufferer from this supposed infectious vessel. 
Disinfection by sulphurous acid and chlorine was practiced on the floating elevator and in the 
elevator warehouse for several days, and the ship sent to the quarantine ground, to be disinfected 
at the discretion of the resident physician. The crew were followed to their boarding-house, and 
their effects thoroughly fumigated and aired. 
*1 made a careful chemical and microscopical examination of the liver, heart, kidneys, stomach and 
black vomit taken from the body of Charles Collingberg, and the general results were as follows : Stomach 
of a deep red and purplish color, with softened and eroded mucous membrane. Black vomit contained 
altered blood corpuscles, mucous cells, broken capillaries, urea and ammonia. The pericardium of the 
heart was highly injected with blood. Muscular structures of heart of yellow color, softened, loaded with 
oil globules and granular matter,.and the transverse striæ were indistinct, and in many fibril]» obliter- 
ated. The liver presented the usual yellow color and contained much oil, as in well-marked yellow 
fever. Kidneys of yellow color, with granular, matted and detached excretory cells filling the tubuli 
uriniferi. A small quantity of urine obtained from his bladder contained albumen and urinary casts. 
Joseph Jones, m.d. 400 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
On August 10th the "Mary Pratt" was sent up to the quarantine station, and on August 13th 
was laid to the wharf, foot of Terpsichore street. August 23d, George M. Moussé was employed 
as steward, and began work on board the " Mary Pratt," clearing up her cabin, reported to be in 
a very filthy condition, and was taken sick with yellow fever on the 29th; was removed to the 
Hotel Dieu September 4th, and died September 5th. 
The vessel was again taken in charge by the Sanitary Inspector of the First District, thor- 
oughly fumigated for a number of days, and no unacclimated persons allowed on board. 
John Hoch, a tailor by trade, working and residing at 433 Tchoupitoulas street, between Robin 
and Race streets, first and second streets above Terpsichore street, at the foot of which lay the 
"Mary Pratt; " had been in the city six months; confined himself entirely to the house and shop, 
save at evening, at which time, the family state, he always went down to the levee to walk about. 
He was seized with yellow fever September 4th, and died. 
Mr. John M. Rawlins, Custom House Inspector, was attacked with yellow fever August 15th, 
and died August 20th, at his residence, 118 Washington street. Mr. Rawlins was from Alabama, 
and had been a resident of the city ten months. He left the city, on duty for the Passes, July 
29th; took official charge of the brig "Hope" August 11th, then eleven days from Havana, with 
sickness on board. The " Hope " was detained at the quarantine station two days ; hatches opened, 
and enough of the sugar broken into to enable thorough fumigation to be effected of both cargo 
and hold. The hammock of Mr. Rawlins was swung near the opened hatches, and, although 
warned by the physician as perhaps exposing himself to disease by this proximity, he expressed 
his entire fearlessness as to the danger, and remained in the position before mentioned. Less 
than forty-eight hours after his arrival in the city, and four days after the arrival at the quaran- 
tine station and opening of the ship's hatches, he was taken ill. The officers and crew of the 
"Hope" were all acclimated; her cargo went up the river immediately, and within a very few 
days she was again at sea. 
Hon. E. W. Pierce, a member of the Board of Health, was taken ill of yellow fever at his 
residence, No. 136 Fourth street, September 7th, and died on the 13th. The residence of Mr. 
Pierce was distant about 280 feet from the house in which Mr. Rawlins died, and in a direction a 
little to the east of north, diagonally across the block of buildings. The residence of Mr. David 
Rosenberg, No. 736 Magazine street, who was attacked with yellow fever on the 9th of Septem- 
ber, and died, was in the same line of direction in the Fourth District, diagonally across another 
block. The prevailing direction of the wind in July and August is from south to north. Between 
the residences of Mr. Rawlins and Mr. Pierce intervened a cottage, but from the gallery of the 
second story of the house of Mr. Pierce was a direct and full view, over the cottage, of the house 
in which Mr. Rawlins died. Just after the death of Mr. Pierce, it was ascertained that two 
unacclimated children had been sick with fever, and a few days later another child was taken 
ill in a similar manner, and the disease pronounced yellow fever. It is probable that the first two 
cases in the cottage were yellow fever, and formed the connecting links between the cases of Mr. 
Rawlins and Mr. Pierce. Information of the occurrence of the case of Mr. Rawlins did not reach 
the Board of Health until twenty hours after his death, and measures of disinfection were not 
put in operation for some hours later. 
Cases rapidly increased in the Fourth District, and from the time of the death of Mr. David 
Rosenberg, on the 9th of September, thirty-five cases were reported to the Board of Health, up to 
the 30th of the month. That other cases occurred, which were never reported to the Board of 
Health, is evident from the fact that the ease of Mr. Rawlins was not reported until twenty hours 
after his death, and the two children in the cottage "were not reported as sick nor submitted to 
examination, and they do not appear in " the official list of cases. We have no data by which 
to estimate the " unreported " cases. 
On the 13th of September Dr. D. B. Albers, Sanitary Inspector of the Second District-where 
occurred the local epidemic of 1870-was placed in charge of the infected district. 
After stating that the yellow fever of 1871 was carried to the Fourth District by the custom- 
house officer, J. M. Rawlins, who contracted it on the brig "Hope," eleven days from Havana, 
Dr. Albers says :- 
"There were sixteen cases under treatment at the time I took charge of the district; nine 
more were taken subsequently, up to the 28th; the last one died on the 23d. No more cases 
occurred up to the 4th of October, when I withdrew from the district, as the threatened epidemic SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
401 
had been prevented, and my presence was imperatively necessary in the Second District. When 
I took charge of the infected district, the fever prevailed in that portion of it bounded by Chip- 
pewa, Magazine, Sixth and Third streets. It did not spread beyond these limits, owing to the 
energetic measures taken to prevent it. The means adopted to check the course of the yellow 
fever were an energetic, thorough and liberal distribution of carbolic acid over the entire vicinity 
of the infected district, extending its application as far as the influence of the poison could have 
prevailed. In this way there were consumed, between Wednesday, the 13th, and Saturday, the 
16th, 10,000 gallons of carbolic acid, and it may be said that the entire vicinity was soaked 
in it. 
" It was freely applied to the filthy streets, unpaved yards, alleys, stagnant gutters and ditches 
by which all of the streets and many of the houses were surrounded, as well as to manure heaps, 
collections of refuse and other nuisances which abounded in that neighborhood. Carbolic acid 
was chosen for this purpose as being the best disinfectant known, as it coagulates all albumen, 
and is certain to destroy all the lower forms of life. It volatilizes easily and freely, and thus 
attacks the hidden germs of disease that float in the atmosphere. 
" This process of disinfection was repeated daily, and the atmosphere became highly charged 
with the vapor of the acid, which found its way into the dwellings of the sick and healthy alike. 
Many persons fancied at first that the smell produced headache, but the most of them soon became 
convinced of their error, and as these are persons who dislike the smell and complain of nausea 
when exposed to it, so would these persons be similarly affected by any unusual smell, while they 
can bear patiently with the most loathsome smells because they are familiar with them. 
"Notwithstanding this, it cannot be denied that the Sanitary Inspector engaged in its distribu- 
tion was the most unpopular man in the neighborhood at that time, but the 'end justifies the 
means,' in this case at least, and the result has been that the disease was checked in its onward 
course, and a malignant and wide-spread epidemic was prevented. Not a single case occurred 
beyond the limits where it was raging on the 13th. In the course of a month, a few isolated cases 
made their appearance again, and continued to do so until frost, which coincides with the remark 
before made, that minute contagious particles will escape destruction, propagate again, and when 
in sufficient force make themselves felt. The importance, therefore, of continuing the application 
of disinfectants every three or four days during the season favorable to its development is evident. 
In no instance has a second case of fever occurred in any house where this course was carried out, 
but when it was objected to and persistently prohibited by heads of families, several members of 
the household took the fever in succession. 
" Whenever a death occurred from the fever, the house was, in every instance, thoroughly dis- 
infected by fumigating the bedrooms, bed clothes and body clothes, alternately, with sulphurous 
acid and chlorine, during several days in succession ; and the principal hotbeds of the fever, as, 
for instance, in Fourth, Fifth and Magazine streets, which were entirely deserted by their occu- 
pants and in charge of the Sanitary Police, were daily disinfected, fumigated and deodorized from 
their very foundation up to the roof, for several weeks." 
Dr. Albers thus states his theory of yellow fever, upon which he based the system of disinfec- 
tion, which was similar to, but more thorough than, that inaugurated in 1867, by Dr. Smith, Presi- 
dent of the Board of Health. 
" The yellow fever germ, or poison, is probably not generated in the human system, nor trans- 
mitted from one person to another in any way. (In those cases which seem to arise by personal 
contagion the poison is without doubt transmitted by the clothing.) 
" It is an organic poison, the resultant of the decomposition of the exhalations and secretions of 
the human body, accumulated and confined in ill-ventilated habitations, brought in contact with the 
effluvia of the public filth of cities and acted on by a constantly elevated temperature above 80° F., 
for two or three months in succession. 
"This poison is taken into the system after the manner of marsh malarial poison (or terrestrial 
emanations), which is strictly endemic, of local origin, not contagious and not portable. 
" The yellow fever poison, however, is portable, adheres to fomites, and can be carried in ves- 
sels, trunks, etc., from one point to another, and thus be propagated, and bears transportation to 
long distances, without losing its power of reproduction when it meets with favorable conditions, 
among which those of a high temperature is essential. It consists, doubtless, of some form of 
microscopic life, occupying that debatable ground between the animal and vegetable kingdom, but 
Vol. IV-26 402 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
capable of rapid self-propagation, lying on and moving along the ground, not influenced greatly 
by winds, or it would spread far more rapidly, and is, like most other minute and tender germs, 
checked by a freezing temperature, which, though it does not perhaps kill the germ or seed, is 
sufficient to suspend its action for a season, to be called into action again, at a later period, by 
particular meteorological conditions or other suitable circumstances." * 
Holding the theory that the germ of yellow fever might survive through the winter and again 
become active during the summer and fall, Dr. Albers endeavored to prevent the yellow fever from 
making its appearance in the Second District, where it had prevailed in 1870, by enforcing the 
strictest cleanliness in that portion of the city that has always been notorious for its unhealthi- 
ness, and where the yellow fever has not unfrequently first made its appearance in former years. 
As, for instance, in the neighborhood of the French Market, where common lodging houses 
abound and people of the lowest condition of life congregate in large numbers and in unrestricted 
license and confusion, no decaying substances of any nature were allowed to remain on any of the 
premises. 
" The water closets of all suspected places were deodorized and disinfected with carbolic acid, 
and a saturated solution of carbonate of iron in strong hydrochloric acid every week throughout 
the entire sickly season. 
" Another one of the most important duties was to visit all the suspected places rendered suspi- 
cious by the presence of fever in them last year, every day, and frequently twice a day, to ascer- 
tain if there was any one sick in any of these houses, and the landlords of all the lodging and 
boarding houses were particularly requested to assist, to the best of their ability, in ferreting 
out any case of sickness that occurred on their premises, on which measure they all coincided, and 
gave frequent information on that point. 
"During the latter part of July, 1871, a party of five men, all natives of Malta, and between 
twenty-four and twenty-eight years of age, less than one year in the United States, arrived here 
from Galveston, where they had resided a short time. These men rented a room on the ground 
floor of the courtyard connected with the building, No. 239£ Decatur street, and which opens on 
the street through an alley 69 feet long and 8 feet wide, with a double iron gate at the entrance. 
This courtyard forms a hollow square, 62 by 36 feet, built all around its four sides, two stories 
high, and occupied by 16 families, comprising 60 persons, all natives of Italy, Sicily and Malta, 
and totally unacclimated, not one of them having been in the country over three years, and the 
majority less than one year. Their water supply is river water and they have no cistern. The 
room that these five men occupied is 14| feet wide, 151 feet long and 11 feet high, with a door 
9 feet high, 4 feet wide, and a window opening on the courtyard, which never admits any sun- 
light, and almost no ventilation. 
" Soon after their arrival they were joined by two more of their countrymen, from Galveston, 
and all seven occupied this room. Their occupation was to peddle onions, lemons and berries. 
The boxes in which they bought the latter served them as bedsteads, which, with a few mattresses, 
a table and a few cooking utensils, constituted their only incumbrances. 
" Two of these men were taken with yellow fever almost simultaneously on the 24th of October. 
As soon as I obtained information that they were sick, I had them taken to the hospital, where 
they soon after died. I had the others removed to another room, at the time unoccupied, in the 
same yard, of the same dimensions as the former, allowing them to take nothing out with them 
but the clothes they had on at the time, while their former room underwent a thorough disinfec- 
tion and fumigation for ten days, after which they again occupied it. 
" All their clothes, mattresses, etc., which remained in their first room were then washed and 
scalded, deodorized with chlorine, fumigated with sulphur, disinfected with carbolic acid and 
abundantly aired, a continued watch being kept over them, night and day, the whole time. To 
their clothing, which consisted of woolen shirts and woolen pants, shoes without socks, and a 
straw hat, and which they did not change, some of the fever germs or poison must have adhered, 
and when, fourteen days later, two more of their countrymen arrived here from Galveston, and lived 
with them in the same room, one of them was taken sick with the fever within three days, car- 
♦ "Annual Report of the Board of Health to the General Assembly of Louisiana, December 31st, 1871," 
pp. 64-71. SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
403 
ried to the hospital on November 17th, and died on the following day. The other took sick 
within seven days, November 20th, and died November 23d. 
" This shows that although disinfection and fumigation will destroy the poison, still minute 
contagious particles will escape its influence, and that during a season favorable to its develop- 
ment, the disinfection must be continued and persevered in every three or four days throughout 
the season. 
"No other person in that yard or in that neighborhood took the fever afterward. 
" There were also three other deaths from yellow fever in the Second District-on Franklin 
street, between Canal and Bienville streets, a distance of two squares. An Italian, by the name 
of Dominique Gaisalla, who had resided at No. 38 Franklin street for about twelve months, and 
who was a lemon peddler by occupation, and a friend and associate of the above mentioned per- 
sons from Malta, at No. 239J Decatur street, and in daily communication with them, was taken 
sick October 26th, and died October 30th. He was not attended by any physician. The Coroner 
held a ' view ' on his body and had him buried under a certificate of ' congestion of the brain.' 
"Mrs. Reese, residing at No. 12 Franklin street, a native of Baltimore, and unacclimated, was 
acquainted with the before-mentioned person and had visited him during his sickness. She was 
taken on November 1st and died November 6th with black vomit. The husband of this lady 
took the fever about December 18th, and remained sick until December 28th, when he died of 
undoubted yellow fever, according to the burial certificate of his attending physician, at No. 237 
Dryades street, in the upper part of the city, to which place he had been removed. Frank 
Busoti, an Italian, and a waiter in a bar-room and restaurant at the corner of Custom-house and 
Franklin streets, visited both of the before-mentioned persons while they were sick, carrying 
them refreshments and drinks. He took yellow fever November 7th and died the 14th."* 
The following observations should be coupled with the preceding statements of Dr. Albers. 
1. Dr. Albers states that no cases were attacked in the Fourth District, between the 28th of Sep- 
tember and the 4th of October, when he withdrew to the Second District. The official record of 
the Board of Health shows that two cases occurred in this district on the 28th of September, at 
129 Washington street and 190 Third street; one case occurred at 780 Magazine street, on the 
2d of October, and another case at the corner of Tchoupitoulas and 7th streets, on the 3d of Octo- 
ber. The statement of Dr. Albers would lead one to suppose that the disease had been completely 
arrested or stamped out by the sanitary measures, and especially by the free use of carbolic acid. 
So far from being the case, 53 cases occurred during the month of October, against 37 in the 
month of September, and after the vigorous use of carbolic acid in the infected district. Of the 
53 cases officially reported for October, 40 cases occurred in the thoroughly il disinfected" Fourth 
District in which the disease had been stamped out. 
2. It appears also, from the statement of Dr. Albers, that " the principal hotbeds of the fever, 
as, for instance, on Fourth, Fifth and Magazine streets, were entirely deserted by their occu- 
pants." 
The carbolic acid certainly acted as a valuable sign and warning to all in the city as to the 
location of the yellow fever, and thus fulfilled the office of a local and very efficient quarantine. 
3. The disease evidently occurred a second time in houses disinfected and surrounded with 
disinfectants, as at 118 Washington street, where cases were officially recorded as occurring 
August 15th, October 14th, and October 27th. 
A fatal case occurred at 433 Tchoupitoulas street on the 5th of September, and another on the 
12th of October. Two cases occurred at 140 Fourth street on the 10th and 11th of September; 
another case on the 15th; another on the 20th of September in the same house. A case occurred 
at 119 Washington street, September 21st; another in the same house October 27th; one case at 
780 Magazine street, September 27th, and another October 2d. One case at 129 Washington 
street, September 16th, and another, September 28th, and a third on the 12th of October. 
The following singular statement occurs in the report of the President, Dr. C. B. White:- 
"By the culpable neglect of the attending physician, information of the occurrence of the 
case of Mr. Rawlins did not reach the Board of Health until twenty hours after his decease. 
Measures of disinfection could not be put in operation for some hours later."j- 
* " Annual Report of the Board of Health to the General Assembly of Louisiana," December 31st, 
1871, pages 65-C8. t " Annual Report of the Board of Health," 1871, p. 17, 404 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
The experience of the family of Mr. D., the brother-in-law of Mr. Rawlins, occupying the 
other half of the double tenement, has interest in connection with the subject of disinfection. 
Believing, from the bèginning of the case of Mr. R., that his attack was yellow fever, the resi- 
dence of Mr. D. was thoroughly treated by disinfectants, and every person who waited upon Mr. 
Rawlins, or even visited the rooms, on coming from them made a complete change of all their 
clothing, which was without delay carried from the room and washed. 
No case of yellow fever occurred in this family till the one, No. 53, on October 14th, and No. 
90, October 27th, both of which were so light that the attending physician is doubtful of the diag- 
nosis given. On the 14th and 15th of September cases occurred in houses each side of the resi- 
dence of Mr. D., and by the 14th of October there had been twenty-seven unmistakable cases 
within a circle of a radius of 150 feet, taking the house of Mr. Rawlins as a centre. 
Owing to the almost complete cessation of yellow fever, about October 1st, in this district, gen- 
eral disinfection had ceased, and none was used until recurring sultry weather and the appearance 
of new cases of fever indicated the propriety of its use. The experience of this family and the 
use of disinfectants may be only a coincidence, but is worthy of consideration and record. 
The history of the Fourth District epidemic may be closed with the statement that the total 
number of cases in that district, measuring one and three-fourths miles long and one mile wide, 
was sixty-six, of which twenty-four terminated in death. The striking localization of the fever 
is made evident by the fact that within an area of which the corner of Constance and Washing- 
ton (the house of Rawlins) is the centre, and extending in every direction from that point, six 
hundred and sixty feet, occurred 45 of the total cases and 15 of the deaths."* 
4. Whatever effects the sanitary measures, and more especially disinfection with carbolic acid, 
may have had upon the spread of yellow fever in the Fourth District, the changes of the weather 
appear to have exerted even more important effects. Thus, the President of the Board of Health, 
in the absence of any official record of the temperature and changes of the weather, states that 
" During the prevalence of yellow fever this year, in marked contrast to last year, the weather 
remained warm, exceedingly sultry, rainy, with a remarkable stagnant condition of the atmo- 
sphere, greatly resembling the early period of the epidemic of 1853." . . . 
" On October 3d occurred a violent storm, which to the southward and eastward assumed the 
proportions of a hurricane. The rain fell in enormous amount, flooding yards and streets, and 
the violence of the wind thoroughly ventilated the most out-of-the-way corners. 10j95 inches of 
rain fell in twenty-four hours. By examination of the table it will be seen that the Fourth 
District epidemic had greatly declined before the coming of the storm. The storm seems, how- 
ever, to have exerted a decided and favorable influence on the public health, as but three domestic 
cases of fever died in the next fifteen days, the three other deaths being of cases foreign to New 
Orleans. "f 
5. That portion of the Fourth District in which the yellow fever was introduced by Mr. Raw- 
lins is not a business centre, is removed from the shipping, and a vast proportion of the inhabitants- 
were permanent residents and acclimated. 
6. Yellow fever did not appear in the Second District until late in the season, the first cases 
observed by Dr. Albers being on the 26th of October. The arrest of the disease in this district 
was fairly attributable to the supervention of cold weather rather than to the use of disinfectants. 
Dr. Alfred W. Perry states that " only five cases of yellow fever were reported in the Third District, 
against 59 deaths in 1870 ; two of the five cases had been exposed to the disease in Natchez, and 
came here and died in a few days afterward. In the other three cases no particular source of con- 
tagion could be traced, although there may have been such. In these cases the houses were fumi- 
gated with sulphurous acid ; carbolic acid was sprinkled plentifully in the vicinity and on the 
premises, so that its vapor would diffuse into the air." While Dr. Perry says that " the good effects of 
this action are shown by the fact that no second case of the fever occurred in the same house or 
neighborhood, while during the preceding year many succeeding cases occurred in the same house,, 
and that the fever was confined to one or two blocks; " on the other hand, he neglects to state the 
fact that the first cases occurred in 1871, in the Third District, on the 24th of October, when the 
temperature, of course, precluded any extensive spread of the disease. 
* " Annual Report of the Board of Health," 1871, p. 20-21. f Op. cit., p. 25. 
J "Annual Report of the Board of Health," 1871, p. 75-76. SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
405 
James J. Jackson, M.D., Sanitary Inspector of the Third District, states that in 1871 "the 
first cases of yellow fever in this district were confined to the shipping, and especially to vessels 
lying beneath the level of the wharves. All cases occurring on shipboard were sent to the hospital 
for treatment and the vessels thoroughly fumigated. Late in the season the disease spread to the 
block bounded by Elysian Fields, Frenchman, Victory and Levee streets, where it was confined 
until its final abatement. The inhabitants of this locality were principally Italians, who lived 
huddled together in small apartments, and were the sole victims of the fever."* 
In the First District, 1871, the first case of yellow fever occurred at 433 Tchoupitoulas street, 
September 9th, and the last at 347 Dryades street, December 29th. 
No well-marked case of yellow fever occurred in the Fifth and Sixth Districts. 
In considering the history of yellow fever in 1871 in New Orleans, it is important to note the 
fact that the submergence of that portion of the First and Second Districts lying between the old 
and new canals, and between Basin street and the Metaire Ridge, resulting from the break in the 
banks of the new canal on the 3d of June, 1871, caused by the elevation of the waters of Lake 
Pontchartrain after a succession of strong southeast winds, which interfered with the outflow of the 
waters, augmented by the break in the river levee at Bonnet Carré, was attended neither by the 
appearance of yellow fever nor by an increase in the number and severity of the ordinary mala- 
rial fevers in the overflowed districts. 
The privies were overflowed in this district and much of their contents escaped, and when the 
waters became stagnant, and as the filthy streets and premises were gradually exposed to the 
burning rays of the sun in June and July, as the waters receded and were dissipated by evapor- 
ation a foul stench arose. For a series of years the St. Charles, St. James and City Hotels and 
the Charity Hospital have been daily discharging the contents of their privies into Gravier and 
Common streets, and the filthy streams flowing into the gutters have finally found their way into 
the canals and drains in the rear of the city. If there be anything in filth, and especially in 
human filth and excrements, combined with heat and moisture, to engender yellow fever de novo, 
such conditions are annually present in New Orleans, and yet the district of the city in which the 
largest amount of human excrements is poured has been remarkably exempt from yellow fever. 
This disease has almost invariably originated in and about the shipping along the river front and 
in the new and old basins. 
The President of the Board of Health, in his official report, thus congratulates himself and 
his assistants on the use of disinfectants during the summer and autumn of 1871 :- 
"The experience of the year is in favor of their use. Some families in which they were used 
freely on the occurrence of the first case escaped additional attacks. Other families in which, by 
prejudice or neglect of the physicians, or their own choice, they were not used, the disease passed 
through the whole family, attacking all its members in succession. 
" The general prevalence of the disease in the Southern States, and numerous cases scattered 
about in New Orleans, show that the failure of the fever to become general was not owing to any 
unfavorable meteorological or climatic conditions. 
" Last year New Orleans suffered from yellow fever. Its ravages were confined to three blocks 
in the Third District, a limited portion of the Fifth District, and as an epidemic it was confined 
to a portion of the Second District of four squares by twelve. In Mobile it began later than in 
New Orleans, but attacked every portion of the city. In New Orleans great efforts were made to 
arrest the disease by hygienic remedies. No efforts whatever were made in Mobile. This fact 
seems of value. In every Southern city, town or village where yellow fever appeared at all this 
year it assumed the epidemic form, save in New Orleans, and New Orleans is the only place 
where an early, energetic, well-planned and persistent attempt was made to control the disease."')' 
YELLOW FEVER OF 1872. 
Total deaths in New Orleans in 1872, less still-born, 6122; still-born, 466; totaldeaths, including 
still-born, 6588. The following deaths were caused by the various forms of fever: Fever, 1; 
bilious, 22 ; congestion, 165; gastric, 1 ; hectic, 2 ; intermittent, 27; malarial, 51; nervous, 1; 
puerperal, 10; remittent, 26; scarlet, 5; typhoid, 67; typhus, 4; yellow, 39; total deaths by 
* "Annual Report of the Board of Health," 1870, p. 49. 
f "Annual Report of the Board of Health," 1871, pp. 25, 26. 406 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
fevers, 401; consumption, 784; infantile convulsions, 227 ; diarrhoea, 195; cholera infantum, 52; 
cholera morbus, 20 ; dysentery, 123 ; inflammation of bowels, 150 ; total by bowel affections, 440 ; 
smallpox, 29. 
Total admissions Charity Hospital, 5541; total deaths, 825; fever, intermittent, cases 909; 
malarial, cases 431, deaths, 28; remittent, cases 41, deaths, 1; bilious, cases 28, deaths, 3; 
typhoid, cases 21, deaths, 7; continued, cases 10, deaths, 1; dengue, cases 1; typho-malarial, 
cases 5, deaths, 2; yellow, cases 11, deaths, 8; ephemeral, cases 1; puerperal, cases 4, deaths, 3; 
congestive, cases 24, deaths, 18; bilious remittent, cases 2, deaths, 2 ; diarrhoea, cases 298, deaths, 
95; dysentery, cases 289, deaths, 59; total bowel affections, cases 594, deaths, 156. 
The epidemic of this year, if it could be called such, was still more limited, only 83 cases and 
39 deaths having been officially reported. The monthly deaths were as follows : August, 1 ; 
September, 5; October, 24; November, 7; December, 2. On the other hand, the eo-called con- 
gestive fever destroyed 165. 
The disease was widely scattered over the city, commenced late in the season, and showed no 
tendency to spread; 17 cases were reported in the First District, 4 cases in the Second District, 1 
case in the Third District, 59 cases in the Fourth District, 1 case in the Fifth District, 1 case in 
the Sixth District. 
The mortality of these "disinfected" cases was, in like manner great, reaching nearly 50 per 
cent. 
The Fourth District originated 61 of the cases. 
The yellow fever area of 1872 surrounded the yellow fever area of 1871, and scarcely a case 
occurred this year in the locality where it prevailed last year. The central points of most potent 
yellow fever infection existed at the corner of Magazine and Jackson streets. 
The following facts are consolidated from the interesting reports of Dr. A. W. Perry, Sanitary 
Inspector of the Fourth District, where the yellow fever first appeared and to which it was chiefly 
confined. 
It will be observed from the report of Dr. Perry and from the preceding reports of the Presi- 
dent of the Board of Health, that the yellow fever of 1872 commenced, as in 1871, in one of the 
most healthy and cleanly portions of the Fourth District, which is regarded as the best part of the 
city. In 1870 yellow fever was confined to a portion of the city four by twelve blocks wide and 
deep in the Second District of the city, and to a locality ten by six blocks wide and deep in the 
First District, both of which are well built and paved, are near the river, and are usually espe- 
cially free from malarious diseases. In 1871 and 1872 the disease occurred in, and was almost 
wholly confined to, limited portions of the Fourth District, portions of the district less liable to 
swamp fevers than its other parts, and far more healthy in that respect than the rear portion of the 
city bordering the swamps for miles. The localized infection of yellow fever during these years 
established a marked difference between this disease and the endemic paroxysmal fevers of the 
Mississippi Valley. 
The first case occurred August 28th, in the person of Frank Henning, a native of Sweden, aged 
thirty-six years, two years in the city ; a druggist by occupation, and employed in a drug store 
corner of Washington and Rousseau streets, where he was taken sick. He was sick in the drug 
store two days, then went to a house on Livandais street, almost a hundred yards distant, where he 
remained two days, and was then sent to the Hotel Dieu, where he died September 1st. Although 
the most careful inquiry was made, no history could be traced of the disease having been imported. 
" This case may be considered as the starting point of the yellow fever of this year, for from this 
case six persons, who had direct and recent communication, were attacked with yellow fever. The 
first of these secondary cases was a young man who waited on Henning. Another was a young 
lady whom this last young man visited immediately after recovering from the yellow fever. Two 
others were fellow clerks in the same store with Henning, the first case. In one other case the 
man attacked frequently visited Henning in the drug store, and soon after was taken sick with the 
fever, and his wife also. The disease continued to increase slowly in a few limited areas in this 
district, until October 13th, when it reached its highest point." The following record shows the 
gradual rise and decline during October: 1st, 1 case; 2d, 3 cases; 3d, 2 cases; 7th, 1 case; 8th, 2 
cases; 9th, 1 case; 10th, 2 cases; 11th, 1 case; 12th, 3 cases; 13th, 7 cases; 14th, 1 case; 15th, 
1 case; 18th, 4 cases; 19th, 2 cases; 20th, 1 case; 21st, 2 cases. 
" A case occurred on Rousseau street, between Jackson and Philip, which gave origin to SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
407 
seven others, and a group of thirteen cases occurred within 150 yards of the corner of Jackson 
and Magazine streets. There occurred 10 cases in September, 37 in October, 10 in November, 
making a total of 57 in the Fourth District. The fever has shown the same tendency as last 
year to confine itself to small localities, and it has shown itself to be exceedingly communicable. 
The frequent communication of yellow fever this year is probably not a new feature in the dis- 
ease, but is shown strongly this season, because all cases were promptly reported, and the details 
of the cases were kept. Out of 57 cases originating in this district, in 27 there was recent and 
direct communication. 
" All of the houses where the disease occurred were disinfected with carbolic acid in the fol- 
lowing manner :- 
"When the case was reported, a few gallons of crude carbolic acid were sprinkled, with a 
watering pot, around the house, in the yard and adjacent streets. The object of this was to cause 
an impregnation of the air of the locality with carbolic acid vapor. On the termination of the 
case, either in recovery or death, rooms in which the patient had been were disinfected by throw- 
ing a few sprays of pure carbolic acid, diluted with fifty parts of water, into every part of the 
rooms, upon the walls, ceiling, furniture. In the form of a fine spray a minute portion of car- 
bolic acid was thus brought in contact with everything in the room, and every organic germ 
must have been destroyed. All bedding and clothing which had been used was either boiled or 
soaked in diluted carbolic acid. I found, by direct experiment, that pure carbolic acid dissolves 
readily in fifty parts of water, forming a clear solution which does not stain or injure the most 
delicate colors of calico, silk or broadcloth, and yet is strong enough to destroy the vitality of all 
the lower forms of life. The use of any well-directed system of disinfection in a disease neces- 
sarily involves a theory of the nature, production and communication of the disease. Our sys- 
tem of disinfection is based on these propositions :- 
"1. That yellow fever is produced by an organic living germ. 
"2. That it is portable in ships, cars, clothing, etc. 
" 3. That it is solid, and not readily diffused through the air, but sticks to solid bodies. 
" One attack of yellow fever is usually a protection against another. The apparent exceptions 
to this protecting influence of a first attack are more frequent than in smallpox, but most of these 
exceptions must vanish when it is remembered that in mild yellow fever there is no pathogno- 
monic sign, like the corruption in the exanthemata, and a certain distinctive diagnosis cannot 
be made from malarial fevers. The local exceptions are not more numerous than in smallpox. 
That yellow fever is portable is generally admitted, and too many instances are on record in all 
medical works, where vessels have arrived in seaports of the United States and Europe with 
cases of yellow fever on board, and large numbers of persons who visited these vessels have been 
attacked with yellow fever, to require any extended proofs here. A vessel loaded with sugar 
arrived from Cuba at St. Nazaire, France, in July, 1861 ; four cases of yellow fever had occurred 
on the voyage. The last case was well thirteen days before the vessel arrived in St. Nazaire. 
Within a few days after her arrival well marked yellow fever attacked the men who visited the 
vessel, those who were engaged in unloading her, some of the crews of vessels lying near, and 
some persons living in the town who had no direct communication with the vessel were attacked. 
In all there were 44 cases and 26 deaths. 
" If we admit that yellow fever depends on a living germ it is theoretically possible to control 
the spread of yellow fever by destroying the life of these germs. The difficulty is to find them 
exactly. We find by experience that the winter here either destroys these germs or suspends 
their vitality. The probability is that most of them are destroyed, and only a few are left, and 
that when the yellow fever occurs here without importation it is caused by these germs which 
have remained over from last year. This is rendered probable from the circumstance that 
yellow fever only makes its appearance here after hot weather has lasted two or three months. It 
is' likely that the yellow fever germs, whose vitality was only suspended, revive when the hot 
weather commences, and that they require this interval before they have multiplied sufficiently to 
make themselves felt by causing disease. The less number of germs that are left alive the longer 
time will be required to produce the requisite quantity. Every germ that can be destroyed in the 
first or first few generations is equivalent to destroying millions in the later generations. If this 
were not so, and all the germs which are left at the end of the fall, scattered around the city, 
were to revive the next year in the first warm or damp weather, it would attain its full develop- 408 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
ment suddenly, instead of gradually spreading from one or more points, and requiring months 
for its full development. In the fever zone, as I may call it, if any hygienic measures will 
delay the development of the disease until the cold weather, it is practically almost as good as 
totally destroying the disease. A disease germ cannot originate anew ; it must be the descend- 
ant of some parent germ, and it is simply ridiculous for us to run to spontaneous generation when- 
ever we meet a living individual whose parents are not apparent. There is no experimental evi- 
dence of the new creation of any living thing, from the lowest to the highest organized animal ; 
and there is an immense weight of evidence against it. In any house where one or more persons 
have been taken with the yellow fever there are certainly some few germs present on the premises. 
By sprinkling carbolic acid on the ground in the vicinity, we destroy some diseased germs ; the 
vapor of the acid, diffusing in the air, kills others. In disinfecting a room we use an apparatus to 
throw a solution of carbolic acid in the form of a spray which is so fine that it diffuses itself in 
every direction, in every crevice and fold, and yet each particle is a liquid, and as such has a 
stronger and more certain effect in destroying vitality ; for it is well known that the liquid condi- 
tion is absolutely necessary for the chemical actions of substances on each other. The apparatus 
used to produce this spray is composed of a copper vessel, holding two gallons of water, which is 
placed on a small sheet-iron furnace, and in which steam is generated to the pressure of four to 
five pounds to the inch ; connected to this is a quarter-inch rubber tube, eight feet long, through 
which the steam is conveyed to a brass nozzle, with an opening one-sixteenth inch in diameter. 
The carbolic acid solution is supplied to the steam nozzle, so that it flows slowly over the jet of 
steam, which breaks the liquid up into the finest spray. The steam kettle is placed in the mid- 
dle of an apartment, and the steam nozzle and reservoir of carbolic acid solution are carried around 
the room, and the resultant carbolic acid spray directed upon everything which is required to be 
disinfected. 
" In the history of yellow fever this year it will be observed that it required more than six 
weeks from the first case, August 28th, for it to reach its climax, October 13th, seven cases being 
attacked that day, though it declined rapidly to only one case in the second week in November. 
The decrease of the fever above shown can only have resulted from two causes, which have not 
been in operation in some previous years. 
" The disinfection with carbolic acid certainly destroyed a large number of disease germs, 
and the growing and very prevalent belief in the communicability of the fever had caused many 
families to send off the well members as soon as any one was taken sick with the fever and has 
also cut-off a large proportion of the intercourse with the infected. From August 28th to Novem- 
ber 15th there was no change in the temperature or barometric pressure which could account for 
the diminution of the disease. The maximum daily temperature varied only 6.3° F., and the 
barometric pressure one inch. On November 15th the weather suddenly changed to be very 
cold, the temperature falling to 33° F. 
" The large proportion of cases in which the disease has been shown to have been communicated 
shows the disease had a strong tendency to spread. The yellow fever reached its highest point 
October 13th, and the cold weather first came one month afterward, and then the fever had almost 
disappeared."* 
It will be seen that the preceding theory of the nature of yellow fever and of the principles of 
disinfection to be practiced for its arrest, as represented by Dr. Perry, did not differ from that of 
the President of the Board of Health in 1867, Dr. Smith, nor from that of Dr. Albers previously 
recorded; nor from that of Dr. C. B. White. The President of the Board of Health, writing con- 
cerning the yellow fever of 1871 says : " It was kept clearly in view that though the sick persons 
were confined to a limited space, yet the poison was of necessity more widespread. It is evident 
that the presence of the poisonous agent must and does precede for some hours, if not days, the 
attacks of illness. The peculiar localization of yellow fever, as observed in previous years, and 
its slow and regular march forward in these localities, suggests that, if it be the multiplicatioh 
and spread of either vegetable or animal life, agents powerfully inimical thereto, although not 
able to reach all hidden and closed places, and thus utterly destroy all germs, might, at least, 
destroy those likely to be carried or wafted in to infect neighboring localities. If the poisonous, 
or poison-causing agent spread along the ground, it seemed not unreasonable to hope that a pow- 
* "Annual Report of the Board of Health," December 31st, 1872, pages 93-98. SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
409 
crful agent, like carbolic acid, freely applied to the streets, would prevent its crossing them, and 
by its vapor rising into the air, as it were, wall in the infected places. 
" The effect of the thinnest possible film of corrosive sublimate in preventing insects from cross- 
ing into safes and cupboards is a fact of domestic economy well known. There may be remedies 
•of analogous action toward the cause of yellow fever. . . . 
" These facts seem to suggest that the yellow fever plant, or contagium particle, may, by its 
growth, or during its development and general prevalence, exhaust its soil (the locality of its mor- 
bific influence) of those elements necessary to its growth, and which may require some time to 
again accumulate. It is not difficult to conceive of a vegetable growth so developed by unusually 
favorable, known or unknown, climatic or meteorological conditions, as to almost exhaust its soil 
of the ingredients peculiarly necessary to its existence, and to so considerable a degree that for 
successive years, in unfavorable conditions, the same growth should be but feeble and of scanty 
distribution. Experience seems to teach that if the disinfection practiced this year be of value, 
a repetition of it at brief intervals is probably necessary. Begging the truth of the " Germ 
Theory," it is easy to make a plausible explanation of this necessity. The cause of yellow fever 
is invisible or microscopic, but is present in abundance. Disinfection reaches and destroys the 
larger portion of these animal or vegetable organisms, and checks the progress of the disease, or 
even completely destroys it. The conditions of soil and meteorological conditions are favorable, or the 
disease would not have appeared, and still remain favorable. The few germs not reached multiply 
rapidly, and in a few days the morbific cause is ready to attack any who come within its influence." 
The preceding observations are presented not for the purpose of discussion, but simply to illus- 
trate the theories upon which the Board of Health conducted its "system of disinfection" with 
carbolic acid ; but we may observe that the cases occurring in the Fourth District might be 
variously cited, according to the views of the writer, as causes of direct contagion, of the portability 
of infection or of exposure to a poison common to the locality in and around the drug store in which 
the first case, Henning, worked. 
CHOLERA AND YELLOW FEVER OF 1873. 
The year 1873 was characterized by the prevalence in New Orleans of Asiatic cholera, cerebro- 
spinal meningitis, smallpox and yellow fever. The total deaths, including still-born, numbered 
7995; excluding still-born, 7505; deaths from the various forms of cholera, 359; deaths from 
smallpox, 505 ; deaths from yellow fever, 226 ; deaths from meningitis and cerebro-spinal menin- 
gitis, 174; total deaths from these diseases, 1264. If the deaths from these diseases and those 
still-born be subtracted from the total mortality, the remainder, 6241, is about a fair average of 
the mortality for the last ten years. 
The various forms of fever occasioned the following number of deaths : Fever, 5 ; bilious, 28 ; 
congestive, 246; dengue, 6; gastric, 3; intermittent, 16; malarial, 109; nervous, 5; puerperal, 
17; remittent, 40 ; scarlet, 5; typhoid, 57; typhus, 5; yellow, 226. Total by the various forms 
of fever, 768; various forms of fever exclusive of yellow fever, 542. 
Affections of the bowels caused, respectively, the following deaths : Cholera sporadica, 142 ; 
cholera infantum, 118; cholera morbus, 99; diarrhoea, acute and chronic, 209 , dysentery, acute 
and chronic, 153 ; inflammation of bowels, 152. Total deaths from bowel affections, 873. In 1872 
the total deaths caused by bowel affectjpns numbered only 440, and, in view of the great increase 
in 1873, it would be more accurate to place the deaths by Asiatic cholera (the so-called cholera 
sporadica of the Board of Health) at about 433 deaths, against 142 entered upon the "official" 
reports. 
505 deaths were caused in 1873 by smallpox-a preventable disease and imported; about 433 
deaths were caused by Asiatic cholera, imported from Europe ; 226 deaths by yellow fever, imported 
from the West Indies, and 542 deaths by the various other forms of fever, which were due to 
causes which might, to a great extent, be controlled by drainage, improved hygiene of the streets, 
drains, canals, gutters, privies and habitations of New Orleans. 
The yearly death rate for 1873 was high, being 37.05 per thousand of living inhabitants, and 
if the officially reported deaths by smallpox 505, cholera 241, and yellow fever 226, be excluded, the 
death rate was 31.72 per thousand of living inhabitants. 
* " Annual Report of the Board of Health," 1871, pages 18-20. 410 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
1236 white, 783 colored children under two years of age died during 1873, and in relation to 
population, according to the United States census of 1870, 181.56 white and 335.47 colored children 
under two years of age died per 1000 of population in these ages and classes, respectively. Infan- 
tile convulsions caused 256 deaths, and consumption 850. 
In the Charity Hospital the admissions numbered 5090, deaths 993 ; of those admitted, 3029 
were foreigners and 2035 natives of the United States, and of these latter 672 were natives of 
Louisiana. 
Of the various forms of fever treated in the Charity Hospital; Intermittent, cases 687, deaths 
5 ; malarial, cases 510, deaths 59 ; typho-malarial, cases 2, death 1 ; remittent, 38 cases, 2 deaths; 
typhoid, 17 cases, 5 deaths; bilious, 9 cases, 2 deaths; bilious remittent, 9 cases, 2 deaths; catar- 
rhal, 2 cases; pernicious, 7 cases, 6 deaths; puerperal, 2 cases, 1 death; congestive, 13 cases, 11 
deaths; continued, 6 cases; dengue, 88; Chagres, 1; yellow, 118 cases, 75 deaths; scarlet, 1 case, 
1 death; urethral, 1 case, 1 death. Of bowel affections: Cholera, 34 cases, 27 deaths; cholera 
morbus, 12 cases, 9 deaths ; diarrhoea, 277 cases, 53 deaths ; dysentery, 185 cases, 73 deaths ; Phthisis 
pulmonalis, 214 cases, 136 deaths. 
The first case of yellow fever which occurred in 1873 was traced to the bark "Valparaiso," 
which, after a so-called thorough disinfection and fumigation at the quarantine station, arrived in 
New Orleans June 26th. The first case occurred on the 4th of July and died on the 8th. Of the 
226 deaths by yellow fever only 68 were Americans. Of the 388 cases and 226 deaths, the monthly 
record was as follows: July, 8 cases, 5 deaths; August, 40 cases, 29 deaths; September, 184 cases. 
108 deaths; October, 135 cases, 79 deaths; November, 22 cases, 14 deaths. 
The President of the Board of Health states that the above were all that were reported to the 
Board of Health, " though probably 10 per cent, of all the recoveries were not reported. Many 
physicians did not report their cases until the strongest evidences of dissolution were apparent." 
If this statement be true, as it undoubtedly is far within the actual bounds of the cases not 
reported, and if, at the same time, it be affirmed that the disease was limited and arrested by the 
" carbolic acid disinfection," why, it may be asked, did yellow fever not spread from those centres 
where it was not reported, and in which no disinfection of any character was practiced ? 
These facts, on the contrary, show in the clearest manner that the limited nature of the epi- 
demic was due to the peculiar conditions of the climate and population. 
It is worthy of note that in 1873 the various forms of fever, exclusive of yellow fever, caused 
537 deaths, of which number congestive fever caused 246 deaths, and the so-called malarial fever 
109 deaths. The total deaths from fevers in 1873 numbered 763. 
The plan of disinfection pursued in 1873 did not differ materially from that of 1872: the 
streets of the infected district were sprinkled with carbolic acid, and this agent was distributed 
over an area considered to be beyond the point actively infected by the fever contagion. The 
premises in the vicinity of the case-yard, walks, etc.-were disinfected with colorless carbolic 
acid, dissolved in water by means of hand sprinkling pots. When the case terminated by death, 
removal or recovery, the premises were disinfected. Floors were sprinkled with dilute white 
carbolic acid, clothing and bedding either sprinkled in the same way or freely with boiling water. 
Walls, ceilings and furniture were disinfected by a steam atomizer, throwing a spray of dilute 
white carbolic acid. 
YELLOW FEVER OF 1874. 
Total deaths in New Orleans, 1874, exclusive of still-born, 6798, including still-born (495), 7293. 
Cholera sporadica, 6 ; cholera morbus, II ; cholera infantum, 80 ; diarrhoea, chronic and acute, 182 ; 
dysentery, chronic and acute, 150; inflammation of bowels, 140 ; total diseases of bowels, 469; 
consumption, 810; inflammation of lungs, 258; pneumonia, 15; smallpox, 587; fever, 1; 
continued, 9; congestive, 254; intermittent, 37; malarial, 122; nervous, 1; puerperal, 20; 
remittent, 62 ; scarlet, 4 ; typhoid, 95 ; typho-malarial, 13 ; typhus, 2 ; yellow, 11 ; total deaths 
from fevers, 631. 
Total admissions, Charity Hospital, 5231 ; deaths, 860. Of the admissions, foreigners, 3013, 
natives of United States, 2201, including 764 natives of Louisiana. Diarrhoea, cases 381, deaths 82 ; 
dysentery, cases 74, deaths 42 ; phthisis pulmonalis, cases 287, deaths 145 ; pneumonia, cases 121, 
deaths, 37. Fevers, malarial, cases 712, deaths 95 ; intermittent, cases 929; remittent, cases 62 ; 
typho-malarial, cases 9, deaths 5 ; pernicious, cases 1, deaths 1 ; typhoid, cases 5, deaths 4; con- SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
411 
gestive, cases 4, deaths 3 ; yellow, cases 9, deaths 6 ; bilious, cases 2 ; catarrhal, cases 2 ; dengue, 
cases 2 ; continued, cases 3. 
Yellow fever caused only 11 deaths, 6" of which occurred in the Charity Hospital. Smallpox, 
on the other hand, caused 587 deaths. The various forms of fever caused 631 deaths, the greater 
portion of which, namely, 413, were caused by congestive, intermittent and malarial fevers. 
The cases and deaths from smallpox were as follows: January, cases 154, deaths 82; February, 
cases 196, deaths 89; March, cases 203, deaths 99; April, cases 248, deaths 97 ; May, cases 230, 
deaths 98; June, cases 141, deaths 66; July, cases 65, deaths 30; August, cases 12, deaths 6; 
September, cases 13, deaths 6 ; October, cases 8, deaths 3 ; November, cases 23, deaths 12 ; De- 
cember, cases 45, deaths 17; total cases, 1338 ; total deaths, 605. Six hundred and five deaths by 
smallpox are at the rate of 2.88 deaths per 1000 population, and 8.90 per cent, of the total death 
rate. Of 1338 cases of smallpox 712 were white and 626 colored, a rate of 4.59 cases to 1000 of white 
population, and 11.38 cases to 1000 of colored population, estimating white population at 155,000 and 
colored at 55,000. The total number of deaths for 1874 was 6798. The total death rate per 1000 
per annum was 32.37, and the annual death rate, had not smallpox, an eminently preventable dis- 
ease, prevailed, would have been 29.49. In the face of such facts, the President of the Board of 
Health affirms " that persistent and decided effort was made by isolation, disinfection and ventila- 
tion to prevent the spread of smallpox." * The number of deaths from smallpox entered upon the 
mortuary report differed from those just given as officially reported to the Board of Health, and 
presented in tabular form,j_ thus: January, deaths 87 ; February, 82 ; March, 88 ; April, 94; May, 
79; June, 73; July, 41; August, 10; September, 6; October, 2; November, 10; December, 15; 
total, 587. 
One hundred and ten deaths were recorded as caused by typhoid, typho-malarial and typhus 
fever; ninety-five of these were recorded as due to typhoid fever. The heaviest mortality from 
these diseases occurred during the months of June, July, August, September and October, and the 
deaths were as follows: January, 3; February, 1; March, 2; April, 2; May, 4; June, 13; July, 
24 ; August, 19 ; September, 11 ; October, 18 ; November, 8 ; December, 4 ; total, 110. 
Much difference of opinion existed as to the nature of the disorder, which prevailed so exten- 
sively in some portions of the city as to be with propriety called epidemic. The rate of mortality from 
the disease did not exceed two to three per cent., and the total estimated cases for July and August 
would therefore be almost one thousand. The disease received various names, as typho-malarial 
fever, typhoid fever, continued fever and fièvre muqueuse. 
The President of the Board of Health states that of the disease " very few cases and no deaths 
occurred at the Charity Hospital." This statement is incorrect, as nine cases, with five deaths, of 
typho-malarial fever, and five cases and four deaths of typhoid fever, were reported and published 
in the " Report of the Board of Administrators of the Charity Hospital for 1874." 
A portion of these cases were without doubt genuine typhoid fever. I observed in two fatal 
cases hemorrhage from the bowels, and in one case, in which a post-mortem was held, the glands of 
Peyer presented the characteristic lesions of genuine typhoid fever. 
Dr. D'Aquin, from the records of thirty-two cases, regarded the disease as enteric fever. His 
notes show the average duration of the disease to have been twenty-one days. Diarrhoea pres- 
ent in many cases. No hemorrhage from the bowels. Epistaxis frequent about fifth or sixth day 
in light cases. Relapses of severity occurred in four of the thirty-two cases. Rose-colored spots 
were present in certain of the cases. The disease seemed to spread from member to member of 
families. In six severe typical cases the march of the temperature corresponded in a marked 
manner with the typical typhoid fever temperature of Wunderlich. 
The heaviest mortality of 1874 occurred in the months of July (700) and August (708). In 
September the mortality fell to 440, and rose again to 626 in October. The unusual mortality of 
July and August was due, in part at least, to the elevated temperature, or so-called heated term, 
which prevailed in all sections of the United States, affecting the north, west and south in succes- 
sion. Two cases of sunstroke were recorded in July and 23 in August; total for the year, 25. 
Congestion of the brain caused 214 deaths; 76, or almost one-third, occurred in the month of 
August. Congestive fever caused 254 deaths, one-third of which, or more exactly 81, occurred in 
*" Annual Report of Board of Health, 1874,'' p. 25. 
f Ibid, p. 24, p. 61. 412 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
the month of August. Therefore, 180 deaths out of a total of 708 in the month of August, were 
caused by sunstroke, congestion of the brain, and congestive fever. 
The heaviest mortality of 1874 appears to have occurred during the week ending Sunday, 
August 16th, and amounted to 296, when in ordinary years, free from epidemic diseases, the mor- 
tality would have been not more than between 120 and 140. This frightful mortality resulted 
chiefly from the excessive heat, and to this cause alone may be attributed, during this short space 
of time, between 156 and 176 deaths. The deaths during the week ending August 16th, according 
to ages, were : under 1 year, 33 ; 1 to 2 years, 17 ; 2 to 5 years, 19 ; 5 to 10 years, 9 ; 10 to 15 years, 
2 ; 15 to 20 years, 9 ; 20 to 25 years, 18 ; 25 to 30 years, 19 ; 30 to 40 years, 58 ; 40 to 50 years, 34 ; 
50 to 60 years, 40 ; 60 to 70 years, 19 ; 70 to 80 years, 10 ; 80 to 90 years, 1 ; 90 to 100 years, 0 ; 
unknown, 8. 
YELLOW FEVER, 1875. 
Total deaths in New Orleans, 1875, from all causes, less still-born, 6117, including still-born 
(418), 6535. 
Yellow fever caused 61 deaths, distributed as follows : August, 5 ; September, 24; October, 20; 
November, 9 ; December, 3. The different forms of fever caused the following deaths: Continued, 
2; congestive, 187 ; gastric, 3; intermittent, 30; malarial, 116; nervous, 4; puerperal, 19; remit- 
tent, 36; scarlet, 144; typhoid, 57; typho-malarial, 14; typhus, 2; yellow, 61; total deaths by 
fevers, 685; consumption, 799 ; inflammation of lungs, 261; pneumonia, 30; cholera sporadica, 
4; infantum, 100; morbus, 12; diarrhoea, 167; dysentery, 126; inflammation of bowels, 104; 
total diseases of bowels, 513. 
Smallpox caused 342 deaths, as follows: January, cases 93, deaths 38; February, cases 152, 
deaths 55; March, cases 240, deaths 98; April, 132 cases, 44 deaths; May, cases 90, deaths 30; 
June, cases 83, deaths 31; July, cases 56, deaths 21; August, caàes 39, deaths 16; September, 
cases 7, deaths 4; October, cases 7, deaths 4; November, cases 19, deaths 6; December, cases 17, 
deaths 5; total cases, 935; males, 496; females, 429; not stated, 10; white, 415; colored, 477; 
not stated, 43; total deaths, 342; white, 131; colored, 201; not stated, 10. 
As in the preceding years, the highest mortality fell upon the colored race, and this decreased 
during the progress of the year, with the elevation of the temperature. The decrease was clearly 
referable to climatic causes and not to any measures of disinfection. 
Scarlet fever caused, during 1875, a larger mortality than in the nine preceding years; thus, 
deaths from scarlet fever, 1867, 24; 1868, 14; 1869, 13; 1870, 44; 1871, 5; 1872, 3; 1873, 8; 
1874, 4; 1875, 144. In 1875 the monthly deaths from scarlet fever were as follows: January, 1; 
February, 1; March, 2; April, 2; May, 2; June, 8; July, 20; August, 21; September, 28; 
October, 18; November, 20; December 21 ; total, 144. 
The death rate from malarial fevers and the general death rate was lower in 1875 than in 
1874. In the latter year, 1874, the total death rate per 1000 was 32.73; whites, 28.06; colored, 
45.53; while in 1875 the death rate was : colored, 39.69 ; white, 25.45 ; and death rate for whole 
population, 29.13. The death rate is based upon an estimate of 210,000 inhabitants, 155,000 
whites and 55,000 colored. 
In 1875 yellow fever appeared in Louisiana at three points ; in the city of New Orleans, at Cous- 
hatta, on Red river, and at Port Eads. The total number of cases recorded in New Orleans during 
the year was 100, of which two came from Pascagoula and three from Port Eads. Key West, 
Barancas and Parvill's Point, Florida and Scranton, Pascagoula and Moss Point, Mississippi, suf- 
fered with yellow fever. 
The total recorded cases in New Orleans in 1875, excluding those from Pascagoula, Port Eads, 
was 95. The mortality was heavy, reaching 61 per cent., being a total of 61 deaths. 
The disease first appeared in the Second District, and was almost entirely confined to a locality 
four blocks by five. This was the principal focus of infection of the summer. In this locality the 
first case occurred August 8th, and the last one November 28th, the total number of undoubted 
cases being 41. " Disinfection of streets was thoroughly effected, but that of yards and habita- 
tions, owing to very great opposition, was so far interfered with as to render the immediate arrest 
of the fever impossible, even granting that the process of disinfection is able to promptly and 
entirely destroy yellow fever poison." 
The following is the monthly record of cases and deaths from yellow fever in 1875 : August, 413 
SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
cases 10, deaths 8 ; September, cases 59, deaths 28 ; October, cases 20, deaths 15 ; November, cases 8, 
deaths 8 ; December, cases 3, deaths 2. 
In the Charity Hospital 16 cases were treated, with 11 deaths. Total admissions to Charity Hos- 
pital, 4845, deaths, 753. Of the admissions 2634 were foreigners anil 2198 natives of the United 
States, including 816 natives of Louisiana. The cases and deaths from fevers were as follows: 
Malarial, 731 cases, 67 deaths; intermittent, 695 cases, 5 deaths; remittent, 84 cases, 1 death; 
typho-malarial, 11 cases, 5 deaths; typhus, 4 eases, 1 death; congestive, 4 cases, 2 deaths; bilious 
remittent, 4 cases ; scarlet, 1 case ; catarrhal, 1 case ; pernicious, 7 cases, 7 deaths ; bilious, 2 cases, 
2 deaths; yellow, 16 cases, 11 deaths; diarrhoea, cases 282, deaths 75; dysentery, cases 158, 
deaths 38; phthisis pulmonalis, cases 263, deaths 151; pneumonia, cases 113, deaths 37. 
From the reports of Dr. S. S. Herrick, Sanitary Inspector, First District, we gather that 21 
cases properly belong to the First District for 1875, though six more were treated at the Charity 
Hospital and the Touro Infirmary. Only two foci of infection seem to have been established. These 
were in the neighborhood of the saw mill on the New Canal, between Galaxy and Miro streets, and 
at the head of the New Basin. The source of infection' for neither locality could be traced. The 
earliest cases at the first spot died before they were recognized as yellow fever, and of the whole 
family not one was left to throw any light on the origin of their sickness. Two other cases 
sickened while this locality was undergoing disinfection for the first four. " After their termina- 
tion, disinfection was repeated, and no more cases followed." 
At the head of the basin four cases occurred during a period of time much more extended than 
at the other place. The first sickened between August 28th and 29th, and disinfection followed 
September 2d. The second sickened September 5th, followed by disinfection on the 9th and 10th. 
The other cases sickened on September 22d and 27th, respectively. 
In the Second District the deaths from yellow fever in 1875 were as follows : August, 4; Sep- 
tember, 7; October, 13; November, 4; December, 1; total, 29; 6 cases in August; 22 cases occur- 
ring during September; 14 in October; 4 in November, 1 in December; total, 47 cases. 
In the Third District, 8 cases of yellow fever occurred : August, 1; September, 2; October, 5. 
During the yellow fever of 1875, the same liberal and lavish use of carbolic acid was made 
both within and without the houses, and each case, as it occurred, was circumscribed by a large 
area, saturated with a solution of carbolic acid, upon the theory that the germ of yellow fever 
traveled slowly along the ground. All the alleys, yards and empty lots of every square upon 
which a case of yellow fever was reported were sprinkled with crude carbolic acid by means of 
hand pots and sprinkling carts. About 70 gallons of crude carbolic acid were used per square. 
In a similar manner the cross streets were treated with carbolic acid at a rate of about 15 gallons 
per 100 yards length of street. We have no accurate estimate of the amount of carbolic acid thus 
used, but thousands and tens of thousands of gallons were used in 1870, 1871, 1872, 1873, 1874 
and 1875. 
YELLOW FEVER, 1876. 
The total deaths from all causes in New Orleans during 1876, exclusive of still-born, was 6257 ; 
inclusive of still-born, 6685. 
The monthly deaths were as follows: January, 436; February, 460; March, 559; April, 447 ; 
May, 601; June, 653; July, 536; August, 469; September, 503; October, 477; November, 524; 
December, 592. 
Total deaths from fevers, 1876; bilious, 7; catarrhal, 30; congestive, 129; gastric, 11; inter- 
mittent, 33; malarial, 144; nervous, 1; pernicious, 33; puerperal, 18 ; remittent, 49; scarlet, 
123 ; typhoid, 53 ; typho-malarial, 14 ; typhus, 2 ; yellow, 42. Total deaths by fevers, 689. 
Smallpox, 586 cases, 232 deaths. The cases of smallpox occurred as follows : January, 39 ; 
February, 69; March, 44; April, 63; May, 31; June, 22; July, 22; August, 8; September, 8; 
October, 31; November, 82; December, 187. Total, 586. It will be observed that, as in preced- 
ing years, the smallpox was most destructive and prevailed to the greatest extent during the cold 
months and decreased to a great extent during the heat of summer, thus manifesting a directly 
opposite relation to yellow fever. Apparently a certain degree of cold concentrates and intensifies 
the smallpox poison, while a certain degree of heat dissipates and destroys it. The yellow fever 
poison, on the other hand, is developed and spreads only at elevated and tropical temperatures, 
and is arrested by cold. These facts indicate that both diseases are caused by organic poisons of 
definite chemical constitutions and relations. 414 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Deaths in 1876 from diseases of the bowels: Diarrhoea, 153; dysentery, 132; cholera, 9; 
cholera infantum, 73; cholera-morbus, 13 ; inflammation of bowels, 71. Total deaths from bowel 
affections, 451. * 
Total deaths from consumption, 871. 
Yellow fever prevailed to a limited extent, and was confined chiefly to the Fourth District. 
Total cases of yellow fever in the entire city, 96; total deaths from yellow fever, 42. 
Total admissions to Charity Hospital 1876, 5690; total deaths, 742. Of the admissions 2091 
were foreigners, 2684 natives of the United States, and of these latter, 1015 were natives of Louisi- 
ana. The following is the record of the cases of deaths from the various forms of fever in the 
Charity Hospital during 1876. Fever, intermittent, cases 136; malarial, cases 1161, deaths 92; 
bilious, case 1 ; bilious remittent, 100 cases, 2 deaths; remittent, 11 cases, 5 deaths; malarial, 
chronic, 3 cases; typho-malarial, 5 cases, 2 deaths; dengue, 2 cases; bilious, 17 cases; continued, 
2 cases, 1 death; typhoid, 9 cases, 4 deaths; pernicious, 11 cases, 8 deaths; catarrhal, 1 case; 
congestion, 3 cases, 3 deaths ; puerperal, 4 cases, 4 deaths ; yellow, 3 cases, 2 deaths ; enteric, 1 
case, 1 death ; rheumatic, 1 case ; rubeola, 124 cases ; malarial hæmaturia, 2 cases. Phthisis pul- 
raonalis, cases 307, deaths 128 ; pneumonia, 120 cases, 49 deaths; diarrhoea, 354 cases, 60 deaths; 
dysentery, 160 cases, 31 deaths. 
In 1876, the first case of yellow fever officially reported to Dr. J. B. Gaudet, President of the 
Board of Health, occurred on the 11th of August, on Tchoupitoulas street, between First and Sec- 
ond streets, and died with black vomit August 17th, at 24 Eighth street. Anna Maria Valender, 
aged nineteen; native of Germany; in New Orleans eighteen months. When taken ill was resid- 
ing as a servant in the family of Ambrose Leitz, on Tchoupitoulas street, lake side, between First 
and Second streets; removed second day of illness to 24 Eighth street; died Thursday 17th, at five 
o'clock p. m. The attending physician, Dr. Joseph Schmittle, and the consulting physicians, Drs. 
F. Loeber, S. S. Wood, F. B. Gaudet, Charles Faget, Sr., A. C. Gaudet, and Joseph Holt, pro- 
nounced it a genuine case of yellow fever. 
On Wednesday evening, the 16th, all the premises in the square bounded by Tchoupitoulas, 
Fulton, First and Second streets were thoroughly sprinkled with refined carbolic acid, Calvert's 
No. 5, in solution, one part of acid to fifty of water. The banquettes were sprinkled with the same. 
The boundary streets, particularly the gutters, were sprinkled with the crude carbolic acid, one 
barrel being used. On the evening of the 18th, immediately after the funeral, the rooms and 
premises of No. 24 Eighth street were sprinkled with the pure acid solution. This method of dis- 
infection was extended to all the premises in the square bounded by Tchoupitoulas, Fulton, Eighth 
and Ninth streets, and also on the square bounded by Tchoupitoulas, Fulton, Seventh and Eighth 
streets. The banquettes were sprinkled with the pure acid solution, and a line of crude carbolic 
acid extended through the boundary streets. Two barrels of the crude acid were used. The fol- 
lowing day Dr. Le Monnier visited the house 24 Eighth street, and thoroughly disinfected the 
bedding, clothes and furniture of the deceased. 
Careful and repeated investigation by the President of the Board of Health, Dr. Gaudet, by 
Dr. Le Monnier, Secretary of the Board of Health, by Dr. Joseph Holt, Sanitary Inspector of the 
Fourth District, and by the sanitary officers, failed to discover the slightest clue to foreign infec- 
tion from any ship, person or material. 
Case ii.-Male, aged nineteen years; native of France, resident of New Orleans eighteen 
months ; attacked 1st of September, on Annunciation street, between Louisiana avenue and Dela- 
chaise street; died with black vomit September 6th. 
Case hi.-F. E., age seven years; native of Tennessee, in New Orleans three years; residence 
125J Philip street, lower side, between Annunciation and Laurel streets. Taken sick September 
1st. Delirium, jaundice and black vomit on the fourth day; child recovered. Case not reported 
until the subsequent prevalence of yellow fever confirmed the diagnosis of the attendant physician, 
Dr. Mitchell. Cases occurred in the same house: on September 7th (Mr. J. C. E., aged thirty; 
native of Germany; in New Orleans three years; recovered). Mr. E., twenty-nine years; native 
of Virginia; in New Orleans three years; September 7th; recovered. G. E., aged six years; native 
of Tennessee; in New Orleans three years; September 11th; recovered. J. C. Ep, age four years; 
native of Tennessee; in New Orleans three years; September 13th; recovered. 
Case iv.-K. S., age thirteen ; native of Honduras; in New Orleans twelvemonths; Philip 
and Annunciation streets ; taken sick September 5th ; black vomit 8th ; died 10th. Disinfection SECTION XV PUBLIC AND INTERNATIONAL HYGIENE. 
415 
of premises was attempted the following morning, but was prevented by the illness of two of the 
family. These recovered without manifesting symptoms sufficient to confirm a diagnosis. Within 
one square radius of this house thirty-three of the recorded cases took the disease. Fifteen of 
these were fatal. 
Case v.-A. B. F., age three years ; native of New Orleans ; taken sick September 5th at 120 
Jackson street, between Annunciation and Laurel streets; died September 10th, with jaundice and 
black vomit. Case not reported to Board of Health until September 28th. 
Case vi.-Mrs. D., age twenty-three ; native of Michigan ; in New Orleans four months. Has 
resided in Third District until three weeks prior to illness, when she removed to 104 Jackson street, 
between Chippewa and Annunciation. Taken ill September 5th, Dr. Thomas Layton attending. 
" Her case presented all the prominent features of yellow fever, such as a fever of one paroxysm, 
and of seventy hours' duration ; general redness of the skin, with appearance of œdematous thick- 
ening, as the rash of scarlatina; a maintained temperature of 103° to 104°; great dullness of the 
sensorium and delirium. This stage was terminated by a sudden fall of temperature, prostration, 
slow pulse. Capillary stasis, yellow, but not cyanotic hue of skin, eyes yellow, albumen in urine, 
and on the fifth day copious black vomit frequently ejected. Being eight months pregnant, she 
was delivered of a still-born child on the ninth day of her illness. Recovered. She came near 
flooding to death sixty hours after delivery." 
Case vii. , age sixteen, male; native of New Orleans; corner Orange and St. Thomas 
streets; taken sick September 7th ; died September 12th. 
Case viii.-Mr. J. C. E., aged thirty; native of Germany; in New Orleans three years; 125J 
Philip street ; taken sick September 7th; recovered. 
Case ix.-Mrs. E., age twenty-nine; native of Virginia; 125| Philip street; September 7th; 
recovered. 
CAse x.-C., age twenty-eight, male; native of England; in New Orleans three years; 173 
Rousseau street, between Soraparu and First streets ; taken sick September 8 th; black vomit and 
death September 11th. Policeman. Premises disinfected. 
Case xi.-M. M., female, native of Ireland; in New Orleans three years; 20 Josephine street, 
between Tchoupitoulas and Rousseau; Sept. 8th; case reported Sept. 11th; recovered. 
Case Xu.-A. R., colored, female, age twelve; native of Arkansas; in New Orleans seven 
years; residence 45 Polymnia street; servant in family of Mr. E. (Case 8), 125J Philip street; 
taken sick Sept. 8th ; recovered. 
Case xiii.-C. H., female, age ten; native of Massachusetts; in New Orleans nine years; 122 
Philip street, corner Annunciation ; Sept. 9th ; case reported Sept. 21st ; recovered. Fifteen days 
previous to illness the family had returned from a tour through the Northern States. 
Case xiv.-G. E., age six; native of Tennessee; in New Orleans three years; 125| Philip 
street; taken ill Sept. 11th; recovered. 
Case xv.-M. J., age eight; native of New Orleans; in New Orleans four months after 
residing in St. Louis four years; died Sept. 18th; disinfection after funeral; residence 135 Jack- 
son street, between Annunciation and Laurel. 
Case xvi.-S. W., colored, female, age fifty; native of Virginia; in New Orleans five years; 
sick nurse in family of Mr. E. (125J Philip street, Case 8) ; residence 72 Union street; Sept. 12th; 
on the third and fourth days vomited blood ; recovered. 
Case xvii.-J. G. W., male, age thirty-three; native of Glasgow; in New Orleans, three 
years; 166 Jackson street; taken sick Sept. 12th; died Sept. 18th; disinfection Sept. 19th. 
Case xviii.-J. C. E., age four years ; native of Tennessee ; in New Orleans three years ; 125| 
Philip street; Sept. 13th; recovered. 
Case xix.-Sister E., age thirty-eight; native of Germany; in New Orleans three months; 
St. Joseph's Asylum, Josephine street, corner Laurel; resided in Asylum as cloistered nun; taken 
sick Sept. 13th ; black vomit on third day; reported 18th ; died Sept. 24th. 
Case xx.-Mrs. J. E.W., age thirty-six ; native of Pennsylvania ; in New Orleans five years; 473 
Annunciation street, between Philip and First streets ; taken sick Sept. 14th ; died Sept. 21st; black 
vomit, suppression of urine. At this time the sanitary force of the Fourth District, under the 
direction of Dr. Holt, was engaged in the general disinfection of the infected district. 
Case xxi.-F., age 18 years ; native of Ireland; in New Orleans three years; 58 Orange street; 
Sept. 14th; recovered. 416 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Case xxii.-S. E., one year ; native of New Orleans ; 125J Philip street ; Sept. 15th ; recovered. 
Case xxiii.-Sister Francis, age twenty-one; native of Michigan; came to New Orleans Octo- 
ber, 1874; has resided as a cloistered nun at St. Joseph's Asylum; taken sick Sept. 15th; 
reported Sept. 18th; recovered. (Josephine and Laurel streets.) 
Case xxiv.-Sister Alfreda, age thirty; native of Prussia; came to New Orleans 1870; has 
resided since as a cloistered nun in St. Joseph's Asylum, Josephine and Laurel streets; taken sick 
Sept. 16th; reported Sept. 18th; recovered. 
Case xxv.-M. W., female, age seven; native of New Orleans; 191 Josephine street; Sept. 
16th ; recovered. 
Case xxvi.-A. W., female, age four; native of St. Louis; in New Orleans two months; 161 
Laurel street; Sept. 16th; albumen in urine, black vomit; recovered. 
Case xxvii.-Sister B., age twenty-five ; native of New York; in New Orleans ten months; 
St. Joseph's Asylum, Josephine and Laurel streets; suppression of urine; black vomit; taken 
sick Sept. 17th; died Sept. 21st. 
Dr. Thomas Layton, Physician of St. Joseph's Hospital, states that: "In the cases of the sis- 
ters the usual pains in the head, back and limbs were present. The fever was one of unbroken 
paroxysms, with a decided typhoid tendency in the cases which recovered. In these the patients 
continued having fever, as observed by the thermometer, for a great many days. This secondary 
fever was of a low grade, and at the time the pulse was at or about the normal standard. All 
have resembled each other strikingly in the general symptoms and appearance at the outset." 
The disinfection of St. Joseph's Asylum, corner of Laurel and Josephine streets, was com- 
menced by the sisters, directed by Dr. Layton, on Sunday, Sept. 17th. A solution of the pure 
carbolic acid was used. All bedding and clothing removed from the sick were wet with it; also 
the floors of rooms and halls, the sewers and privies. The ejecta of patients were carbolized and 
buried in the yard, to avoid the possibility of infecting the privies. On the 20th of the month all 
of the floors of the building, privies, drains and yards were thoroughly treated with the pure car- 
bolic acid solution, one part to forty, by the sanitary officers; this was repeated on the 25th. 
Living on the premises of this asylum are 210 whites; 25 of these are cloistered nunfe. Number 
of persons acclimated by having had yellow fever, six. No case of yellow fever occurred in this 
institution after the 17th, and this result was referred by the physician in charge, the Sanitary 
Inspector of the Fourth District and the Board of Health, to the thorough disinfection of this 
institution. 
Case xxviii.-Mrs. S., age thirty-five; native of England; in New Orleans three years; 418 
Prytania street, between Seventh and Eighth; Sept. 17th; died Sept. 23d. 
Case xxix.-J. R. M., sailor, ship "Belgravia," age thirty-five; native of England; had been 
living on shipboard, but had visited the infected district; taken sick Sept. 17th; black vomit; 
died Sept. 20th. The ship " Belgravia " arrived, direct from Liverpool, August 20th, with cargo of 
bricks and salt; lay at the foot of Second street; ship thoroughly disinfected. 
Case xxx.-S. D., female, age eight; native of New Orleans; 71 Laurel street, between 
Josephine and St. Andrew; Sept. 17th; high fever; one paroxysm of eighty hours; temperature 
106°, pulse 136; albumen in urine; recovered; reported 23d. 
Case xxxi.-M. H., female, age seven years; native of New Orleans; 122 Philip street; 
died Sept. 22d. 
Case xxxii.-G. E. W., age thirty-six ; native of New York ; in New Orleans seven years ; 137 
Laurel street, Sept. 18th; died Sept. 21st. 
Case xxxiii.-Mrs. E. R., age twenty-five; native of Texas; in New Orleans some months; 
505 Annunciation street; Sept 18th; died 23d. An intense fever of eighty hours'duration. On 
third day of attack delivered of a seven months' foetus. 
Case xxxiv.-Mr. G. C. R., age twenty-two years; native of Ohio; in New Orleans two 
weeks; 505 Annunciation street, between First and Second. " Was taken sick September 19th, 
during the night; chill followed by fever of one paroxysm of forty-eight hours and very intense. 
This stage was characterized by those common symptoms, the exanthematous redness of the skin, 
bloodshot eyes, red tongue and gums, and great irritability of the stomach. On the third day 
the dangerous symptoms were greatly intensified by mental shock occasioned by startling bad news 
told him, and also by getting out of bed. He rapidly sank into an adynamic state, presenting 
the nervous depression and irritability of typhoid ; extreme yellowness of skin and eyes ; urine SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
417 
solidly albuminous on test, with casts; occasional black vomit; during the last two days incessant 
hiccough. Died at eight o'clock a.m., Oct. 4th, after an illness of fifteen days." 
Case xxxv.-A. D., age fourteen ; native of Arkansas; in New Orleans nine months; inmate 
Jewish Orphans' Home, Jackson street, between Rousseau and Chippeway; Sept. 21st; fever sixty 
hours ; during eighteen hours temperature 104|°; after bloodletting by cut cups fell to 102°, with 
decline of fever on third day; pulse became slow and feeble. This stage was followed by oppression 
over epigastrium, vomiting of clear blood ; urine albuminous ; catamenia returned ; recovered 
under care of Dr. F. Locker at the First Infirmary.* 
Case xxxvi.-G., female, aged twenty-four; native of Louisiana; in New Orleans ten years; 
130 Philip street, between Annunciation and Laurel streets ; September 22d ; recovered. 
Case xxxvii.-W. C., three years; native of Mississippi; in New Orleans two years; 502 
Annunciation street ; September 22d ; died 26th. 
Case xxxviii.-John Maxwell, aged thirty years; native of Alabama; in New Orleans four 
days; residence, 429 Annunciation street, between Jackson and Philip streets. Taken ill Sep- 
tember 23d; Dr. Ason the attending physician. The clinical signs were those of a severe case of 
yellow fever ; a period of malaria ending in rigors, superseded by a fever of many hours' dura- 
tion ; hiccough and cramp in stomach twelve hours before death. Post-mortem changes rapid. 
Died September 29th. It is evident that in the preceding case the period of incubation of the 
yellow fever poison could not have exceeded four days. We also observe the promptness with 
which a stranger was attacked when coming into the infected district, and yet, when strangers 
remained in the central portion of the city and did not visit the infected district, they escaped 
entirely. A refugee from Savannah, Mr. C. Ring, who came to New Orleans with the intention 
of opening a branch of his house in the cotton business, placed himself under my care and 
remained during September and October at the City Hotel, and, by my advice, avoided the Fourth 
District. He escaped. The cause of the fever, as shown by the brief record of the preceding thirty- 
eight cases, was circumscribed in its action and the spread was slow. It is unnecessary, as we 
have by the preceding observations established the local, indigenous origin of the disease, and its 
slow spread and marked localization, to further protract the examination of individual cases, and 
we proceed to record the results of the labors of the Board of Health to confine and destroy the 
disease by disinfection. 
Of the total number of cases occurring in the entire city of New Orleans during the summer 
and fall of 1876, namely, 92, more than two-thirds, or 74, occurred in the Fourth District. Of 
these 74 cases the first occurred in August; 53 in September, and 20 in October. Total number 
of cases in Fourth District, 74; whites, 71; colored, 3; natives of foreign countries and other 
States, 53; natives of New Orleans, 17; of Louisiana, 4; number of deaths, 35. Mortality in 
Fourth District nearly 50 per cent. 
We are indebted to Dr. Joseph Holt, the Sanitary Inspector of the Fourth District, for a record 
of the efforts of the Board of Health to control the disease by disinfection. The following facts 
are condensed from his report to the Board of Health.j- 
The first case in 1876 occurred August 11th, in Tchoupitoulas street, between First and Second 
streets. Removed to 24 Eighth street, between Tchoupitoulas and Fulton, where she died on the 
18th. Careful investigation failed to connect this case with any foreign importation. The second 
case was attacked September 3d, at 125 J Philip street. Besides the difference of twenty-three days 
in the appearance of these cases, there had been no communication, and between them were five 
squares, measured diagonally. These squares were compactly built, and many of the inhabitants 
were ascertained to be wholly unacclimated. It is not likely, therefore, that the disease could 
have spread from the first to the second case without influencing others on its way. It is more 
reasonable to believe that the causes of infection in the first case operated independently to pro- 
duce it in the second. 
In the immediate neighborhood of 125J Philip street, corner of Annunciation, the disease 
*" Cases of Yellow Fever in New Orleans in 1876, reported to the Board of Health by Joseph Holt, 
Sanitary Inspector of Fourth District, New Orleans." 
f " Cases of Yellow Fever in New Orleans in 1876." New Orleans Medical and Surgical Journal, Novem- 
ber, 1876, pp. 337-368. "Analysis of the Record of Yellow Fever in New Orleans in 1876." New Orleans 
Medical and Surgical Journal, January, 1877, N. S., Vol. IV, No. 4, pp. 480-495. 
Vol. IV-27 418 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
spread with some degree of activity; thus, from September 3d to September 7th inclusive, five 
cases occurred, and all within a radius of two hundred feet. Many of the cases occurring about 
this time were suspected, but recovering, were not pronounced yellow fever, because of their lack- 
ing some of the unquestionable diagnostic features found only in cases usually fatal. It was not 
until the 13th of September that the Board of Health had alarming evidence of the epidemic 
tendency of the disease, as shown in its advance toward the heart of the city. By this time it had 
passed Constance street and appeared in St. Joseph's Asylum. The invasion was west and north- 
west, directly in the face of a strong and constantly prevailing northwest wind. Within a period 
of eighteen days from the 3d of September it had spread over an area of thirty-nine squares, 
densely inhabited. This area was bounded by Magazine street and the river front, St. Andrew 
and Second streets. Of the 74 cases recorded, 60 were within these limits. Those who were 
stricken elsewhere in the Fourth District had been much exposed within this area. This rule 
prevailed, with three exceptions only, to the end of the season. This is true, also, to a great 
extent, with reference to the 18 cases which occurred in other districts of the city; the majority 
could be traced to the infected district. 
From the time of its appearance, on the 3d of September, to the last case on the record, Octo- 
ber 13th, the visitation continued forty days. It reached its height in twenty days, continued 
without spreading fifteen days and declined in five days. 
EFFORTS OF THE BOARD OF HEALTH TO CONTROL THE YELLOW FEVER OF 1876, IN NEW ORLEANS, 
BY THE LIMITATION AND ACTUAL DESTRUCTION OF ITS CAUSE-DISINFECTION. 
In the first case, as we have seen, the disinfection with carbolic acid was pushed vigorously and 
made complete, and this case remained isolated, no others occurring in the infected or adjoining 
squares. 
The Cases n, m, iv, v and vi, in the second focus of inspection, appearing eighteen and twenty 
days later, were not disinfected. These became the recognized centre of the epidemic, and from 
this centre the disease spread, and in eighteen days had invaded 39 squares, besides scattering 
cases beyond these limits. 
A general disinfection was commenced on the night of September 22d. Until this time, all 
efforts had been limited to the disinfection of the houses and premises of those who died. On the 
night of the 22d a quadruple cordon of the pure acid solution, one part to forty of water, was 
thrown around the infected area, by a thorough sprinkling of the boundary streets and banquettes, 
a line for each side of the street, and in the same way for the next inner line of boundary streets. 
The object of this was to put a stop to the march of the pestilence by forming around the infected 
locality a barrier. To accomplish this required 235 gallons of the pure acid. On the night of the 
23d the sixteen streets of the infected area were similarly disinfected. From this date the daily 
occupation of the sanitary force consisted in disinfecting the premises of the squares within this 
area. To complete five squares was a day's work. Whenever a case occurred outside of these 
limits, the premises of the square and of the one opposite, together with the boundary streets, were 
disinfected. Every precaution was taken to avoid bringing the acid in such proximity to the 
patients as might do harm. For this reason the premises of the sick and those adjoining, one on 
each side, were not touched. A special cordon of the pure solution was made around these. On 
the night of the 28th, beginning at ten o'clock, the sprinkling carts were filled with the crude 
carbolic acid, undiluted. They were then driven through a double line of boundary streets of the 
infected area, in the manner already described for the night of the 22d. The following night a 
single line of the same was extended through the sixteen intersecting streets. This was done as a 
precautionary measure, inasmuch as a prevailing strong wind, together with a burning heat of 
sun, had been acting to dissipate the volatile combination of cresylic and carbolic acids, here spoken 
of as pure acid, distributed on the nights of the 22d and 23d. The crude acid was used in order 
to retain these more volatile constituents, by reason of their combination with tar and the heavier 
tar products. These are, no doubt, of themselves, powerful disinfectants. For the work of these 
two nights twenty barrels of crude acid were used. Great stress was laid upon the assumed limit- 
ing power of the disinfectants. The area infected was so immense as not to permit of an actual 
and complete disinfection of its entire surface with any amount less than an unlimited supply of 
the acid. To disinfect all houses and premises was utterly impossible. The most that could be 
hoped for in this direction was to apply the agent, although, at best, in an imperfect and unsatis- 
factory manner, to as many premises as we were able. SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
419 
The main effort of Dr. Joseph Holt, Sanitary Inspector of the Fourth District, was expended 
upon hedging in the pestilence by carbolizing the streets and gutters-"just as would be done, in 
its own proper way, in the case of a great fire." 
Except where some one had died, not a private house, and only two-thirds of the premises, 
were disinfected-many not touched, except the privies. It was clearly proved, therefore, that, 
even after our best efforts, cases would continue to occur in this locality. From the beginning it 
was the established rule to pay particular attention to the carbolizing of privies. Even in cases 
where admittance to premises was otherwise refused, this much was insisted on; second to this, 
the carbolizing of street gutters. 
RELATION OF DISINFECTION TO THE SPREAD, THE FORMATION AND FINAL CHECK OF THE YELLOW 
FEVER IN NEW ORLEANS, IN 1876. 
There were seventy-four recorded cases. During the twenty days from Sept. 3d to the night 
of the general disinfection, Sept. 23d, there occurred 35 cases. During the twenty days following, 
to October 13th, the date of the last case, there occurred 38 cases. Seventeen of the 38 fell sick 
during the first five days, leaving 21 cases for the remaining fifteen days. Of the 38 cases, 11 
occurred outside of the infected districts. Eight of these had been nursing the sick or visiting 
socially in the infected area. The remaining three had no such history, but had evidently con- 
tracted the disease outside of this locality. They occurred in persons who had been in close prox- 
imity to the sick, about the intersection of Eighth and Constance streets, who had been infected 
in the diseased locality. This appearance gave reason to fear the development of a new centre 
of infection. This new area comprised the sixteen squares bounded by Magazine and Chippewa, 
Washington and Ninth streets. 
From September 29th to October 5th, the disinfection of this quarter was accomplished. 
With reference to the occurrence of the disease in public institutions and on ships, Dr. Joseph 
Holt records the following important facts :- 
On the 13th of September a case occurred in St. Joseph's Asylum, corner of Laurel and Jose- 
phine streets. On the 15th another; one on the 16th, and one on the 17th. Two of these were 
fatal. On the 17th the building and premises were disinfected with the pure acid solution. The 
same was applied to all bedding and clothing removed from the patients. This was accomplished 
by the sisters, guided by Dr. Layton. Again, on the 20th, by the sanitary force, the yard, sewers 
and privies were thoroughly treated with the pure acid, one part to fifty of water. This was 
repeated on the 25th. (Other public institutions, to be mentioned, were disinfected in the same 
way.) No case after the 17th. 
Living on the premises were 210 white persons, of whom 25 were cloistered nuns. Of the 
entire number, six were already acclimated, by having had yellow fever. 
In the Jewish Orphans' Home, corner Jackson and Chippewa streets, a case occurred Septem- 
ber 21st, one on the 25th, and one on the 27th. Two of these were fatal. The interior of this 
building was repeatedly disinfected by the inmates, directed by Dr. Locker, in the manner just 
mentioned. The premises, including yards, drains and privies, were disinfected by the sanitary 
force, September 26th. No other case occurred. Residing on the premises were 110 white persons, 
of whom six had previously had yellow fever. 
In the Convent of the Sisters of Mercy, on St. Andrew street, between Constance and Maga- 
zine, a ease occurred September 29th. It terminated fatally. This institution was disinfected 
October 2d. Living on the premises were 43 Sisters of Mercy, 19 employés and 70 orphans-122 
persons-all white. Ten of them had already had yellow fever. In the immediate neighborhood 
of these institutions the private residences invaded, but never disinfected, seemed to fare differ- 
ently. The disease, in many instances, attacked in succession every member of the family liable 
-frequently three, four, and as many as eight. 
The sailing ship "Belgravia" arrived direct from Liverpool August 29th. She landed about 
the foot of Second street, where she remained to the present time. The crew were allowed to go 
on shore at will. One of the sailors was taken ill aboard ship September 17th. On the 20th he 
was conveyed to the Touro Infirmary, where he died the same day. On the 20th the ship was 
thoroughly disinfected with carbolic acid and chlorinated lime. The bedding and clothes of the 
deceased were tied in a bundle, weighted with stones, and sunk in the river. The ship was 
thoroughly washed throughout. After this she was repeatedly carbolized and cleansed. During 
the ten days following the death of this case the crew remained closely about the vessel. After 420 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
this time some of them became reckless, and frequented the places in the infected area, where 
this man caught the disease. Two of the crew fell ill of the disease on the morning of October 
8th, and died at the Touro Infirmary, one on the 12th and one on the 14th inst. The command- 
ing officer predicted the illness of these men, in a conversation with Dr. Joseph Holt, a few days 
before they were taken, because of their foolhardiness. Living on board, officers and crew, twenty 
men, none of whom had ever been exposed to yellow fever. 
Just astern the " Belgravia " lay the sailing ship "Evangeline." Officers and crew unaccli- 
mated. The captain's wife spent a Sabbath evening with a friend living in the infected centre, 
October 11th. She was taken ill the following evening and died, having thrown up black vomit 
freely, October 16th. The same method of disinfection was pursued as with the " Belgravia." No 
other case occurred. 
Dr. Joseph Holt presents the following- 
RÉSUMÉ. 
Total number of cases: White, 71; colored, 3 (74) ; natives of New Orleans, 17; of Louisiana, 
4; of other States and countries, 53; deaths, 35; total amount of disinfectants used: Pure car- 
bolic acid, Calvert's No. 5, 19 barrels, ranging from 45 to 50 gallons each = about 912 gallons. 
Total crude carbolic acid compound, 40 barrels, containing 45 gallons each = 1600 gallons. Total 
areas disinfected, streets and premises of 64 squares. Total areas disinfected a second time, 
streets and premises of 24 squares. The following is the census of the 39 inhabited squares 
bounded by Magazine street and the river front, St. Andrew and Second streets, not includ- 
ing asylums. Number of premises, 1143; persons on premises, white, 5869; colored, 538; total 
population, 6407 ; born in New Orleans, 3713; in Louisiana, 211; arrived in New Orleans since 
1867, the date of the last great epidemic, 467 ; born in New Orleans since 1867, 1760; number 
who have already had yellow fever, white, 1163; colored, 34; total persons who had had yellow 
fever, 1196; number who never had yellow fever, 5211. 
Dr. Holt concludes, from his experience during the yellow fever of 1876, in New Orleans:- 
" That carbolic acid not only retards decomposition and modifies its products, but seems to 
destroy directly the yellow fever infection, and in order to accomplish this, it is not essential that 
all surfaces be subjected to the actual contact of the disinfectant. The destructive influence seems 
to extend beyond the limit of actual contact. 
"That when the suppression of the disease is to be accomplished by disinfectants, these are to 
be thoroughly applied from the first moment of alarm. There must be an absolute parallel 
between the management of this disease and the management of a fire. The Board of Health is 
the central office, each physician having at heart the welfare of his fellow citizens constitutes 
himself, as it were, an alarm box. The first occasion of alarm is made known to the board. . . As 
in the case of fire, the only hope of extinguishing a pestilence is in the very earliest knowledge of 
its existence."* 
YELLOW FEVER OF 1877. 
New Orleans escaped yellow fever in 1877, only one death having been reported from this 
disease, and this occurred in the month of November, in the case of a passenger from Havana, who 
passed through the quarantine. 
YELLOW FEVER OF 1878. 
Yellow fever appeared in the month of May, but did not commence its ravages until July. Its 
presence was not seriously suspected or fully recognized until the second week in July. 
The deaths from yellow fever in New Orleans in 1878 were as follows:- 
May 2 
June 0 
July 50 
August 974 
September1873 
October1044 
November 90 
December 3 
Total4056 
* " Analysis of the Record of Yellow Fever in New Orleans in 1876." New Orleans Med. <fc Surg. Journ., 
N. S. IV, No. 4, July, 1877, p. 494. SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
421 
Immediately upon the recognition of the disease, in the month of July, Dr. Samuel Choppin, 
President of the Board of Health of the State of Louisiana, who appears at that time to have 
been a strong believer in the efficacy of carbolic acid, caused all the localities where cases were 
reported to be thoroughly treated with carbolic acid. The gutters, yards, streets or lanes and 
vacant lots were literally deluged with carbolic acid. 
The disease was unchecked by the cordon of carbolic acid, and marched rapidly from district to 
district until every district of the town was invaded, and the infection was carried by steamboats 
and railroads far into the interior of the valley. 
The charmed spell of carbolic acid disinfection of gutters and streets was forever broken. 
In 1879, 49 cases of yellow fever with 19 deaths were reported in a limited area of the Fourth 
District. 
YELLOW FEVER OF 1880. 
In 1880,* one death occurred in the Touro Infirmary in the month of July, in the case of a 
sailor on the bark " Excelsior," which was sent back to quarantine, and the disease spread no 
further. 
A case reported as one of yellow fever occurred in October, in the person of a young man re- 
cently arrived from the country ; he was said, however, to be a native of this city. 
No case was reported in 1881, f and in 1882 J five cases were reported, which proved fatal, 
namely, one in June, one in July and two in August. 
Thorough inspection and cleansing and disinfection of the premises, isolation of the sick, and 
the prompt destruction by fire of infected clothing, beds and bedding, and the prompt burial of the 
dead were the measures employed successfully for the arrest of the yellow fever of 1882 by the 
President of the Board of Health. Not one gallon of carbolic acid was sprinkled in the streets or 
poured into the gutters ; but the privies, yards and houses were cleaned and disinfected. 
The death from yellow fever reported in 1883 § occurred late in the season, after the suspension 
of quarantine, the patient coming from Vera Cruz, among a body of Italian emigrants. 
From the preceding facts relating to the practice of disinfection in New Orleans, Louisiana, 
more especially with reference to carbolic acid disinfection against yellow fever, smallpox and 
cholera, the following conclusions may be drawn :- 
1. In all efforts to arrest the spread of yellow fever by disinfectants and sanitary measures in 
cities situated in temperate latitudes where yellow fever is not indigenous it must be noted :- 
(а) Epidemics of yellow fever vary greatly in their rate of increase, and in the rapidity of their 
spread, and the size of the area which they may invade. 
(б) Even in a large city containing a large unacclimated population, and possessing apparently 
all the topographical and climatic conditions favorable for the rapid spread of yellow fever, 
the disease, although introduced from foreign parts, may for a series of years show no 
disposition to spread. 
(c) The origin and spread of yellow fever is closely related to the temperature. 
These propositions will be clearly illustrated by the following important table, illustrating the 
natural history of yellow fever in its relations to climate and seasons in New Orleans, Louisiana :- 
* Report of Joseph Jones, m.d., President Board of Health, State of Louisiana, 1880. 
t Ibid., 1881. J Ibid., 1882. ? Ibid., 1883. 422 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
MONTHLY DEATHS BY YELLOW FEVER DURING A PERIOD OF THIRTY- 
TWO YEARS, 1847-1878.* 
Year. 
fl 
0 
s 
August. 
September. 
October. 
November. 
| December. 
Total Deaths by 
Yellow Fever. 
Date of First Case. 
1847 
74 
965 
1,100 
198 
33 
2,306 
July 6th. 
1848 
4 
33 
200 
467 
226 
20 
808 
June 21st. 
1849 
1 
17 
314 
416 
112 
9 
769 
July 28th. 
1850 
i 
4 
62 
33 
4 
... 
107 
One death Jan. ; two March ; one May. 
1851 
8 
6 
2 
1 
17 
1852 
2 
8 
91 
198 
105 
ii 
456 
• July. 
1853 
2 
31 
1521 
5,133 
982 
147 
28 
4 
7,849 
May 22d. 
1854 
2 
29 
532 
1,234 
490 
131 
7 
2,425 
First death June 12th. 
1855 
5 
382 
1,286 
874 
97 
19 
7 
2,670 
June 19th. 
1856 
14 
40 
16 
4 
7 
74 
June 28th. 
10 years.. 
3 
IF 
2,046 
8,225 
5,041 
1,794 
453 
55 
17,481 
1857 
1 
1 
1 
8 
98 
82 
8 
200 
One death reported in January. 
1858 
2 
132 
1,140 
2,204 
1,137 
224 
5 
4,845 
One death reported January 10th. 
1859 
1 
59 
28 
3 
91 
June. 
1860 
3 
7 
5 
15 
1861 
1862 
1 
1 
2 
1863 
2 
2 
About 100 cases in U. S. River Fleet. 
1864 
About 200 cases and 57 deaths, U. S. 
Gunboats and River Fleet. 
1865 
1 
1 
1866 
10 years.. 
-ÏT 
' 137 
5 
1,154 
56 
2,277 
89 
1,387 
31 
366 
4 
21 
192 
5,354 
One death August 10th. 
1867 
3 
11 
255 
1,637 
1,072 
103 
26 
3,107 
One case died June 10th. 
1868 
5 
5 
October 5th, died in Charity Hospital. 
1869 
1 
2 
3 
July 17th. 
1870 
i 
3 
231 
242 
ÎÔ6 
S 
588 
May 26th. 
1871 
2 
9 
22 
19 
2 
54 
July 30th. 
1872 
1 
5 
24 
7 
2 
39 
August 28th. 
1873 
3 
19 
208 
79 
17 
226 
July 9th. 
1874 
2 
6 
2 
8 
11 
August 19tb. 
1875 
5 
24 
20 
9 
3 
61 
August 8th. 
1876 
10 years.. 
- 
4 
15 
1 
286 
19 
2,135 
I' 
1,489 
4 
267 
£ 
40 
42 
4,136 
August 11th. 
1877 
November. 
1 
1 
1878 
2 
50 
974 
1,893 
1.044 
90 
3 
4.056 
May 25th. 
2 years.... 
2 • 
- 
50 
974 
'1,893 
1,044 
9f 
3 
4,057 
32 years.. 
5~ 
'I'T 
2,248 
10,639 
11,346 
5,714 
1,177 
T19~ 
31.028 
1879 
- 
- 
- 
19 
1880 
1 
1 
2 
1881 
0 
1882 
i 
1 
2 
4 
1883 
1 
1 
Total 
5 
50 
2,250 
10,641 
11,346 
5,715 
ÏJ78 
IÏ9* 
31,054 
* Reports of Joseph Jones, M.D., President of the Board of Health, State of Louisiana, 1880, 1881, 
1882, 1883. 
2. From the preceding table it is evident that, as a general rule, the great epidemics, as those 
of 1847, 1849, 1853, 1854, 1855, 1858, 1867 and 1878, commenced early in the hot months (May, 
June and July), and attained their maximum intensity in August and September. Thus, during 
the period of thirty-two years the deaths from yellow fever in New Orleans were as follows :- 
January, 6; February, 0; March, 2; April, 0; May, 5 ; June, 49; July, 2248; August, 
10,639; September, 11,346; October, 5714; November, 1177; December, 119. 
The curve of yellow fever, therefore, corresponds, to a certain extent, with the curve of tem- 
perature. Thus, from the records of thirty-eight years, which I have consolidated and calculated 
from the most reliable data, the mean temperature of New Orleans is as follows: January, 56.28; 
February, 58.03 ; March, 64.27 ; April, 69.41; May, 75.90; June, 81.35; July, 83.21; August, 
83.14; September, 79.64; October, 70.27; November, 62.80; December, 56.43; spring, 69.56; 
summer, 82.53; autumn, 70.75; winter, 56.91; year, 69.51. The origin and spread of yellow 
fever, therefore, depends absolutely upon an elevated temperature, ranging from 70° to 85° F., SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
423 
and its decline depends upon a mean temperature, ranging from 65° to 56° F. These figures, of 
course, relate to the mean or average monthly temperature, the extremes being much higher or 
lower, ranging during the year, in New Orleans, as shown by meteorological observations, extend- 
ing from 1817 to 1878, from 17° F. to 100° F. 
3. Carbolic acid disinfection, as practiced in New Orleans-by deluging the gutters and streets 
-has no value to arrest the spread of yellow fever, smallpox or Asiatic cholera. 
4. Yellow fever germs do not originate in the foul canals and filthy gutters of New Orleans, 
and cannot be prevented from germinating by pouring disinfectants into these foul receptacles. 
5. Yellow fever germs do not travel along the surface of the ground at a certain rate, and 
their march cannot be arrested or their infective power destroyed by the saturation of the soil by 
any known disinfectant. The truth of this proposition has been established, as far as carbolic 
acid is concerned, upon a grand scale in New Orleans, and especially by the results of the great 
yellow-fever epidemic of 1878. 
6. Yellow fever is not indigenous to New Orleans. 
7. Yellow fever is not indigenous to Louisiana. 
8. Yellow fever is not indigenous to the Mississippi valley. 
9. Yellow fever can be excluded from New Orleans and the Mississippi valley by a rigid and 
effective quarantine. 
10. Quarantine, to be effective, must include not merely inspection and detention for a reason- 
able period, but also discharge of infected cargo, ballast, clothing, baggage and bedding, thorough 
ventilation, fumigation, disinfection and cleansing. 
11. All ports in which yellow fever may be introduced should be kept under thorough and 
daily inspection, said inspection to extend to the shipping as well as to the dwellings and 
inhabitants. 
12. In the event of the appearance of yellow fever, the case or cases should be at once isolated 
and the surrounding houses, yards and streets thoroughly cleansed and disinfected. Fight the 
enemy immediately, on sight, vigorously, continuously, and with the best-known agents and 
appliances. 
After the reading of the address of the President and the appendix thereto, Dr. 
George Troup Maxwell remarked that the reading of these papers would alone, 
in the broad view which they unfolded of the science of public and international 
hygiene, and in the vast number of facts which they contained illustrating the history 
of naval hygiene, and of disinfectants and disinfection, amply repay him for his long 
and fatiguing journey from Ocala, Florida. 
Dr. W. L. Schenck, of Osage City, Kansas, after dealing with the importance 
of publishing the address and the appendix without alteration or abridgment, 
offered the following resolution:- 
Resolved, That the thanks of the Section be voted to the President for his able 
address. 
The French Secretary, Dr. Le Monnier, said that the author of these papers 
had devoted his life to the investigation of malarial and yellow fever in various 
Southern cities, but more especially in Savannah, Georgia, and New Orleans, 
Louisiana. 
Dr. Le Monnier further stated that the position of Secretary of the Board of 
Health of the State of Louisiana and Coroner of the Parish of Orleans, which 
he himself had filled, as well as his private practice, during the past twenty years 
(the period embraced in the history of disinfection, and especially of carbolic acid 424 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
disinfection, in New Orleans, here unfolded), enabled him to affirm positively that in 
no other paper or work could such accurate and extensive information be obtained. 
The following resolution was offered by Dr. R. Le Monnier, of New Orleans, 
seconded by J. B. Lindsley, of Nashville, Tenn., and adopted, viz.:- 
Whereas, The Address, with its Appendix, of our President, is replete with the 
most minute details of the history of that terrible scourge, Yellow Fever, a subject 
of the highest interest to the whole Mississippi Valley, and perforce to the people 
of the United States, be it therefore 
Resolved, That it is the unanimous wish of this Section that the Publishing 
Committee be requested to publish in full both the Address and Appendix. SECTION XV PUBLIC AND INTERNATIONAL HYGIENE. 
425 
SECOND DAY. 
REPORT OF AN INQUIRY INTO THE FACTS RELATING TO THE 
EFFECTS OF OVERFLOWS OF THE MISSISSIPPI RIVER AND 
ITS TRIBUTARIES, AND RICE CULTURE. UPON THE PUBLIC 
HEALTH, AND THE BEST MEANS OF CONTROLLING THEIR 
BALEFUL INFLUENCE. 
RAPPORT D'UNE ENQUÊTE SUR LES EFFETS DES DEBORDEMENTS DU MISSIS- 
SIPPI ET DE SES TRIBUTAIRES, ET DE LA CULTURE DU RIZ, RELATIVEMENT 
A LA SANTÉ PUBLIQUE, ET LES MEILLEURS MOYENS DE CONTRÔLER LEUR 
PERNICIEUSE INFLUENCE. 
BERICHT ÜBER EINE UNTERSUCHUNG DER THATSACHEN, WELCHE SICH AUF DIE WIR- 
KUNGEN DER ÜBERSCHWEMMUNGEN DES MISSISSIPPI UND SEINER NEBENFLÜSSE, UND 
DES REISSBAUES AUF DIE ÖFFENTLICHE GESUNDHEIT BEZIEHEN, UND DIE RESTEN 
MITTEL ZUR BEHERRSCHUNG IHRES VERDERBLICHEN EINFLUSSES. 
BY RICHARD H. DAY, M. D., 
Baton Rouge, La. 
Being appointed by the distinguished and worthy President of the Fifteenth Section 
of the Ninth International Medical Congress to investigate the effects of overflows 
(chiefly) of the Mississippi river, and rice culture, upon the public health, I beg to 
state that I have diligently labored to discharge the duties involved in this investigation. 
Realizing the high and paramount importance of the strictest exactitude in all med- 
ical researches, I endeavored to make my inquiries comprehensive and searching, that 
I might obtain such data and facts as would be reliable and prove of real value to the 
medical profession. To this end, in consultation with the President of the Fifteenth 
Section, and at his suggestion, I drew up the annexed series of questions to the medical 
profession, which were kindly published, first in the Journal of the American Medical 
Association, and subsequently in Gaillard's Medical Journal and in Daniel's Texas Med- 
ical Journal, for which courtesy and kindness I now tender publicly my sincere and 
hearty thanks. The more fully to reach the profession and enlist their earnest coopera- 
tion, and to obtain the results of their observations and rich experiences, I had five 
hundred copies of the questions printed in letter form, and mailed a copy to every 
physician of prominence in every Southern State whose address I could learn, and 
whose locality I had reason to believe embraced such local conditions as to give him 
the ability to answer the questions with precision and clearness. Besides this, I wrote 
many private letters, urging upon each to whom I wrote the high importance of his 
personal effort to give all the facts, within the range of his own personal knowledge, 
elucidating the questions propounded. 
I was not ignorant of the fact that, from the earliest history of medicine down to 
the present day, marshy and low-lying sections of lands subject to inundations, in the 
tropic, semi-tropic and even temperate zones, had always been regarded, both by the 
profession and the laity, as fruitful fields of bilious fevers, dysenteries and allied dis- 426 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
eases when these soils, as the waters subsided, were exposed to an elevated temperature 
and the scorching rays of the sun. But it was to get the facts gained by the observa- 
tions and experiences of Southern physicians, relating to overflows and rice culture, that 
this investigation was initiated, and to arrive at true conclusions in relation to the 
potential factors and conditions affecting or modifying these general results. This was 
deemed essential, since it was well known that every overflow of the Mississippi river 
and its tributaries was not succeeded by general sickness of the immediate inhab- 
itants, nor, to the same extent in every portion of the inundated districts, and that 
rice culture, was not always attended with the same injurious effects upon the health 
of the people in these sections. 
It is to be regretted, indeed, that our busy and intelligent Southern medical prac- 
titioners have been so remiss in keeping records of dates and facts touching these sub- 
jects, and that, in consequence, so few have been able to reply to the questions asked, 
corresponding to the standard of our present enlightened demands. It is not to be in- 
ferred from this, however, that this class of physicians are lacking in general intelligence, 
mental acumen, or interest in the advancement of their profession. So far from this, 
they will be found in consultation clear and independent thinkers, and ready and skill- 
ful practitioners of medicine; they simply have not aspired to authorship and notoriety, 
and have been content to utilize the fruits of their rich experiences for the benefit of their 
own immediate neighbors and patrons. I deem this expression of truth but a simple 
act of justice to the great body of physicians outside of our large cities and the great 
centres of medical thought, activity and scientific research. And to the more promi- 
nent of this class I have mainly addressed my inquiries. 
I have received replies from physicians of Louisiana, Mississippi, Alabama, North 
and South Carolina and Georgia. Three write that, not living in localities subject to 
overflow, nor where rice is cultivated, they have no experience in the matter, and 
hence no facts or data to give. 
All the physicians living in districts subject to overflow, without a single dissen- 
tient, affirm that there is an increase of sickness immediately succeeding overflows. 
That this sickness is malarial in character, intermittent, remittent, algid and pernicious 
in type, and is lessened or modified in character by local conditions ; such as a soil 
naturally or artificially well-drained ; the period of overflow, whether early or late in 
the season, and of short or long duration, and by the occurrence of copious showers of 
rain during the recession of the waters, thereby flushing the soil and washing the vege- 
table and animal matters off, deposited by the inundating waters. 
I quote as follows : Dr. I. P. Moore, an educated and skillful physician of Yazoo 
City, Miss., says: "I have kept the dates of those overflows which were unusual, 
1867, 1882, 1883, 1884-partial in 1874. In almost any year much of the low lands are 
covered with water. Health is very much influenced in overflows, or even in high 
water years, by the earliness or lateness of the season in which the waters recede within 
their banks. The later receding, the more sickness ; but even when late, should we have 
hard showers of rain to wash the banks and flush the ground occasionally as the water 
leaves, the health is greatly promoted. Sickness is at once checked by a copious rain." 
Dr. A. Maguire, of Jeaneratte, La., and long a resident of St. Mary Parish, a 
highly educated and able physician, writes : "In 1879, there was a severe storm in 
September. The water remained some forty-eight hours submerging vegetables. From 
the fields, fetid exhalations from decayed pea vines, etc., poisoned the atmosphere, and 
in the country on the Franklin road from P. L. to G. D's, many cases of pernicious 
hemorrhagic fever took place." 
Dr. C. J. Ducoté, of Avoyelles Parish, a very successful and educated physician, 
says, "I have generally observed an increase of sickness immediately succeeding these 
overflows-intermittent and remittent malarial fevers and malarial hæmaturia." SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
427 
Dr. C. D. Owens, of the same Parish, one of our most cultivated physicians, testi- 
fies: " I have invariably observed an increase of sickness succeeding every overflow of 
which I have had any knowledge, of all forms of recognized malarial fever, including 
dysentery; the diseases assuming adynamic or ataxic features well pronounced ; local 
dropsies, jaundice and hemorrhages being often the attendants or sequelae of many of 
these cases." 
Dr. L'Admirault of Point Coupe Parish, of long experience and one of our best 
educated physicians, states : " During the inundation, diarrhoeas and dysentery; after 
recession, malarial fevers of all types, pernicious, comatose (convulsive among children), 
some algid and choleraic in form." 
Dr. L. F. Donaldson, of Bonne Carre, La., a very intelligent and skillful practi- 
tioner of medicine, writes: "During the overflow not much change, if any, for the 
better; but as soon as the waters recede, then malarial complaints, dysentery and diar- 
rhoeas are very rife. Malarial fevers and dysentery almost epidemic and very fatal in 
character." And such is the testimony of all as to the effects of overflows upon the 
public health. 
EICE CULTURE. 
It is pretty clearly established by the experience of these careful observers, that the 
cultivation of rice is not, per se, and necessarily, so detrimental to health as is generally 
supposed, and is not conducive to the production of malarial hæmaturia; but that its 
obnoxiousness to health is the result of the improper and insanitary mode of its culti- 
vation. Dr. O. Huard, formerly of New Orleans, but for the last ten years a resident 
practitioner of St. John Parish, and, withal, a very intelligent and close medical obser- 
ver, writes: "Rice is, very extensively cultivated in this parish, and yet, with an 
extensive practice, I have only seen three cases of malarial hæmaturia in these ten 
years. And I attribute this to the fact that the lands slope from the river back, with 
good natural drainage, so that as soon as the water is let off the rice, the lands quickly 
dry; while in St. James Parish, about Grand Point, where no rice is cultivated, but 
largely tobacco, malarial hæmaturia rages furiously every summer. ' ' 
It is the general experience that malarial hæmaturia has increased in frequency, 
if not in severity, during the past forty years, but that said increase is not due to the 
increased cultivation of rice. Dr. C. J. Ducoté, already quoted, writes: "Malarial 
hæmaturia has increased in frequency, if not in severity, during the last forty years; 
that said increase is not due, at least in Avoyelles Parish, to the increased cultivation 
of rice, for there is a larger number of cases of that malady in the low lands where no 
rice is cultivated, than there is on the high lands where it is cultivated." 
Dr. I. B. Moore, of Yazoo City, Miss., says: "Hæmaturia (malarial), so far as I 
know, was unknown here till 1868, when it developed in quite a number of cases in 
the persons of those who had suffered frequent attacks of fever in 1867, continuing 
through the winter and spring of 1868, producing its usual morbid change, malarial 
cachexia, great poverty of blood, sallow skin, jaundiced conjunctivæ, enlarged spleen, 
urine loaded with bile, etc. This was the class of cases, with but few exceptions, 
attacked with malarial hæmaturia; and ever since, such has been the case. About as 
many cases in 1868 as any year since, showing but little or no increase since that 
date." 
The observations and experience of Dr. Jas. R. Sparkman, of South Carolina, cover 
so many points of the deepest interest and extend over such a long period of time, and 
are so admirably and forcibly expressed, that I am constrained to incorporate his report 
without abridgment. 428 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
DR. JAMES R. SPARKMAN'S REPORT AND REPLIES TO QUESTIONS SUBMITTED BY DR. 
RICHARD H. DAY, OF BATON ROUGE, LA. 
" 1. I have been familiar with the diseases of this section of the country since 1836. 
My professional observation covering an area of forty miles. 
"2. I have had frequent opportunities of noting the effects of freshets and the over- 
flows of our rivers upon the public health of this locality. 
' ' 3. An increase of sickness generally follows immediately after the subsidence of 
these overflows. 
" 4. Occurring as they do, at all seasons, we have noted during and after a winter or 
spring freshet an increase of catarrhal fever with bronchial and pneumonic trouble. 
Occurring in summer or autumn, congestive fever follows, sometimes of malignant type. 
The general rule is an increase of malarial fever, both remittent and intermittent; for- 
merly, the mortality was grave, but since the use and dosage of quinine has become 
better understood, malarial fevers are successfully treated and excite but little appre- 
hension. 
"5. No statistics now available; all my memoranda of endemics and epidemics from 
1836 to 1861 lost in the vital struggle through which we passed from 1861 to 1865. 
' ' 6. The effects of rice culture upon the public health can only be answered satisfac- 
torily by collection of facts (from memory) during my experience of half a century. 
You can make such a digest of this collection as will suit your purposes for publica- 
tion. 
" I shall have to consider topography in connection with different systems of culture. 
In this country there are upward of fifty thousand acres of wood and marsh lands 
subject to the influence of the sea tides, with a rise and fall of three to five feet, less as 
you advance up the rivers. Of these tide lands, the area of cultivation up to 1860 was 
about forty-six thousand acres. Rice the specialty, since its introduction as a crop in 
the last century; the preparation for cultivation involves an elaborate system of embank- 
ments with dikes, ditches and floodgates, all of which have to be kept up annually, for 
sufficient drainage to insure successful cropping; ordinary hoe work and ploughing with 
animals essential. These embankments are sufficient to resist the ordinary rise of the 
tides, but during storm or gale tides and freshets they are entirely submerged. The 
soil is entirely alluvial, and these overflows, during storm or gale lasting from two to 
four days, and during freshets from ten to thirty days, cause frettings or washes, or 
breaks, not infrequently involving partial or total loss of the crops, with an unsanitary 
condition afterward which bears directly upon the public health. 
" In ante-bellum days my professional experience covered some thirty odd rice estates, 
with a slave population of about four thousand and white several hundred. Most of 
the managers of these estates, with their families, resided the entire year directly on 
the plantations. The owner, or proprietor, spent the summer months in travel, or 
resorted to the seashore or adjacent islands, or select pine-land villages, a few miles 
distant from the rice fields. For many decades prior to 1840 Georgetown was regarded 
as one of the most sickly ports of the Atlantic sea coast. The most fatal fever was 
called ' ' cold fever, ' ' and was the dread of all strangers, especially the seafaring class 
who visited this port during the sickly season. No vital statistics were then kept, and 
the mortality cannot be reached; but this congestive type of fever was unmistakably 
pernicious and fatal. In a conversation with the quarantine physician at Staten 
Island, New York, he informed me that the fever of Georgetown had resisted their 
best efforts to control it, and that nearly every man put ashore there for treatment 
died promptly. I understand a better record is now reported there. 
" The system of rice culture prior to 1840 I conceive to have been the chief factor in 
the development of the malignant fever which had for half a century before decimated 
the population of the town, which is surrounded by rice fields. For the steady and SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
429 
uniform maturity of the grain it was considered essential that the rice plant should 
receive uniform supply of nutriment. To this end, the long or "lay-by flow" was 
put on the fields as soon as the conception of the grain was determined, and this flow 
was kept steady, at one gauge, until the grain was ripe, or ready for the harvest. The 
water was never drawn off, with a view to freshening it, but this " lay-by " or long 
flow was continued from forty-five to sixty days, until the day of the harvest. The result 
may readily be conceived. The decomposition and putrescence of forty-six thousand 
acres of flowed land, exposed to summer and autumnal sun heat in this climate, was 
quite sufficient, we think, to generate the most deadly miasm. A case in point demon- 
strating the poisonous character of the effluvia resulting, was that of a wealthy planter 
(afterward governor of the State), who stood at the floodgate of a large field while the 
water was draining off, preparatory to the harvest. The stench was intolerable; he 
sickened, nauseated and was obliged to leave. On his way home-a distance of six 
miles-a protracted chill overtoook him; a congestive fever followed, which nearly cost 
him his life. An exposure of two hours at the floodgates was followed, in less than six 
hours, with malarial fever of nine days. From summer freshets similar results fol- 
lowed. The summers of 1840 and 1841 furnished memorable demonstration. In 1840 
there was a long and high overflow of our rice lands during the months of July and 
August. The stagnant waters of the rice fields were washed out, as it were, of their 
embankments, mingling with the general current of the rivers, passed down to the 
ocean, causing a débouché of the turbid waters for several miles beyond the ordinary 
limit of the water from up the streams. The influx of the sea tides brought back a 
highly-offensive, brackish deposit, which skirted high-water mark for several miles 
above the lighthouse, which is situated on North Island-below Georgetown about 
twelve miles. This island had been for many years the favorite summer resort of 
many planters and the wealthier families of the town, and was considered safe from 
fever. The village consisted of twenty-odd houses. Before the freshet had subsided, 
I was summoned to a case of " cold fever " within a few yards of the lighthouse, on a 
sandy plain looking directly out upon the ocean. This case terminated fatally in thirty- 
six hours from its first symptoms, and gave my first experience with "cold fever." 
My residence was in Plantersville, a pine-land village, seventeen miles beyond George- 
town; but being called to this case (one of my winter patients), I was reluctantly 
compelled to remain on the island for ten days, ministering to others, who were unable 
to procure medical advice from Georgetown-all the doctors there being down with 
fever. I attended seventeen cases of fever, most of them severe remitting, of conges- 
tive type-all traced directly to the poisoning influence of this August freshet. 
" In 1841 a similar invasion of fever occurred after a slight freshet in August- 
nearly every house on the island having sickness, which caused the abandonment of 
the island as a summer retreat, from that year. At the beginning of that decade I 
strenuously urged the change of rice culture, on the score of public health. Irrigation 
of the rice fields was adopted generally-say twice or thrice a week-in lieu of the 
long stagnant "lay-by flow," and preparatory to the harvest the new plan was adopted 
of washing out the fields by the free ingress and egress of the waters several days 
before the harvest commenced. This at once insured a better condition of things for 
ourselves and farm hands, and beyond question, I say that the public health has im- 
proved. In fact, the town of Georgetown to-day will show as good a statistical record 
as most of our Southern cities. 
" Many intelligent observers formerly claimed that the negro was not subject to cli- 
mate fever-from the experience derived from the imported African and his immediate 
descendants-at the beginning of this century. At this date it is conceded that a 
certain degree of acclimation can be secured by continuous residence immediately on 
the rivers, and also that the colored man is not as liable to malarial troubles as the 430 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
white. But my experience is, that neither white nor black is exempt, children of both 
classes being more liable than adults. 
" As to drinking water, while the rivers are ordinarily regarded as wholesome, the 
custom is to supply our field laborers with water from our wells and springs-conveyed 
in barrels and jugs-during the season of planting and hoeing. Ditch or dike water 
is, and should be, forbidden at all seasons. 
" I have no experience with convicts or State prisoners on rice estates. No cisterns, 
except in the town of Georgetown, and but few there; well water the main reliance of 
the whole county. ' ' 
The foregoing reports reveal a remarkable unanimity of medical experience, col- 
lected, as it is, from physicians residing in separate and remote sections of our country, 
each reporting facts observed by himself, without conference or consultation with the 
others, and is so much the more reliable and valuable to the profession as a working 
basis in practical sanitation. 
MALARIAL SUSCEPTIBILITY OF THE AFRICAN. 
Whether the negro is equally susceptible with the white race to the noxious influ- 
ences of overflows, is a question somewhat mooted. The general impression prevails 
that he is not. I again quote :- 
Dr. Ducoté.-" The white is more susceptible to the effects of overflows and rice 
culture than the colored race." 
Dr. A. Maguire.-" More severe on whites than blacks." 
Dr. C. D. Owens.-"Colored race resists the effectsof all malarial causes more than 
do the whites, but as the former are less careful in regard to regimen and the laws of 
health, they sicken in about the same proportion. It is, therefore, difficult to separate 
the effects of overflows, as regards the colored race, from want of sanitation, which 
must be credited with some part of the cause of sickness among them." 
Dr. McKinnon.-" Cotton plantations on the Alabama river are almost depopulated 
of white people from malarial causes, increased, no doubt, from overflows. Colored 
people seem to enjoy an immunity against these ills to a very great extent." 
Dr. Donaldson.-"I notice a difference between the two races." 
Dr. C. P. Moore.-" Colored are less affected than whites by malaria, and hence 
less affected by overflows." 
Dr. Sparkman.-" Many intelligent observers formerly claimed that the negro was 
not subject to climate fever, from the experience derived from the imported African and 
his immediate descendants at the beginning of this century. At this date it is con- 
ceded that a certain degree of acclimation can be secured by continuous residence 
immediately on the rivers; and also that the colored man is not so liable to malarial 
fevers as the white. But my experience is, that neither whites nor blacks are exempt; 
children of both classes being more liable than adults. ' ' 
My own experience, extending over a period of more than fifty years, is that in all 
overflowed and malarious districts the colored people are equally 'affected with the 
white people, and quite as subject to all forms of malarial fever, with a much larger 
mortality in proportion to the number of cases. And yet I am well satisfied that this 
result is largely due to the indiscretions, imprudences and negligencies in their mode 
of living and to their local and home insanitary surroundings. 
DRINKING WATER. 
All of my correspondents fully realize the injurious effects of the use of impure 
drinking water, and the necessity of an abundant supply of that which is pure. All 
give the first preference to good cistern water. In the light of recent investigations and 
the positive knowledge thereby gained of the general impurity of most of the water SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
431 
used for drinking purposes, and its well known evil effects upon health, the question of 
securing pure drinking water is a problem at this day deeply agitating all populous 
communities, and is equally important to our rural populations. 
Summing up all the facts and information collected in the foregoing investigation, 
we may fairly and logically formulate the following propositions :- 
1. That overflows, as a general rule, are injurious to the public health. 
2. That they are more or less injurious, according as the inundations are late or 
early in the season, and whether of long or short duration. 
3. That their evil effects upon health are lessened, or entirely antagonized, by good 
natural or artificial drainage, and by copious showers of rain occurring during the 
period of the subsidence of the waters. 
4. That rice culture is inimical to health only by reason of the improper and 
insanitary manner of its cultivation. 
5. That, as a rule, it is perhaps true that the colored race is less susceptible to the 
injurious effects of overflows, marshy and malarial soils, than the white race. 
6. That carefully caught and protected rain-water in large cisterns, is the most 
wholesome drinking water, and should be used either for drinking or cooking purposes, 
preferably to all other waters. 
As practical working corollaries, logically deducible from the foregoing propositions, 
to guide medical men and sanitarians in their labors and teachings in the promotion of 
sanitation and the betterment of the health and physical condition of the communities in 
which they live, the following rules may be insisted upon as necessary and essential :- 
1. That all swampy and wet soils, and lands subject to overflows, before being 
settled upon and put in cultivation, should be cleared of trees, underbrush, etc., to 
admit freely the sun's rays and the free circulation of the winds, and thorough and 
perfect drainage of the soil, so that rapid drainage and drying of the soil shall not be 
impeded. 
2. That in the culture of rice, the common plan of keeping the fields covered for 
long intervals with stagnant water should be avoided, and in lieu thereof, frequent 
irrigation with fresher and purer water should be adopted, and supplied to the growing 
crop as often as needed ; and the ditches and conduits be so constructed as to let off the 
superincumbent water rapidly and promptly. 
3. That more fully to protect and promote the health of the laborers and residents 
in the river deltas and the low lands that are cultivated, the dwellings should be not 
less than four feet from the ground, the floors laid tight, and the doors and windows so 
arranged as to afford free ventilation, with galleries on all sides, wide enough to prevent 
beating rains from wetting the rooms and dampening the beds and clothing. 
4. That the houses should be erected upon ridges or the most elevated grounds, so 
that water shall not settle under or around them ; and only a few shade trees be allowed 
to grow, to break the force of the direct rays of the sun; and brush and undergrowth 
be removed so as to facilitate the free moving of currents of the atmosphere. 
5. The enforcement of rigid cleanliness in person and surroundings, a due supply 
of good, wholesome and substantial food, good cistern water, and the avoidance of all 
excesses and intemperances by which the physical and mental forces are weakened 
and broken down, and resistance to morbid influences enfeebled. 
A due observance of these plain and common sense rules, we humbly conceive, will 
conserve and promote the health and comfort, and consequently the happiness of the 
people residing in the rich and alluvial sections of this and other countries. In the 
language of Dr. Moore, I repeat, ' ' There is no reason why our rich valley should not 
be a teeming beehive of industry, filled with a prosperous and rich people. ' ' 
In conclusion, I desire to emphasize the statement, that whatever facts and princi- 
ples have been educed in this investigation, reasonably believed to be promotive of the 432 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
health and comfort of the inhabitants of the great Mississippi Valley in these United 
States, are equally true and applicable to the river deltas and valleys of all other coun- 
tries ; and from this standpoint, as medical sanitarians, we can take a broad and com- 
prehensive view of the field of practical sanitation, and anticipate with laudable pride 
the future glory and triumphs of preventive medicine, and in some measure realize its 
vast importance and grand possibilities, in the promotion of human health and comfort 
and the prolongation of human existence. 
TO THE MEDICAL PROFESSION. 
Dear Doctor :-In accordance with the request of Dr. Joseph Jones, of New Orleans, 
La., President of the Fifteenth Section of the Ninth International Medical Congress, I 
w'ill investigate the important questions embraced under Section vi of the Inquiries 
prepared for the Council of this Section by Dr. Jones. 
In order to throw light upon these important questions, I have, upon consultation 
with the President of the Fifteenth Section, drawn up the following questions, relating 
chiefly to the effects of overflows and rice culture upon the public health ; and, in 
order to obtain reliable information, I address the following inquiries to the medical 
men in those localities, and respectfully request, as early as possible, a full and specific 
answer to each question. 
Question 1. How long have you been cognizant of the results of overflows of the 
Mississippi river and its tributaries upon the public health ? 
2. Have you closely observed the effects of said overflows upon the public health ? 
3. Have you generally or uniformly observed an increase of sickness immediately 
succeeding these overflows ? 
4. If so, what diseases? Their character and type? 
5. What local or general conditions (including topography) have you noted con- 
trolling or modifying the effects of overflows upon the public health ? 
6. Have you kept statistics of the number and dates of these overflows, and the 
cases of sickness (if any) resulting therefrom ? If so, please give statistics. 
7. What is your experience of the effects of rice culture upon the public health? 
and what the rate of death per 1000 population before and since the commencement 
of rice culture ? 
8. Has malarial hæmaturia increased in frequency and severity during the past 
forty years? And is said increase due to the increased cultivation of rice in the delta 
of the Mississippi river, or in other localities where rice is cultivated ? 
9. What effect has the camping and working of State prisoners in the low lands and 
swamps had upon said prisoners, held by Louisiana, Arkansas, Mississippi or other 
States so employing their prisoners ? 
10. How many deaths have been caused among State prisoners by malarial diseases 
directly traceable to exposure to the malaria of the swamps ? 
11. Give facts bearing upon the relative effects of overflows and rice culture upon 
the colored and white races. 
12. Relations of drinking water to the AeaZtA of the inhabitants of rice, sugar and 
cotton plantations. Effects of swamp water. Effects of cistern, well and spring water, 
for drinking purposes. 
13. The best means of protecting the health of the laborers and inhabitants in such 
localities. 
The physicians of the valley of the Mississippi river and the rice regions of Arkan- 
sas, of Alabama, Georgia, North and South Carolina, Florida and Texas, are earnestly 
requestly to furnish their replies to Richard H. Day, m. d. , 
Baton Rouge, La. P. O. Box, 181. 
jfi@" Please answer categorically. SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
433 
DISCUSSION. 
Dr. J. A. S. Grant-Bey, of Egypt.-The Nile is formed by the White and 
Blue Niles, about 2000 miles from its mouth; only one branch between that and the 
Mediterranean Sea, the Atbara, being only a little to the north of Khartoum, at the 
junction of the White and Blue Niles. 
For a distance of upward of 1500 miles the Nile has no tributary, and for the 
most part flows in a tortuous manner, over many cataracts, through a desert country. 
Thus far the Mississippi and Missouri joining to form the main river may be 
compared to the Nile, and the yearly overflow takes place in both rivers; but in the 
case of the Nile the principal and rich part of the flood comes from the Blue Nile, 
which rises in Abyssinia, and brings with it a fertilizing mud derived from the disin- 
tegration of granite rocks. 
The White Nile, which comes from the equatorial lakes, is more or less laden 
with vegetable matter; but this has little effect on the main body of the river, which, 
although very muddy, is aerated and purified as it passes over the various cataracts. 
It is only along the northern border of the Delta that we have rice culture, but, 
although it is said that about one in ten of the inhabitants of Egypt is affected with 
hæmaturia, I have never heard of malarial hæmaturia. The hæmaturia in Egypt is 
caused by the haematobium bilharzia, a distinct and well-known organism. 
We have malaria in the swampy parts of the Delta, but it takes the form of 
ordinary intermittent and remittent fevers unaccompanied by hæmaturia. In the 
rice-growing districts we have a prevalence of elephantiasis, or big leg. Of course, 
in the Mediterranean there is no tide, so that the rice fields are not deluged by 
freshets from the sea, but the rice lands are more or less salty. 
As in the Mississippi, so in the Nile, we have sometimes a good flood and some- 
times a bad flood; and a bad flood may be from excess or want of water; both are 
equally disastrous. 
As the Nile assuages, toward the end of October, we often meet with cases of what 
has been called pernicious fever, but I think I may say that English practitioners 
out there consider that it is not a specific fever in itself, but is the result of some other 
fever, malarious or otherwise, during the course of which some organ, like the kid- 
ney, has become involved, and fatal blood poisoning is the result, probably from the 
formation of ptomaines. 
According to Sir Wm. Dawson, the Delta of the Nile cannot be much more than 
7000 years old, and in the time of Herodotus, some 450 years B. c., we learn that 
the hippopotamus was quite common in the Delta, showing that at that time a great 
portion of it must have been marshy, and must, therefore, have given rise to diseases 
of a malarious character. These were no doubt controlled by a perfect system of 
canalization when the country was quiet, but when in an unsettled state canals would 
be neglected, and pestilence would be the result. 
It was pretty much in this state that the great Mohammed Ali found it in 1806, and 
it is to his energy and intelligence that we owe the present immunity from pestilen- 
tial diseases of an endemic character. Mohammed Ali was for Egypt what St. 
Patrick was for Ireland. 
As to the colored races in America being equally liable to be affected by malaria 
with the white race, I should say most decidedly that it is not so in Egypt, if I may 
be allowed to substitute the Arab for the negro. 
The Arabs are, of course, more exposed to malarious influences than the white 
races in Egypt; still, malaria cannot be said to be very prevalent among them, and 
Vol. IV-28 434 
434 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
perhaps the main reason lies in this : that they live more naturally than Europeans 
-their diet is spare and simple, and by religion they are total abstainers. 
I should like to know what Dr. Day means by an insanitary cultivation of rice. 
I should like also to know what he means by malarial hæmaturia. 
Dr. Maxwell said-I am much interested in the subject of Dr. Day's valuable 
paper, for if the malarial poison were eliminated from Florida, where I reside, her 
citizens would enjoy almost complete immunity from sickness. Malarial feyers con- 
stitute about all the diseases to which Floridians are subject, and though they are 
not nearly so frequent or severe as the outside world believe and charge, those forms 
of disease are general, and require treatment. More than forty years ago the late dis- 
tinguished Dr. M. K. Mitchell, of Philadelphia, father of the now more distinguished 
Weir Mitchell, in lectures, published by his class, in 1846, expressed the idea of 
a living germ as the probable cause of malarial fevers-an inference which he drew 
from, among other circumstances, the close relation between the beginning of the 
rainy season, in countries where the line between the dry and rainy seasons is well 
defined, and the appearance of malarial fevers. 
Thirty years ago, Prof. Joseph Jones, our distinguished President, demonstrated 
the destructive effect upon the blood of malarial diseases. And within recent years, 
Drs. Klebs, Tommasi-Crudelli and others, have shown that the malarial poison is 
a microorganism, which destroys the corpuscles and other important elements of the 
blood, and thus causes the fever, and the resulting anaemia. They have shown, 
also, that heat, moisture and oxygen are essentials for the propagation of the germs. 
This fact explains, I think, the unhealthfulness of rice culture. It is not that there 
is any poisonous emanations from the rice plant, or dangerous chemical changes in 
the soil, for Prof. Joseph Jones and others have demonstrated that chemical results 
from decaying organic matter have no such effects, but the moist condition of the 
soil, from the fact that water is necessary in the cultivation of rice, heat and oxygen 
being also present, gives the conditions for the propagation of the organism. 
Malarial hæmaturia is the most severe and most fatal form of malarial fever. 
This is because hæmaturia is the consequence of repeated attacks of milder forms of 
the disease. I have never known a case of hæmaturia to occur with the first parox- 
ysm of fever in a previously healthy person. Only after a succession of attacks, the 
blood meanwhile becoming less nutritious and the tissues more feeble, does hæma- 
turia appear. 
I am satisfied that the free use of mercury contributes to the production of the 
disease, and of its fatal results, for the same effects upon the blood which Dr. Jones 
attributes to malarial fever, on page 771 of the latest edition of the United States 
Dispensatory, are said to result from the action of mercury. Thus the fever and 
mercury mutually contribute to produce the condition of blood and tissues which, 
when a congestive paroxysm supervenes, terminates in the so-called hæmaturia. 
In an experience of forty years in malarious districts, I have never in a single 
instance used the mercurials or other cathartics in the treatment of any form of 
malarial fever, and to that fact I attribute my good fortune in not having had a case 
of malarial hæmaturia in any patient whom I have treated. My experience with 
the disease has been in cases that have either occurred in the practice of others, or 
in those who have undertaken their own cases, but in every instance the history 
shows profuse use of drastic medicines. 
Dr. Byrd, of Arkansas, in reply to Dr. Maxwell, said that in his experience the 
gravest form of malarial trouble was hæmaturia. He disagreed with Dr. Maxwell SECTION XV PUBLIC AND INTERNATIONAL HYGIENE. 
435 
concerning the effect of calomel. He regarded calomel as of great value in many 
cases of malarious disease, whether acute or chronic. He had never seen the severe 
effects attributed to its action by Dr. Maxwell. 
Dr. Jones said-Several valuable papers are at hand to be read, and I am unwilling 
to trespass to any extent upon the valuable time of this Section. I cannot, however, 
refrain from directing the attention of this learned body to the remarkable sanitary 
history of Savannah, Georgia, during the present century. 
During the years 1856 and 1857 Dr. Jones made a careful examination of the 
medical topography and mortuary statistics, and presented the following facts illus- 
trating the injurious effects of rice culture on the health and longevity of the white 
inhabitants. 
Savannah is situated on the Savannah river, eighteen miles from its mouth, on 
a sandy plain, elevated forty-two feet above half tide. On the north this plain is 
terminated abruptly by the Savannah river, a turbid stream pursuing its slug- 
gish course through the rice fields and low grounds of South Carolina and Georgia. 
On the east and west the city is flanked by extensive tide swamps, formerly under 
wet or rice culture, at the present time, and for the past fifty years or more, under 
dry culture. 
The dry culture system, by thorough drainage of paludal districts above and 
below Savannah, and of the islands and lands immediately across the river in front 
of the city, was instituted in 1818. 
The sandy plain extends for several miles beyond the city. 
Savannah, therefore, is surrounded on all sides except the south by malarious 
districts. In fact, up to 1818 she might be justly regarded as a city situated in the 
midst of a vast marsh or rice field, reclaimed by a system of dams or embankments 
and canals from its original condition of a rich alluvial swamp. With the establish- 
ment and perfection of the dry culture system and of the draining and cultivation of 
the surrounding low lands, the health of Savannah has steadily improved. 
Thus, during the ten years from 1810-1819 inclusive, during the wet or rice cul- 
ture system, the deaths among the whites averaged as one in fourteen of the white 
population. 
In the ten years from 1820-1829 inclusive, the deaths were in the ratio of one 
in seventeen of the entire white population; and in the ten years from 1830-1839 
inclusive, as one in twenty-four; in the eight years from 1840-1847 inclusive, as one 
in thirty-three. 
The great mortality occasioned by fevers referable chiefly to the action of heat, 
moisture and malaria in Savannah, is shown by the fact that the various forms of 
fever, including yellow fever, remittent, intermittent and congestive paroxysmal 
fevers, occasioned more than one-third of the mortality in Savannah, Georgia, dur- 
ing a period of fifty years, 1804-1853 inclusive, or, more exactly, 4888 deaths from 
the various forms of malarial fever and other fevers in a grand total of 14,332 deaths 
from all causes in the white inhabitants. 
Dr. Jones expressed his high appreciation of the great value to medical science of 
the paper of his friend, Vice-President Richard H. Day, of Baton Rouge, Louisiana. 
Dr. Day, in closing the discussion, replied to the inquiry of Dr. Grant-Bey. By 
an insanitary cultivation of rice is meant the plan of keeping the fields covered for 
long intervals with stagnant water. The improved method is that of frequent irri- 
gation with fresh water at intervals sufficient for the nutrition of the rice. 
Malarial hæmaturia is a blood disease. The blood is in a disorganized condition 436 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
before hæmaturia is manifested. It is devoid of red corpuscles. A similar disin- 
tegration of the red blood corpuscles may be produced by the injection of bile acids 
under the skin. The bile acids are retained in the blood by reason of the malarial 
poison. The hæmaturia is simply a blood disease and the passage of disintegrated 
blood through the kidneys. 
THE HISTORY OF HYGIENE IN MODERN EGYPT, WITH CRITICAL 
REMARKS AND PRACTICAL SUGGESTIONS. 
L'HISTOIRE DE L'HYGIENE DANS L'ÉGYPTE MODERNE, AVEC DES REMARQUES 
CRITIQUES ET DES SUGGESTIONS PRATIQUES. 
DIE GESCHICHTE DER HYGIENE IM HEUTIGEN EGYPTEN, NEBST KRITISCHEN BEMER- 
KUNGEN UND PRAKTISCHEN RATHSCHLÄGEN. 
BY J. A. S. GRANT-BEY, M. D., LL.D., ETC., ETC. 
Senior Surgeon to the Egyptian Government Railways. 
For a long period "before the time of the illustrious Mohammed Ali (whose reign 
dates from 1811 to 1848 A. D.) both personal and public health in Egypt must have sunk 
to a very low ebb, seeing that medical matters were left entirely in the hands of reli- 
gious sheiks, old women, barbers and bone setters; all of whom, even at the present 
day, carry on their art with considerable eclât among an ignorant and superstitious 
population. There were no doctors, properly so called, and certainly no sanitary service. 
Plague and pestilence, of one kind or another, were continually ravaging the country, and 
no pains were taken by the government of that time either to prevent or cure disease: 
while the remedies used by the above-mentioned medical corps were not of a nature to 
give much encouragement either to the sick or to their friends. Most of these remedies 
are too disgusting to record, while others of them are simply superstitions. 
The result of this was that Egypt was looked upon by the whole of Europe as 
unclean, so that it was put upon a perpetual quarantine that completely ruined its com- 
merce. 
How the ancient Egyptian and Arab races could have sunk to this degradation, after 
such a brilliant career as we have depicted to us in history, can only be understood from 
the knowledge we have of how an ignorant and tyrannical race, on conquering a more 
intelligent and civilized one, always stifles its life and further progress. 
When Mohammed Ali succeeded in taking the government of Egypt into his own 
hands, he must have had a grand field for introducing improvements, as everything was 
in a chaotic state. He showed himself, however, quite equal to the occasion, so that 
looking back from this date (1887), Mohammed Ali is still considered the father of the 
principal and most beneficial reforms that have ever been introduced into Egypt. 
This enlightened ruler, seeing the necessity of having his country put on an equal 
footing with European nations in order to secure its prosperity, among the other reforms 
he introduced, sent to Europe for doctors, who formed in 1825 a sanitary service * for 
the cure and prevention of disease, and at the same time to train up a number of the 
natives (young men and young women) in the medical art.f Their success was very 
* First for the troops and then for the civilians. 
f A number of young natives were also sent every year to different European countries to 
study medicine. SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
437 
marked and soon began to bear fruit in various ways. This sanitary service has con- 
tinued to exist ever since, under different names and with varying success, but the 
brightest page of its history is at the commencement of its career. It had been in 
existence but a comparatively short time when Mohammed Ali, annoyed at the per- 
petual quarantine kept up against the different ports of Egypt by Europe and Turkey, 
and being convinced of the success of his sanitary service, invited Europe, in 1846, 
to send a medical commission to examine into the sanitary condition of his country, 
with the view of having the quarantine removed. 
In answer to this request three separate and independent medical missions, respec- 
tively composed of French, Austrian, Turkish and Russian physicians, were sent to 
Egypt;* and, after visiting different parts of the country, and having spent ample time 
at the various places visited to see with their own eyes what was the sanitary state of 
the country, they, separately and independently, sent in very favorable reports, and 
proved to the satisfaction of Turkey and Europe that plague had disappeared from the 
country, and that there had not been a single case of cholera for many months, f In 
those days this was considered conclusive evidence that neither plague nor cholera was 
endemic in Egypt, so the oppressive quarantine was removed, and Egypt was free to again 
develop the commerce she had lost. Time proved the correctness of the view taken 
by Europe of the opinion of the three medical missions, for the plague has not again 
appeared in Egypt since 1844, and cholera only at lengthened intervals, being always 
an imported malady. 
But times change and we change with the times, so that in these latter days the 
commerce of Egypt has been lost sight of, and British politicians, with an assiduity 
worthy of a better cause, have compassed sea and land to have cholera declared an 
endemic disease of Egypt, $ with what intent we do not pretend to judge; but there is 
no difficulty in divining what would have been the immediate result if Europe had 
been gained over to this unfounded opinion. Egypt would have been once more in its 
dire history subjected to a perpetual quarantine, Europe not yet being ripe for doing 
away with this most unsatisfactory and ineffective measure for preventing the spread of 
a contagious disease. 
In order to give some plausibility to the new-fangled theory, three (the traditional 
three) separate (not, however, independent) medical missions were resorted to. Of 
these two were got up for the purpose of counteracting the widespread opinion that the 
cholera had been imported into Egypt, and the third for the purpose of discrediting the 
discovery of Dr. Robert Koch, who, apparently, demonstrated to the world at large and 
to the medical profession (not tainted with politics) in particular that the importation 
had been from India. 
These missions were as follows:- 
1st. The mission of Oculist Dutrieux in Egypt; 2d. The mission of Surgeon-gene- 
ral Hunter to Egypt; 3d. The mission of Drs. Klein and Gibbes to India. If any of 
these missions could in any sense be called scientific, it would be Dr. Klein's; but they 
had each and all of them to work up to a preconceived, not to say erroneous, theory. 
We all know what has been the fate of the first two missions. They have been dis- 
credited by the world at large, and time, that proves all things, laughs them to scorn; 
* Russian mission, in 1846. French mission, in 1847. Austrian and Turkish mission, in 
1849. f There had already been three epidemics of cholera, viz., 1831, 1837, 1848. 
J If cholera were endemic in Egypt, then surely we should have it in its epidemic form every 
three or four years, just as in India. But those who contend for its endemicity have yet to 
admit that it has not been epidemic in Egypt for a period of seventeen years, viz., from 1865 to 
1883, and again from 1883 to present date, September, 1887. But arguments and facts are 
thrown Overboard when they stand in the way of the attainment of a political aim. 438 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
for nearly four years have now elapsed since the cholera epidemic terminated, but no 
more cases of cholera have been reported, although it has been diligently searched for 
by those who are expected to favor the endemic theory. The first two missions referred 
to were made to have a semblance of success by the honors that were heaped upon their 
leaders and abettors, while official opponents were rewarded as is usual under such cir- 
cumstances. 
The result of Klein's mission was not so well known at this time as that of the two 
others because his report had not yet been made public, but from what he had offi- 
ciously allowed to escape from his lips» at some of the medical meetings in London, it 
appeared that he wished us to believe that he had entirely upset Dr. Koch's comma- 
bacillus theory, as the same comma bacillus had been discovered vegetating on the 
gums of people in perfect health and in old cheese, as well as in other diseases besides 
cholera. But when Dr. Klein was taken to task, it was clearly brought out that he 
had not employed the most decisive method for separating one kind of comma bacillus 
from another. 
He had used his microscope to good purpose, and no doubt he was highly gratified 
at having found, as he thought, the Koch comma bacillus under circumstances that 
precluded its having any connection with cholera. Quod erat demonstrandum ! ! ! 
There, we were led to believe, he stopped all further research, as he thought he had 
gained a complete victory; for we do not find, after his demolishing one theory, that he 
had another to put forward. All was reduced to chaos once more. 
For some unaccountable reason he neglected to cultivate (?) the apparently undis- 
tinguishable comma bacilli. Now, it is inadmissible that such an able investigator as 
Dr. Klein should have been ignorant of the well-known scientific fact that it is only in 
the artificial cultivation of these low organisms that one can be distinguished from the 
other when they are microscopically alike ; for this had already been demonstrated by 
Dr. Koch. Klein's .mission, therefore, had literally fallen short of effecting its pur- 
pose, and the only thing left for us now to stand by is the unanimous opinion of the 
three separate and independent medical missions sent to Egypt during the cholera of 
1883, by France, Germany and Russia, viz., that cholera is not endemic in Egypt, 
but is always an imported disease, and that the comma bacillus of Koch, be it the 
cause of cholera or not, is always found in cholera, and in no other disease ; so that, 
however choleriform the symptoms of a case may be, we can now positively assert that 
it is not true cholera if the comma bacillus of Koch is not found in the dejecta or ejecta. 
This being admitted, then surely no one will deny that whatever prevents the develop- 
ment of the cholera comma bacillus will also prevent or cure the disease indicated by 
the presence of that organism. 
This cholera affair, in a politico-medical point of view, forcibly reminds us of the 
Suez Canal business in a politico-engineering point of view. It was England's most 
earnest desire, under the Palmerston ministry, that the projected Suez Canal should not 
be dug, so she sent out to the Isthmus an engineering mission, at the head of which was 
a most distinguished engineer, who was bound to find that the canal was impracticable. 
This engineer acted up faithfully to his instructions ; nevertheless the canal was dug, 
and something deeper than "flat-bottomed boats " now sail through it, while Egypt has 
not become "the salt marsh" that was predicted. No one who knew the English 
engineers could for a moment doubt their capability of taking accurate levels, yet very 
little credit was given to their would-be-discovery, in face of the opposite results of the 
French engineers. 
Now, the discovery of Oculist Dutrieux and of Surgeon-general Hunter is just on a 
par with that of the celebrated English engineers ; no one outside a very narrow polit- 
ical circle believes in the would-be discovery at all, hence Egypt has not been subjected 
by Europe to a perpetual quarantine. SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
439 
Had the erroneous theory emitted by the above-named gentlemen been generally 
believed in, it would have had a most baneful effect on the commerce of Egypt, and 
would have misled the profession. 
It is admitted on all hands that after the death of Mohammed Ali, August, 1849, 
the stimulus given to the medical service began to flag under the Viceroy Abbas Pasha 
(January 1849 to 1854), and only revived again for a short time under the Viceroy Said 
Pasha (1854 to 1863), and again under the ex-Khedive Ismail Pasha (1864 to 1879), 
till his financial difficulties swamped everything, so that the medical service was ulti- 
mately rendered powerless for want of money even to pay the employés with. Under 
these circumstances sanitary reforms were at a standstill ; but under the more consid- 
erate rule of H. H. Tewfick Pasha, the present Khedive, who, more than any Egyptian 
sovereign of his line, has sacrificed his personal interest for the public good, the med- 
ical service has been reorganized and divided into two distinct departments, by 
Khédivial decree of 3d January, 1881-a quarantine department,* with its headquarters 
at Alexandria, and a Sanitary Department, f having its headquarters at Cairo. The 
Sanitary Budget was also increased from £54,000 to £60,000 a year, and the new 
arrangement bade fair to become a success, as far as the Sanitary Department was con- 
cerned; for under the able presidency of H. E. Dr. Salem Pasha, a large medical school 
was built near the Kasr el Ainee hospital ; abattoirs were erected at Cairo, Tantah, 
Mansoura and Portsaid. Two hospitals were built, one at Mausoura and the other at 
Tantah, the intention being to construct two hospitals every year till all the provinces J 
were supplied with proper hospital buildings, for up to 1881 all the government hospitals 
were simply houses that had been built for some other purpose, and could not, there- 
fore, be expected to fulfil all the conditions required for such institutions. Even at the 
present time Cairo and Alexandria are destitute of proper hospital buildings belonging 
to the government, notwithstanding the recommendation to the government by the late 
Sanitary Board to have a cottage hospital built on the Kasr el Ainee ground (Cairo). 
Besides that, many excellent suggestions for the good of the public health were made 
to the government, that retains the executive power in its own hands, but few of them 
were ever carried out. 
In 1882, owing to the Ara by rebellion, every administration was upset for several 
months, and scarcely had the Sanitary Board got into working order again when a 
severe epidemic of cholera broke out (June 22d, 1883), which tried the strength of the 
Sanitary Department to the utmost. But no one can, with any j ustice or truthfulness, 
deny that it stood to its work manfully, and did its best with the material it had in 
hand. Several of the sanitary doctors and some of the hospital nurses contracted the 
disease while attending the sick, and not a few of them died. One or two native doc- 
tors were accused of cowardice and neglect of the sick, and probably the accusation 
was well founded ; but in more civilized countries, no doubt, the same complaint 
might just as truthfully be made. As the epidemic spread, many of the sanitary doc- 
tors were isolated in the cordons sanitaires, and thereby the Sanitary Department 
became crippled in its resources, and had to accept the proffered help of England, so 
that, some time before the epidemic ceased, a number of English doctors arrived, who 
* The duty of the Quarantine Department was to guard the ports and frontier towns, so as to 
prevent contagious diseases from entering the country. 
f The duty of the Sanitary Department was to keep the country in a good sanitary condition, 
and supply all the medical wants of the country, etc., etc. 
J Egypt, for governmental purposes, is divided into fourteen provinces. Each province has 
its hospital, with doctor and staff. A chief doctor stays at the headquarters of the governor of the 
province, and he has under him so many doctors, midwives, veterinary surgeons and barbers, 
according to the number of villages in the province. 440 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
were speedily sent to the infected towns that stood most in need of their services. 
These gentlemen were more or less kept in hand by Surgeon-general Hunter, who had 
been sent to Egypt by Lord Granville, "for the purpose of investigating and reporting 
as to the origin of the cholera and the best means for its repression." Surgeon-general 
Hunter is represented as a gentleman having "distinguished general and medical 
attainments, as well as a special experience of Oriental maladies." However, instead 
of acting up to his public instructions, he declared, on the first evening of his arrival 
in Egypt, and in the presence of a mixed multitude of ministers of State, army officers, 
lawyers, doctors, etc., that the British Government had sent him to tell them that the 
cholera had taken its origin in Egypt, and had not been imported, and he challenged 
any one to contradict him. 
Having commenced by taking this stand, one could easily guess in what groove his 
investigations would run. It was but natural to suppose, therefore, that he would 
influence the newly-arrived English doctors to adopt his theory without any more inves- 
tigation than he had carried out himself, and we now know what success he met with 
in this respect and the rewards he has lavished on his supporters. 
Dr. Salem Pasha, however, in the name of the Sanitary Board, had already taken up 
Dr. Hunter's challenge, and the Board consistently and intelligently upheld its opinion 
against repeated attempts at coercion; but, as fate would have it, might has prevailed 
against right. 
At first an attempt was made to gag the Board, but this having failed, it was sum- 
marily dismissed. It was well known to the members of the Board for several weeks 
that its death knell had sounded, but they never dreamed that treachery would be 
employed, masked by a form of constitutional procedure. This honorable (!) piece of 
business was entrusted to a personage who had only a short time before turned Irish 
peasants out of their homes in the middle of winter, to die of cold and hunger. This 
was just the sort of merciless being to send to Egypt to carry out a coercive policy, and 
he was not slack in acting up to his instructions; for on the 13th of February, 1884, by 
a mandate signed by him, and by him alone, the Sanitary Board was dismissed in a most 
arbitrary manner, and with censure rather than with thanks for past services, because, 
no doubt, it had committed the unpardonable sin of maintaining that the cholera was 
not one of the endemic diseases of Egypt. When the death warrant was served, per- 
mission was asked by the Board to finish their report, already nearly completed; but 
this was denied them, on the ground that it would be the business of the new Board 
to see to that. Up to this date, however, no report has made its appearance, and the 
one made up in part from the sanitary archives by the British consul at Cairo, and sent 
home to the Foreign Office, has, it is to be feared, been suppressed; for nothing has 
been heard of it since. Notwithstanding the short and checkered life of the old Sani- 
tary Board-extending only from Jan. 3d. 1881, to Feb. 13th, 1884, and including a 
rebellion and a cholera epidemic-yet it could point to a considerable amount of good, 
honest work, achieved under most trying circumstances. 
A native doctor, President of the Quarantine Board, who had fallen upon several 
devices to screen himself from the imputation of having allowed the cholera to enter 
the country, was one of the most clamorous in supporting Dr. Hunter's groundless 
theory of the endemicity of this disease in Egypt, and he was rewarded for his patron- 
age by being appointed Director of the new Sanitary Board, with an Englishman as 
sub-director. 
Twelve months had scarcely passed when the government had to dispense with the 
services of both these gentlemen, and their places were filled up by a native layman and 
an English Army Surgeon-major. 
After a few months the native Director resigned, for reasons not very creditable to 
the service, and no one was appointed to succeed him, so that the English Surgeon-major SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
441 
was left alone, without any chief, and therefore was entirely responsible for the admin- 
istration of the Egyptian sanitary service. 
Lately we had brought to our notice a most useful sanitary measure respecting 
infectious diseases, but it was pushed forward at a very inopportune time, with the result 
of proving a dead letter. If the sanitary authorities had exhausted every available 
means for preventing the dissemination of infectious and contagious diseases, then they 
might expect, and would certainly deserve, the support of the consuls in the further 
prosecution of sanitary measures that might even encroach on the liberty of the sub- 
ject. But while the most ordinary sanitary measures are neglected, and the sanitary 
officers themselves have not the confidence either of the public or of the profession, it 
will be an utter impossibility to get infectious diseases reported, or even to elicit the 
sympathy of the consuls in this matter. There is by far too much buzzing and confu- 
sion in the Egyptian sanitary hive to allow of a projected measure to be well considered 
and made fit for launching on such a number of communities as we have in Egypt, and 
each one under the special protection of its consul, who has always at hand that power- 
ful weapon for good or evil-the capitulations. 
As the sanitary service is now administered by a comparative stranger to the coun- 
try, while most of his subordinates are without any sanitary training, we are not at all 
surprised at the European fangled sanitary measures that are served out to us tale quale, 
as if we were in Europe instead of in Egypt. 
It is not our object, however, to cavil and find fault, but rather to lend a helping hand 
in preparing the ground for the reception of the excellent measures that may be pro- 
posed from time to time by the sanitary administration. 
It has also been our endeavor, in as popular a way as possible, and through the 
medium of an Arabic medical journal, to enlighten the minds of the Egyptian public 
on matters that concern the health and welfare of the individual and of the nation at 
large, so as to facilitate the universal application of intelligent sanitary measures.* 
Could we effect this, we should have no dread of the capitulations, as they would prob- 
ably never be appealed to. But we are convinced, from personal experience, that 
public measures, however well devised for the preservation of the health of the com- 
munity or for statistical purposes, can never be officially carried out unless they meet 
with the cooperation of the people themselves. 
It is with the view of securing this cooperation that we call the serious attention of 
the public to matters that are of vital importance for the health of the individual, the 
well-being of the state and the continuance of the Egyptian race.f 
In a country like Egypt, where a European civilization has been grafted on without 
any special preparation made for it, and where it drags along at a slow pace and is only 
kept from being entirely inert through the influence of foreigners, it must strike every 
reflecting mind that an earnest effort ought to be made to educate the natives up to 
the reforms that are being introduced among them. 
* To effect this purpose, a few of us medical men practicing in Cairo, both native and European, 
have formed ourselves into an editorial committee, and have for the past eighteen months pub- 
lished a monthly Arabic medical journal, The Shiffa, in order to fill up a felt lacuna in the 
medical education of the country and to keep the native medical practitioners up to the times. 
Dr. Schmeïl, a Syrian medical man, is the chief editor. The articles are partly original and 
partly excerpts from European medical journals. 
f For the past eleven years a scientific medical journal, The Maqtataf, has been circulated 
pretty considerably in Syria and in Egypt. It is edited by two enterprising Syrians, Mr. Nimo 
and Mr. Saruf, and among its articles there are many that are more or less medical, sanitary, 
etc., and there cannot be the slightest doubt that literature of this sort published in the Arabic 
language materially aids the authorities in carrying out measures of medical and sanitary reform. 
The medical and sanitary articles are, as a rule, by well-known medical men in the East. 442 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Much, no doubt, is being done by way of encouraging a love for knowledge by the 
many schools that have been established in different parts of the country, but, we fear, 
no attempt has been made (by the government at least) to bring home, in an intelligent 
way, to the native mind the absolute necessity of studying and conforming to the laws 
of health in order to control sickness, disease and death. On account of this neglect 
the application of some sanitary measures has been frustrated by the boisterous rising 
of the natives against the sanitary officials. This would never occur if the govern- 
ment were careful to prepare the public for the measures to be carried out ; and, as it 
is the duty of the State to concern itself with the health interests of the people, it 
must employ a special class of persons technically acquainted with health and its 
requirements for man and beast-persons whom the unskilled general public can iden- 
tify as presumably possessing the necessary knowledge. And it is for the State to 
make this knowledge useful to the community and, if need be, to prepare the com- 
munity for its application. 
The State is not called upon to change the direction of the wind nor the course of a 
river, but much might be done to have the air kept fresh and healthy, and the water 
supply pure, and to prevent the criminal diminution of the population. 
When no special epidemic was raging, we heard little or nothing about dead bodies 
being thrown into the Nile, but as soon as a human epidemic manifested itself, then our 
attention was attracted to what may have been undermining the health of the inhabit- 
ants for years, and the health department had to bear the brunt of the blame. But 
was it the fault of the Board of Health, seeing that it had no power to execute its own 
rules and regulations nor the necessary influence to induce the government to execute 
its suggestions ? 
The usual excuse given by the government for not carrying out a proposed sanitary 
measure is the want of money, while thousands of pounds are being recklessly spent in 
paying fraudulent claims, and in upholding expensive sinecures, and in endeavoring to 
tap the American oil wells through Gehel ez Zert on the Red Sea. 
Having thus exposed the position of the Egyptian sanitary administration, with 
special reference to its impotency as an executive power when not backed up by the 
government, we hope that, by a careful perusal of the articles we have already com- 
menced to publish in the Arabic language, the inhabitants themselves will aid the sani- 
tary authorities by taking the initiative in carrying out simple measures for home and 
personal healthiness, as may be suggested through a more intelligent understanding of 
the laws of health. 
This, in itself, would probably urge on the government to execute the larger 
measures proposed by the sanitary administration for the proper cleansing of towns and 
for the supply of pure water to man and beast throughout the country. SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
443 
THE PLACE OF SANITARY SCIENCE IN EDUCATION. 
LA PLACE DE LA SCIENCE HYGIÉNIQUE DANS L'EDUCATION. 
DIE STELLE DER SANITÄTSWISSENSCHAFT IN DER ERZIEHUNG. 
BY A. W. LEIGHTON, M.D., 
Of New Haven, Conn. 
IN THE FOLLOWING PAPER WILL BE BRIEFLY SKETCHED : 
(a) The history of a Human Life, and note its bearing on our educational needs. 
(ö) Recall the character impressed upon education by the various civilizations of the 
past, and in the light of such past experience discuss some of the elements of strength 
and weakness in our American civilization, and consequently in the controlling ideas 
which dominate our education. 
(c) Adhering as closely as possible to ways and means already established, show how 
these various educational measures may be utilized and gradually modified, so as prac- 
tically to popularize sanitary notions, both in their personal and public aspects, with the 
least radical changes, and with due recognition also of the claims of other more and 
even less important training and interests. 
Guizot's Law.-The endeavor to formulate the experience of the race into some 
pregnant generalization of social stability culminated in Guizot's historical analysis, 
isolating the very essence of the superiority of modern European over ancient civiliza- 
tions. He showed that the evolution of each of the typical phases of ancient civiliza- 
tion was controlled by some dominant principle, by some preponderating influence 
which usurped authority, developed society in subordination to itself, and determined 
the character of all things-institutions, ideas and manners. The historian also showed 
that this domination of a single, all-pervading element in each of those ancient civili- 
zations was the original germ of final decay, resulting either in a state of chronic 
torpidity, as in Phoenicia, Egypt, and India, or in a sudden and brilliant development, 
as in Greece and Rome, necessarily attended, however, by early exhaustion, and fore- 
shadowing a proportionately rapid decline. 
On the other hand, he showed how, from the very cradle of our own civilization, we 
have been accumulating, in unprecedented number and variety, strong competitive forces 
that sway, and, above all, equilibrate the acts of men; robust ideas which have served not 
merely as the watchwords of as many epochs, but which survived and still remain living 
issues, exerting a perpetual and healthy influence upon human affairs. 
To the ancient Roman municipal principle, together with Roman ideas of law aud 
order, has been added the moral and political influence of a mighty Christian corporation 
-the Church. Modifying these strong forces came our barbarian heritage of a powerful 
sense of personal liberty. Then came the separation of Church and State, and the 
principle of freedom of thought and conscience. Later sprang up art, science, litera- 
ture, political rights, socialism and other elements which now vie with the ancient forces 
of monarchy, aristocracy, militaryism, the Church and each other. 
In modern times, and particularly in this country, we have witnessed the birth of 
yet another giant force-the industrial spirit-whose pristine vigor is testing the physi- 
cal and moral stamina of men as never before. Andrew White, indeed, applying 
Guizot's law to the United States, attributes to this all-absorbing "mercantilism" a 
despotic tendency, which he shows has already become inimical to other and better 
elements of our civilization. He deplores the increasing consecration of wealth and 
brains to this single interest ; the decline of true patriotism, the backwardness of 
science, literature and the arts relatively to our material prosperity. He deplores the 
obvious effect of this unchecked motive on the physical development of our people- 444 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
" the hurry, the crush, the dying out of families, the dyspeptic type which enables an 
American to be recognized in any country. ' ' In fact, he concludes that, notwithstanding 
the elements of soundness which we share in common with the strongest nations of 
Europe, we are still liable to retrograde through greed and its accompanying corrup- 
tion, indifference and physical degeneracy. 
It is becoming clearer every day that the necessity underlying Guizot's law grows 
directly out of the natural complexity of our organization, which will not for long 
brook indifference to a single vital interest. Let it be noticed also, that the richly 
diversified complexion of modern life, largely necessary though it be, the enormous 
aggregation into cities, the intensified struggle for existence and for preferment, the 
hitherto impossible inter-communication throughout the world, have brought greatly 
increased risk to the integrity of the organism itself, and rendered imperative a broader 
revival than was every necessary in the past, of an instinct which in our age has always 
been relatively weak-the instinct of self-preservation enlisted as an enlightened com - 
petitive force, proportionate, at least, to the magnitude of the rôle which health plays 
in the fruition of all other interests. 
Whatever conceptions dominate society, whether narrow or liberal, or whatever ele- 
ments of character are believed to be, on the whole, most advantageous, must early 
concern education as a means of developing these advantages. It is, no doubt, true 
that the direction impressed on education has always depended upon the ruling motives 
of the day-upon the ideas which society formed of the perfect man or of the repre- 
sentative man of the times. 
"Among the Romans it is the brave soldier, the orderly citizen, yielding to disci- 
pline; among the Athenians it is the man who unites in himself the happy harmony of 
moral and physical perfection; among the [ancient] Hebrews the perfect man was the 
pious, virtuous man, who should be capable of attaining the ideal traced by God him- 
self in these terms: 'Ye shall be holy, for I the Lord your God am holy.' " * 
For further illustration, witness a later period. With Christianity came the ideal 
of a man scorning this world, with eyes fixed on the life to come, naturally resulting 
in a culture almost exclusively religious and moral. The absolute sufficiency of the 
Scriptures stifled free inquiry, imprisoned education in the Church, and gave to it an 
austerity and narrowness never realized in the older systems. In fact, the sway of this 
ideal was more disastrous in results to education and to the whole character of life than 
the previous conceptions of the pagans had been, and before the world could be aroused 
from the lethargy, the indifference to the body, and the contempt for this life thus pro- 
duced, centuries were ruthlessly squandered on this supreme absurdity, and the gloom 
of the dark ages seemed bent on forever obliterating the light of all previous human 
experience. 
Indeed, while recognizing our indebtedness to this period for some of the germinat- 
ing forces of the modern world, we must also notice that to this ascetic age can be 
traced the tap-roots of a multitude of our popular prejudices-of our dimness of per- 
ception where simply the health side of morality is concerned, of our ingrained apathy 
to this particular class of selfish interests, of our reluctance to incur expense in warding 
off calamity still half believed to be providential. Furthermore, our continued resig- 
nation to invalidism, and to a suggestively fluctuating death rate, exposes our lineage 
and our ancestral contempt for the prudential virtues, reveals our tardy progress in 
these respects since the days when the body was esteemed an enemy of the soul, when 
even personal and domestic cleanliness and decency were proscribed as worldly, and 
when the resulting ravages of plague and physical disorder were hoped and believed to 
be warded off and charmed away by amulets and prayers. 
* J. Simon. "L'éducation et l'instruction chez les anciens Juifs." SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
445 
From the renaissance of learning, however, can be observed the promise of a better 
public opinion and of rational aims for education. The revival of interest in the artistic 
and philosophical treasures of Athens and Rome, so long buried under the priestly ban, 
began to reëxcite a normal interest in this life, and to restore some traces of the old 
classic respect and care for the body. The rapid circulation of ideas after the invention 
of printing, and the proportionate stimulation of modern thought and scientific inquiry, 
especially the biological inquiry of the last two decades, has enlarged our knowledge 
of hygiene far beyond what the Greeks possessed or had occasion to teach. But the 
complicated conditions of life now actually demand this larger knowledge of facts, and 
the fiercer rivalry that characterizes the times requires, as we have said, a correspond- 
ingly forcible impulse, as a compensating element to limit other strong impulses, to 
offer a secular check to the excessive modern reaction against moral training, to curb 
some of the murderous tendencies of greed and the suicidal tendencies of ambition, to 
elevate and give a new significance to the idea of citizenship, to the idea of municipal 
government and to the idea of international brotherhood. This social and moral aspect 
of sanitation constitutes its chief claim upon public education, while its paramount 
importance to the individual should give it a conspicuous place in any liberal education. 
But let us next examine the individual aspect of sanitary science; for, after all, the 
natural history of a single organism must furnish the principal guiding aud limiting 
data from which to j udge of the times and specific uses of sanitary training. 
Organic Data.-The infant enters this world a delicate animal, the miniature of a 
man structurally-not quite a miniature mentally, but possessed of a variable stock of 
inherited tendencies and possibilities. The chief feature of the problem before this 
organism is growth-rapid growth-for twelve to fourteen years, and thereafter, by 
progressively diminishing increments, it must, practically, reach a maximum in about 
twenty-one years. The child must do more than simply grow. The quick circulation 
of blood through its tissues, its active respiration and its voracious appetite are neces- 
sitated by the direction of its metabolism chiefly to surplus constructive ends and to the 
accumulation of a surplus capital of latent or potential energy, stored away, by means 
no longer mysterious, in the growing tissues, for future and often sudden expenditure 
in the development or exercise of faculty. 
Thus, during the early manifestations of intelligence, the primary law of growth 
asserts itself, and for the first score of years the chief function of our hearty, fat and 
jolly little vertebrate should be unimpaired, luxurious, bodily development. 
The first half-dozen years, with their reflex enjoyments, irritations aud dangers, are 
the parents' absolute charge. It is exclusively to the previous training of parents and 
of their authorized agents, not to the child's intelligence, that we must look for the 
conditions of a sounder childhood-for the promise of an undamaged nervous structure, 
of a more permanent dentition, and of an unimpaired digestive and excretory function. 
The next half dozen years preceding puberty realize the culmination of the senses 
of touch, sight, hearing, taste and smell. There is now a general sensuous acuteness 
which becomes blunted in later years. The eye, which gives us fully one-half of our 
practical information, is now, according to the physiologists, at its dioptric prime, when 
its media are clearest and its muscular mechanism most mobile. From six to twelve 
is the age of maximum pure memory, unaided by artificial tricks or associations. 
The object of this early acuteness is clear. It announces the commencing limits of 
parental care, when the child must begin to maintain for himself and for herself inde- 
pendently the conditions of life, which are by no means simple. 
The foundations of the conceptive faculty and of the judgment are now being laid 
upon rock or sand, according to the character and variety of the experiences permitted 
and enjoined. If adequate notions have ever been, or shall ever be entertained by 
young men and women upon any timely subject, there must first be an initial intro- 446 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
duction to a variety of things, simple phenomena, and elementary ideas underlying 
this subject, and out of which the conceptions are to be built as a structure is built 
out of bricks. The early and marvelous development of an exquisitely sensitive 
and retentive nervous apparatus equips the young to rapidly accumulate the useful 
bricks, if only they are brought face to face with the right material. Hence, observa- 
tion, instruction, description and comparison should be directed to the data underlying 
the first concerns of life. These hitter are an ability to earn and to lead an independ- 
ent existence, an ability to maintain health as perfectly as is compatible with necessary 
independence, an ability to recognize and respect the interests of others, and to ennoble 
and render life pleasurable. 
Herein lies the necessity of jealous selection, which is intensified by the fact that 
the brain has only a limited capacity. Herein lies the wisdom of so guiding these 
early introductions to the concrete, and of so handling children's common occupations 
and studies as to suggest and enforce those particular truths which they will first need 
to know. 
Before arriving at any separate treatment of sanitary training, we ought already to 
appreciate the general tenor and spirit of education as applied to the ends above 
described. 
The occurrence of puberty at the twelfth to the fourteenth year marks the dawning 
of faculties that at once begin to play a controlling part generally underrated by all 
save the doctors, whose revenues tally with the accumulation of clinical evidence on 
this point. There is now a sudden and imperative diversion of much of the latent 
energy acquired from food to increased and new constructive and developmental ends. 
Puberty inaugurates the first epoch that is conspicuously beset with accidents peculiar 
to the child's own volition and considerably beyond parental care; involving more or 
less permanent impairment of adult health and mental tone. The directions in which 
the child's intelligence is now led are a truer augury of adult soundness than of future 
business or other capacity ; subordinate only to the ominous consideration that his ances- 
try-the invisible artisans-are moulding and grinding him slowly but steadily into 
their own similitude. 
The untutored, ambitious and ignorant practices which young people stumble into, 
or acquire from positive misguidance, are capable of stunting growth and diverting 
vital energy into useless channels or worse. This fact applies especially to girls, 
because puberty is for them a far more sudden process, and there should be allowed for 
them a far larger margin of energy undiverted from the normal occupation of simply 
physical development. Puberty is the favorite starting point of vicious habits ; the 
physical import of some of which, though occasionally considerable, has been grossly 
exaggerated in the case of boys, and this exaggeration has been forced to bolster up a 
monstrous superstition and a proportionately outrageous quackery that thrives and 
fattens out of the pockets of the foolishly-alarmed and misinformed ; while, strange to 
say, the moral deformity often acquired, and of which the physical is usually but a 
trifling incident, has been universally, nay, religiously ignored. Alcohol and tobacco 
manliness asserts itself at this age, when, unfortunately, the system is most susceptible 
to the harmful effects of these drugs. 
The necessity of allowing for the preoccupation of the vital powers for the few years 
including puberty, applies, as I have said, chiefly to the female; the phenomena in 
boys being far more gradual, are of less significance so far as developmental dangers 
are concerned. 
Early death often has its compensatory advantages; but permanent damage or 
maiming from unnecessary exposure or unseasonable indulgence in acts perhaps harm- 
less enough in themselves, has no bright side; yet the perusal of a physician's ledger or 
note-book would reveal how frequently chronic troubles can be traced back to this SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
447 
epoch when young folks are being thrown upon their own resources, and are beginning 
to test the quality rather than the quantity of their training. 
Among the diseases which most frequently date back to this age of increasing inde- 
pendence of action are to be enumerated chorea, hysteria, epilepsy, headache, worry, 
insomnia and other neuroses wholly or partly of reflex origin; all frequently involving 
an hereditary element, but yet largely dependent on over-excitation of the brain and 
spinal cord. The penance of permanent pelvic or uterine derangement is often unwit- 
tingly contracted for by the untrained novitiate of womanhood. Chlorosis and consti- 
pation, also; the latter in girls commonly arising from an inhibitory influence on the 
rectum, emanating from the tender and swollen ovaries and womb. In both sexes con- 
stipation and its sequelæ are ultimately to be attributed to neglect of physiological 
information and to popular errors regarding the use of purgatives. 
A general want of recognition of the glandular activity of puberty frequently under- 
lies chronic tonsillitis, acne, and scrofula. A strong predisposition to the last of these 
is doubtless often inherited, but it cannot be too emphatically stated that about one-half 
of the cases investigated are found to be acquired de novo, or superinduced by needlessly 
faulty hygienic conditions or extreme poverty. 
While weathering puberty, the vast majority are forced from school into self-sup- 
porting occupations, where competition soon gives the preference to preliminary fitness 
and health. This phase of youth suggests another critical test of the times and nature 
of early education. 
We now approach the age of voracious reading instincts, when it is apparent how 
this boon which society is so anxious to give everybody is to be used. It is indeed a 
sad reflection that multitudes who could read prefer to spend their leisure in idleness ; 
also, that the ease with which literature really finds its way into the hands of the 
laborer does not keep pace with his ability to read. 
But what of the literature of those who do read ? The cheap novelette and the 
newspaper are confessedly created on business principles, to supply a popular demand 
for amusement and gossip, not to elevate this demand. The periodicals and books 
found in the homes of the well-to-do comprise everything, good and bad. Both, how- 
ever, are on the whole over-stimulating, and almost equally lacking in all that might 
create an incentive to right living. For the great army of young people, a desire to 
read, to continue and benefit by their elementary advantages, might be encouraged by 
the evening continuation schools, and the correspondence schools, both of which are, 
however, but in the infancy of their usefulness. 
Besides bread-winning, we find the years succeeding puberty busily occupied with 
all the fun that is going on, innocent fun, for the most part. I am not going to indict young 
America with pessimistic tendencies. Suffice it here to recall the fact that wherever 
the spontaneous enjoyment of sport involves real moral danger, there we shall almost 
invariably discover a lack of apprehension of what constitutes a physical sin. Point 
out the man who belittles the indiscriminate sowing of "wild oats," and we shall dis- 
cover an ignoramus who believes that an occasional gonorrhoea is ' ' healthy, ' ' cleansing 
the blood of unhealthy humors, just as firmly as he believes that the odors from dogs and 
barnyards are healthy, or that amber or some other amulet can ward off disease. 
Wherever the infected prostitute is freely permitted to ply her trade, with no public 
precaution to prevent innocent wives, children and nurses from suffering the conse- 
quences of the licentiousness of others, there we shall find ignorant lads whose sorry 
plight is the standing universal joke ; lads who little reckon on the harvest which even 
they themselves are to reap in later years. 
Some time before physiological maturity, the young wife or maid makes her first 
serious attempt at cookery, housekeeping, and the care of children. This is no longer 
a matter of mud pies and rag babies. From the very outset weighty interests depend 448 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
upon immediate success or failure. The contentment and health of husband and 
children, as well as her own, may be at stake, and at once dependent upon her knowl- 
edge and training. No matter what she may have studied, that only will conspicuously 
help her now that enables her to nourish, warm and ventilate a healthy infant-that 
prevents her murdering good food materials. I have often been struck with the sur- 
prisingly fair appearance of fish, meat, vegetables, and other food stuffs that are exposed 
for sale in the poorest quarters. Frequent as are the exceptions to this rule, one can 
hardly conceive of the black art that everywhere contrives to convert fresh and whole- 
some provisions into the vilest of messes. The children are, of course, the chief sufferers 
on this account, but the husband will generally prosper directly as the wife foresees the 
dangers that beset her's and the children's health. 
Our coy maiden has perhaps acquired at school, or through the rivalry of compan- 
ions, the power of postponing her alvine and renal evacuations for incredible periods, 
the former often for weeks. She has also cramped her breathing power, forced her 
pelvic viscera as far downward as they will conveniently go, danced, bathed, and other- 
wise exposed herself at those times when harm was likely to result. And now she 
adds to such talents the traditions of married women-that abortions are, of course, 
trivial affairs, which may safely be induced by tansy and turpentine ; that confinement 
should be followed by a purge, but that fish must not be eaten during convalescence, as 
a woman values her life. Other traditions pertain to the care of infants, and had best 
be omitted. Nothing is more common in general practice than to see invalids starving 
on beef tea (wasA), or sick infants nursed with a diet of corn meal or cracker water. 
Young children are often fed with tea, coffee, beer, and coarse adult food. Au idea 
prevails among Northern mothers that an icy bed room toughens the shivering children, 
and that "night air " must not be admitted into even a hot chamber. The indiscrimi- 
nate resort to quack nostrums now begins to be a feature of unenlightened domestic 
economy, and the wretched consequences are to be attributed far less often to direct 
toxic action than to the fooling away of valuable time when effective measures might 
have been taken, according to the indications of a correct diagnosis. When woman 
performs the functions of nurse, perhaps under medical direction, the lives of those 
dearest to her, the lives of all, at one time or another, are at the mercy of her intelligent 
cooperation, of her ignorance, dullness or pig-headed obstinacy. 
Our newly made voter, meantime, forms many crude and a few respectable political 
notions, and long before these are a credit to him he exercises his franchise. If he is 
often ignorant and gullible in general politics, he is particularly so in all that relates 
to public sanitation, and this defect follows him into the "common council " and into 
the "aldermanic board." Nevertheless, it is universally admitted that the health 
authorities can never become efficient until they obtain fairly intelligent cooperation on 
the part of citizens. 
In brief, at the age of maturity, both men and women have essayed most of the 
experiences of life. All have advanced through certain orderly increments of growth, 
and have displayed the principal functional activities and tissue metamorphoses. All 
have run the worst of the gauntlet of disease, along which the majority of their fellows 
have fallen, and surviving, are now destined to bear onward clinical proof of the vari- 
able extent of protection afforded by parents, teachers and a feeble and uneducated 
natural instinct. The faculties, both physical and psychical, have developed apace, 
and the relative vigor of these powers is not thereafter to be materially altered. The 
majority have instinctively ventured the marriage or similar relations, and their 
tissues, minds and morals are to carry through life the impress of these experiences, 
whether happy or vicious. With a certain freedom of choice practically within narrow 
limits, all have necessarily been forced into occupations and into social conditions 
which, as a rule, they are thenceforth to retain. In various senses, the characters of SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
449 
that particular generation have been determined ; and if it shall surpass the previous 
one in health, in richness and variety of thought, or in morals, it will be chiefly owing 
to causes operating previous to maturity-causes hereditary and educational. After 
life may be principally concerned in perfecting and consolidating the man along lines 
of development already marked out; but, the chimeras of educational enthusiasts aside, 
and with due recognition of, the iron hand of heredity, we have still left to us the 
fact, of the most practical if not of supreme importance, that physiological adolescence 
was preeminently the plastic age. Afterward comes the long swell, culmination, and 
decline of human energy, but always, however, accompanied by progressive rigidity of 
tissues, habits, and prejudices. 
If it were true that parental care, a knowledge of the three K's, ordinary observa- 
tion, and contact with the world could successfully anticipate the various vital phases 
of life as they arise;-could in fact suffice for timely, efficient, and relatively economi- 
cal education, little further need be said. But the facts are that home training too 
often perpetuates the faults and narrow family traits of parents which should be cor- 
rected and liberalized by contact with other teachers, other ideas and examples; while, 
again, systematic education has not anticipated the critical occasions for its utility. 
Some particular kinds of intelligence needed at once in early life have been discrimin- 
ated against, while many others that are not at all necessary until later years, if ever, 
have received the preference. 
The fact is that the subjects of our sketch have been assuming functions in advance 
of fitness. Many of these essays eventuate seemingly well by virtue of the law of natural 
adaptability and tolerance of bad conditions, by virtue of chance also and native wit. 
Very frequently these functions are bunglingly performed, and hence the raw material 
of universal discontent and of cowardly lamentations, none of which are so bitter as 
those compelled by needless disease. The hope, however, is still indulged, that through 
the vicissitudes of early inexperience, the wisdom of middle and later years may be 
assured; but this hope proves illusory, and as the sands of life are running out, men 
admit that they have just begun to discover what could have been of the utmost use 
only at the threshold of their career. 
Conclusion.-Thus the exigencies of an individual life emphasize the verdict of 
sociology against the domination of a single idea or class over other equally important 
ideas. On the other hand, breadth in education is seen to receive its primary justifica- 
tion, only in so far as breadth tends primarily to place a youth promptly in command 
of his functions as they arise-his inevitable functions as a complex organism, a worker, 
a neighbor, a parent and a citizen. 
Such a type of manhood, based upon efficiency, enhances the significance of certain 
recent applications of modern science to the practical problems of life as they occur 
to-day ; enhances the value of every effort to produce, in available shape, the elements 
at least of a science of health-domestic and public, as well as personal ; the elements 
of rational ethics and practical charity; the elements of a popular political economy; 
the elements, in fact, of all those intellectual and moral needs that are human and 
universal, in contrast to those that conduce merely to elegance. 
One already discerns the first crude recognitions of health as a rival element, thus 
far, of course, marked by amusing blindness to the scope of subject. High schools and 
private academies have for some time offered an isolated and often optional course in 
personal hygiene as a sacrifice to this shrine. Among quite recent advances it must be 
noted that, even in conservative Connecticut, since my indictment of the modern 
system for sanitary neglect in the public schools, Yale and elsewhere (Veio Englander, 
March, 1885), we have had the pleasure, after the ebullition of some ridicule, of seeing 
advertised the first lectures on pulic health that the ancient Yale Medical Department 
has ever given; while, as I speak, the teachers of the elementary schools throughout 
Vol. IV-29 450 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
the State are industriously cramming up the new State text-book on hygiene, which in 
a few days they must introduce to children as young as the ninth year. 
The name and pretence of hygiene, however, must not be mistaken for the spirit. 
High schools give relatively too much attention to anatomy and physiology, too little to 
domestic health, and absolutely none in the public and social sense of the term. This 
instruction also comes too late, as the great majority of children are obliged to go to 
work before even their elementary schooling is finished. 
The new Connecticut text-book for the lower grades, where the real work of the 
public schools is done, originated ultimately, like many of its predecessors, as a po- 
litical expedient, comes before the public, finally, as a sop to the so-called temperance 
faction, not as an unbiased contribution to the cause of true sanitary science. 
Nothing but disappointment, however, is likely to follow any radical treatment of 
the subject, or entire reliance on any text-book and a certain number of quizzes thereon. 
Certainly, if a text-book covers the cardinal points, if it is of special public as well as 
of personal interest, if it enlarges our ideas of neighborliness and citizenship, it may 
well be considered among many means. But it should not stand for an isolated study, 
foreign to, and unassimilated with, the rest of the public system. 
The Common Branches.-I think that the common branches alone could be so taught 
as to popularize health notions, among others-commercial, economic, patriotic, etc. 
And how could this be done? By discrimination in the selection of subject matter. He 
who selects the exercises in school readers or the problems in the arithmetic, he who 
adapts a geography, or who compiles a school history, determines, in a measure, the 
trend of early ideas, the range of vocabulary, and especially the early conceptions of 
the applicability of knowledge. 
To learn to read, then, might mean to learn to appreciate clear and useful ideas, as 
well as to get the cue for graceful intonation. The comparative history of physical 
culture, the annals of sanitary investigation, striking incidents of the dependence of 
success or bankruptcy upon personal or municipal health intelligence, the growing 
debility and decline of some families and peoples, and the increasing vigor of others, 
the pathology of crime, the physical basis of poverty, and an abundance of similar 
material offer as interesting a field for selection as can be found-offer as useful and 
elegant a vocabulary, as wide a scope for linguistic analysis, for elocutionary effect, for 
collateral observation and investigation, and as fruitful themes, also, for the practice of 
composition. 
The monotonous, commercial tones of our arithmetics might easily be varied by 
numerical problems in air-space allowance, domestic heating, plumbing, relative cost 
of foods, comparative mortality rates, and so on. Occasional paragraphs in geography 
exhibit considerable elasticity, and might include, for instance, the telluric and pa- 
ludal origin and distribution of diseased and healthy conditions, as well as the source 
of the banana and tobacco crops. Drawing exercises could also be varied in a similar 
manner. A comparison of the ways in which people now live and formerly lived, with 
reference to the healthful tendencies of modern life, and the permanent physiological 
results of many events, would constitute a good running corollary in our school 
histories. 
In our advanced schools the practical references and applications of physics and 
chemistry could profitably be directed to the phenomena conspicuously underlying 
sanitation-to those involved in the hygiène of the eye, of food, especially of milk 
adulteration and preservation, of stoves, furnaces, steam-heating systems and the 
various methods of lighting, to the phenomena of ground air and water, of decomposi- 
tion and of purification-in fact, to what the ordinary householder and voter should 
be called upon to deal with. The cooking lessons which are being introduced into the 
common schools are, of necessity, largely sanitary in effect. SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
451 
In this way the teaching of the common branches could be rendered contributory to, 
if not, indeed, independent of, a special course, from the outset familiarizing the young, 
if not with advanced knowledge of themselves, at least with the facts and ideas directly 
underlying such knowledge, and leading gradually up to it. 
Morally considered, such a rendering of the common branches would be suggestive 
and excitant of the altruistic emotions, and would be apt to encourage just such senti- 
ments as are needed to facilitate dignified dealings, man with man. The spectacle of 
disaster from want of forethought primarily awakens interest in the prudential virtues. 
Sanitary literature is, moreover, largely the history of the interdependence of man- 
kind as brothers and safeguards one of another. Nowhere does the primeval question, 
" Am I my brother's keeper? " receive a clearer or more emphatic answer than in the 
story of the reciprocal precautions required by social life, and in these modern applica- 
tions of the golden rule. 
This study elevates voluntary right doing to a higher plane of urgency; and the 
fact receives the strongest possible enforcement that voluntary cooperation can never 
be superseded by the executive machinery of the law. Throughout society there is 
a low, constantly-swelling undertone of smothered exasperation engendered by the 
slowly increasing aggregate of petty injustice, petty frauds and infringements, delays 
and grievous compromises that are practically beyond the help of the courts or of pub- 
lic opinion because of their very pettiness, and of the loss of dignity and the net pecu- 
niary loss occasioned by invoking the aid of the expensive and uncertain public machin- 
ery of justice. A disposition to do what is right from self-interest, uncompelled by fear 
of the strong arm of the law, requires just such culture as sanitary science offers; just 
such a revelation of the utter defenselessness of any person or of any community 
against the heedlessness and ignorance of others. 
Continuation Schools.-Another promising institution, strong while yet in its infancy, 
I invoke to aid the cause. I refer to the continuation schools or enterprises w'here volun- 
tary and often isolated effort is taking form for the purpose of obtaining secondary and 
higher educational advantages for an interesting class whose circumstances thrust the 
desired education out of reach, or, perchance, whose leisure hours would preferably have 
been hours of senseless waste and apathy to all that is elevating and ennobling. 
For this class there would otherwise be an abrupt transition from school and its 
forced mental activity to labor and a condition of mental stagnation. Here the fault 
evidently lies in a too sudden withdrawal of every inducement to read and to think. 
These enterprises seek to hold on to what has been gained in the common school, and 
then to supervise the critical years of early manhood and womanhood, and by giving 
wholesome and attractive occupation to the mind, free from petty restraint, to lead on 
to more permanent habits of acquisition and self-reliance. 
Many of these enterprises are characterized by a system of central expert guidance 
and examination, together with a prescribed course of periodical and other reading. 
"The Chautauqua Circle," " The Correspondence University of Chicago," "The 
Meisterschaft Language System," and others, are typical of such projects, as the lyceum 
is of an older and more local expression of the same endeavor. All such voluntary 
effort, without exception, including even the Sunday school and evening public schools, 
present, to a greater or less degree, opportunities for sanitary or collateral study. In 
some an extended special course would be convenient, and would be an attractive addi- 
tion to the advertised curricula. In others much could be done in the indirect manner 
which I have suggested. 
Special Text-books.-Before dismissing the subject of an elementary text-book for 
general use, it should be noted that not one at present approaches any adequate treat- 
ment of sanitary science. The production of such a work, however, would remove the 
objections of many who think we cannot dispense with a book. It should be element- 452 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
ary, concise and comprehensive. It should be devoid of anatomical and physiological 
refinement. Brevity and clearness require considerable reliance upon truthful and 
artistic illustration. The book should, above all, be such as would keep abreast of the 
age of the pupil, and such as one would desire to preserve and refer to in later years. 
It should open with some fundamental biological principles, and proceed at once to 
dietetics as applied to age, occupation and the sick-room; not omitting Flint's reassur- 
ances about over-feeding, nor the physiological basis of the sugar instinct, nor yet the 
frequent necessity of overcoming a repugnance to fat. Intemperance should be pre- 
sented among numerous correlated evils that lie deep in the constitution of society. Its 
causes include not merely the opportunities for drunkenness, but also many unhy- 
gienic and adverse social conditions, such as discontent, idleness, unhealthy, contentious 
or cheerless homes, which oftener cause drunkenness than result from them. Insuffi- 
cient or improper diet, hereditary tendencies to excess and shiftlessness, defective edu- 
cation, etc., are other important factors. 
Then should follow the care of the brain and nervous system, of the eyes, skin, 
teeth and emunctories, the hygiene of marriage so far as regards age, and the intensifi- 
cation of hereditary diseases. 
Then the hygiene of dwellings and of occupation, heating, lighting, ventilation and 
drainage, adhering closely to the few principles that are practically beyond cavil. 
The final chapters should be devoted to public sanitation and the duties of citizen- 
ship that pertain to overcrowding, water supply, sewerage, surface and subsoil pollu- 
tion, pollution of potable waters, communicable diseases, vaccination, quarantine, etc. 
Sexual hygiene is of primary importance, and elementary knowledge begins to be 
applicable at puberty, that is, as a rule, near the end of the common-school course. 
But, for obvious reasons, I would suggest two supplementary chapters meeting the 
special needs of the sexes respectively, for the use of parents in the proper education of 
their children. Long before the States could be induced to lay aside prudery suffi- 
ciently to attempt the control of inevitable prostitution in the interests of the innocent 
victims of lust, who outnumber the sinners a hundred fold, it ought to be feasible to at 
least bring the sources of information within the reach of young men before it is too 
late. I mean at the age when the arts of the prostitute are most alluring, and when 
seventy-five per cent, of these willing lads are about to follow ignorantly after her, 
"straightway as an ox goeth to the slaughter." 
Then is the time, if ever, to enforce the fact that much of the prevalent disease that 
goes by common names is in reality the concealed and direct result of syphilis ; to 
deny the tradition that gonorrhoea is but an inconvenient streak of luck ; and to show 
that from it frequently proceed the strictures and prostatic diseases of later years; rheu- 
matic troubles of various kinds, and, saddest of all, much of the uterine and pelvic 
suffering of those innocent and confiding women who themselves bring to the altar all 
purity and good faith, and who, alas! can learn of no impediment. 
The bearings of this work on conduct and our duty as men and citizens should be 
conspicuous on every page, and this should be its strong claim to public recognition. 
The advantage of a special instructor in connection with or independent of a text- 
book are obvious. In the public schools particularly there is need of an expert physi- 
cian, as in the Belgian system, to act as a health inspector and adviser, as well as gen- 
eral manager of health instruction. On the other hand, it is safe to assume that in 
elementary schools, whatever children generally should know and feel, adult teachers 
generally ought to be able to impart. The claim is measurably true that ' ' the normal 
school lies at the very basis of national safety and prosperity ;" and the immaturity of 
its graduates warrants any reasonable occasion, such as this, for further delay in sending 
them forth. 
Public Libraries.-Closely allied to the work of the continuation schools are the SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
453 
public libraries scattered throughout the land. Here is a powerful educational instru- 
ment well nigh turned over to mere transient amusement. Strong indeed as is the 
passion for trashy books, yet the people should have a chance to read good ones. It 
should be made easy for people to brush against the very best. Let the public library 
elevate the public taste, not the popular clamor drag down the management. 
Colleges.-A constant adjustment of college education to the life needs of its recipi- 
ents has been tardily going on, and the resultant tendencies are marked by a liberality 
and freedom heretofore undreamed of. The inductive sciences have come into promi- 
nence in consequence of this adjustment, and in recent years biology has come to the 
front as one of the best expressions of the principles underlying, not only life, but con- 
duct. Taught as the classics are taught, as mere book-lore, these sciences have indeed 
failed of the whole effect that was expected of them-of strengthening the faculties, 
of promoting keener observation, and quicker and closer adaptation to the exigencies 
of real life. Improved methods of teaching will doubtless enhance the net gain ; but 
we are doubly gainers by every advance in the selection of sciences which not only 
humanize our learning, but also bring its data more nearly within our actual experi- 
ence. Dealing with the guidance of personal action in daily and practical life, and 
with the moral and political bearings of conduct and a large class of apparently indif- 
ferent activities, sanitary science deserves to rank among the highest kinds of learning 
which society must utilize to its own integrity, and which it is therefore the duty of 
the State and of its representative institutions to encourage and enforce. 
In the sense in which the technical sciences are special studies, sanitation also is 
destined to become a special department of practice as soon as a demand can be created 
for expert assistance. But elementary and widespread intelligence must necessarily 
precede this demand, and hence college work lies at present with the undergraduate 
departments. At first, elementary instruction should be attempted in college and 
common schools alike. Later, when students enter with some preparation in this 
branch, it should take its proper place among the other advanced courses which it is 
the province of a college to follow into their higher and wider applications. 
The University.-Any adequate treatment of the subject from the university stand- 
point would include :- 
1. An enthusiastic specialist, free from the distractions of manifold and remote 
duties and interests. 
2. A collection of typical sanitary appliances and materials for experiment, which, 
with excursions, would facilitate a full demonstration of the principles and details. 
3. A well-stocked sanitary library, which, in America, is one of the rarest 
advantages. 
This outfit could not only form the nucleus of a special department for all who 
might be desirous to pursue systematic study with abundant facilities, but its relations 
with the professional schools should be intimate. Here the medical students, pre- 
sumably familiar with the personal applications of physiology, might inquire into the 
technical and public aspects of the subject. Doctors, as a rule, are lame in the details 
of mechanical appliances. Both they and the public generally are eternally referred to 
books and pamphlets, when they need to examine and witness the action of appliances. 
Here the civil engineers might readily supplement their mathematical and mechan- 
ical training with ætiological, histological and other studies essential to an intelligent 
treatment of many municipal engineering problems. 
Architects, ministers, lawyers, and those who contemplate divers other avocations 
would be sure to find something applicable to their particular needs, for the element of 
health enters into trade and manufacture, into architecture and sermons, pedagogy, law 
cases and legislative enactments. 
The Press.-Passing now from agencies mainly educational to those which must ever 454 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
be potentially so, we have to consider, first, the wide influence of a cheap press, osten- 
sibly devoted to spreading the news, but in reality wielding a mighty authority over 
the masses, to whom the newspaper comes as the infallible gospel of the hour. Selfish 
commercial and political chicanery, or worse, the mere whim of the despot who occupies 
the editorial chair, too often determines the nature of this influence. The animus is not 
infrequently obscure. One often waits for weeks and months before the announcement 
of a commercial or political move, or perchance an accidental circumstance reveals the 
policy at the bottom of some bland news item or editorial professedly in behalf of the 
beloved people. 
These editors please themselves as to what the public shall or shall not know. They 
will get a community all torn up over any and every scheme that suits their ideas, and 
they will also garble, abbreviate, ignore or cold-pack any contribution or utterance, on 
the slightest provocation. 
This thraldom to partisan or to petty motives extends even to the selected miscellany. 
Not long since, when an associated press applied for the admission of their reporter 
to the sessions of the "Connecticut Academy of Arts and Sciences," the storm 
of spontaneous opposition that instantly overwhelmed the proposal left a sad after- 
thought concerning the diffusion of knowledge. It was shown, however, that the only 
interest the applicants had in scientific discussions was to get copy, to reduce science to 
bombast, and to make sport or spurious erudition for their patrons. 
But when the worst has been said of journalism, we must ever return to it with 
forbearance and with hope, as to one of the grandest instrumentalities for popular enlight- 
enment. When the press emulates the standard set by its better representatives, public 
health stands ready to purify its columns. I do not mean that the mortality tables of 
the rural districts, or the ordinary reports of the doings of health boards could be of any 
use to the general reader. But once let a paper undertake to really boom local sanitary 
problems, or to ventilate the question in a general way, and the public would soon get 
a liberal education, with class day and diploma thrown in. It has been truly observed 
that " the damnable iteration day after day of earnest conviction wears like the dropping 
of water upon the stone." Once discard the legends of miraculous cures, mon- 
strosities, snake and lizard ejections, and so on, and substitute therefor the wonders of 
science which really exist, and the press would soon have an inquiry and contribution 
department that would be a credit to the intelligence of journalism and of its patrons. 
Boards of Health.-Some nicely gotten up annual reports of State Health Boards are 
regularly circulated among the physicians and influential tax payers of our communi- 
ties, for obvious reasons, but their contents, meagre though they be, seldom reach beyond 
the select few. Now, in view of the hampered condition of these public benefactors, 
bound hand and foot by limited and uncertain jurisdiction, it would seem rational, in 
accordance with a well known law of moral dynamics, that this pent-up wisdom should 
frequently find vent in the public prints, in the shape of matured discussion and 
valuable contributions to the general stock of information. 
The Pulpit.-Theoretically, it is urged with great vehemence in certain quarters, that 
there is an irreconcilable antagonism between the doctrine of a divine special providence 
as it is generally conceived of, and the opposite doctrine or induction of an established 
order never interfered with. The Bible itself seems to be hopelessly contradictory on 
this point, although evidencing a preponderance of belief in a divinity frequently 
repenting his own established plan and varying it for the purpose of occasional revenge, 
chastisement, or reward. Practically, however, ministers of wide and unexceptionable 
reputation unhesitatingly assure me that they could easily reconcile these discrepancies, 
and could conscientiously teach that physiological law is part of God's law-that for a 
person to endanger his own or another's health, or for a community to do likewise, is a 
sin against God. Nevertheless, one frankly confessed the difficulty with such teaching SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
455 
to be, that where there is one member of a congregation intelligent enough to understand 
the operation of secondary causes, nineteen would construe his sermon as a profane 
limitation of the God-like prerogatives. He admitted that about once a year he him- 
self preached a sermon directing attention to the origin of much sickness, distress and 
consequent irritability and wickedness, in ignorance of and disobedience to physiological 
law, but he always felt obliged to intersperse some evidence of the fatherly interference, 
for the benefit of His favored ones and for the glory of His name. 
At the death-bed, and when the harm is done beyond repair, what alternative, 
indeed, is there, but the lesson of patience and readiness for the inevitable fate that 
awaits us all ? In his contact with the bereaved and the ruined, it would afford vain 
comfort for the dominie to insist on the lesson of disobedience, even if, indeed, the 
lesson were tolerated. But in the pulpit the personal element disappears; at all events, 
when the scourge is rife in distant places, or when the preacher can take a text nearer 
home without directly exasperating any of his parishioners, he need lose no opportu- 
nity to brand the avarice or the stupidity that precipitates public distress or private 
wreckage as he believes it should be branded, a crime-a case where sanitary science 
overlaps the province of morals and extends the significance of both. 
What the confessional is capable of as an educator may readily be inferred from the 
extreme latitude of the topics dealt with. Devout Catholic women, whose physicians 
have enjoined separation a thoro for therapeutic reasons, have frequently admitted that 
the measure has been nullified by their confessors, who teach that it were far better to 
die from rapid child-bearing and exhaustion or to remain invalids, than to thus endanger 
the integrity of their marriage contract. 
Periodicals.-For persons of scholarly and scientific tastes, there is a generous peri- 
odic literature, which constitutes an arena wherein all sorts of questions of general 
import may be discussed; an instrument for advancing and spreading information on 
any of the interesting topics of the hour or of the age. As a rule, this literature is 
relatively poor in sanitary contributions as compared with others of an instructive 
nature. During the years 1884, 1885 and 1886, the following periodicals published a 
variable number of articles chiefly sanitary in tone : Harper's, 6; The Century, 6; 
The North American Review, 9; The Atlantic, 0; The Popular Science Monthly, 51 long 
and 55 short; Littell's Living Age, 4; The Contemporary Review, 5; The Nineteenth Cen- 
tury, 11. The figures alone suggest a very important work to be done here by reaching 
the few whose culture finally affects the many. 
The Novelist.-But it is to the creator of the really popular literature of the day-to 
the novelist, that the inspiration should come to rightly educate as well as to amuse. 
That light reading is an educator, far-reaching and powerful, is nowhere denied, but its 
uncoordinated and deleterious influence has provoked against it a hostility that is not 
sufficiently outspoken. Dazed with the excitement of this ephemeral and overwrought 
world of romance, the attention of its slavish devotees is observed to return only slug- 
gishly to the prosaic realities of life, and then frequently with an impaired power of 
self-control. Many bad features, however, could easily be overlooked, if the good 
elements were at all conspicuous, if there resulted on the whole higher ideals and more 
accurate information, but until discriminate indulgence is reduced to a fine art, or until 
the need for it becomes less urgent, discontent and indifference to duty will continue to 
be the principal lasting effects. 
Novelists, as a rule, are fair students of the bearing of medical science on their trade. 
When it is necessary to rid a story of characters at just the right time-when the 
flower must fade, or the fiend must dangle-or when provision must be made for the 
customary ante-mortem revelations, repentances, and codicils, the conscientious novelist 
is rarely at a loss for symptomatology and tolerable therapeutics also. 456 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Now, is there no place for prophylaxis in romance, to vary the tedious ruin and 
rescue that now overtakes everybody ? 
Is nobody shrewd enough to study and champion a cause which was grand enough 
to enlist the pen of Charles Kingsley ? 
Such an author might be assured of an ever fruitful source of inspiration and sug- 
gestion of novel, startling, pathetic and pleasing situations. In his excursions among 
the people for materials, he would look upon humanity from a unique standpoint, as 
advantageous as many another favorite one. With no forced nor far-fetched effort on 
his part, his stories, or some of them, in his own characteristic style, would indicate a 
deeper insight into human nature, and 'nto the romantic, tragic, and even comical 
situations growing out of the operation of nature's inexorable laws. 
If faithfully pursued, these studies would furnish yet another evidence of conscious 
social worth, aside from the author's money valuation of himself. He would find the 
new ideas shading into and completing other social, moral or political phases of his 
book, and the latter would, in consequence, approach a perfection, and win a corres- 
ponding appreciation not otherwise attainable. 
I have striven to show that the burden of popular enlightenment is distributed; 
that no one of its many agencies has a monopoly, and that the sanitary function of our 
educational resources is not sufficiently emphasized. Above all, I hope I have shown 
that the prospect of general intelligence in this, that is so vital to efficient manhood and 
social stability, is not solely dependent on any book or any specialty, but is founded on 
the possibility of making some aspect of the problem an integral part of many of the 
living issues of the time; and finally, on the possibility of attaining the desired com- 
pass, symmetry, and moderation during the pre-adult age of education. 
DISCUSSION. 
Dr. Yates, Oldham, England, congratulated the essayist on the value of his 
paper and the breadth of his ideas, and stated that the subject was of primal 
importance to the people of all countries, old or new. It was essential that all proper 
education should begin as early as possible. Education, whether good or bad, com- 
menced with the first hour and only terminated with death. Proper training and 
the teaching of sanitary truths should not be delayed till adolescence and adult age, 
but should begin al) initio and continue through life. Hitherto hygiene has been 
very much neglected as a specific branch of education. Nevertheless, in our own 
country the Ten Hours' Bill, and more recently the Public Health Act, may be cited 
as evidence of the progress of public opinion in the direction of sanitary reform. 
The operation of those acts has been most beneficial, both in the prevention of prac- 
tices formerly prejudicial to the public health, and in the compulsory enforcement 
of provisions designed to abate or remove insanitary conditions. Nevertheless the 
progress of sanitary education is slow, for the supineness and ignorance of the many 
and the active hostility of the self-interested few have for long ages offered an almost 
invincible barrier against progress. He concluded by congratulating the sanitary 
reformers of the United States on their intelligent labors, and wished them signal 
success in their work. 
Dr. R. C. Davis, of Seneca, S. C., in discussing the paper of Dr. Leighton, said: 
The subject is a vast one. It is truly of first importance. Sanitary education is 
fearfully neglected, especially in the southern portion of the United States. Our 
schools and colleges seldom teach it. Our young men and women have their minds 
taught while the body is greatly neglected. Hundreds of our youth are ruined and 
disabled for life by lack of proper care and sanitary instruction while attending schools SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
457 
and colleges. Then this subject must always be before our minds. Our ever}7 effort 
should be made to have sanitary education taught in every school and college. 
Dr. Schenck, of Kansas, said : It is gratifying to those of us who are growing gray 
in the profession to find our young men giving us as interesting papers as the one 
just read, upon the grandest, noblest theme in medicine-the prevention of disease 
and the most perfect attainable development of the physical, intellectual and moral 
forces in man. Those of us who have labored in this field know full well its diffi- 
culties in America. Across the water it may be different. Here all power emanates 
from the people. The legislator is elected by the people upon some issue foreign to 
State medicine ; but he no sooner receives the franchises of the people than, like 
Minerva, he springs from the brain of Jupiter fully fledged. Utterly ignorant an 
hour before, he now knows all about State medicine, and is restive under any inti- 
mation to the contrary. Public and international hygiene must be taught in our 
schools, thoroughly taught ; the people must be educated, and the legislator informed 
on this subject before he becomes a legislator. 
In Kansas we require hygiene and the action of alcoholics to be taught in every 
department of the public schools-but, alas ! how little do the teachers know; and 
have we not " heathen nearer home " ? How little do the doctors know ; how little 
interest they feel, is manifest by the barely two score present in this Section out of 
the 2500 present at this Congress. 
Let us labor, and labor earnestly, to awaken an interest in the profession in pre- 
ventive medicine commensurate with its importance. 
A. Hazlewood, Grand Rapids, Mich., considers the subject of supreme import- 
ance. The difficulties are many, in carrying out the teachings of the essayist. The 
difficulties have been somewhat described by the last speaker. The teachers in our 
public schools are yet unable, from lack of knowledge, to carry out the law which 
directs that sanitary laws shall be taught in all schools. Our school boards are, as a 
rule, yet uneducated in the science of sanitation, even in its simpler axioms. Recog- 
nizing these difficulties, the State Board of Health of Michigan have inaugurated 
and maintained for some years a plan of holding sanitary conventions at intervals of 
a few months, at different points in the State, where essays are read and discussions 
held upon subjects more or less local, viz. : the water supply and sewerage of the 
town where the convention is held, and other subjects of personal hygiene, food 
preparation and adulteration are discussed. 
It is to be hoped that this subject will be well discussed, and some practicable 
measures be suggested, which will enable us to have the children educated in such a 
manner as to develop a sound mind in a sound body, and thus enhance the well-being 
of society. 
Dr. George Troup Maxwell, of Florida, made extended remarks, advocating 
the necessity of physical training in education, and a methodical system of regular 
intermissions during the daily periods of study, and detailed his experience in refer- 
ence to systems of education during his term of service in the school board of the 
State of Delaware. 458 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
A PRACTICAL AND COMMON-SENSE VIEW OF PUBLIC AND 
INTERNATIONAL HYGIENE; THE IMPORTANCE OF THE WORK; 
WHAT IS PRACTICABLE ; THE NECESSITY OF HARMONY AND 
UNIFORMITY OF ACTION AMONG THE STATES OF THE 
REPUBLIC, IN ORDER TO MAKE EFFECTIVE THE WORK OF 
THE INTERNATIONAL MEDICAL CONGRESS TO PREVENT 
DISEASES AND EPIDEMICS. 
UNE VUE PRATIQUE ET SENSEE D'HYGIENE PUBLIQUE INTERNATIONALE; 
L'IMPORTANCE DU TRAVAIL; CE QUI EST PRATICABLE; LA NECESSITE DE 
L'HARMONIE ET DE L'UNIFORMITÉ D'ACTION PARMI LES ÉTATS DE LA 
RÉPUBLIQUE AFIN DE RENDRE EFFICACES LES EFFORTS DU CONGRÈS 
MÉDICAL INTERNATIONAL POUR PREVENIR LES MALADIES ET LES ÉPI- 
DÉMIES. 
EINE PRAKTISCHE UND VERNÜNFTIGE ANSICHT ÜBER ÖFFENTLICHE UND INTERNA- 
TIONALE HYGIENE; DIE WICHTIGKEIT DES WERKES; WAS THUNLICH; DIE NOTH- 
WENDIGKEIT HARMONISCHER UND GLEICHFÖRMIGER HANDLUNG UNTER DEN 
STAATEN DER REPUBLIK, UM DAS WERK DES INTERNATIONALEN MEDICINISCHEN 
CONGRESSES ZUR VERHÜTUNG VON KRANKHEITEN UND EPIDEMIEEN WIRKSAM ZU 
MACHEN. 
BY URIEL R. MILNER, M.D., 
Of New Orleans, La 
Æsculapius was worshiped by the ancient Greeks "as the god of medicine and the 
patron of physicians," and in the Homeric poems he is styled the "blameless physi- 
cian," whose sons were serving in the Greek army before Troy. In the temples of 
Rome the Æsclepiadæ, or children of this famous god, held an hereditary priesthood, 
and were the only regular physicians; but in the course of time they took pupils, and 
initiated them into the mysteries of medicine. 
Hygeia was the virgin goddess of health and daughter of Æsculapius, whose flowing 
garments and smiling face, feeding a serpent from a cup-emblematic of divine wisdom 
and beneficence-fitly represents the divine wisdom of hygienic scientists of to-day. 
But it is different to-day from then. Now, when pestilence sweeps over our 
land, bearing in its dark embrace the pointed shaft of death to the sacred shrines and 
hearts of thousands who were, but a day before, prosperous and happy, or when epi- 
demics suddenly spring forth in great cities, stretching out their dark wings and hover- 
ing, like a funeral pall, over the inhabitants, we call not for the sacred serpents of 
" Epidaurus," to appease the wrath of the gods and heal the sick, but we send for the 
best disinfectants, the best physicians and well-trained nurses. 
The thing is upon us-it is too late now ! All that we can do is to save, as far as 
we can, human life. The pestilence is raging; we cannot check the storm; we may 
prevent accretions to its death-loving maw-rising from the sick room and from ordure 
and from cesspools-by cleanliness and disinfectants, and sweeping the banquettes, and 
flushing continuously the gutters and streets with pure w'ater, to stop the exhalations 
of that poisonous effluvia which was, perhaps, the main cause of the pestilence. 
But when the raging storm is upon us it is too late to attend to those long-neglected 
sanitary matters which, if they had been attended to, would have prevented the pesti- 
lence-such as grading and draining the city, instead of having foul slush pools and 
stagnating ditches, falsely called sewers ; and such as compelling every property owner 
to have his property surrounded by stone or brick banquettes, instead of decaying and 
rotting plank, etc. It is in the time of health and prosperity that cities should fortify 
themselves against the encroachments of disease and pestilence. SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
459 
This exordium brings me to the consideration of the importance of Public Hygiene, 
which we shall view in two aspects: Firstly, local; secondly, public. 
By local hygiene I mean its application as a scientific art to all inhabited localities, 
whether in the rural districts, villages and incorporated towns of the country, or in the 
great cities of trade and commerce. 
The importance of understanding hygienic science as to the behavior of effluvium 
will be illustrated by the following example :- 
About forty years ago I knew a planter whose plantation lay on the Cahawba river, 
Alabama. He had lived for many years upon the eastern bank of the river, and his 
residence and plantation houses were built upon ground sufficiently high above the 
bottom lands to give him good natural drainage. Here his family were healthy and he 
was prosperous. He owned a beautiful building site on elevated ground on the west 
side of the river, where he built himself a palatial residence replete with all the con- 
veniences of modern life, and surrounded by every attraction that wealth and cultivated 
taste could procure. To this new home he brought his family, full of bright hopes of 
enjoying life in full view of his fertile fields across the river. But how sad the sequel. 
Soon the whole family, one after another, were stricken with malarial fever, and they 
were finally compelled to abandon the place. What was the matter ? In their plain 
plantation home on the east side of the river, right in the jaws of the river bottom, 
they were scarcely ever sick ; but here they were continuously sick. The reason 
is this : In their plain plantation home the vapors and exhalations from the paludal 
soil, under the influence of the morning sun, were carried above their heads and wafted 
on ; but in their elevated palatial residence on the west bank, it hovered over and 
setttled upon them. 
Now it is doubtful whether there are any hygienists who would have condemned 
this site before the experiment had been made; but, having been made, the fact becomes 
a unit and a factor in scientific hygiene and sanitary work, and is therefore valuable. 
It shows the importance of not only inspecting the surroundings of proposed sites for 
private and public buildings with the eye, but the necessity of analyzing the atmo- 
sphere to determine what effluvium may pollute it, and to learn its character, nature 
and source, and whether or not it can be certainly destroyed. And it also points to 
the necessity of having well-educated, scientific hygienists who may be consulted and 
employed for this purpose. Local hygienic science should be applied to the proper 
location and construction of buildings in the country, and to the drainage of farms and 
plantations. And when public hygiene, to which I shall soon specially call your atten- 
tion, shall have gained that hold upon the popular feeling and heart of the country 
which it is destined to attain, there shall scarcely be found a habitation in the country 
where health shall not bloom perennially. 
The towns and villages of our rural districts are scarcely ever visited by pestilence or 
epidemics, because they have good pure water from springs or wells, healthy atmo- 
sphere to breathe, not being contaminated with an excess of carbonic acid, as is the 
case in crowded tenement houses ; and they are comparatively isolated from contagious 
and infectious poisons because these prefer the big cities along our sea coasts and the 
banks of our great rivers. Let these villages and towns keep clean, avoid excremen- 
titious accumulations, and the fouling of springs and wells, attend to their surround- 
ings by ditching, draining, and bringing into cultivation all of their paludal lands, 
and they need never be sick unless they are indiscreet in food or clothing. There is an 
old adage that says " there is no rule without an exception." To this I demur. Truth 
has no exception. From a clearly demonstrated problem there is no escape. The 
absolute laws of nature are immutable, whether as observed in the harmonious revolu- 
tions of mighty suns and systems, or in the evolution of a protoplasmic germ cell into a 
man or into an elephant. Therefore, rule, if it means a fact or a law, has no exception. 460 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
If rural communities would perfectly obey the laws of hygiene, particularly by 
providing against local causes of disease, they would certainly enjoy an immunity from 
epidemics ; but only in this way can they be exempted from the danger of epidemical 
visitations ; and by the experience of the past they should take timely warning. We 
shall point the above admonition by the following examples : In the year 1851, an 
epidemic of typhoid fever raged with virulent and destructive effect throughout middle 
Georgia, scourging all the plantations of my section, and did not stop its ravages 
there, but from South Carolina to Texas it swept the country. This epidemic of typhoid 
fever did not die out for three years. About this time the disease became gradually 
sporadic. In those days local sanitary measures were almost wholly neglected on the 
plantations. The quarters of the negroes were filthy, and they were often crowded 
with their families into very small huts. There was one ruling idea among the mas- 
ters and planters of that day, ' ' to make more cotton, to buy more negroes to make 
more cotton." This idea seems to have excluded everything like a well-ordered system 
of sanitary regulations, which should have formed a part of their moral and religious 
code for the government and protection of the health and lives of their slaves. 
The matter of astonishment is that the rural districts in those days were not more 
frequently scourged with virulent diseases. There can be no doubt that this epidemic 
sprang from local filth, whatever the germ may be, and might have been prevented by 
wise and timely local sanitary and hygienic means. In this connection I take pleasure 
in referring to the graduation thesis, "The Spontaneous Origin of Diphtheria and 
Typhoid Fever," by J. M. Wellwood, M.D., Tulane University of Louisiana, Medical 
Department, 1887, published in the New Orleans Medical and Surgical Journal, August 
number. Dr. Wellwood gives a graphic account of an outbreak of typhoid fever in the 
town of Minnedosa, on the little Saskatchewan river, Canada, in the spring of 1881, 
caused by rotting potatoes in a cellar which had. been flooded by an overflow of the 
river; and of an outbreak of diphtheria in the same locality in the autumn of 1882, 
caused by "using water from a shallow well supplied with surface water, and in the 
direct line of drainage from the stables;" and another of diphtheria in the winter of 
1884-5. The Doctor says: " The water supply was good, but the family was large and 
crowded together in a poorly-ventilated, hot room, which was used for every purpose; 
and what was worse than all, they had a large barrel of pig feed, which they kept near 
the stove to prevent its freezing; into this they were in the habit of pouring dish wash- 
ings, sour milk, and other refuse matter mixed with bran. This was found in a state 
of fermentation, and was, doubtless, the cause of the trouble." Hundreds of instances 
like these could be collected in this and all other countries, proving the indigenous 
origin of most of our contagious and infectious diseases, and that the best means of 
preventing them is the execution of a wise and vigorous system of local sanitary laws. 
Everybody has a right to healthy atmosphere and good water, and it is an offense 
against the common rights of man, by individuals or by communities, for them to live in 
such a manner as to pollute either the air they breathe or the water that they or others 
drink. Our exotic diseases are very few indeed, and it» strong laws were enacted and 
executed, compelling local cleanliness in the rural districts, towns and cities of the 
States, exotic diseases would never take root. Now, what is needful for preventing 
diseases and securing health and prosperity for our rural districts, villages and towns, 
is still more urgently demanded for our great emporiums. 
And I shall offer the following rule for forming a pretty clever idea of the sanitary 
condition of any city: The differences in topographical and climatic conditions of the 
great cities of the world and the influence which these exert upon the healths and lives 
of a people being known, the percentage of deaths in any city will enable us to deter- 
mine approximately how clean it is. Everything should be kept clean in great cities; 
the banquettes should be made of stone or brick, and daily swept; drainage should be SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
461 
made perfect, and the sewers should never be allowed to contain stagnating water; the 
streets should be paved with enduring substances; all houses should be built upon dry 
and elevated ground, and perfect drainage from them into the sewers should be made 
imperative. Damp and wet cellars and crowded tenement houses should be equally 
forbidden. The water for drinking purposes should be pure; and there should be an 
abundant supply for flushing the streets. There should be no foul cesspits allowed 
within a city's limits; and the refuse from kitchens, stables and markets should be 
removed daily and consumed in such manner as to prevent foul effluvia. All of these 
things should be enforced by the strong arm of the law and backed by the money of 
the people, and then we shall have an atmosphere so pure and invigorating, and a 
population so vigorous, healthy and happy that they would enjoy perfect immunity 
from all infectious diseases. And will it pay? That is the all-absorbing question of 
this railroad age as to any business or enterprise. Will it pay ? 
I know of no city in the United States where hygienic science has been utilized to 
the perfecting of sanitary work; but Chicago, having the lowest death-rate of any city 
in this country, and considering the fact that she is, perhaps, the largest meat-packing 
centre and fruit mart of the West, we logically conclude that she has the best sanitary 
regulations of all, and is the cleanest of all. I mean no reflection upon this great and 
beautiful city, nor upon Philadelphia, nor upon any other city, but we must adhere to 
our rule. While Chicago has yet much to do in a sanitary regard, what she has done 
has certainly paid. Now, Mr. President, as to our city of New Orleans. 
The great problem now before our people is that of drainage. The difficulty is to 
get a sufficient fall for our sewers and canals, from the river to the lakes. 
Several of our eminent engineers have offered plans showing that the perfect drain- 
age of New Orleans is practicable, that it can be accomplished, but that it will require 
a tremendous outlay of money, and the city is financially embarrassed. Thus, we are 
left sitting upon the ragged edge of uncertain hope and desire, exposed as much now to 
an outbreak of yellow fever epidemics as we have been for the last sixty years. If yel- 
low fever, with us, was an exotic due to importation, then it should never have raged 
in our midst, because our quarantine laws have been rigidly enforced from the days of 
Governor Robertson, more than sixty years ago, down to the present time. The Gov- 
ernor became so'despondent as to say, in his message of 1822: "The State resorted to 
quarantine under the expectation that it would add to the chances of escape from this 
dreadful visitation. If this hope be fallacious, if no good effect has been produced, 
if even a procrastination of its appearance has not resulted from the measure, then it 
should be abandoned and our commerce relieved from the expense and inconvenience 
which it occasions." But the fact is, yellow fever is a home product, it is indigenous 
with us, which fact is proven from the records of its history, from the first epidemic in 
New Orleans, 1796, to the last one in 1878. 
Dr. Thomas (Essai sur la Fièvre Jaune, p. 70), says that the epidemic of 1796 was 
caused by the exposure to the solar heat of a large extent of marshy land in the work 
of ditching and fortifications ordered by the Spanish Baron Carondelet, then Governor 
of Louisiana. 
The great naturalist, Humboldt, held that yellow fever is indigenous in the countries 
where it prevails; but it is not my purpose to argue this question in this place. I have 
only alluded to it in its bearing upon local hygiene, especially in the city of New 
Orleans. I affirm that our only chance to escape epidemics is to remove the cause, no 
matter what the work may cost; and it is perfectly practicable and will pay better than 
any other investment to which capital can be applied in our city. Indeed, if it were 
for no other object than for comfort, the city that does not give its inhabitants good 
banquettes, good streets, drainage, pure water and a healthy atmosphere, belongs rather 
to a barbaric age than to the present progressive civilization. 462 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
We now pass to the consideration of Public Hygiene in a more general sense. By 
public hygiene, I mean not only the central gearing of the machinery of sanitary order 
and health, represented by the State Boards of Health, the American Sanitary Associa- 
tion and their auxiliary bodies, etc., but also the application of this science as an 
important elementary branch of common and public school education, from which those 
who would become teachers may ascend to collegiate classes in our universities and 
medical colleges. 
The order of nature and the harmonious rhythm of the universe teach us the neces- 
sity of order and harmony in all public work. Many of the State Boards of Health have 
disagreed in matters concerning the public health, and every disagreement of this kind 
injures the public confidence and retards the work which these boards are legally con- 
stituted to perform, and for which this International Medical Congress, embodying the 
wisdom of the most learned and advanced thinkers and scientists of the civilized 
world, has assembled at this great Capital to-day. 
It may be that the local sanitary work of these boards may not be much interfered 
with by little jarrings among themselves, but there is a grander aim, far-reaching in its 
scope, embracing not only single States but all of the States, and that is to infuse into 
the minds of the people an intelligent comprehension of the real value of public 
hygiene to the whole country. Hence, it is of the first importance to have the funda- 
mental principles and doctrines of public hygiene defined, and to become the guide 
book, the constitution and laws, so to speak, of the boards of health of all the States. 
In this way there would be a concert of action in every important measure. The 
medical associations of States and societies of cities and counties would act in concert 
with the boards of health upon recognized fundamental principles of hygienic science, 
and a power would be accorded to the medical profession which would be acknowledged 
in all of the State legislative assemblies and in the national councils of the country. 
Our profession would, indeed, rise to the dignity and importance of being the guardian 
of the public health. It would be recognized as a power in the government whose 
counsels should be heeded. Its well-advised measures for public sanitary work 
would receive such State and National aid as would make it a success, and sanitary 
improvements would finally master all preventable diseases. But, again, this recog- 
nized merit and value of our profession by the people at large would awaken an inter- 
est among all intelligent people in hygienic science and lay the foundation for a new 
era in the education of the children and youth of the land. 
And when hygiene in its elementary branches shall be taught in our public schools, 
professorships for this science will be demanded in every university and medical col- 
lege of the country. To build the temple of public hygiene to its grandest propor- 
tions and greatest usefulness, we must lay its foundation in the hearts of the mothers 
of the country and at the threshold and sacred shrine of infancy. The mothers must be 
taught not to nurse their babies too often nor too much, and thus raise them up to observe 
hygienic laws, and they will unconsciously imbibe from their mothers' bosoms their 
first and most lasting lessons in hygienic science. It is an appalling fact that at least 
twenty-five per cent, of the deaths of children up to two and a half years old are 
caused by over-feeding. Their stomachs become so continuously distended with milk 
from the bosom or bottle, or from both, that the muscular fibres become paralyzed, aud 
the physiological function of contraction, motion aud secretion ceases altogether, and 
there is scarcely any absorption of nutriment. The stomachs of such children swing 
in the abdominal cavity like blown-up toy bladders, having their walls so thinned that 
digestion is simply impossible. 
Of course they have colics, and when they cry, the more they are fed the faster 
they are starved. Thus, we have cholera infantum, inanition, marasmus and all of the 
ailments of infancy. They are starved to death with too much food ! Here, then, we SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
463 
have a field for public hygiene which encompasses the human family, and, as a part of 
our philanthropic work, it appeals, with touching pathos, to our profession throughout 
the world. This International Medical Congress should send greeting and wise counsels 
to all the laborers in this field. It is an evil which has its source in ignorance of 
hygienic science, and can be overcome. The family physician can do more than any- 
body else, and the doctor should be not only the guardian, but the mother of the 
children. 
And if there should be a concert of action among physicians to instruct their clients 
in the matter of feeding infants, preventive medicine will soon have raised a monument 
for itself, even in this one work, more enduring than brass. Lithe, bright, beautiful, 
healthy children will gladden the home circles and sweeten the very air with their 
happy songs, spontaneously arising from the fountains of health. 
At this time, however, go wherever you will, you will meet with pale-faced, stub- 
born, feeble, fretful dyspeptics among the girls and boys, whose stomachs were so 
injured in infancy as to create morbid appetites which they cannot govern, and which 
have entailed upon them the miseries of confirmed dyspeptics. These depraved, dis- 
eased appetites lead them into all sorts of bad habits, and thousands of them become 
criminals or fill drunkards' graves. They become the wards of the government, in 
the asylums, poor houses and penitentiaries, and entail upon the country an enormous 
expense. Hence it would pay every State richly, in a material way, to have hygiene 
introduced into every public school and made a branch of common education. But in 
its moral aspect it is of greater importance. The State would raise up a strong and 
vigorous manhood and womanhood, imbued with the principles of self-government, 
and on this foundation the intellectual and moral faculties would grow and strengthen 
with the rolling years. Every succeeding generation would be stronger, more intellec- 
tual, and purer in moral sentiment and life than the preceding. The percentage of 
pauperism, of crime, and of drunkenness and other immoral practices, would daily 
diminish. The physical, intellectual and moral health of the parents would be trans- 
mitted to their children. Children would be born good, and the acme of a perfect civ- 
ilization might be ultimately reached. A generation of statesmen and rulers formed 
of such material as this, would give a momentum to intellectual, moral and material 
progress which would lift the depraved and ignorant out of the slums of beastliness, 
and make them good and profitable citizens. The pillars of society, resting upon such 
shoulders, would be as firm as the everlasting granite. 
I now pass to the consideration of the third division of my subject, International 
Hygiene. By international hygiene I mean those sanitary regulations at the empo- 
riums, upon the great thoroughfares of commerce between the nations of the earth, 
which will prevent the carrying of contagious and infectious diseases, preserve the 
healths of the traveling and emigrating masses, so that at no time will either travel or 
trade be much obstructed. 
In years past, so far as we have been concerned down South, quarantine was a system 
of public oppression. At every cry of yellow fever in any of the South American cities, 
on the Mexican gulf, or in the West India isles, or at any place along the borders of the 
Atlantic, or in a neighboring State, the boards of health of all the States were author- 
ized, and did at once institute, the most rigid quarantine regulations, preventing ships 
and steamers from landing their cargoes, and compelling them, with all on board of 
their vessels, to be retained for fifteen or twenty days, or even longer, at the quarantine 
stations to which they may have been ordered. Thus, the traveling public suffered the 
anguish of imprisonment for a long time, not to speak of their loss of time and money 
and absence from their families and the benefits of pure country air, of which they 
were deprived. The fact is, that yellow fever is indigenous where it prevails, and local 
sanitary work is the only remedy against its outbreaks. Its period of incubation is not 464 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
certainly known, and it is cruel to keep well people at quarantine, to see whether they 
are going to be sick. 
The uncharitableness of charging everything bad upon our neighbors is graphically 
alluded to by the great naturalist, philosopher, and historian, Alexander Humboldt. 
He says: "In all climates men appear to find some consolation in the idea that a 
disease considered pestilential is of foreign origin. As malignant fevers easily originate 
in a numerous crew cooped in dirty vessels, the beginning of an epidemic may be fre- 
quently traced to the period of the arrival of a squadron, and when, instead of attribu- 
ting the disease to vitiated air contained in the vessel deprived of ventilation, or to the 
effects of an ardent and unhealthy climate on sailors newly landed, they affirm that it 
was imported from a neighboring port where a squadron or convoy touched during its 
navigation from Europe to America." 
And I must here be permitted, in vindication of the truth of its indigenous origin in 
every place where it has prevailed, to refer in chronological order to the dates and places 
of its prevalence and to the authorities sustaining this view, from the year 1699 to the 
year 1878, which was collated by Dr. J. C. Le Hardy, of Savannah, Georgia, and made 
available in my pamphlet on " Quarantine and the Indigenous Nature of Yellow Fever," 
published in the year 1880. Dr. Le Hardy commences with La Roche's great work on 
yellow fever, and shows the domestic origin of yellow fever in the city of Philadelphia 
in the year 1699, 1793-'7-'8-'9, and in 1805-'19-'20, and in 1853. And of all of the 
epidemics of this longtime in New York, Boston, Baltimore, Pensacola, etc. 
Dr. Drake, in the " Topography and Diseases of the Valley of the Mississippi," gives 
full evidences of the local origin of the disease in New Orleans from 1791 to 1843, 
inclusive. 
Devezé gives the same opinion (" Traité de la Fièvre Jaune," Paris, 1820, page 311). 
Condie, Folwell and Potter confirm this view. 1798, New London, Holt says it was of 
local origin. The Medical Repository, page 217, Richmond, records that its outbreak in 
the penitentiary of Virginia, 1806, was of local origin. 
The same cause for this dread disease is confirmed as follows :- 
By Campbell, 1817, Charleston, S. C. 
By Watts, 1819, Mobile, Ala. 
By Merrill, of New Orleans, Bay St. Louis, 1820. 
By Dr. Daniell, 1817, 1820, Savannah. 
By Dr. Waring, in Report to City Council, 1820, Savannah. 
By Dr. Hill, Medical Recorder, 1821, Wilmington. 
By Strobel, 1821, St. Augustine. 
By the Memphis Medical Journal, 1823, Natchez, Miss. 
By Dr. Hort, "New York Quarantine Reports," 1825, Florida. 
1826, Apalachicola, " N. Y. Quarantine Reports." 
1837-'39-'43, Mobile, by Dr. Nott, N. O. Journal of Medicine. 
1838, Charleston, by Gaillard. 
1839, St. Augustine, by Monette. 
1840, Augusta, by Uriel R. Milner, N. O. 
1842-'49-'52, Charleston, by Simmons. 
1853, New Orleans, by Dr. Hort, "New York, on Quarantine." 
1853-'4-'5, New Orleans, by E. H. Barton, "Report of Sanitary Commission." 
1853, Houston, Texas, by Ashbel Smith. 
1854, Charleston, by Dr. W. Wragg. 
1854, Philadelphia, by La Roche. 
1854, Charleston, by "Mayor's Report," Dr. McKall. 
1856, Essay on " Bilious and Yellow Fever," page 9, by Dr. Arnold. 
1854, Ossabaw Island, by Dr. Warren. SECTION XV PUBLIC AND INTERNATIONAL HYGIENE. 
465 
1856, Philadelphia, "Six sporadic cases from domestic causes," hy Dr. Jewell. 
1858, Savannah, by J. J. Harris. 
1859, New Orleans, "Incontestably of local origin," by A. E. Axson, Official 
Report. 
1860, New Orleans, "Sporadic cases," by C. Delery, Annual Report Board of Health. 
1863-4, New Orleans : ' ' Yellow fever, the most dreaded scourge of New Orleans, was 
unequivocally generated in a large number (25) of filthy and un ventilated gunboats 
and other naval vessels lying idly at anchor within a mile of the densest portion of the 
city." E. Harris' Report. 
1864, Savannah, by Dr. Le Hardy. 
1866, "Its cause could not be traced outside of the city," by S. A. Smith. New 
Orleans, Report of Board of Health. 
1868-69, New Orleans : "Three deaths each year. The disease originated at home." 
Report of Board of Health. 
1870, New Orleans. "No direct connection with foreign importation was estab- 
lished." Prof. Joseph Jones's Lectures, 1879. 
1871, Charleston (212 deaths). "The origin of the disease could not be traced to 
foreign importation." Robert Libby. Report, H. O. 
1875, New Orleans (100 cases). "Started in the Second District. No trace of 
importation." Annual Report of Board of Health, 1876. 
1876, New Orleans (74 cases). "Careful examination by the President of the Board 
of Health, by the sanitary officers, and by myself, failed to discover in the first case the 
slightest clue to foreign infection from any ship, person, or material. This applies with 
equal force to the following series of cases." Dr. Joseph Holt, Sanitary Inspector, etc., 
and now President of our State Board of Health. 
1876, Savannah, by J. C. Le Hardy : "From local causes." 
Now, if this view of the origin of yellow fever be certainly established, and it becomes 
the doctrine of our medical colleges as a recognized principle of hygienic science, quar- 
antine will at once take its proper place and value in public and international hygiene. 
It will not be abolished, because it is an indispensable sanitary institution connected 
with, and an important factor of the machinery and laws for preserving, the public 
health, but subordinate to local sanitary work and improvements. 
The public mind will be withdrawn from it as a preventive of yellow fever and 
other diseases, and the energies of the people will be devoted to local cleanliness. The 
preventive work will be done mainly at home, while quarantine will take care of all 
infected vessels, receive the sick into the hospitals, disinfect the vessels, crews and 
passengers, and send them on their way rejoicing. 
Then there will be very little delay to the traveling public and very little detention 
and loss to commerce. And the stimulus thus given to the local branches of public 
hygiene will ultimately result in the eradication of all infectious diseases, and prevent 
epidemics everywhere. We shall then not be afraid to receive individuals fresh from 
the quarantine stations, knowing that in a pure atmosphere, with pure water, no infec- 
tious diseases can become epidemic or even dangerous. 
Vol. IV-30 466 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
EPIDEMIOLOGICAL NOTES ON DENGUE DURING THE AUTUMN 
OF 1883, IN BEYROUT, SYRIA. 
OBSERVATIONS EPIDEMIOLOGIQUES SUR LA GIRAFFE (DENGUE) PENDANT 
L'AUTOMNE DE 1883, À BEYROUT, SYRIE. 
EPIDEMIOLOGISCHE NOTIZEN ÜBER DENGUE WÄHREND DES HERBSTES 1883 IN 
BEYROUT, SYRIEN. 
BY JOIIX WORTABET, M. D., 
Of Cairo, Egypt. 
In August, 1883, it was reported from a town on the northern coast of Syria, Lata- 
kia, that they had an epidemic of dengue fever, which soon became so universal that 
very few escaped it. How it came there, or whether it originated on the spot from some 
local causes, seems to be unknown. From the fact that it was not heard of before in 
any other place which would account for its importation, it seems that we must take 
the latter view, and believe that it arose there de novo, from some ' ' climatic state ' ' or 
"atmospheric change," which the ancient physicians attributed either to telluric 
exhalations, or to some intrinsic change in the water held by the atmosphere itself, 
a change which is caused by some unusual condition of the season, and which they 
called by the general name of "the constitution of the seasons." Having once origi- 
nated, it seemed to spread to neighboring places by importation, as the sequel will 
show. 
It appeared in Beyrout about the beginning of September, and in two or three 
weeks spread through the whole town. In October it had become so universal that 
very few escaped it. During the summer many-probably not less than one-third of 
the inhabitants of Beyrout-had gone up to the villages of the Lebanon, either for change 
of air or for the cooler atmosphere, or from fear of an outbreak of cholera in the plains. 
As they returned in October most of them took the dengue. 
In the beginning of November we had a heavy storm of rain with much lightning 
and thunder, which continued two days and which did not appear to have any sensible 
effect on the epidemic-the disease still picking up persons who had previously escaped. 
On the 20th of the same month there was another heavy fall of rain, which continued 
for some days, but notwithstanding this there were fresh occurrences of the fever lin- 
gering through the whole month of December. 
From Beyrout the epidemic was propagated to all the neighboring villages at the 
base of the Lebanon, where it spread very much among the inhabitants; but it did not 
go up to any place higher than 2000 feet above the level of the sea, except in the case 
of persons who took it with them, but from whom it was not communicated to others. 
Like cholera, it seems to find no favorable soil for its extension in the high and dry air 
of the mountains. It spread also northward as far as Batrun (the ancient Botrys, a 
small town on the coast between Beyrout and Tripoli), and southward to Sidon, from 
which place it spread also to the low villages on the adjacent hills. In Sidon the dis- 
ease was so widely diffused at one time that, when a death occurred in the town, the 
burial could be attended to only with much difficulty. I have no certain information 
as to how far south the epidemic went, but I believe it reached Tyre and Acre. 
The former visitations of dengue, as far as they have been noticed in Syria and 
neighboring parts of the East, and as far as I have been able to find out, are as follows: 
It appeared in Syria for the first time in 1861, when it seems to have been as universal 
in Beyrout as it was in 1883. It again made its appearance in 1865, after the cholera, 
and again in 1867, and continued to reappear in the early autumn of 1868, '69 and '70. 
It is reported to have visited Cairo in 1779, 1801, 1835, and in 1845. Since then there SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
467 
have been slight epidemics of it at Cairo, in 1853 and in 1868. There were cases of it 
in Cairo in 1871, and it raged at Port Said in September and October of the same year. 
It was prevalent at Ismailieh in November, 1877, where it has continued to make its 
appearance every autumn since. Cairo aud other parts of the Delta were affected by 
it in 1880, beginning in July and increasing in intensity about the beginning of Octo- 
ber, when humidity is at its height in lower Egypt. I am not aware that it has ever 
appeared in the highly dry atmosphere of upper Egypt-a fact which, taken with 
others, would confirm the view that moisture in the air is a favorable, if not an essen- 
tial condition for the propagation of dengue fever. An epidemic of what now appears 
to have been evidently dengue fever prevailed over all Malta and Gozo in the autumn 
of 1878. The mode of invasion, the symptoms of the disease, its short duration, the 
eruption, and the subsequent debility, mentioned in the printed Report of a commission 
of medical men to the Governor, leave hardly any doubt as to the nature of the epi- 
demic. By a strange oversight it was not then recognized. It was probably brought 
from India with some ship, though the medical commission did not believe that it was 
contagious, and supposed that it owed its origin ' ' to local conditions or to a pandemic 
wave." A heavy fall of rain in the first part of September, followed by a protracted 
and excessive heat and moisture, and the prevalence of sirocco, they thought, materially 
contributed to the diffusion of the disease. 
The epidemic in Beyrout was almost absolutely universal. All the physicians of the 
town, with a single exception, had it-myself sharing the general fate. The premonitory 
symptoms, when the disease was not ushered in suddenly, were general lassitude and 
a falling off of the appetite for two or three days. The actual invasion usually began 
with a chill and fever, severe pains in the limbs, chiefly in the back and knees, frequent 
and full pulse, sleeplessness, and a coated tongue, with a very bad taste in the mouth. 
This continued generally for three or four days, when a red eruption appeared on the 
whole body, sometimes involving the face. On the appearance of the eruption the 
fever generally subsided, and the patient was considered convalescent, though there was 
often a slight rise of the temperature about the sixth day, which was generally unno- 
ticed. The convalescence was usually accompanied by much weakness, and this was 
protracted for some weeks in elderly or debilitated subjects. In a few instances there 
was a real relapse of most of the symptoms of the first invasion, though in a milder 
■degree, and probably without the eruption. 
In looking a little more closely to the main symptoms of the disease we have the fol- 
lowing observations to make: 1. The articular pain which has given this fever its spe- 
cial name-Dengue, a Spanish translation of the word dandy, by which it was called 
among the negroes of the West Indies, both words signifying a stiff gait in walking; in 
Syria it early received the name of ' ' Knee-fever, ' ' and in America it was called ' ' Break- 
bone fever. " All these names point to the pain, which affects chiefly the knees and lum- 
bar portion of the spinal column, and which is quite characteristic of this disease. I 
have never seen any swelling of the joints, though they are said to be sometimes swol- 
len and hot. Pain in the head was very frequent, especially during the first day of the 
fever, and often accompanied by severe pain in rolling the eyeballs upward, or on press- 
ing them with the fingers. 2. The fever generally continued from three to five days. 
Sometimes it and the other symptoms were so mild that the patient did not keep his 
bed ; but occasionally it exceeded the fifth day ; then the case was severer than usual. I 
had the temperature taken carefully in six cases in the hospital, morning and night, and 
it varied between 37.5° C. (99.5° F.) and 40.2° C. (104.5° F.) ; generally, however, a little 
higher in the forenoon than in the afternoon. It is said that in the dengue fever of 
India, after the subsidence of the fever, about the third or fourth day, there is generally 
another rise of the temperature about the sixth day, but this appears to have been rarely 
so in the Syrian epidemic. In only one of the hospital cases did I observe this rise- 468 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
private patients could not be watched so easily, as they left their beds or houses as soon 
as they felt better, and considered the ailment as too trivial and short to need much 
attention. 3. The eruption comes out over the whole body generally about the third 
or fourth day. In some cases it did not appear at all, in others it was the chief symp- 
tom in recognizing the disease. When it came out well it was generally supposed to 
indicate the complete subsidence of the disease, and the same critical relation of the 
eruption to the fever has been always held by the common people as true in the other 
exanthemata; but while this seems to be true in most cases, it is not so in every 
instance. The.eruption was not of one kind. It was generally papillary, like that of 
measles, slightly raised above the skin; sometimes it had a mottled appearance without 
any elevation, and occasionally there was an erythematous blush, like that of scarla- 
tina. In every case the color was more or less red. It was often attended by a 
pricking sensation, and ended by desquamation. The general constancy of the erup- 
tion and its appearance at a certain stage of the fever, followed by a decline of the 
symptoms, clearly point to the classification of dengue among the exanthematous 
fevers. 4. The digestive functions were almost invariably impaired to a very unusual 
degree. The appetite was completely lost, an extremely bad taste was felt in the 
mouth, and the bowels were always constipated. In a few cases there was much 
irritability of the alimentary canal with some vomiting and diarrhoea, which has led a 
few medical men to suppose that there are two varieties of dengue, called by them the 
rheumatic or gastric; but this is evidently a mistake, for the gastro-intestinal symp- 
toms were accidental, and were probably owing to a previous bilious state of the sys- 
tem. The same thing may be said of occasional pain in the throat arising from a con- 
gested state of its mucous membrane. 5. The epidemic was almost universal, sparing 
no age, from the infant at the breast to men in advanced life; and the same account is 
given from the other places in Syria which it has visited. But in no case could death 
be directly traced to it, though in some instances it seems to have stirred up to a fatal 
result some old or latent disease, or it may have acted as a predisposing cause of a sub- 
sequent and serious illness ending in death. The severest case I saw was accompanied 
by some delirium and a considerable amount of inflammation of the testicles, which had 
to be leeched. In some instances it was attended with sore throat and enlargement of 
the lymphatic glands of the neck. In one young woman it seems to have produced 
temporary insanity for a few days. As a general rule, the patient was confined to his 
bed only two or three days. Perspiration was always useful in mitigating the febrile 
symptoms and the attendant pains, but it was never so critical as in intermittent fever. 
6. One more point remains to be noticed, and that is the question of the infectiousness of 
dengue. The fact that it spread from an infected centre to the neighboring towns and 
villages, as we have shown in the early part of this paper, and that when it came into- 
a family it attacked all its members, with hardly an exception, one after the other, in 
the course of a few days, points very strongly to the belief that dengue fever is the 
most infectious of all diseases. I know hardly any instance in which there was expos- 
ure to it during its height of prevalence without the person succumbing to its influence 
of communicability. Mothers and nurses gave it to the youngest infants, who, with 
few exceptions, had the characteristic eruption. Sir W. R. E. Smart, who has exten- 
sively studied a number of its visitations and given a detailed account of them, says: 
" In the whole of this wide dissemination there was sufficient evidence of its infectious, 
if not of its contagious, properties. ' ' ( Transactions of the Epidemiological Society of 
London, Vol. IV, part I.) The medium of infection seems to be more the air than con- 
taminated water, but what this "contagium vivum" is, I could not discover. The 
examination of the blood by the microscope during the fever revealed no disease germs, 
though there was an alteration in the form of the corpuscles. The exposure of every 
one was so great and so constant that it is difficult to say what the period of incubation SECTION XV PUBLIC AND INTERNATIONAL HYGIENE. 
469 
•was. A few persons who took the infection with them to the mountain villages which 
were free of the disease, and did not fall ill before the tenth day after their arrival, 
would show that this was the utmost limit, though the usual time was probably not 
much more than two or three days. 
I have already stated that the epidemic in Bayrout began in September and ended 
in December, its height being in October; and from this and from the history of former 
visitations, and the fact that it has been hitherto limited to tropical and southern lati- 
tudes, viz., India, the West Indies, Brazil, the Southern United States, Egypt and 
Syria, Zanzibar and once Malta, and that at no time did it spread in villages of the 
Lebanon higher than 2000 feet, where the air is cool and dry, it would appear that the 
most favorable-if not essential-condition for its importation and extension is a warm 
and moist climate. This will probably explain why Europe, with the exception of 
Spain, has been spared a visitation from this eruptive fever. 
Respecting the treatment of dengue, it does not appear to me, from the short and 
definite course it runs, that it requires much more than something simple and symp- 
tomatic. If biliary symptoms are prominent, give an emetic followed by a saline purge, 
a hypodermic injection of morphia or a dose of chloral at night, for the insomnia and 
severe pains. Quinine or some tonic to help on the convalescence. 
Note.-Surgeon-general Maclean, in his late work on tropical diseases, recommends for dengue 
one drop of tinct. of aconite every ten minutes, till head is relieved, and the affected joints 
smeared with chloroform and belladonna-ice to the head and tepid sponging of the body. 
Quinine and salicylate of soda were both tried in the acute stage during the epidemic in Egypt, 
but without any good result. In my own practice it seemed to me that in the great majority of the 
cases I had to treat, an emetic of antimony tartrate and ipecacuanha followed by a mercurial 
purge often aborted the disease. 
The history of dengue in Egypt was pretty much what it was in Syria, i. e., everybody was 
affected by it, although many of those attacked paid no attention in any way to their symptoms. 
To prove its transmissibility by human intercourse, we had a remarkable example of this 
during the 1880 epidemic in Cairo. 
When the epidemic was about its height (end of August), a contingent of Egyptian troops 
were sent from Cairo to a town in the Delta called Damanhour, where the malady broke out 
among the soldiers, and spread from them through the town, and about the middle of September 
some of this garrison was sent to Alexandria, and from that date dengue was registered in that 
town. (J. A. S. G.) 
DISCUSSION. 
Dr. McLaughlin, of Austin, Texas, demonstrated under the microscope his 
preparations of the microorganism which he conceives to be the cause of dengue. 
The following is a brief outline of his remarks :- 
In 1885 a severe epidemic of dengue fever prevailed in the State of Texas, 
which was remarkable for its violence and the rapidity of its spread. The clinical 
symptoms of the disease as observed during the prevalence of this epidemic, in the 
main agree with those described in Dr. Wortabet's paper just read by Dr. Grant- 
Bey. In addition to those enumerated in the paper, there were frequently mani- 
fested in the Texas epidemic hemorrhages from various portions of the body, a 
disposition to miscarriages and glandular enlargements; these glandular enlargements 
were frequent sequelæ of this disease. From the epidemic character of this disease, 
its infectiousness and clinical history, I was led to suspect that its infection was a 
microbe, which could be conveyed by air currents, individual contact or infected goods. 
That this microbe found in the blood a suitable environment for its growth and repro- 
duction, that through its fermentive action ptomaines were formed, which gave rise 
to the pyrexia and other symptoms and conditions characteristic of the disease. 470 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
To submit this opinion to practical tests, I made a series of investigations, with 
the following results :- 
1. I examined blood, microscopically, directly from the veins of persons suffering 
from dengue in its various stages; this blood was obtained from many (about twenty) 
different individuals. 
2. Using necessary precautions to exclude alien germs and obtain chemical clean- 
liness, I introduced, upon the point of a sterilized platinum wire, a small fraction of a 
drop of dengue blood into test tubes containing sterilized culture jelly, and grew 
upon the jelly the microorganisms (staphylococci) which the blood contained and 
which seem peculiar to this disease. 
3. Using all necessary precautions against the introduction of any foreign ele- 
ments, I aspirated into a series of Liebig's potash bulbs the blood directly from the 
arm of a dengue patient. I then hermetically sealed these bulbs and allowed those 
microorganisms which the blood contained to grow upon it as a nutritive medium 
(the temperature was constantly maintained at 100° F.). At the expiration of six 
months the first bulb was removed with the blow-pipe and its contained blood 
examined with high powers, the preparations being stained and some cases not 
stained. The same microorganisms found in the blood directly drawn from the arm 
of the fever patients and grown pure on the culture media were also found in the 
blood obtained from this bulb. It is not possible, in the time allowed, to enter into 
the technique of these investigations; suffice it that every precaution was used to 
insure cleanliness and exclude alien germs, in the various investigations which wrere 
made; peculiar affinities and antagonisms were shown to exist between these microbes 
and the basic aniline dyes. These matters, together with a description of the modes of 
generation and peculiar grouping of these microorganisms, as well as the manner of 
conducting these experiments, will be found in a paper read in Section on General 
Medicine of the American Medical Association, held in St. Louis, May, 1886. 
Dr. J. F. Y. Paine, of Galveston, Texas.-The admirable paper of Dr. John 
Wortabet leaves little to be said on the subject of dengue ; yet there are some points 
connected with the clinical history of that protean disease, which were either absent 
in the epidemics referred to, or omitted by the author. 
The epidemic in Texas in 1885 does not confirm the conclusions of Dr. Worta- 
bet with reference to the habitat and atmospheric conditions essential to the spread 
of dengue. In that year every interior city and town in the State was invaded, and 
the period of its prevalence was characterized by unusual dryness. San Antonio, 
Austin and Dallas, ranging in altitude from 600 to 900 feet above the sea level, and 
distinguished for the uniform dryness and salubrity of their climate, suffered in an 
unusual degree, at least three-fourths of the entire population of those cities having 
been attacked. 
Intercurrent complications were by no means infrequent. Pleuritis and peritoni- 
tis were observed in a number of instances, of aggravated type. Glandular swell- 
ings-the cervical lymphatics especially-were of common occurrence ; and it was a 
matter of frequent observation that the salivary glands were involved, the parotids 
most generally. I saw a number of examples in which the inflammatory action of 
the parotids resulted in abscess. The inguinal glands were exceptionally affected. 
Hemorrhages from mucous membranes were noticed in numerous instances, most 
commonly from the nose, throat and bowels. 
Several physicians in Galveston, including myself, attended a number of patients 
who suffered from serious hemorrhage from the colon, the source being clearly defined 
by the tenderness and thickened state of the walls of that viscus. Hæmatemesis took SECTION XV PUBLIC AND INTERNATIONAL HYGIENE. 
471 
place in the practice of several physicians. I saw a few such cases. The vagina or 
aterus, or both, seemed to bear the brunt of this congestive action, as manifested by 
the frequent sanguineous exudations from those parts. It often happened that women 
menstruated out of their regular turn, sometimes profusely, and suffered from 
menorrhagia when seized at a normal epoch. Old women long past the menopause 
were known to lose blood from their genitalia. Miscarriages at every term of preg- 
nancy occurred. 
The universal involvement of the mucous membranes allies it with the catarrhal 
affections. 
The duration of dengue does not, as a rule, exceed five to eight days, but instances 
are not uncommon in which the disease drifts into a long type of fever closely 
resembling typhoid. Dysentery is an occasional sequel. An irritable or hyperæs- 
thetic condition of the alimentary tract has been known to constitute a distressing 
and persistent sequence. The special senses have at times suffered, smell and taste 
being paralyzed. 
Two months are required to effect complete recovery from a well-marked attack 
of dengue. 
. Quinine is generally sufficient to relieve the distressing myalgia, though opiates 
are occasionally demanded. 
Dr. Grant, in closing the discussion, said that dengue seems to be severer in 
Texas than in Egypt. Liver troubles in Egypt complicate all diseases, and quinine 
given without first attending to the liver seems to aggravate the disease. 472 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
THIRD DAY. 
SOME POINTS ON THE GROWTH OF PREVENTIVE MEDICINE 
IN GREAT BRITAIN. 
QUELQUES APERÇUS SUR LE PROGRES DE LA MÉDECINE PRÉVENTIVE DANS 
LA GRANDE BRETAGNE. 
EINIGE BEMERKUNGEN ÜBER DAS WACHSTHUM DER ALLGEMEINEN PROPHYLAXE IN 
GROSSBRITANNIEN. 
BENJAMIN WARD RICHARDSON, M.D., 
Of London, Eng. 
''The English people," so one of our old school books tells us, "being cut off by 
the sea from the rest of the world, commenced to be mariners from necessity. But 
that which at first seemed an inconvenience turned out, in the end, so much to our 
advantage, that for a long time it made England the lord of the ocean." 
We might say now, in regard to sanitation, that, thrown upon her own resources, 
England, by necessity, took up sanitation, and pursued it so practically and diligently 
that she may, in results, safely declare her sanitation to be equal, on the whole, to that 
of any other country. 
Sanitation here has been learned chiefly through the incidents of war, and the 
destruction of life by disease in our armies, which has exceeded that by the sword. 
The terrible lessons taught by the ill-fated Walcheren expedition were the first that 
were duly appreciated. They and some others of minor but significant character led 
our army surgeons and physicians to write and to speak in a manner quite novel to the 
rest of their medical confrères. Hennen and Pringle-the last named, especially- 
were led to give forth a knowledge of preventive measures which have, even in these 
days, not been surpassed. Their experience led the way to study, but not to any great 
advancement. 
Another lesson was demanded, and that came with the Crimean campaign, which, 
with all its disasters, proved one of the most important victories for science that England 
has ever won. 
Meantime, attention was turned to sanitation in another direction. The jails of this 
country were the great centres of spreading plagues, particularly of typhus fever. Our 
illustrious philanthropist, John Howard, penetrated these stables of death, and, by 
the exposure he made of them, led the sanitary physician to look into the subject of 
construction of buildings and lodgment of residents in regard to the production of fatal 
diseases within the four walls of institutions and houses in which people are domiciled 
and enclosed. 
Again, as we became an industrial, manufacturing nation, as well as an agricultural, 
the minds of philanthropists were drawn to the influence of occupation on the health 
of those persons who were doomed to live in the factories of the nation, and the import- 
ant Legislative Act of 1802, the first of a series of acts bearing on sanitation, affords SECTION XV PUBLIC AND INTERNATIONAL HYGIENE. 
473 
proof of the advance which, in the early part of this century, was being made toward 
the application of a set of new sanitary laws for the good of the kingdom at large. 
These were the first beginnings of our sanitary progress on this side the Atlantic. 
They were in the first instance essentially insular in their character. They sprang, as 
it will be seen, out of necessity, and in time they made a science for themselves. 
As the second half of the century drew near, a kind of social revolution was intro- 
duced by the revision of the old poor laws, which had been in existence from the reign 
of Elizabeth, and had become so entirely out of the time that nothing except a revolu- 
tionary reform could be of any service. In the end, the management of the poor, hitherto 
entrusted to several thousand local boards, was concentrated into six hundred central 
boards in special districts called Unions. An astonishing change. The preliminary work 
for this change led to an exposition of startling quality and magnitude. Fortunately, 
the chief of this inquiry (a man now of eighty-seven summers who still lives among 
us), Edwin Chadwick, was most admirably fitted for the duty, and his report to the 
Government, in 1847 on ' ' the sanitary condition of the laboring classes, ' ' laid a new 
foundation, which has been as useful as a sanitary guide to other nations as to our own 
from which it emanated. 
From the date of that inquiry preventive medicine in England has become a dis- 
tinct branch of national learning and culture, and the results have, even by this time, 
become so remarkable that with another four similar decades of progress we may look 
upon England as a new country of healthiness and social purity. 
It will serve best to illustrate this statement by a few details of results. 
In some of our English troops lying at home during the period of the Crimean 
campaign, the mortality, chiefly from phthisis pulmonalis, was greater than the mortal- 
ity of those who were enduring all the dangers and exposures of the campaign. Now 
such a position of things is impossible ; the life of our soldiers at home, in all quarters 
is almost equal in value to that of the most favored classes ; is better than that of all 
classes ; and is one-third better than that of the classes from which the soldiers are 
drawn for service. 
A death rate of twenty per 1000 three decades ago was reduced in last decade but 
one to 18 per 1000, and in the very last decade, to 12.51, with a sick rate brought down 
from 50 per 1000 to 39.38. The same benefit has been extended to the colonial armies. 
A death rate of 30 in the 1000 in last decade but one has been reduced to 10.7, with a 
lowering of the sickness rate from 70 per 1000 to 39.81. 
The most extraordinary reform has, however, taken place in India. Thirty years 
ago, the mortality in our Indian army was such that in an article which I then wrote 
on the " British Juggernaut in India," I could only compare a regiment of English 
soldiers there to the Irishman's famous knife, which retained its continuity by the 
rapid exchange of a new haft to a new blade, and then a new blade to a new haft. 
In 1853, the startling fact was elicited that the Honorable East India Com- 
pany's European regiments were absorbed and required to be renewed every eight 
years, while in her Majesty's regiments the same absorption and renewal was 
required every twelve years. One officer, Dr. F. S. Arnott, reported that he 
had seen a regiment decimated by disease in nine days, and reduced in the space 
of a year at the rate of 215 per 1000, which would have annihilated it in less 
than five years. This able officer considered that the loss of a regiment at the rate 
of 47 in the 1000 during a year of service was an unusual success, and in this estimate 
he was certainly well within the mark. A death rate of 100 per 1000 of the mean 
force existed for a period considerably later than that above stated. But when the 
preventive system got good hold the rate became rapidly reduced, so that between the 
years 1869 and 1878 it fell to 56.67 in the 1000, with a saving of sickness during that 
period of over 25,000. The improvement has shown itself equally in our prison 474 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
departments, and to some minds even in a more striking form, for now, by a strange 
revision of social and hygienic conditions, the prisons of England have become the 
cynosures of health. I am accustomed to keep my attention systematically on the 
prison returns, and, to the best of my knowledge, there has been no outbreak of any con- 
tagious disease in the whole of the past five years. The fact speaks volumes, because 
it shows that nothing but purity of life is required to sweep away all the great plagues 
from the face of the earth. If in one English prison, where the social conditions are so 
sad and disastrous, plagues can be exorcised, surely in a better world the same things 
can be done, and ought to be done if the blessing of good health is not to be added as 
a premium on crime. 
In our manufacturing life great sanitary improvements have also been carried out. 
Not to the same extent as in the barracks and in the prisons, but to as great an extent 
as could be expected among men uninformed, prejudiced and free; for, much as we 
love liberty, the exercise of free will without knowledge is a mighty influence for evil 
against the earnest sanitary reformer. 
In the above I have indicated the bright side of the sanitary question in England, 
and without wishing to depreciate that, being indeed very proud of it, as is natural to 
one who has labored to bring it about, I must report to you that there remains a vast 
work to be done here. The great classes of our people are enormously death-rated 
still. Mr. Chadwick and I not long since made an analysis of three registration dis- 
tricts in London, with a view to learn the death rate question in classes as a guide to 
the salubrity of classes. We took St. George's, Hanover Square, Westminster and the 
Strand for the year 1878, and we found in them, combined as one, a general death 
rate 22.7 per 1000. We then examined into the mean age at death of the different 
classes with the result of finding as follows :- 
For gentry and professional classes, 55.8 years. 
Salaried clerks, commercial clerks, merchant tradesmen, 33.2 years. 
Domestic servants, 34.3 years. 
Artisans and others of the wage or working classes, 28.9 years. 
By a further inquiry, we discovered that while the differences in the above classes 
in regard to life, were most marked in the young, the disparity extended to and through 
the other periods of life. Thus the children of the well to do who had passed the age 
of five years reached on an average to the age of 63 years; the children of salaried 
clerks to 47 years; the children of tradesmen to 54.9 years; the children of servants to 
51 years; and the children of artisans and wage people to 50.7 years. 
I have only time to quote the above facts in proof of the statement that we have 
much to do, notwithstanding all that has been done; and to state the belief, to which I 
have been brought, that now the sanitarian must either wait for the statesman or 
become the statesman himself. In this country the affairs of State block the way to 
affairs of health. With you I hope it is differently ordained. If it is, you will soon be 
ahead of your mother country in relation to that national health which is the only true 
national wealth. Saluti Americanæ. 
In accordance with the request of its author, the preceding paper was read by 
the President of the Fifteenth Section of the Ninth International Medical Congress, 
who embraced this occasion to express his profound regret that Dr. Benjamin 
Ward Richardson had been prevented, by his pressing and important duties, from 
fulfilling his promise of crossing the Atlantic and taking an active part in the delib- 
erations of the Section on Public and International Hygiene. SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
475 
Dr. Jones said that Dr. Benjamin Ward Richardson was one of the first of the 
eminent scientific men of Europe to signify his hearty acceptance of the invitation 
of his American brethren to take an active part in the deliberations of the Ninth 
International Medical Congress. 
Vice-President A. N. Bell, of New York, paid a well-merited tribute to Dr. 
Richardson and to Dr. Edwin Chadwick. Foremost among the promoters of the 
science of preventive medicine in England was Dr. Edwin Chadwick, under whose 
influence practical sanitation exhibited such signal advances as to have resulted in 
making it essentially a department of the Government. 
Dr. Joseph Jones moved that the thanks of the Section on Public and Inter- 
national Hygiene be respectfully tendered to Dr. Benjamin Ward Richardson, of 
London, for his practical and valuable paper. Unanimously adopted. 
In accordance with the resolution the following letter has been addressed to Dr. 
Benjamin Ward Richardson. 
Dr. Benjamin Ward Richardson, 25 Manchester Square, London. 
Dear Sir.-We have the honor to inform you that on the third day of the Congress your letter 
and paper, entitled " Some Points on the Growth of Preventive Medicine," were read before the 
Section of Public and International Hygiene, by its president. 
At its conclusion remarks were made, reciting the great services which had been rendered to 
the cause of preventive medicine by yourself, and a resolution was unanimously adopted, in- 
structing the President and Secretary to convey to you a vote of thanks, passed by the Section, 
for your very valuable contribution. 
In performing this very agreeable duty, we beg leave to add this expression of our great per- 
sonal esteem, and to remain, dear Sir, Yours very respectfully, 
[Signed] Joseph Jones, m.d., 
President Section Public and International Hygiene. 
Walter Wyman, a.m., m.d., 
Surgeon U. S. Marine Hospital Service, Secretary. 
LE VACCIN DE LA FIÈVRE JAUNE : RESULTATS STATISTIQUES 
DES INOCULATIONS PRATIQUÉES AVEC LA CULTURE ATTÉ- 
NUÉE DU MICROBE DE LA FIÈVRE JAUNE. 
THE GERM OF YELLOW FEVER. STATISTICS OF RESULTS OF INOCULATIONS 
PRACTICED WITH THE ATTENUATED CULTURE OF THE MICROBE 
OF YELLOW FEVER. 
DIE INFECTIONSKEIME DES GELBEN FIEBERS. STATISTISCHE RESULTATE DER INOCULA- 
TIONEN MITTELS VERDÜNNTER KULTUREN DES GELBEN FIEBERMICROBEN. 
PAR LE DR. DOMINGOS FREIRE, 
Rio de Janeiro, Brazil. 
Je suis bien heureux d'avoir l'opportunité de présenter devant vous le résultat de 
mes expériences sur la fièvre jaune. Comptant sur le prestige de l'autorité des savants 
qui se trouvent réunis à l'heure qu'il est dans cette grande métropole de la civilisation 
Américaine la communication que j'ai l'honneur de vous offrir portera en elle l'espoir 
de faire avancer d'un,pas considérable la question médicale la plus palpitante pour les 476 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
deux Amériques, ainsi que pour le monde en général, c'est-à-dire, l'extinction de cet 
affreux fléau de la race humaine, devant lequel on ne peut s'empêcher de frémir en 
songeant aux ravages dont il est la cause chaque année. 
Vous savez tous que j'ai annoncé depuis 1880, que la fièvre jaune était due à la pré- 
sence dans l'organisme d'un être infiniment petit, siégeant dans le sang et dans la 
trame la plus intime des tissus, se révélant dans les liquides des sécrétions, et causant 
par suite de son évolution des désordres qui terminent souvent par la mort. Depuis 
cette date j'ai poursuivi sans cesse mes recherches non seulement dans le but de démon- 
trer la transucissibilité du microbe amaril, mais encore dans le but d'obtenir son atté- 
nuation et de le transformer en vaccin. J'ai publié neuf mémoires sur ces différents 
sujets,* outre un rapport intitulé Doctrine Microbienne de la Fièvre Jaune et ses Inocu- 
lations Préventives, dans lequel j'ai condensé toutes mes idées sur la pathologie et la 
prophylaxie de la fièvre jaune. Deux de ces travaux ont été faits en collaboration avec 
MM. Paul Gibier et Ch. Rebourgeon, élèves distingués tous les deux de l'éminent 
savant M. Pasteur et qui ont bien voulu s'associer à moi pendant mon séjour à Paris 
cette année même. Dernièrement, à Rio Janeiro, j'ai continué les mêmes recherches 
avec notre distingué confrère et votre compatriote M. le Dr. Sternberg, qui, comme 
vous le savez, a été envoyé en mission par le Gouvernement de l'Union Américaine afin 
de se mettre au courant sur le résultats de mes études. J'accomplis ici un devoir eu 
exprimant toute ma reconnaissance pour l'intérêt et le zèle indéniables qu'a développés 
ce savant médecin, ainsi que pour le concours efficace qu'il m'a prêté. 
Vous voyez donc, Messieurs, que la doctrine que je soutiens sur la nature et la pro- 
phylaxie de la fièvre jaune a été le fruit d'une longue série d'expériences poursuivies 
assidûment pendant sept années. Que cette considération puisse servir de justification 
à la confiance assurée que j'ai dans les faits que j'ai observés non seulement par rapport 
à l'étiologie et la pathogénie de la maladie, mais aussi sur le point de vue de la pratique 
des inoculations préventives que j'ai proposées. 
Après ce rapide inventaire des matériaux accumulés sur la question je vous prie de 
vouloir bien m'entendre sur quelques détails qui feront l'objet de cette communication. 
Je diviserai mon exposition dans plusieurs parties afin d'embrasser méthodiquement 
toutes les réflexions jusqu'à un certain point hétérogènes que j'ai à développer. 
1° HISTOIRE NATURELLE DU MICROBE AMARIL. SA CLASSIFICATION. SON 
ÉVOLUTION. SA CULTURE.. 
L'histoire naturelle de tous les microbes en général est encore très obscure. La 
science commence à peine à balbutier les premiers mots sur cette étude aussi ardue que 
délicate. Nous pouvons même affirmer qu'elle a été injustement oubliée, les observa- 
teurs ayant préféré jusqu'ici de créer les méthodes techniques destinées à chercher et 
cultiver les microbes avant de s'appliquer à connaître à fond leur manière de vivre, 
leurs caractères physiques et chimiques, urs mœurs et leur physiologie. Cet oubli est 
sans doute une des causes les plus importantes de la confusion qui régne dans les clas- 
sifications des organismes infiniment microscopiques. Chaque auteur se croit autorisé 
à présenter sa classification, basée elle même sur des données incomplètes, telles que les 
caractères de forme, de grandeur, de groupement en colonies, aussi variable les uns que 
les autres, quelquefois pour le même micro-organisme. Aussi voyons-nous tous les 
jours se répéter la singulière anomalie d'un même être microscopique placé dans des 
classes très différentes, selon le caprice des classifications ; et tel microbe qu'on regar- 
dait aujourd'hui comme un microcoque sera-t-il peut-être demain relégué dans la divi- 
sion des bacilles, ainsi qu'il est déjà arrivé au microcoque du choléra des poules que 
quelques auteurs allemands prétendent inclure dans le groupe des bacilles. 
* Ces mémoires sont les suivantes. SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
477 
Dans l'affolement de communiquer la vitesse d'une locomotive aux recherches 
microbiologiques, on'est allé jusqu'au point extrême d'oublier que la microbiologie 
n'est qu'une branche de la botanique, et qu'il est encore trop tôt que de vouloir divor- 
cer l'une de l'autre, tout l'intérêt devant être au contraire que les botanistes prêtent de 
leur part une coopération active dans le mouvement scientifique suivi dans cette direc- 
tion. On a proclamé l'émancipation de la microbiologie d'une manière tout-à-fait pré- 
maturée. On a voulu se donner le plaisir de créer une nouvelle science, sans que les 
fondements de son organisation eûssent été jetés sur un terrain suffisamment solide ; le 
résultat en a été que l'édifice vacille sur ses assises et qu'on ignore absolument le nord 
qu'il faut viser pour mener à un bon port les questions bactériologiques. On s'imagine 
à présent que la microbiologie est une science complètement autonome, tout-à-fait 
indépendante des lois que gouvernent la botanique, erreur désastreuse qui dénature le 
but vers lequel doit marcher la médecine et qui cause par conséquent un retard lamen- 
table dans son évolution progressive. Il ne faut pas croire qu'un être vivant par le seul 
fort qu'il est d'une grandeur infiniment petite et qu'il fait son habitat dans les couches 
les plus lointaines de notre organisme, n'obéisse pas aux mêmes lois biologiques qui 
régissent tous les autres êtres, bien plus grands qu'eux et qui vivent en dehors de nous 
mêmes, soit à la surface de la terre, soit dans la profondeur des eaux. Non, les micro- 
organismes, comme les plantes en général, doivent avoir un certain nombre de phases 
correspondant aux âges de leur vie, ils doivent se nourrir comme toutes les plantes aux 
dépens d'échanges entre le milieu dans lequel ils plongent et les matériaux qui font 
partie de leurs propres tissus, tout en vivant ils doivent sécréter, comme tous les végé- 
taux, de certains principes utiles à leur entretien, ils doivent s'assimiler les substances 
formées dans leur intérieur par suite de leur élaboration vitale, et excréter d'un autre 
côté tous les principes impropres à leur nutrition, représentant le capùt mortuum de 
leur travail organique. 
C'est le tort des médecins, Messieurs ; et je ne suis pas suspect dans le cas présent 
car je parle contre ma profession, et par suite contre moi-même. Mais je ne peu pas, 
m'empêcher de reconnaître que dans toutes les époques les médecins ont eu le grand 
tort de tâcher de s'éloigner toujours le plus possible des sciences naturelles et physico- 
chimiques. Au moment même où nous recevons de la main de ces sciences les plus 
grands bienfaits, qui pourraient faire faire un grand pas, soit à la pathologie, soit à la 
clinique, soit à la thérapeutique, voilà que nous leur tournons le dos, ne sachant pas 
nous profiter de toutes les richesses que ces sciences sauraient nous prodiguer encore da- 
vantage, voilà que nous nous berçons dans nos anciennes illusions, et croyons pleins 
de vanité que nous n'avons plus de besoin de leurs services. On disait, messieurs que 
nous sommes des ingrats incorrigibles, renonçant la protection d'un bienfaiteur qui 
pourrait nous être utile plus tard et méconnaissant la valeur des dons qu'il nous a 
accordés. 
Mais voyons, Messieurs, qu'est-ce que c'est un microbe ? 
C'est un végétal au bout du compte ; et notre devoir serait de l'étudier comme tel, 
d'après les mêmes méthodes applicables aux végétaux microscopiques, et non de les 
considérer comme des êtres extraordinaires, presque surnaturels, obéissant à des lois 
spéciales en dehors du plan général tracé par la nature. Nous devons nous rappeler 
que la médecine n'est qu'une science naturelle ; venions à jamais cette tendance au 
mystérieux qui a enveloppé dans d'épaisses ténèbres les questions relatives à l'infection 
et à la contagion. Suivons pas à pas la nature, étudions-la dans son harmonie d'en- 
semble, et une fois en possession des microbes, comme nous le sommes, ne les lâchons 
pas pour courir après les mêmes chimères qui nous ont égarés et trompés pendant une 
si longue série de siècles d'ignorance et de scepticisme. 
Fermé dans ces idées, j'ai tâché de m'astreindre aux principes généraux de biolo- 
gie, afin de classifier et suivre l'évolution du microbe amaril. 478 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Quelques naturalistes sont d'avis que les microbes appartiennent au royaume des 
protistes créés par Glæcker, espèce de groupe hybride où les royaumes végétal et ani- 
mal se confondent entre eux dans une interférence de caractères qui me semble bien 
loin d'exprimer la vérité. S'il est vrai que par suite des mouvements qu'ils exécutent 
ainsi que par la composition chimique de leur protoplasme les microbes nous rappellent 
certains infusoires, et que par la composition chimique de leur enveloppe et la résistance 
à certains réactifs, tels que l'ammoniaque et la potasse, ils nous rappellent les cellules 
végétales, il n'est pas moins vrai qu'aucun des caractères ci-dessus n'est exclusif ni aux 
animaux ni aux plantes. Certes, on connaît des végétaux qui jouissent de la propriété 
d'exécuter des mouvements assez nets et qui semblent être même doués d'une irritabi- 
lité spéciale semblable à celle des animaux. Il suffit de citer à l'appui de ce que je 
viens de dire l'exemple bien connu de la mimosa pudica et celui encore plus frappant 
de la disuda muscipara et de toutes les plantes dites carnivores, ayant le singulier pri- 
vilège d'attraper leur proie dans les griffes dont leur feuilles sont pourvues et plus encore 
celui de digérer comme les animaux, la viande et d'autres substances, ainsi que l'a suf- 
fisamment démontré l'éminent Darwin. Même chez les plantes occupant une place 
élevée dans la hiérarchie phytologique, on pourrait en rigueur admettre qu'elles exé- 
cutent des mouvements. En effet, il est impossible de concevoir la croissance sans un 
changement de place dans l'espace. D'ailleurs tout le monde sait que à l'occasion du 
printemps qui succède au froid excessivement intense des régions glaciales, on peut 
apprécier â l'œil nu l'éclosion des bourgeons poussant comme par enchantement aux 
branches des arbres. 
Quant à la composition du protoplasme des microbes, nous ferons remarquer que la 
cellule embryonnaire de tous les végétaux renferme.dans son intérieur un protoplasme 
également azoté, associé à la matière amylacée et à d'autres substances. D'un autre 
côté, on sait que la cellulose qui constitue la membrane enveloppante des microbes ou 
tout au moins ou congénère de ce principe immédiat se rencontre aussi dans le man- 
teau des Ascidiens et des Tuniciens, de même que dans les vers à soie, dans l'infusoire 
de l'infusoire connu sous le nom de euglena viridis et dans les corpuscules de Purkinje 
siégeant dans les ventricules latéraux de notre cerveau. J'ai donc mis de côté le royaume 
des protistes lorsque j'ai cherché de classifier le microbe de la fièvre jaune, vu que je le 
regarde comme inadmissible à l'état actuel de la science, et, j'ai préféré de la placer 
dans la classe des algues, en m'appuyant sur l'autorité de savants tels que Robin et 
Littré, Germain St. Pierre et d'autres. En 1880, époque où j'ai découvert le microbe 
amaril, je lui ai donné de cryptococcus xanthogenicus, parce qu'il m'a offert les propri- 
étés principales qui caractérisent le genre cryptococcus.* Modernement on a créé le 
le genre micrococcus pour désigner les microbes cellulaires ou ovoïdes, cause de beau- 
coup de maladies infectantes et contagieuses. Pour plusieurs botanistes, d'après ce qui 
m'a renseigné le Dr. Pizarro, Professeur distingué de botanique et zoologie à la Facul- 
té de Médecine de Rio de Janeiro, le genre microcoque ne serait que le même genre 
cryptococcus, la différence consistant à peine dans la reproduction au moyen de spores 
pour celui-ci, tandisque les microcoques se reproduiraient par bourgeonnement. Un 
certain nombre d'auteurs, tous médecins cliniciens et par conséquence incompétents à 
résoudre des questions d'histoire naturelle, se sont étonnés de ce j'eûs classifié mon 
cryptocoque ou microcoque parmi les algues, et non parmi les champignons ou schizo- 
mycètes. U y a plus qu'une question de mot dans cette objection ; je peux affirmer 
aujourd'hui que j'ai parfaitement raison, ou que des botanistes du rang de Cauvet, de 
Van Ermenghen, Van Tieghen et d'autres, sont d'accord à considérer de tels micro- 
* "Les criptococcus, dit Robin ("Traité du Microscope," p. 522 et 896), sont à l'état d'amas 
de cellules ovoïdes ou parfois sphériques juxtaposées en ainas, en séries plus ou moins longues 
ou isolées, et d'un sujet à l'autre peuvent être sous nucléole ou pourvus d'un nucléole brillant." SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
479 
organismes comme appartenant à la division des algues. Ce dernier savant s'est expri- 
mé d'une manière positive sur ce sujet dans un congrès international de botanique 
réuni il y a quelques années, ses conclusions ayant été adoptées par cette assemblée 
savante. 
Ceci posé, faisons une description succinte des caractères du microbe amaril et de 
son évolution. Il se présente sous la forme monocellulaire, commençant par de petits 
points ronds, presque imperceptibles, même avec un grossissement supérieur à 700 
diamètres, points qui peu-à-peu vont en croissant, réfractant fortement la lumière, ne 
tardant pas à présenter des zones obscures sous certaines incidences de lumière. Ces 
petites cellules sont circulaires (sphériques), entourées d'un rebord à couleur cendre ou 
noir, contenant dans leur intérieur des masses de protoplasme. La reproduction, comme 
je l'ai maintes fois surprise, s'opère (il me semble) par la rupture de la membrane 
d'enveloppe. Le déchirement de chaque cellule peut avoir lieu sur un seul point, 
simulant nn bourgeonnement, mais presque toujours la membrane d'enveloppe se 
rompt en divers points d'une manière irrégulière, et sur les lambeaux résultant de ce 
déchirement on note des amas-pigmentaires visqueux, auxquels adhèrent les cellules- 
germes.* Celles-ci se fixant sur les débris des cellules détruites se groupent très-souvent 
d'une manière plus ou moins symétrique, tantôt sous la forme de poire, tantôt sous la 
forme de pommes de pin ou d'oranos, tantôt sous la forme de longs chapelets plus ou 
moins flexueux. La grandeur de ces micro-organismes n'est que d'un millième de mil- 
limètre à un millième et demi de millimètre. 
Chaque cellule adulte au moment de proliférer laisse échapper en dehors deux pig- 
mente différents, l'un jaune, destiné à s'infiltrer dans tous les tissus et à produire la 
couleur ictérique qui a donné le nom à la maladies, l'autre, noir, qui est insoluble et 
destiné à être entraîné dans le courant circulatoire, produisant soit des obstructions 
capillaires, soit des stases sanguines dans le parenchyme des organes. L'ouvrie est 
occasionnée, ou moins en grand-partie, ainsi que le démontre l'examen microscopique, 
par l'agglomération des microbes et leurs débris dans l'intérieur des canalicules uri- 
naires, y provoquant par leur séjour la dégénérescence colloïde, qui transformerait 
chaque tube urinifère dans un cordon sans cavité, il empêcherait ainsi la filtration 
rénale. La matière noire du vomissement est due à ce pigment. Ceci a paru étrange 
dans le commencement. Mais, après la publication de mes premières recherches, on 
s'est assuré qu'il existe dans la nature un grand nombre de microbes qu'on a appelés 
chromogènes, et qui jouissent de la propriété de fabriquer des pigmente dont la nuance 
est variable, quelquefois des matières colorantes d'une couleur éclatante. Citons à 
l'appui de ce que je dis, le pigment bleu foncé fabriqué par le bacillus cyanogenus et la 
belle teinte rouge paupre que nous offre le microcoque prodigiosus et le microcoque indi- 
ens. D'ailleurs la présence de ces pigmente a été constatée par beaucoup de médecins, 
parmi lesquels je citerai les Drs. Rebourgeon, Issartier et le Prof. Artigalas, de Bor- 
deaux. 
Mr. le Professeur Cornil, dans son Traité sur les Bactéries m'a reproché d'avoir repré- 
senté dans les dessins de mon livre Doctrine Microbienne de la Fièvre Jaune, des masses 
de pigment, vu que, détail, ces pigmente sont des corpuscles accidentels et non des 
Bactéries. Je sais bien que ce sont des corps accidentels, mais ce qu'il ne faut pas per- 
dre de vue c'est que ces corpuscles accidentels sont corrélatifs avec la vie du microbe 
amaril convaincu de ce que l'observateur n'a pas le droit de corriger la nature et de 
supprimer ce qu'elle nous présente d'une manière frappante, j'ai cru de mon devoir de 
* Je donne le nom de spore à ces cellules-germes. Même donné que les microcoques ne puis- 
sent se reproduire que par bourgeonnement, chaque bourgeon formant une petite cellule commen- 
çante ne serait en rigueur qu'une spore. Je ne vois pas l'utilité de créer de ces distinctives sub- 
tiles, qui ne faut qu'encombrer la science de noms qui ne signifient rien d'essentiel. 480 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
conserver dans mes dessins les pigments rencontrés dans les cultures, d'autant plus que 
les mêmes pigments jouent un rôle très important dans la pathogénie de la maladie, 
les deux phénomènes, ictère et vomissement noir, étant l'expression symptomatique de 
leur présence dans l'organisme des malades. Mr. le Prof. Cornil lui-même n'a pas 
méconnu le grand intérêt qu'on doit attacher à ces matières pigmentaires, car il s'y 
rapporte plusieurs fois dans son Traité déjà cité. Ainsi, il s'y exprime dans les termes 
suivants, à la page 522 : " Les cellules hépatiques sont tuméfiées, remplis de gouttes de 
graisse formant une couronne autour du noyau ; elles continuent des grains de pigment 
jaune. Les contours des cellules montrent souvent des dépressions remplies de pigment."' 
A la page 528 le même auteur, se rapportant à l'examen du rein d'un individu mort 
de fièvre jaune, nous dit: " Parfois ces cellules renferment des grains de pigment jaune." 
A la page 529 nous trouvons encore les mots suivants : " Dans le contenu de l'intestin 
nous avons trouvé dans deux cas des amas denses de grands microbes ronds, de 1 g 
environ, énégaux, auprès desquels il existait toujours du pigment jaune ou brun." 
Mr. le Professeur Cornil a donc vérifié plusieurs fois les pigments que je représente 
dans mes dessins. Je suis heureux de pouvoir dire qu'il a constaté également la pré- 
sence du microbe amaril dans des organes remis du Brésil. Lorsque j'ai été a Paris, il 
y a quatre mois environ, j'ai eu l'honneur de recevoir la visite de cet illustre savant 
dans le laboratoire de pathologie comparée du Muséum d'Histoire Naturelle, où je fai- 
sais mes recherches en collaboration avec les Drs. Gibier et Rebourgeon. Nous avons 
eu l'occasion de lui présenter les cultures sur les milieux liquides et solides, d'après les 
méthodes Pasteur et Koch et de le satisfaire, quant à l'exigence de coloration, qu'il 
m'avait reproché dans son Traité de ne pas avoir fait. Dans cette occasion il a pu com- 
parer le microbe à l'état frais qu'il n'avait pas encore vu avec le microbe mort et teinté 
avec le chlorhydrate de rosaniline. 
Je profite cette occasion pour lui remercier de l'attention qu'il a prêtée à mes re- 
cherches, ainsi que des encouragements et de la bienveillance avec lesquelles il m'a 
accueilli. Le microbe que je lui ai montré avait exactement la même forme et la même 
grandeur que celui qu'il avait décrit dans son Traité sur les Bactéries, ainsi que vous 
pouvez constater vous-même, Messieurs, eu comparant le dessin du livre de Cornil (page 
523), que j'ai l'honneur de vous présenter, avec le microbe que je vous montrerai tout- 
à-l'heure, sur les plaques préparées à Paris même et au Brésil pendant que j'ai travaillé 
avec le Dr. Sternberg. 
Passons maintenant, Messieurs, à dire quelques mots sur la culture du microbe 
xanthogénique. J'ai fait des cultures avec le succès le plus complet dans du bouillon 
du bœuf, du lait et les solutions du gélatine. Je préfère faire les solutions du gélatine 
non avec de l'eau distillée, mais bien de l'eau commune, parce que cette dernière con- 
tient différents sels numéraux et même quelque matière organique utile au microbe. 
Vous pouvez trouver tous les détails sur la pratique des cultures que j'ai faites dans la 
première partie, (chapitre III), de mon rapport Doctrine Microbienne de la Fièvre Jaune 
et ses Inoculations Préventives publié à Rio Janeiro en 1885. 
Outre la méthode Pasteur pour la culture des microbes, j'ai appliqué aussi à mon 
microbe la méthode de Koch sur les milieux solides. 
L'expérience m'a démontré que la microbe amaril se colore facilement, bien plus 
facilement même que beaucoup d'autres, au moyen des couleurs d'aniline, telles que 
le chlorhydrate de rosaniline, le violet méthyle, et le brun Bismarck. Dans la note que 
nous avons présentée, il y a quelques mois, à l'Académie des Sciences, nous avons 
signalé ce fait, et Mr. les Drs. Gibier et Rebourgeon ont bien voulu montrer dans la 
salle des Pas-Perdus, à beaucoup de personnes, parmi lesquels, plusieurs savants mem- 
bres de l'institut, les colonies du microbe xanthogénique teinté en violet, et parfaite- 
ment visible, au moyen d'un microscope Verick, oculaire No. 3 et objectif à immersion 
homogène. SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
481 
En outre, nous avons pu cultiver le même micro-organisme d'après la méthode de 
Koch. Transplanté dans des tubes contenant de la gélatine, qu'on perfore au moyen 
d'un fil de platine stérilisé d'avance et chargé d'une petite goutte de culture, le micro- 
organisme, maintenu dans l'étuve à une température de 15 à 25 degrés, se dévéloppe en 
colonies qui prennent la forme d'un clou, dont la tête serait à la surface et la pointe en 
dessous, enfoncée dans la gélatine. Celle-ci se liquéfie peu-à-peu, d'une manière irré- 
gulière, et la liquéfaction commence toujours sur les couches superficielles; ce qui dénote 
que le microbe en question est aérobie. 
Pour terminer ce que j'ai à vous dire sur l'évolution du microbe amaril, je vous 
dirai qu'il jouit de la propriété d'élaborer des produits appartenant à la classe des pto- 
maines (leucomaïnes de Gautier), aux dépars des matières albuminoïdes et autres dont 
ils se nourrisent. 
Ces ptomaines sont très toxiques ; j'ai fait avec elles de nombreuses expériences sur 
des chiens et des grenouilles, expériences qui m'auraient démontré que ces alcaloïdes 
exercent une influence remarquable sur le nerf grand sympathique et sur les nerfs 
pneumo-gastriques. Plusieurs symptômes de la fièvre jaune s'expliqueraient plausible- 
ment ainsi, en vertu des désordres profonds imprimés par ces poisons dans le système 
cardiaque et dans l'innervation vaso-motrice. 
Dans les cultures elles-mêmes, il se forme de ces ptomaines; et la preuve en est, que 
si l'on fait l'ensemencement du microbe dans la gélatine, neutre aux papiers réactifs, 
au bout de quelques jours cette gélatine manifestera une réaction franchement alcaline. 
D'ailleurs, au moyen des procédés connus, on peut extrain de ces cultures des 
ptomaines semblables à celles qui se forment dans l'intérieur de l'organisme atteint 
de la fièvre jaune. 
. 2° INOCULABILITÉ DU MICROBE AMARIL. SON ATTÉNUATION. 
J'ai fait un grand nombre d'expériences d'inoculation chez les animaux, afin de 
constater la transmissibilité de la maladie. J'ai remarqué le suivant : que non seule- 
ment les inoculations faites directement avec du sang et des cultures virulentes, tuent 
les lapins et les cochons d'Inde, dans l'espace de deux à dix jours, mais encore le 
séjour de ces animaux dans une atmosphère plus ou moins saturée de microbes donne 
le même résultat ; plusieurs de ces animaux moururent simplement pour avoir respiré 
Pair du laboratoire où je faisais mes expériences et mes autopsies ; les organes de ces 
animaux présentaient de nombreux microbes spécifiques. J'ai mis hors de doute l'ino- 
culabilité du microbe par des injections hypodermiques, intra-veineuses et intra-viscé- 
rales ; j'ai fait plusieurs séries d'expériences, lesquelles, je suis heureux de vous l'an- 
noncer ici, ont été pleinement constatées récemment par Mr. le Dr. Rangé, médecin 
de premiere classe de la marine Française aux îles du Salut, (Guyane Française). Le 
compte rendu de ces expériences a été publié dans les Archives de Médecine Navale de 
l'année dernière. 
La transmission de la fièvre jaune effectuée d'individu à individu avec un sang pri- 
mitivement virulent et dont la virulence ne perd pas de son énergie, malgré son pas- 
sage à travers différents organismes, met ainsi en évidence que l'agent producteur de la 
maladie n'est pas mort, mais vivant et susceptible de reproduction pas transmis- 
sions successives. Cet agent ne peut pas être autre chose que l'unique élément anor- 
mal figuré, que l'on rencontre constamment et infailliblement dans tous les cas prouvés 
de fièvre jaune, c'est-à-dire le micrococcus xanthogénicus. 
Ces preuves directes ayant mis hors de doute la nature parasitaire et contagieuse de 
la fièvre jaune, je me suis appliqué à atténuer le microbe, afin de le transformer dans 
un produit vaccinal. 
On sait que la fièvre jaune, à de très rares exceptions près, attaque une seule fois le 
même individu ; ce caractère est propre à presque toutes les maladies transmissibles de 
Vol. IV-31 482 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
nature virulente. Si on arrive pourtant à atténuer les cultures du microbe xanthogé- 
nique de sorte à ce qu'elles produisent doucement des perturbations fonctionnelles et 
des changements de composition dans le sang et dans les tissus, propres à conférer l'im- 
munité, nous aurons obtenu pour la fièvre jaune le même grand désidératum obtenu 
pour la variole, comme pour le choléra des poules et pour le charbon chez les animaux 
qui possèdent la réceptivité pour ces maladies. 
Or, j'ai remarqué qu'au bout d'un certain nombre de cultures successives le microbe 
produit une grande partie de sa virulence et pouvait être inoculées chez les cobages sans 
produire la mort. Ces animaux résistent à une injection de 50 centigrammes ou un 
gramme du liquide de culture atténuée; ils présentent une légère fièvre, de l'amaigris- 
sement et quelques autres symptômes qui se dissipent au bout de peu de jours. En 
outre, sur un grand nombre d'animaux ainsi vaccinés, ayant fait, quelques jours après, 
une injection de sang virulent, j'ai constaté qu'aucun d'eux ne mourait, tandis que la 
même injection tuait tous ceux qui n'avaient pas été inoculés avec les cultures atté- 
nuées. 
Voici de quelle manière on prépare le vaccin : On injecte le sang d'un malade mort 
ou sur le point de mourir de fièvre jauue, dans les veins d'un cochon d'Inde ou d'un 
lapin ; puis, le sang de ce premier animal est inoculé dans le sang du second de la 
même espèce et ainsi de suite jusqu'au sixième ou septième animal. Avec le sang de 
ce dernier, ou fait des cultures qu'on transplantera quatre fois au moins; c'est alors que 
je commence à les inoculer à l'homme, non sans avoir préalablement vérifié sur les ani- 
maux, si ces inoculations n'étaient pas susceptibles de produire des accidents d'une cer- 
taine gravité. 
On obtient ainsi une dixième ou douzième génération du microbe primitif, dont la 
virulence est notablement amoindrie. L'atténuation est dfle aux nouveaux milieux 
que le microbe traverse en passant par l'organisme du cochon d'Inde, et en étant 
cultivé ensuite dans des ballons stérilisés contenant du bouillon de bœuf ou de la 
gélatine. 
Du reste, les cultures s'atténuent d'elles mêmes à la longue sous l'influence de l'air, 
au point qu'un liquide primitivement virulent peut être inoculé sans danger sept ou 
dix jours après. 
Ces cultures une fois atténuées conservent indéfiniment cette atténuation jusque et 
pendant les saisons épidémiques durant lesquelles leur activité augmente presque in- 
sensiblement. 
Cependant, j'ai procédé à des expériences qui m'ont conduit à la régénération de la 
virulence de ces cultures ; et je puis maintenant à toute époque de l'année durant et 
en dehors de la période épidémique, perpétuer la virulence des cultures et les faire pas- 
ser, à ma volonté, de l'état toxique à l'état atténué et vice-versa, les soumettons gra- 
duellement à l'énergie nécessaire à la vaccination et jusqu'à l'activité infailliblement 
mortelle. 
Voici comment j'ai procédé pour l'obtention de cet important désidératum. 
1° J'ai pratiqué l'inoculation par la méthode hypodermique, en faisant, sous l'aile 
de pigeons ou de poules, une injection d'un gramme de culture atténuée qui m'a servi 
pour les inoculations sur l'espèce humaine. 
2° Trois heures après, j'ai sacrifié les volatiles dans le sang desquels la culture avait 
été à l'état d'incubation ou de digestion, recueillant ce sang dans des ballons stérilisés ; 
opération à laquelle j'ai procédé avec toutes les précautions techniques nécessaires pour 
empêcher l'introduction de germes étrangers dans les ballons. 
3° Immédiatement après, j'ai inoculé ce sang à de petits oiseaux dans une propor- 
tion égale à 0.3 de centimètre cube pour 30 grammes du poids des animaux. 
Tous ceux qui out servi à cette expérience ont succombé dans un espace de un à sept 
jours. SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
483 
L'expérience répétée quinze fois sur des tiés et des sanhassüs* a fourni des résultats 
identiques. 
4° L'autopsie pratiquée, j'ai trouvé dans le corps des oiseaux des lésions semblables 
à celles produites par la fièvre jaune et entre ces signes, je citerai, comme étant d'une 
haute importance diagnostique la matière noire couleur d'encre à écrire rencontrée dans 
le gésier et dans les intestins. 
Le sang de ces oiseaux, examiné au microscope montrait les microbes caractéristiques 
de la maladie. 
5° Le sang des poules et des pigeons sacrifiés, d'après ce que j 'ai dit au paragraphe 
2°, a conservé la virulence mortifère durant 16 jours après lesquels l'atténuation s'est 
déclarée. 
6° Le même sang inoculé à des cochons d'Inde (cobaye) (inoculation intra hépatique, 
dans le péritoine ou simplement sous-cutanée) et ce dans la proportion de 0.5 de cen- 
timètre cube pour 500 grammes du poids de l'animal a manifesté également la propriété 
toxique, tuant les sujets dans un espace qui a varié entre deux, trois, sept et dix jours. 
Les lésions anatomiques confirmèrent le diagnostic de la fièvre jaune ; le liquide 
rencontré dans l'estomac était très obscur et noir et les urines contenaient de l'albu- 
mine. 
7° Si on injecte le sang du pigeon ou de la poule No. 1 à un de leurs congénères Nos. 
2, 3, 4 ou 5, on remarque que l'énergie du virus diminue progressivement à mesure que 
s'élève le nombre des transplantations faites successivement d'un animal à un autre. 
On peut donc ainsi se procurer constamment une série de cultures systématiquement 
graduées. 
8° Les cultures atténuées inoculées à des animaux (oiseaux ou cochons d'Inde) leur 
confèrent l'immunité de la vaccination, les rendant réfractaires à l'action du virus 
mortifère. 
9° On trouve dans tous les cas, dans les cultures graduées ainsi, le microbe spéci- 
fique avec les caractères ordinaires. 
10° Me bornant, quant à présent, à la description de ces faits, je n'entrerai pas, 
pour le moment, dans la question de la théorie interprétative applicable à cette réap- 
parition de la virulence des cultures par le fait de sa simple permanence durant quel- 
ques heures dans l'intérieur d'un organisme animal réfractaire lui-même à la fièvre 
jaune et ce, d'accord avec ce que démontrent mes observations décrites dans mon der- 
nier ouvrage re répétées récemment, avec un résultat identique par le Dr. Rangé, mé- 
decin de la marine française. 
Le fait d'un organisme se refusant à un état morbide déterminé et pouvant aider à 
la virulence de cet état morbide pourra, quelque extraordinaire que cela paraisse, nous 
fournir l'explication d'un grand nombre de questions relatives à des particularités de 
■contagion durant les épidémies, comme il se prêtera aussi à expliquer bien des circons- 
tances obscures concernant l'hérédité de diverses affections. 
3° VACCINATION PRATIQUÉES CHEZ L'HOMME. SES RÉSULTATS PRATIQUES. 
C'est seulement après les longues expériences déjà décrites, sur le pouvoir virulent 
du microbe de la fièvre jaune, que je me suis encouragé à l'inoculer dans l'organisme 
humain. 
Les premiers 400 vaccinations furent faites par la méthode endermique, mais en- 
suites j'ai adopté de préférence, la méthode hypodermique beaucoup plus sûre et plus 
pratique. ( 
On procède de la manière suivante : Les cultures sont tirées des ballons avec tout 
* On donne ces noms à des oiseaux appartenant au genre tanagra, et qui se nourissent d'or- 
ganes, de bananes et d'autres fruits. 484 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
le soin nécessaire pour éviter l'entrée de germes étrangers et conservées dans de petits 
flacons de quatre à huit grammes préalablement stérilisés par la chaleur et bouchés à 
l'émeri. Dans une seringue Pravaz on recueille quelques gouttes du liquide préalable- 
ment versé dans une capsule bien propre et on en introduit ensuite sous la peau une 
quantité variant d'un dixième de centimètre cube à un centimètre cube, selon l'âge de 
l'individu. 
Les troubles consécutifs à la vaccination rappellent les prodromes de la fièvre jaune ; 
ils se traduisent par de la céphalalgie intra-orbitaire, des frissons, une lassitude géné- 
rale avec pesanteur des jambes, rachialgie, réaction fébrile (37.5°, 38.39° centig. ) 
légère barre épigastrique et quelquefois des nausées et même des vomissements, le tout 
ne se prolongeant pas au delà de deux ou trois jours, sans l'intervention d'aucune 
médication. Localement il n'y a rien qui puisse expliquer ces phénomènes, car il se 
produit à peine autour des frigûres une légère aréole rouge, qui se dissipe prompte- 
ment. 
Je vais vous donner le résumé des résultats obtenus jusqu'ici au moyen de la pra- 
tique de ces vaccinations, lesquelles sont pratiquées gratuitement et ont été autorisées 
par l'arrêté ministériel du gouvernement Brésilien No. 4546 du 9 Novembre, 1883. 
Pendant l'épidémie de fièvre jaune qui a reigné à Rio Janeiro 1883-1884, j'ai vac- 
ciné 418 personnes, non seulement avant l'épidemie, mais pendant que celle-ci était 
dans sa plus grande intensité. 
Le nombre des personnes non-vaccinées mortes de la fièvre jaune s'est élevé à 650. 
Parmi les personnes vaccinées, il en est sept qui figurent également sur la liste des décès 
comme étant mortes de la maladie. Bien qu'il reste des doutes sérieux au sujet de ce 
diagnostic, je suivrai le conseil de mon distingué confrère le docteur Trouessart : je ne 
chercherai pas à dissimuler ces quelques rares insuccès, surtout en face du chiffre impo- 
sant de vaccinations heureuses (411), que j'ai le droit de porter à mon actif. Ce chiffre 
de sept décès donne une proportion excessivement favorable, surtout si l'on réfléchit 
que les malades en question appartenaient à la classe ouvrière et habitaient des estala- 
gens, chambres étroites, humides et mal aérées, dans le quartier le plus malsain de la 
ville, où. la mortalité a été considérable parmi les personnes non-vaccinées, et surtout 
les ouvriers étrangers. Sur les 650 personnes non-vaccinées mortes de la fièvre jaune 
(d'Octobre 1883 à Juin 1884), 577 étaient des étrangers, 73 seulement étaient des Bré- 
siliens. Or, j'ai vacciné 307 étrangers ; les Brésiliens qui complètent le chiffre de 418 
venaient tous de l'intérieur et se trouvaient, par conséquent, dans les mêmes conditions 
de réceptivité que les étrangers, la fièvre jaune étant inconnue dans l'intérieur du Bré- 
sil et ne sévissant que sur le littoral maritime. Aucun des Brésiliens vaccinés n'est 
mort de la fièvre jaune. 
Les résultats obtenus l'année suivante (de Janvier à Août 1885), à l'aide d'inocula- 
tions faites, non plus à la lancette comme les précédentes, mais par la méthode hypo- 
dermique, sont encore plus favorables. Dans cette intervalle, le nombre des décès de 
fièvre jaune parmi les personnes non-vaccinées, à Rio de Janeiro, s'est élevé à 278, dont 
200 étrangers et 78 Brésiliens, sur lesquels 44 seulement étaient nés dans cette ville. 
Aucun d'eux n'avait été vacciné. Dans cette même période, j'ai vacciné 3051 per- 
sonnes, dont 2186 nationaux et 865 étrangers. Sur les 2186 nationaux, 625 étaient des 
enfants en bas-âge issus d'étrangers, et par conséquent aussi réceptibles que les étran- 
gers eux-mêmes. Pendant toute la durée de l'épidémie, pas un seul n'avait succombé. 
L'immunité a donc été absolue. 
Ces chiffres parlent d'eux-inêmes, je crois. Eh bien! ce n'est pas tout; car pendant 
la dernière épidémie qui a sévi à Rio en 1886, les résultats statistiques sont venus con- 
firmer leur éloquence. 
En effet, pendant cette période, nous avons vacciné 3473 personnes, ainsi réparties : 
Brésiliens 2763, étrangers 710. Parmi les 2763 Brésiliens, on rencontre 489 fils d'étran- SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
485 
gers, tous très jeunes, et qui en réalité peuvent se rattacher aux 710 étrangers, comme 
présentant le même degré de réceptivité que ces derniers. De plus, 222 provenaient 
de différentes provinces de l'intérieur et du midi, c'est-à-dire dans des conditions très- 
favorables pour contracter la maladie. C'est donc en réalité à 1421 vaccinés qu'il faut 
porter le nombre de ceux pour lesquels le séjour ne peut être invoqué comme cause 
d'immunité contre la contagion. Restent 2053 sujets Brésiliens, dont l'âge varie de 
quelques mois à 60 ans. Dans ce groupe, un grand nombre, par leur âge, leur condition 
d'habitation dans les quartiers de la ville les plus éprouvés par le fléau, se trouvaient 
dans les conditions les plus favorables pour en devenir victimes. Parmi les personnes 
vaccinées, il n'y a eu que huit décédés de fièvre jaune ; une desquels avait été inoculée 
en 1885, tandis que dans le même espace de temps la mortalité par la même maladie 
parmi les personnes non-vaccinées a été de 1389, ainsi réparties : étrangers 1079, Bré- 
siliens 310. 
Si nous faisons le résumé général des vaccinations pratiquées par la méthode hypo- 
dermique, pendant les épidémies de 1885 et 1886, nous trouverons le résultat sui- 
vant :- 
1° Vaccinations pratiquées en 1886 3473 
Morts vaccinés 7 
2° Vaccinations pratiquées en 1885 3051 
Mort vacciné 1 
Total des vaccinés 6524 
Total des morts vaccinés 8 
Mortalité des morts vaccinés 0.1 p. c. 
Mortalité des non-vaccinés, d'après les chiffres officiels, et dont la mort est due à la 
fièvre jaune, pendant les années 1885 et 1886 : 1667. 
Maintenant faisons le calcul de manière a comprendre également la statistique de 
1884, à l'époque où nous employions la méthode endermique ; nous aurons :- 
Vaccinés 6942 
Morts vaccinés 15 
Ce qui donne à peine 0.2 p. c. pour la mortalité des vaccinés. 
Morts non-vaccinés : 2317. 
Je ne vous offre ici qu'un abrégé très-court, tous les détails statistiques ont con- 
stitué un mémoire qui a été présenté à l'Académie des Sciences de Paris. 
Toutefois, je pense que c'est bien assez pour démontrer les bienfaits réels qui pour- 
ront résulter de la généralisation de ce moyen prophylactique. 
Pour tous les détails relatifs aux statistiques je vous engage de lire les ouvrages sui- 
vants dont j'ai l'honneur de vous offrir quelques exemplaires :- 
1° Rapport sur les inoculations préventives de la fièvre jaune durant l'épidémie qui 
a régné en 1883 et 1884, à Rio de Janeiro et présenté au Ministre de l'intérieur au Bré- 
sil, ce rapport est annexé à mon ouvrage " Doctrine Microbienne de la Fièvre Jaune." 
2° Le vaccin de la fièvre jaune. Résultats statistiques des inoculations préventives 
pratiquées avec la culture du microbe atténué, de Janvier à Août de 1885. 
3° Statistique des vaccinations pratiquées avec la culture atténuée du microbe de la 
fièvre jaune de Septembre 1885 à Septembre 1886. 
Je vous recommanderais encore la lecture du mémoire présenté par les Drs. Rebour- 
geon, Gibier et moi à l'Académie des Sciences de Paris, et intitulé : Résultats obtenus 
par l'inoculation préventive du virus atténué de la fièvre jaune. 
Cette note a été présentée et lue devant l'Académie des Sciences par le regretté Prof. 
Vulpian, qui l'a précédée de quelques considérations très flatteuses pour nous, en nous 
rendant ainsi un service considérable pour la réussite de nos recherches. Je dois vous 
dire que le Prof. Vulpian a bien voulu se charger de prendre un grand intérêt pour mes 
travaux, après les avoir examinés minutieusement. Il a non seulement analysé les cul- 486 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
tares et les préparations microscopiques, mais encore les livres et les carnets où je fai- 
sais inscrire les noms, nationalités, ages, etc. de toutes les personnes vaccinées. Sa 
patience est allé jusqu'au point de lire un grand nombre de petites notes recueillies par 
mon auxiliaire, le Dr. Cominhoé Fils, relatives aux symptômes observés dans chaque 
individu dans les trois premiers jours suivant la vaccination. J'ai été très content de 
cette rigueur, elle a donné en résultat une forte impulsion communiquée à ma décou- 
verte ; c'est un grand service que je dois à ce grand médecin qui vient de disparaître de 
la scène du monde scientifique, comme un météore lumineux qui a plongé majestueu- 
sement dans la nuit de l'éternité. 
Je terminerai ma communication, Messieurs, en vous présentant nos salutations de 
remerciment, et en vous montrant sous le microscope plusieurs préparations du microbe 
amaril cultivé dans l'agar agar peptonisé et coloré par le chlorhydrate de rosaniline. 
After the reading of the paper of Dr. Domingos Freire, the President, Dr. Jones, 
tendered the thanks of the Section for the energy and scientific zeal displayed by 
Professor Freire, in performing a long and tedious sea voyage from Rio de Janeiro 
to Washington for the purpose of laying the results of his investigations and experi- 
ments before his brethren of the medical profession of America and other countries. 
The President had invited Professor Carmona, of the University of Mexico, to 
be present, and in like manner unfold his method of ' ' inoculating " or " vaccinating ' ' 
against yellow fever. 
Although Professor Carmona had accepted his invitation in a hearty and enthu- 
siastic manner, he had not, as yet, arrived in Washington. 
It is truly remarkable and interesting that two native-born Americans, with the 
blood of its ancient inhabitants coursing through their veins, should have, in two 
widely separated countries in North and South America, boldly attempted to settle 
one of the most important problems-namely, the arrest, prevention or modification 
of yellow fever by inoculation. 
In order to apply the principles established by the immortal Jenner to the arrest 
or modification of yellow fever, Dr. Jones had, during the past seventeen years, as 
opportunity offered, performed experiments on living animals with the blood and 
black vomit of yellow fever. 
The animals thus experimented on in 1870, 1873 and 1878 universally died, in 
periods ranging from 12 to 72 hours, and the blood was found to contain numerous 
bacteria and micrococci. Such experiments had deterred him from inoculating the 
human being; and as there has been no epidemic of yellow fever in New Orleans 
since the year 1878, he regarded his experiments as incomplete. 
During the yellow fever epidemic of 1878, Dr. Jones conducted an elaborate 
series of experiments on the atmosphere of infected localities and houses containing 
yellow fever patients. The method consisted essentially in passing from 100,000 to 
400,000 cubic feet of air through ice in fragments and through ice-cold water, and 
then subjecting the water to examination with the higher powers of the microscope. 
As the results of the seexperiments have been recorded in the New Orleans Medical 
and Surgical Journal for 1879, it is unnecessary to enter into a detailed statement. 
The following facts, however, will be stated as bearing on the paper of Dr. Freire, 
now under consideration. 
1. The atmosphere in the rural and badly drained and unpaved districts presented 
microorganisms, spores and vegetable cells differing from those of the paved districts. 
2. In the well-paved districts he had found in the air, by the aid of the high 
powers of the microscope, minute spores, microbes and micrococci, varying from one SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
487 
ten-thousandth to one twenty-thousandth of an inch in diameter, similar to some of 
the particles found in the blood and black vomit of yellow fever. 
3. In the air of the poorly drained, unpaved and malarious portions of the city 
of New Orleans he had, on the contrary, found similar microorganisms to those which 
he had observed in the blood of malarial fever patients. 
In conclusion, Dr. Jones said that he had hoped that those persons who had set 
up claims to be microscopists and who had attempted to decry and disparage the labors 
of Professor Domingos Freire would have the manliness to meet him face to face 
in an open and just discussion of its methods and results. 
Dr. Jones advocated the thorough investigation of this subject, not by prejudiced 
partisans, inexperienced in the diagnosis and treatment of yellow fever, but by earnest, 
and just, and experienced, and accomplished observers, supplied with such liberal 
appropriations by their respective governments, and armed with all the chemical, 
philosophical and microscopical reagents, and instruments of the greatest perfection, 
which are adapted to the thorough investigation not merely of the subject of inocu- 
lation against yellow fever, but of all points relative to the origin and propagation 
of this disease, to its nature, history, pathology and treatment. 
Dr. Domingos Freire then presented to the Fifteenth Section numerous microscop- 
ical specimens of the yellow fever microbe. Dr. Y. R. Lemonnier, French Secretary, 
translated the paper of Dr. Freire into English. The President requested Dr. Freire 
to answer such questions as the members of the Fifteenth Section might propound, 
and Dr. Felix Formento, of New Orleans, Italian Secretary, acted as interpreter, 
as Dr. Freire was not fully conversant with the English language. 
The following is a brief outline of the discussion of the paper of Dr. Freire by 
the officers, Council and members of the Section on Public and International Hygiene. 
DISCUSSION. 
Upon conclusion of the reading of the paper and translation, Dr. Felix For- 
mento, of New Orleans, Louisiana, asked Dr. Freire whether he adopts the Pasteur 
theory of the attenuation of the virus by oxidation. 
Dr. Freire replied that the attenuation is due to two causes, viz. : 1st oxidation 
through the red corpuscles of the blood, and 2d, to the fact that when virus is trans- 
planted it may not find in the second animal the same soil as in the first, and it 
becomes modified ; but all this is as yet only conjecture. 
To inquiries of Dr. Joseph Jones, regarding the exact microscopic appearance 
of the microbe, its size, shape, etc., and what it forms in final development, and its 
histological structure, Dr. Freire replied that its histological structure, like that of 
other microbes, is obscure. It is of a vegetable nature and has a cellular form, com- 
posed of an envelope enclosing a protoplasm. He assented to Dr. J ones' remark that 
he would then call it a micrococcus, the lowest form, and referred to the more extended 
description made in his paper. Its diameter is one-thousandth of a millimetre, and its 
form remains the same in the virulent and attenuated cultures. 
Dr. Jones-" Have you ever found the microbe in the blood of a living patient? ' ' 
Dr. Freire-"Yes, in all cases of genuine yellow fever." 
Dr. M. K. Taylor, United States Army, inquired whether the appearance of 
the microbe of yellow fever is sufficiently marked to enable an accomplished micro- 
scopist to distinguish it from a microbe of malaria. 488 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Dr. Freire replied that several different microbes of malaria have been described. 
Yet all of them are very different from the microbe of yellow fever, and the charac- 
teristics of the yellow fever microbe are sufficiently striking to enable a microscopist 
to distinguish it. 
Dr. P. H. Bailhache, United States Marine Hospital Service, inquired whether 
the vaccination in one family arrested the progress of the fever in that family. 
Dr. Freire answered in the affirmative, stating that his vaccinations were made 
in the portions of the city where the disease was most virulent, and that in families 
of ten or fifteen members, living in a cité ouvrière, if vaccination was practiced after 
the outbreak of the fever, among the members not yet affected, this vaccination, 
in a very large number of cases, arrested the further progress of the disease in that 
family, whereas where it was not practiced, they all were stricken down with the 
fever and many, if not all, died. 
Note.-Dr. Freire stood on the platform while the questions were asked by different members 
of the Section. Dr. Felix Formento stood at his side and translated the questions into French, 
and translated into English his replies as made. 
The following resolution, offered by Dr. Felix Formento, of New Orleans, was 
adopted :- 
Be it Resolved, That the grateful thanks of the Fifteenth Section, Public and Inter- 
national Hygiene, of the Ninth International Medical Congress, be tendered to 
Dr. Domingos Freire, of Brazil, for his most eloquent, scientific and masterly address, 
expounding the nature of a doctrine the practical application of which may, to a 
certain degree, cause the gradual disappearance of one of the most fatal diseases 
that affect mankind, revolutionizing the social and political condition of certain por- 
tions of the world. 
Be it Resolved, That the Executive Committee of the Ninth International Medical 
Congress be earnestly requested to publish the paper of Dr. Freire in extenso in the 
Transactions of the Congress. 
The foregoing resolutions were duly transmitted to President N. S. Davis, of the 
Ninth International Medical Congress. 
Dr. J. NIcF. Gaston, of Atlanta, Georgia, said he feared that anything he might 
say would detract from the decidedly favorable impression made by the statistical 
report presented in regard to the protection afforded by inoculation of the cultured 
viras of yellow fever. But it turned out that he was residing in Brazil during the 
early investigation of this subject by Dr. Freire, and had kept abreast of all that he 
had done since toward a verification of the prophylactic virtues of yellow fever. 
Shortly after his return from Brazil, in 1884, he undertook to enlist the attention of 
the officials of the United States Government in behalf of an investigation of the 
claims of yellow fever inoculation. Communications were at different times addressed 
to the Secretary of the Treasury and to President Cleveland, which only elicited 
responses that there were no funds set apart for such an undertaking. 
Supposing that an appeal to the municipal authorities of New Orleans might be 
more successful, a letter was addressed to Dr. Joseph Holt, President of the Board 
of Health, setting forth what had been accomplished by Dr. Freire in Brazil, and 
requesting his cooperation in securing consideration for yellow fever inoculation. 
Fortunately, about the same time he had received a report of successful inoculation 
from a physician in Panama, and was prompted, by his own convictions of the import- 
ance of the method, to present it to the meeting of the American Public Health 
Association at the city of Washington. SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
489 
The proposition was favorably entertained, and the result was shown in the early 
drafting of a bill providing for the appointment of three medical men as commis- 
sioners and the appropriation of $30,000 to investigate the claims of yellow fever 
inoculation. 
Dr. Holt showed great energy in laying this before Congress ; but, unfortunately, 
there were influences at work against the measure, from New Orleans, and every 
available means of reaching the members of Congress by journals and circulars were 
practiced by the medical men connected with the New Orleans Medical and Sur- 
gical Journal. If there be any credit connected with such a proceeding they are 
entitled to its benefits. But on the other hand, if any detriment has been caused to 
the progress of a good work, they must be held responsible at the tribunal of public 
opinion for this untoward result. 
While this bill was still pending before Congress, he presented a series of resolu- 
tions at the meeting of the American Medical Association, for memorializing the 
United States Congress in favor of its adoption. This memorial, setting forth what 
had been accomplished by Freire, Carmona, Finlay and others, was signed by him- 
self, as chairman, and Dr. R. 0. Hooper, of Little Rock, Arkansas, but without the 
name of the third member of the committee, Dr. T. G. Richardson, of New Orleans, 
who excused himself from signing it, on account of opposition to the measure. 
In view of these unfavorable influences, the American Congress only voted an 
appropriation of $10,000 for the investigation, which involved the interests of vast 
portions of the people in this country, and the President appointed but one com- 
missioner to enter upon the exploration of the data connected with yellow fever 
inoculation in Mexico and Brazil. Dr. George Sternberg, of the Army staff, was 
assigned to this duty, and, his salary being already provided for, it was doubtless con- 
sidered that the small appropriation would suffice for the investigation. 
Unfortunately, instead of proceeding first to Mexico, in June of the present year, 
when it might have been expected that yellow fever would be found there, as it falls 
within the Northern hemisphere and has summer comparing to that of the United 
States, Dr. Sternberg was ordered to Rio de Janeiro, where yellow fever was not likely 
to occur, being the winter of that region south of the equator. 
It is likewise to be noted that he went to investigate the processes of Domingos 
Freire, when every one conversant with foreign literature should have known that 
Freire was in Paris, for the purpose of laying his views and experiments before the 
Scientific Academy of France. He thus remained in Rio de Janeiro for a month, in 
the absence of Freire, but was, perhaps, able to turn the time to profitable account 
in verifying the statistics which had been published previously, under the authority 
of the Brazilian Government. After the return of Freire to Rio de Janeiro, he had 
an opportunity of observing his processes in preparing the various cultures of the 
micrococcus discovered previously by him, but there was no occasion for testing the 
application of this inoculation in cases of yellow fever. 
It will not be a matter of surprise, therefore, if Dr. Sternberg has returned from 
his sojourn in the pleasant winter climate of Brazil without bringing any satisfactory 
information touching the merits of inoculation against yellow fever. 
The Government of these United States is, of course, responsible for the course 
taken by Dr. Sternberg, as he went under orders from the President, and, as an officer, 
had no alternative but to obey orders. 
Anticipating what might ensue from this ill-timed visit, which might have other- 
wise been made profitable in Mexico, Dr. Gaston introduced a resolution at the 
meeting of the American Medical Association in Chicago, recommending that two 490 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
additional members of the medical profession should be added to the Commission, 
whose acquaintance with the language and customs of the population in the respect- 
ive countries should fit them for assisting in the investigation of the scientific aspect 
of the matter by the skillful bacteriologist properly placed on duty by the Government. 
Notwithstanding that a motion to lay on the table was rejected and the resolution 
was passed in a full session of the Association, there was presented a motion to recon- 
sider the vote, and this also was voted down by the Association. On the last morn- 
ing of the meetings, when the number present was small, a preamble touching the 
work of Dr. Sternberg was accompanied by a resolution rescinding the previous action, 
and though this was claimed by Dr. Gaston to be out of order, it was held open for 
consideration by the President of the Association. A motion to consider the pre- 
amble and resolution separately was seconded, but was precluded by a call for the 
previous question, which was sustained. 
Thus the resolutions passed at a full session of the American Medical Association, 
over a motion to lay on the table and one subsequently to reconsider, were rendered 
of no effect, and we now stand where the officials of the Government of the United 
States had previously placed the matter. 
In the memorial which had been provided for, the names of Dr. Guiteras, 
familiar with Mexico, and of Dr. H. M. Lane, resident for a number of years in 
Brazil, were proposed as proper for adding to the Commission, and the importance of 
such an increase of the persons for the proper execution of such duties as devolve 
upon this Commission, must be evident to all who have taken the trouble to examine 
this subject. 
Believing that the sense of this Section should be expressed without bias from 
local or personal considerations, the following preamble and resolutions were respect- 
fully submitted and unanimously adopted :- 
Whereas, Inoculation against yellow fever, if it proves upon further 
tion to be successful, is calculated to confer great benefits upon the human race 
throughout the world ; and 
Whereas, The facts observed by Dr. Domingos Freire afford a reasonable assur- 
ance of protection in Rio de Janeiro ; therefore 
Resolved, That this Section recommends thorough investigation of inoculation 
against yellow fever, and that adequate appropriations be made by the several Gov- 
ernments represented in this Congress for this object ; 
Resolved, That this action be communicated for consideration in the general ses- 
sions of the Congress. 
The resolutions of Dr. Gaston were transmitted to Dr. N. S. Davis, President 
of the Ninth International Medical Congress. 
As a matter of historical record, Dr. Jones here embodies in the Transactions of 
the Fifteenth Section the original letters of Professor Freire, of Brazil, and of Pro- 
fessor Carmona, of Mexico. 
Rio de Janeiro, 8 Octobre, 1886. 
Cher Confrère:-J'ai l'honneur de rendre réponse à votre aimable lettre datée du 28 Août. 
Je vous félicite pour la position que vous a été confiée en qualité de Président d'une des plus 
importantes Sections du Congrès International qui se réunira à Washington. Je suis sûr que 
vous saurez accomplir cette tâche avec tout le profit pour la science et l'humanité. Le pro- 
gramme que vous avez bien voulu me remettre comprend des sujets du plus haut intérêt, et sans 
doute que leur discussion sera des plus lumineuses. 
Quant aux questions que vous me faites, je vous réponds comme il suit:- 
A la première que je me regarde très heureux d'avoir mérité le grand honneur d'être choisi 
Vice-Président de la Section dont vous êtes le digne Président, et je m'empresse de vous envoyer 
mille remerciements pour ce motif. SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
491 
À la deuxième qu'il me sera peut-être possible d'aller comme délégué du Gouvernement Bré- 
silien ; et pour cela je tâcherai de faire les démarches nécessaires. 
Quant à la troisième question, je réponds également affirmativement. Je ferai un rapport 
résumé de tous les points concernant la fièvre jaune, en l'accompagnant de tous les documents 
nécessaires pour illustrer non seulement la partie clinique proprement dite, mais encore les relevés 
statistiques recueillis jusqu'ici. 
Agréez, mon cher illustre confrère, l'expression sincère de mes sentiments les plus dévoués. 
Domingos Freire. 
N. B. Je vous remets avec cette lettre une brochure sous le titre! Notice sur la Régénération 
de la Virulence des Cultures Atténuées du Microbe de la Fièvre Jaune, que j'ai l'honneur de sou- 
mettre à votre considération. 
Je vous remets aussi la statistique de l'année 1885. 
Mexico, le 20 Octobre, 1886. 
Dr. Joseph Jones. 
Monsieur.-N'étant pas à Mexico à l'époque de l'arrivée de votre lettre, datée le 28 Août de 
la Nouvelle-Orléans, je n'étais pas en possibilité de vous répondre immédiatement. 
Aujourd'hui je le fais en vous disant: 
1° Que j'accepte volontiers l'offre que vous me faites d'être nommé un des Vice-Présidents 
de la quatorzième Section, pour représenter la République du Mexique dans la prochaine 
réunion du Congrès Médical International. 
2° Que je serai présent à Washington le 5 Septembre, 1887, pour représenter la même Ré- 
publique, dans la quatorzième Section du Congrès Médical International. 
3° Que je ferai un écrit sur mes travaux relatifs à la fièvre jaune et sur les résultats des ino- 
culations préventives de ce terrible fléau. 
Agréez Mr. le Dr. l'assurance de ma considération distinguée. 
Dr. M. Carmona y Vallê. 
METROPOLITAN DEFENSES AGAINST INFECTIOUS DISEASES. 
DÉFENSES MÉTROPOLITAINES CONTRE LES MALADIES CONTAGIEUSES. 
DIE VERTHEIDIGUNGSMITTEL DER ENGLISCHEN METROPOLE GEGEN INFECTIÖSE 
KRANKHEITEN. 
BY EDWARD SEATON, M.D., F.R.C.P., ETC., 
London, England. 
In this Section of Public Hygiene no subject can be more important than that of 
the system of defenses against the spread of infectious fevers in great cities; for with 
the rapid increase in the facilities of travel, every community is more or less dependent 
for its freedom from invasion on the perfection of those arrangements in the towns with 
which it is in frequent communication. A person incubating a disease which takes 
twelve days to develop, may, during that period, not only travel from London to dis- 
tant parts of the continent of Europe, but may reach America before the disease declares 
itself. I need not, therefore, excuse myself for bringing before you a brief description 
of the system of defenses against infectious diseases in our English metropolis, or, to 
speak more precisely, that part of our system which comprises the isolation and treat- 
ment of the infectious sick. 
In discussing this subject, it is always well to have in mind an ideally perfect arrange- 
ment for the prevention of epidemics by quarantine or isolation for a large town, and 492 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
I will, therefore, quote, from an official report of my own, a description of such arrange- 
ments, which are ideal in the sense that they are none of them carried out in entirety 
in any of our large towns, but which have been proved to be practicable, not only by 
the experience of some of the towns in England, but also, I believe, by that of import- 
ant cities on this great continent of America. 
The Corporation, or Town Council, delegates its principal functions as sanitary 
authority to a "Health Committee," which has charge of all the arrangements for pre- 
venting epidemics. The Medical Officer of Health is the responsible adviser of this 
committee, and being also its chief executive officer in work which is distinctly medi- 
cal, he is placed in a position of great trust. He is armed with sufficient powers. 
All householders are required, under penalty, to notify to him the existence of danger- 
ous, infectious diseases, to wit, cholera, typhus fever, smallpox, enteric fever, diph- 
theria and scarlet fever, it being recognized that their concealment may be a risk to the 
whole community. The medical gentlemen who are in professional attendance on such 
cases are required, for a fee, to furnish certificates of the nature of the disease, on printed 
forms, with which they are kept supplied. Information from these sources is usually 
reliable and complete, but it may be supplemented by that which comes from relieving 
officers, school board inspectors, clergy, district visitors and others. From wherever it 
comes, it converges in one centre-the office of the health department. This office is 
in a convenient situation, and open to the public at all hours. It is under the control 
of the medical officer, who visits it frequently, and when absent is represented by the 
chief inspector or clerk, who is well acquainted with his movements. From the office 
messages may be sent to the ambulance stations or to the ' ' isolation ' ' hospital. Of the 
" epidemic " or " isolation " hospital it is needless to say more than that its situation 
is sequestered, away from the vicinity of dwellings, but at the same time not too remote 
from the population it is intended to serve ; its appearance is attractive, and its admin- 
istration free from all taint of pauper associations. Here, also, as at the office of the 
health department, everything is under the control of the medical officer, who is respon- 
sible for keeping the town free from epidemic disease. It is understood that the hospital 
exists for this purpose. It must be ready for use at any moment, though it may be 
empty for months together. The expense of maintaining it, with its nursing staff 
constantly in efficient working order, is considerable, but the enlightened rate-payers 
regard the outlay for this purpose as they do that for keeping up the fire brigade. 
Close to the hospital buildings are some empty but furnished houses, into which persons 
who have been exposed to the infection of smallpox or typhus fever can be received for 
that period (about a fortnight) in which the disease may be incubating, or in course of 
development, during which it is desirable they should be under medical supervision. 
The committee, representing a corporation powerful in its resources, is not only able to 
enforce the seclusion of individuals for the public good, but is also ready to board them, 
pay their wages, and even to afford them reasonable compensation for any loss of busi- 
ness they may sustain. Furthermore, the arrangements for immediately isolating the 
sick, and watching those who may become centres of infection, are supplemented by 
ample provision for disinfection of houses, bedding, clothing and furniture, which is 
scientifically and rigidly applied. To this it may be added, that in the case of smallpox 
no system of prevention is perfect which does not amply provide for vaccination or 
revaccination at the infected house and neighborhood. In England the arrangements 
are under the control of the poor law or destitution authority, but this is wisely sup- 
plemented, in some towns, by the health authority, which provides free vaccination to 
those who have been exposed, or are likely to be exposed, to infection, and this is 
offered to them at their homes. 
The above is an outline of the general conditions for dealing successfully with infec- 
tious diseases, to be fulfilled in the case of a large town. The larger the town the SECTION XV PUBLIC AND INTERNATIONAL HYGIENE. 
493 
greater must be the difficulty of fulfilling such conditions. In the metropolis, with its 
vast inhabited area and its huge population, the difficulties are exceptional, and it is 
no wonder that it is only by slow degrees that they are being overcome. 
The greatest of all the difficulties arises from the want of unity and uniformity in 
London municipal government. There is no one corporation, town council or board 
of health for London, as there is for the large provincial towns in England, as well as 
for Glasgow and Edinburgh. There is a multiplicity of authorities for the metropolis, 
but no one authority to undertake the whole work of preventing the spread of infec- 
tious diseases within the metropolitan area. There are the several Boards of Guardians, 
forty in number; there are the vestries, also forty in number; there is the Metropolitan 
Asylums Board, and, finally, there is H. M. Local Government-all of which authorities, 
up to the highest-the Imperial Department-have a hand in the work, but none of 
which are saddled with the whole responsibility of dealing with epidemics. The neces- 
sity of having one body alone to undertake this work is coming to be recognized more 
and more by those who take a part in municipal affairs, and by degrees the Asylums 
Board, as it is called, is beginning to be regarded as the suitable authority for the 
purpose. 
I will not enter now into a discussion of the circumstances which led to the creation 
of the Board, in 1867, or into the nature of the functions assigned to it, or the character 
and results of the work it has achieved during the twenty years of its existence. A 
most interesting report of the Chairman of the Board, Sir Edwin Galsworthy, published 
last March, which, together with other important publications of the Board, have been 
supplied by the able and courteous Clerk of the Board, Mr. Jebb, are here and at your 
service. They contain full information on those points. But at present I will only 
refer to them as indicating the difficulties in the way of rendering this Board more effi- 
cient for the purposes which it might so advantageously fulfil. Before the establish- 
ment of the Board, in 1867, London was dependent for its infectious hospital provisions 
upon the charities, the smallpox hospital, at Highgate, the fever hospital, at Islington, 
and the general hospitals, some of which took in cases of infectious diseases. The 
various Boards of Guardians also treated cases in imperfectly isolated wards attached 
to the workhouses. This accommodation was very insufficient, and in the case of the 
workhouses the aggregation of the infectious sick in proximity to the paupers consti- 
tuted a source of public danger. It was, no doubt, owing to the difficulty of isolating 
infected persons, having been felt mostly in the case of paupers, that led to the Asylums 
Board being established, and to its being chiefly constituted of representatives of the 
Board of Guardians. This was most unfortunate, as, by its constitution, the Board has 
always been prevented from taking a comprehensive view of what is meant by the preven- 
tion of infectious disease. Its name indicates this fault. It is, or was, intended to provide 
asylums, or places of refuge, for the infectious sick and for imbecile paupers. The 
disadvantages arising from the origin and constitution of the Board are twofold: In 
the first place, its policy has always been dictated by the traditions of the Poor Law 
Board, which has in view the relief of destitution at the least possible expense to the 
rate-payers; whereas, we know, from the teachings of sanitary science, that, for the pre- 
vention of epidemic disease, the policy of a public health authority must be guided by 
very different principles. In the second place, in the management of the hospitals 
themselves the prevention of disease is entirely subordinate to the treatment of disease. 
One example of this fault is enough. The medical treatment of persons suffering with 
smallpox is important, yet an authority which was guarding the public health would 
naturally look upon its prevention as still more important. From this point of view, 
to allow unrevaccinated nurses to attend on the sick would be more unpardonable than 
to neglect to give the patient such medicines or wine as the physician deemed necessary. 
Yet it had to be admitted in Parliament, three years ago, that unrevaccinated nurses 494 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
had been allowed to attend upon persons suffering from smallpox. Thirdly, the Board, 
being saddled with the responsibility of providing for the imbecile paupers of Loudon, 
is charged with the supervision of a large number of great establishments, and is unable 
to concentrate its attention on the prevention of epidemic disease. 
Notwithstanding the defects in its constitution, the Board has done a great deal 
toward establishing a good system of defense against infectious disease. The Local 
Government Board has the right to nominate a third of the members, and it has nomi- 
nated several who have special knowledge or experience which is useful to the Board. 
The late Chairman of the Board, Sir Edmund Currie, showed great devotion to its 
interests, and brought splendid administrative powers to its service. Under the 
guidance of the present chairman, Sir Edmund Galsworthy, and some of his able col- 
leagues, many of the present arrangements have been perfected, and in particular the 
ambulance arrangements for the removal of patients to extra-mural hospitals, are worthy 
of attention. As it will, no doubt, be interesting to the Section, I will very briefly 
describe the present arrangement. 
The hospital provision consists, at the present time, of five intra-mural and three 
extra-mural hospitals. The former provide for as many as 1475 beds, and the latter 
766. So that, at present, the total accommodation is not more than about 2000 beds 
for a population of 4,000,000. The five intra-mural hospitals are the following:- 
1. The Eastern, at Homerton,9 acres of land, 400 beds. 
2. The Northwestern, at Haverstock Hill, . . . .11 " " 200 " 
3. The Western, at Fulham,6 " " 184 " 
4. The South western, at Stockwell,8 " " 322 " 
5. The Southeastern, at Greenwich,11 " " 366 " 
1472 " 
The extra-mural hospitals are the following :- 
The hospital ships off Dartford, Kent; 350 beds, for smallpox. 
At the Gore Farm, near Dartford, are a few huts ready for use. 
At Winchmore Hill there is a convalescent home for scarlet fever, with room for 
416 patients. 
All cases of smallpox are now removed out of London to the ships. The ambulance 
arrangements are excellent, and I can testify, from personal experience, that the journey 
from the patient's home, or from one of the intra-mural hospitals, can be conducted 
without any detriment to the patient. There is j ust a small proportion of cases which 
may suffer by the journey, and which it is, indeed, doubtful whether removal from 
the home at all is desirable. I refer to cases of hemorrhagic smallpox and women in 
the puerperal state affected with the disease. A committee of the Board is at present 
considering the question of the best means of dealing with such cases. The recent 
observations of Dr. Buchanan, the Medical Officer of the Government, and Mr. Power, 
the eminent member of his staff, have aroused the attention of all observers to the pos- 
sibility of the spread of smallpox by aerial dissemination of the particulate matter from 
hospitals. The committee is at present considering the feasibility of constructing hos- 
pitals on the plan recommended by Professor Burdon-Sanderson, for consuming all their 
own air, and any observations or experience which can be furnished by the members 
of this Congress will be welcome. 
DISCUSSION. 
Dr. P. H. Bailhache, U. S. Marine Hospital Service, referring to the sugges- 
tion of Professor Sanderson, as quoted by Dr. Seaton, concerning the erection of 
hospitals constructed to consume their own air, stated that he believed that such a 
hospital has been erected in Detroit, Michigan. SECTION XV PUBLIC AND INTERNATIONAL HYGIENE. 
495 
OUTLINE OF INVESTIGATIONS INTO THE NATURE, CAUSES AND 
PREVENTION OF ENDEMIC AND EPIDEMIC DISEASES, AND 
MORE ESPECIALLY MALARIAL FEVER, DURING A PERIOD OF 
THIRTY YEARS, WITH A CLAIM TO PRIORITY IN THE DETERMI- 
NATION OF THE CHEMICAL AND MICROSCOPICAL CHARACTERS 
AND CHANGES OF THE BLOOD IN THE VARIOUS FORMS OF 
MALARIAL PAROXYSMAL FEVER AND THE APPLICATION OF 
THE RESULTS OF THESE INVESTIGATIONS TO MEDICAL DIAG- 
NOSIS AND MEDICAL JURISPRUDENCE. 
RÉSUMÉ D'INVESTIGATIONS DANS LA NATURE, LA CAUSE ET LA PRÉVEN- 
TION DES MALADIES ENDÉMIQUES, SURTOUT DE LA FIEVRE PALUDÉENNE. 
EXPÉRIENCE DE TRENTE ANS ET PRETENTION À LA PRIORITÉ DANS LA 
DÉFINITION DES CARACTÈRES CHIMIQUES ET MICROSCOPIQUES, DES 
CHANGEMENTS DU SANG DANS LES DIVERSES FORMES DE LA FIEVRE PA- 
LUDÉENNE AIGUË, ET L'APPLICATION DES RESULTATS DE CES DÉCOU- 
VERTES A LA DIAGNOSTIQUE ET A LA JURISPRUDENCE MEDICALES. 
UMRISS DER WÄHREND DREISSIG JAHRE ANGESTELLTEN UNTERSUCHUNGEN ÜBER 
DAS WESEN, DIE URSACHEN UND VERHÜTUNG ENDEMISCHER UND EPIDEMISCHER 
KRANKHEITEN, INSBESONDERE DES MALARIAFIEBERS, MIT PRIORITÄTSANSPRUCH 
AUF DIE BESTIMMUNG DER CHEMISCHEN UND MICROSCOPISCHEN EIGENSCHAFTEN 
UND VERÄNDERUNGEN DES BLUTES IN DEN VERSCHIEDENEN ARTEN DES INTERMIT- 
TIRENDEN MALARIAFIEBERS, UND DIE ANWENDUNG DER ERGEBNISSE DIESER 
UNTERSUCHUNGEN AUF DIE DIAGNOSE UND GERICHTLICHE MEDICIN. 
BY JOSEPH JONES, A.M., M.D., 
Of New Orleans, La. 
The investigations of the author on the physical, chemical, microscopical and patho- 
logical changes of the blood, organs, secretions and excretions in human beings suffer- 
ing with the various forms of malarial fever, were instituted in the Marine Hospital 
and Poor House of Savannah, Georgia, in the year 1856, and were vigorously prosecuted 
during three years, 1856, 1857 and 1858. 
My first publications were made in the Southern Medical and Surgical Journal, 
edited by Dr. Henry F. Campbell and Dr. Robert Campbell, and published in Augusta, 
Georgia. In an article published in May, 1858,* after presenting the history, symptoms, 
chemical analyses and pathological anatomy of the case of diabetes mellitus, and of 
several cases of malarial fever, the following conclusions were reached:-• 
If we compare the blood of these cases with that of health, and with the blood of 
the patient suffering with diabetes mellitus, we will observe the following points of 
agreement and disagreement:- 
1. The colored blood corpuscles are diminished greatly and rapidly in malarial 
fever. This destruction of the colored blood corpuscles is far more rapid in malarial 
fever than in diabetes mellitus. 
2. The salts of the colored blood corpuscles are diminished to a remarkable extent 
in malarial fever, while they are normal in amount in the blood of diabetes mellitus. 
3. The blood coagulates slowly and the clot is soft in malarial fever, while the 
reverse was the case in this specimen of diabetic blood. 
•;;:'"Case of Diabetes Mellitus," treated by Joseph Jones, A.M., M.D. Southern Medical and 
Surgical Journal, New Series, Vol. xiv, Augusta, Georgia, May, 1858, No. 5, pages 290-315. 496 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
4. The fibrin is often diminished in malarial fever, and the serum presents a golden 
color, while in this case of diabetes mellitus the fibrin was slightly increased and the 
color of the serum was normal. That the poison of malarial fever induces profound 
changes in the colored blood corpuscles, and other constituents of the blood, I have 
demonstrated by the following facts:- 
(a) The urine of patients suffering with malarial fever contains an increased quan- 
tity of iron. The increase of the iron in the urine is subsequent to the destruction of 
the colored corpuscles in the blood. 
(&) In examinations of the organs after death, from all the forms of malarial fever- 
intermittent, remittent and congestive-I have observed that the dark blood of the 
spleen and liver do not change to the arterial hue when exposed to the action of the 
oxygen of the atmosphere. After death from phthisis, cirrhosis of the liver, organic 
disease of the circulatory apparatus and apoplexy and mechanical inj uries, as far as my 
observations extend, the blood of the spleen and liver always changes to the arterial 
hue when exposed to the action of the oxygen of the atmosphere. 
(c) Animal starch accumulates in the malarial fever liver, while grape sugar, as far 
as my observations extend, is absent. I have tested the livers of malarial fever for 
grape sugar and starch. An abundance of starch * was obtained, without a trace of 
grape sugar. The livers were set aside and examined after intervals of twelve hours. 
The last examination was made thirty-six hours after the first. At every examination 
the result was the same, an abundance of animal starch and no grape sugar. These 
facts are important, not only in their bearing upon malarial fever, but also in their 
bearing upon diabetes mellitus. M. Cl. Bernard f has demonstrated that the transfor- 
mation of glycogenic hepatic matter (animal starch) formed by the liver into glucose is 
the result of the action of a special ferment, which is formed and exists in the blood, 
independent of the liver. From the facts which we have previously stated, it is evident 
that in malarial fever this ferment is destroyed, while the liver still possesses the 
power of transforming the nitrogenized and non-nitrogenized elements into animal 
starch. We have now facts sufficient to draw important distinctions between malarial 
fever and diabetes mellitus. In both diseases the blood corpuscles may be greatly 
diminished. In both diseases the nervous and muscular forces may be correspondingly 
diminished. Here the analogy ceases. 
The destruction of the colored corpuscles is rapid in severe types of malarial fever, 
and slow in all forms of diabetes mellitus. The salts of the blood corpuscles are normal, 
if not increased, in this case of diabetes mellitus, while they are greatly diminished in 
malarial fever. In malarial fever the blood loses its power of changing its color in the 
spleen and liver. In malarial fever the color of the liver and the bile is altered, and 
the spleen is enlarged, softened and filled with a purplish-brown mud. In diabetes 
mellitus all the organs are normal in appearance. In malarial fever the blood has lost 
its power of converting animal starch into glucose. In diabetes mellitus this power is 
greatly increased. 
The following table affords a comparison of normal, diabetic and malarial blood:- 
-So abundant is this animal starch in the malarial fever liver, that if a small particle of the 
substance of the liver be mashed upon a glass slide, treated with a saturated solution of iodine in 
alcohol, and viewed under the microscope, numerous beautiful blue masses of this animal starch 
colored by the iodine will be seen. If the fibrous capsule be torn off from the surface of the liver, 
spread upon a glass slide, and treated with tincture of iodine, these blue masses will be seen scat- 
tered among the meshes of the fibrous tissue. With reference to the discovery of animal 
starch, see American Journal of the Medical Sciences, Oct. 1857, page 203. 
Moniteur de Hôpitaux, April 14th, 1857; also, American Journal of Medical Sciences, 
July, 1857, page 203. SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
497 
Normal 
Blood. 
Normal 
Blood. 
Diabetic 
Blood. 
Malarial 
Blood. 
Malarial 
Blood. 
Malarial 
Blood. 
Solid Matters in 1000 parts of Blood 
" " " " " " Liquor Sanguinis 
200.000 
240.000 
161.490 
122.447 
159.489 
166.551 
100.000 
120.000 
80.961 
74.275 
86.978 
89.203 
Dried Blood Corpuscles in 1000 parts of Blood 
120.000 
150.000 
92.702 
51.987 
79 437 
85.968 
Moist " " " " « « « _ 
480.000 
600.000 
370.808 
207.948 
317.748 
343.872 
Liquor Sanguinis " " " " " 
400.000 
520.000 
629.192 
792.052 
682.252 
656.128 
Fibrin in 1000 parts of Blood 
2.000 
3.500 
2.806 
1.925 
0.877 
1.450 
Fixed Saline Constituents in 1000 parts of Moist 
Blood Corpuscles 
8.120 
10.500 
11.981 
0.841 
10.728 
1.648 
Fixed Saline Constituents in 1000 parts of Dried 
Blood Corpuscles 
65.000 
70.000 
49.916 
3.240 
42.914 
6.595 
Fixed Saline Constituents in 1000 parts of Dried 
Blood 
70.000 
80.000 
56.108 
27.083 
36.341 
37.909 
Fixed Saline Constituents in 1000 parts of Solid 
Matters of Liquor Sanguinis 
88.053 
95.000 
68.488 
44.779 
30.205 
75.558 
Fixed Saline Constituents in 1000 parts of Liquor 
Sanguinis 
8.550 
10.100 
5.320 
3.326 
2.647 
6.630 
We have now all the necessary facts for the intelligent treatment of this case. The 
indications in the treatment of this case of diabetes mellitus are:- 
1. To strengthen digestion. His stomach fails to digest the nitrogenized elements, 
the substances which he needs to supply the rapid waste of his tissues. 
2. To afford the organic and inorganic materials of structure. 
3. To quiet and strengthen the nervous system. 
4. To arrest the destruction and transformation of the elements of the blood, tissues 
and food into animal starch and grape sugar. 
The article on diabetes mellitus was followed by nine articles published in nine con- 
secutive numbers of the Southern Medical and Surgical Journal, extending from June, 
1858, to February, 1859, inclusive, giving 53 cases of malarial fever in detail, illustrated 
by the details of 16 autopsies, 66 analyses of the urine, and nine elaborate analyses of 
the blood, the whole constituting a closely printed octavo of 235 pages.* 
At the meeting of the American Medical Association in Louisville, Kentucky, in 
1859, the author presented an extended memoir, based upon his physical, chemical, 
microscopical and pathological investigations of the various forms of malarial fever, 
embraced in six chapters, and covering, in a closely printed volume of 419 pages, the 
results of the critical study of several hundred cases of malarial fever (intermittent, 
remittent, congestive and pernicious), illustrated by elaborate tables of the changes of 
the temperature, pulse and respiration, and of the blood, urine and organs in the various 
stages of the disease, f In this work the author endeavored to delineate correctly the 
natural history, chemistry and pathology of the various forms of malarial fever, and to 
base upon these results a rational and scientific method of treatment. 
Preceding this publication medical literature possessed only a few detached obser- 
vations relating to intermittent fever, but possessed no systematic investigations detail- 
ing the changes of the pulse, respiration, temperature, blood, urine and organs, in the 
various forms of malarial fever. 
With reference to the blood, it was clearly established by these investigations, which 
preceded the American Civil War- 
1. That the malarial poison rapidly destroys the colored blood corpuscles in all the 
various forms of intermittent, remittent and congestive fever. 
*" Observations on Malarial Fever," by Joseph Jones, A.M., m.d. Southern Med. and Surg. 
Jour., June, July, August, September, October, November, December, 1858; January and February, 
1859 ; New Series, Volumes xiv and xv, Augusta, Georgia. 
f " Observations on some of the Physical, Chemical, Physiological and Pathological Phenome- 
na of Malarial Fever," by Joseph Jones, a.m., m.d. The Transactions of the American Medical 
Association, Vol. xn, Philadelphia, 1859, pages 209-627. 
Vol. IV-32 498 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
2. The destruction of the colored blood corpuscles may take place rapidly during 
the active stages of the disease or more slowly during the chronic stages of the disease. 
3. The destruction of the colored blood corpuscles was demonstrated both by chemi- 
cal and microscopical analyses, and the peculiar appearance presented by the pigments, 
granules and colorless corpuscles pointed out. 
4. The fibrin is decreased in the various forms of malarial fever, and the changes in 
the physical and chemical characters of this element were applied to the explanation of 
certain phenomena witnessed more especially in the hemorrhagic fevers. 
5. The changes in the color of the liver and spleen in malarial fever are shown to 
be characteristic of this disease, and to be due chiefly to the action of its poison upon 
the colored blood corpuscles. 
6. The microscopical and chemical differences between the changes of the blood and 
organs in malarial and yellow fevers were carefully defined. 
7. Principles of treatment, based upon the results of chemical and microscopical 
analyses and investigations with the thermometer, and upon pathological research. 
In 1859 and 1860, the author undertook an extended investigation of the diseases of 
the various geological and physical divisions of the Southern (slave States). The investi- 
gations of the soil, waters and diseases of the rice plantations, low grounds and swamps 
of Georgia first engaged his attention. One of the most important objects of this inves- 
tigation was the determination, by chemical analyses and microscopical investigations, 
and by experiments upon living animals, of the natural cause of the various forms of 
malarial fever. 
The accomplishment of this end necessitated extensive travel among the swamps 
and rice fields, and careful chemical and microscopical examination of the waters, and 
the following facts were determined, which have a direct bearing upon the subject now 
under investigation:- 
1. The complex chemical nature of the soil and waters, and especially of the organic 
matters. 
2. The vast variety of vegetable and animal microorganisms found in the waters 
of the swamps, rice fields, creeks, marshes and rivers of the malarial regions of the 
Southern States. 
3. The poisonous nature of the exhalations from the stagnant waters of swamps and 
rice fields and their power to induce dysentery and malarial fever in human beings. 
4. The poisonous nature of the waters of swamps and rice fields and their power to 
induce the various forms of malarial fever when drunk by human beings. 
5. The poisonous nature of the stagnant waters of swamps and rice fields when 
injected subcutaneously into living animals. 
As far as our researches extend these were the first experiments ever devised in the 
history of medicine for the direct solution of the problem of the poisonous properties 
of the stagnant waters of swamps, marshes and rice fields by introduction into the 
blood of animals. 
As these researches contained much matter of value to the agriculturist, and as 
they contained not merely numerous analyses of the soil, mineralsand waters of Georgia 
and South Carolina, and the results of an extended search for the beds of phosphates 
which have in late years proved of so great value to the agriculturists of America and 
Europe, but also elaborate hygienic and sanitary rules for the guidance of the laborers 
in the rice, sugar and cotton plantations, many of the results were embodied in a 
paper or volume of 319 pages to the Cotton Planters' Convention.* 
During the American Civil War, 1861-1865, the author conducted an extended 
series of investigations upon the diseases of the troops in the field and in the military 
* " First Reports to the Cotton Planters' Convention of Georgia on the Agricultural Resources SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
499 
hospitals in Virginia, North Carolina, South Carolina, Georgia and Tennessee, and 
among the Federal prisoners confined in Richmond, Va., and Andersonville (Camp 
Sumter), Georgia, and a large number of the cases of typhoid and malarial fever 
passed under his observation in the field and general hospitals, and in the beleaguered 
towns and cities. The great military hospitals of the Confederate armies located in 
Gordonsville, Charlottesville, Virginia, Charleston, South Carolina, Savannah, Augusta, 
Atlanta, Marietta, Macon, Vineville and Andersonville, Georgia, afforded the grandest 
field ever offered to a Southern physician and surgeon for the investigation of the various 
forms of endemic, epidemic and contagious fevers, and of the gunshot wounds, casual- 
ties and diseases incident to the campaigns and battles of great armies. 
A careful consideration of the causes which the author has recorded in his " Medi- 
cal and Surgical Memoirs," Volume II, pp. 152-161, with reference to the microorgan- 
isms of the intestinal canal, and of the mesenteric and Peyer's glands and urine in 
typhoid fever, and the comparison of these with the subsequent observations of Klebs 
and others, justify the claim of the author as one of the discoverers of the microorgan- 
isms of typhoid fever. 
During the civil war, 1861-1865, he had no means of presenting his labors to the 
scientific world. 
These investigations, with accurate details of cases, with elaborate drawings, were 
continuously forwarded to the Surgeon-General's office in Richmond, Virginia, in 1862, 
1863 and 1864, and constituted three large manuscript volumes. 
These labors were destroyed by fire at the time of the burning of the Confederate 
capital. 
The author retained the first and original draft of the cases and drawings, and from 
them he has reproduced the details and illustrations recorded in the second volume of 
his ' ' Medical and Surgical Memoirs. ' ' 
We will content ourselves with the mere record in a foot-note of some of the publi- 
cations relating to malarial fever and kindred diseases .* 
After a continuous term of service in the Charity Hospital of New Orleans, from 
October, 1868, to April, 1870, during which period the author was continuously and 
•of Georgia," by Joseph Jones, m.d., Augusta, Georgia, 1880 ; see also "Medical and Surgical 
Memoirs," containing Observations on the Geographical Distribution, Causes, Nature, Relations 
and Treatment of Various Diseases, 1855-1856, by Joseph Jones, m.d., Volume n, New Orleans, 
1887, pp. 1111-1116. 
* " Sulphate of quinine administered in small doses during health is the best means of prevent- 
ing chills and fever and bilious fever and contagious fever in those exposed to the unhealthy climate 
of the rich lowlands and swamps of the Southern Confederacy," by Joseph Jones, m.d. Southern 
Medical and Surgical Journal, Volume xvn, No. 8, Augusta, Georgia, August, 1861, p. 593-614. 
■" Indigenous remedies of the Southern Confederacy which may be employed in the treatment of 
malarial fever," by Joseph Jones, m.d. Number 1, Southern Medical and Surgical Journal, Volume 
xvii ; Number 9, Augusta, Georgia, 1861, pp. 673-718. Number 2, Southern- Medical and Sur- 
gical Journal, Volume xvn, No. 10, October, 1861, Augusta Georgia, pages 754'787. " Rela- 
tions of Pneumonia and Malarial Fever, with practical observations on the Antip~r:,<?dic or Abor- 
tive method of treating pneumonia," by Joseph Jones, m.d. Southern Medical -and Surgical 
Journal, September, 1866, page 229. "On the prevalence of pneumonia and of typhoid fever in 
the Confederate army during the war of 1861-1865," by Joseph Jones, m.d. "Sanitary 
Memoirs of the War of the Rebellion," collected and published by the United States Sanitary 
Commission, New York, 1867, page 335. " Investigations of the Diseases of the Federal prison- 
ers confined in Camp Sumter, Andersonville, Georgia," by Joseph Jones, m.d. " Sanitary 
Memoirs of the War of the Rebellion," collected by the United States Sanitary Commission, New 
York, pages 467-655. "Trial of Henry Werz," 2d Session, 40th Congress, 1867-1868. Execu- 
tive Document, No. 23, Medical Testimony, Dr. Joseph Jones. " Reports embracing description 500 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
exclusively engaged in clinical studies in the wards, in chemical and microscopical 
analyses in the laboratory, and in post-mortem examinations and pathological researches 
in the dead-house, the cases treated, with all the chemical, microscopical, pathological 
and therapeutical data, and anatomical and microscopical specimens, were classified 
and published, for the use of the medical profession and the students of the medical 
departments of the University of Louisiana, in two groups. 
The first group related chiefly to diseases of the nervous system.* 
The second group embraced the microscopical and chemical changes of the blood in 
malarial fever, diseases of the circulatory and respiratory system, and of the spleen, 
kidneys and liver. 
A large portion of the second division was devoted to the consideration of dropsy as 
a symptom of various diseases, and this most important subject was discussed under 
the following heads:- 
1. Dropsy arising from derangement in the nutrition of the tissues, leading either to an 
increase of secretion or a diminution of absorption. 
2. Dropsy arising from derangements of the blood, leading to derangements of the nutri- 
tion of the tissues, with an increase of secretion or a diminution of absorption. 
3. Dropsy arising from derangements of the circulatory apparatus, attended with venous 
obstruction and congestion, increased serous effusion from the distended blood vessels and 
diminished absorption, cardiac dropsy, hepatic dropsy. 
4. Dropsy arising from derangements or lesions of the organs which regulate the amount 
of the blood, as well as its constitution, by regulating the amounts of the watery elements, and 
by the elimination of excrementitious materials. Renal dropsy. 
Each division was illustrated by cases, post-mortem examinations and microscopical 
and chemical investigations, and the changes induced by the action were noted through- 
out the entire investigation ; but it was chiefly under the second division of dropsy that 
the malarial poison was recognized as a principal factor, in the profound changes it pro- 
duced in the composition of the blood. 
Thus we held that the prolonged action of the malarial poison not infrequently 
induces such changes in the composition of the blood, and such derangements in the 
liver and spleen, as to lead to the effusion of serous fluid into the areolar tissue and 
peritoneum-abdominal cavity. The changes of the blood induced by malarial fever 
appear to be the chief cause of the dropsical effusions, although in some cases this symp- 
tom may be attributed to the mechanical obstacle afforded by the enlarged spleen and 
liver. 
of the Stockade, and condition of the prisoners therein confined, and condition of the hospitals, 
etc," page 618, page 641, manuscript, pages 1721 and 1766. "Investigations upon the nature, 
causes and treatment of Hospital Gangrene as it prevailed in the Confederate armies, 1861-1865," 
by Joseph Jones, m.d. "Surgical Memoirs of the War of the Rebellion," collected and published 
by the United States Commission, New York, 1867, pages 142-580. The Charity Hospital of 
New Orleans has, from the removal to this city, in the winter of 1868, up to the present moment, 
furnished an extensive field for investigation in therapeutics and pathology upon all subjects 
relating to the etiology, pathology and treatment of fevers. During a period extending from 
1869-1886 inclusive, the cases of various diseases treated by the author in the wards of the 
Charity Hospital numbered 6311, with 668 deaths ; the various forms of malarial fever num- 
bered 2885 cases, with 88 deaths. During this period a large number of cases of malarial fever 
were also treated in private practice. 
* Memoranda of Medical Clinic at Charity Hospital, New Orleans, Louisiana, 1869-1870. 
By Joseph Jones, M. d. Section I. Diseases of the Nervous System. The New Orleans Journal 
of Medicine, April, 1870, pages 233-273. Section II. Dropsy Considered as a Symptom. New 
Orleans Journal of Medicine, July, 1870, pages 484-563. "Medical and Surgical Memoirs," by 
Joseph Jones, m.d., New Orleans, Louisiana, 1876. SECTION XV PUBLIC AND INTERNATIONAL HYGIENE. 
501 
After the illustration of the effects of the malarial poison in altering the physical 
and chemical constitution of the blood and in inducing dropsy, by elaborate chemical 
analyses and by the detailed reports of cases, we thus formulated the general results. 
1. In malarial fever the specific gravity of the hlood and serum is diminished. The 
specific gravity of the blood in this disease ranges from 1030.5 to 1042.4, and the specific 
gravity of the serum from 1018.0 to 1023.6. In health, on the other hand, the specific 
gravity of the blood ranges from 1055 to 1063, and the specific gravity of the serum 
from 1027 to 1032. 
2. In malarial fever the colored blood corpuscles are greatly diminished. In health the 
dried blood corpuscles may vary from 120 to 150 parts in the 1000 of blood, and the 
moist blood corpuscles from 480 to 600. In malarial fever, on the other hand, the dried 
blood corpuscles range from 51.98 to 107.81, and the moist blood corpuscles from 207 
to 323.63. 
The careful comparison of these analyses of malarial blood with each other reveals 
the fact that the extent and rapidity of the diminution of the colored corpuscles cor- 
responds to the severity and duration of the disease. 
A short but violent attack of congestive or remittent fever in its severest forms will 
accomplish as great a diminution of the colored blood corpuscles as a long attack of 
intermittent fever or the prolonged action of the malarial poison. 
3. In malarial fever the relation between the colored corpuscles and liquor sanguinis is 
deranged. Thus, in healthy blood the relative proportion of moist blood corpuscles in 
the 1000 parts, and of liquor sanguinis, may vary from 480.00 to 600.00 of the former, 
and from 520.00 to 400.00 of the latter; while in malarial fever the globules vary from 
207.92 to 323.63, and the liquor sanguinis from 792.08 to 676.37. 
4. The fibrin of the blood is diminished to a marked extent in most cases of malarial fever, 
and is altered in its properties and in its relations to the other elements of the blood, and to 
the blood vessels. 
5. The organic matter of the liquor sanguinis, and especially the albumen, is diminished 
in malarial fever. Thus the solid matters of the serum may vary in health from 90.00 
to 105.00; while in malarial fever they vary from 62.78 to 80.22 parts in the 1000 parts 
of blood. 
It is chiefly to this latter change, namely, the diminution of the blood in malarial 
fever, that dropsical effusions are to be traced. 
The other changes of the blood without doubt lead to congestions of the liver and 
spleen and to derangements of the capillary circulation and nutrition of the organs and 
tissues ; but a careful examination of three diseases, as anæmia, chorea and pyaemia, 
in which the colored blood corpuscles are greatly diminished, will show that this cause 
alone will not induce dropsy. 
In the watery state of the blood induced by the action of the paludal poison, com- 
paratively slight obstructions of the circulation in the spleen and liver might lead to 
dropsical effusions. It would appear also that from the derangement of the circulation 
caused by the retention of the malarial poison in the blood and nervous system, certain 
effete products are not sufficiently and properly eliminated from them, as, for instance, 
urea, and may be active in the production of dropsy. New Orleans Journal of Medicine, 
July, 1870, pp. 498-500. 
During the past 18 years, 1879-1887, I have repeatedly demonstrated to the medical 
students of the University of Louisiana, in the wards, amphitheatre and dead-house, 
the diagnostic characters which distinguish the blood of malarial fever from that of 
yellow fever and other diseases, and have from time to time made permanent record 
of various portions of our labors in the medical press. * 
* See Memoirs: "Outline on Hospital Gangrene," etc. New Orleans Journal of Medicine, 502 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
The service as President of the Board of Health of the State of Louisiana, 1880-'84, 
necessitated the careful and scientific examination of subjects relating to the nature, 
causation and control of yellow and malarial fevers; and certain questions arising during 
the progress of medico-legal investigations also required the thorough and continuous use 
of the microscope in the determination of the physical and minute characters of human 
blood in health and disease. 
During his service as President of the Board of Health of the State of Louisiana 
during these four years, extending from April, 1880, to March, 1884, the author was 
enabled to put to the crucial test the actual application of every principle relative to the 
nature and exclusion of foreign pestilence. 
During the period specified the means instituted were effective in excluding yellow 
fever from the Mississippi Valley; and the principle of diagnosis based upon his 
clinical and pathological researches gave precision and confidence to the official 
decisions of the Board of Health, and prevented panic, alarm and useless quarantine.* 
January, 1869, Vol. xxn, pp. 22-49 ; April, 1869, pp. 201-234. " Leucocythæmia or Leukæmia" 
(white cell blood or white blood). Outline of clinical lecture delivered in the Charity Hospital 
by Joseph Jones, m. d. Neto Orleans Journal of Medicine, July, 1869, pp. 425-438. "Heart- 
clot." Outline of clinical lecture delivered at the Charity Hospital, New Orleans, La., by Joseph 
Jones, m.d., New Orleans Journal of Medicine, July, 1869, pp. 469-487. "Memoranda of Med- 
cal Clinic, at Charity Hospital, New Orleans, 1869 and 1870," by Joseph Jones, m.d. Sect. 1st: 
" Diseases of the Nervous System." New Orleans Journal of Medicine, April, 1870, pp. 233-274. 
Sect. 2d : " Dropsy considered as a symptom of various diseases." New Orleans Journal of Med- 
icine, July, 1870, pp. 484-563. "Contributions to the Natural History of Yellow Fever," by 
Joseph Jones, m. d. New Orleans Medical and Surgical Journal, January, 1874, Vol. I, New 
Series, pp. 466-516. " Contribution on Changes of the Blood in Yellow Fever," by Jos. Jones, 
M. n. New Orleans Medical and Surgical Journal, September, 1874, pp. 177-266. " Black Vomit 
of Yellow Fever," by Joseph Jones, M. d. New Orleans Medical and Surgical Journal, Septem- 
ber, 1876, pp. 159-165. "Malarial Hæmaturia; Nature, History and Treatment; illustrated by 
cases," by Joseph Jones, M. d. New Orleans Medical and Surgical Journal, February, 1878, 
pp. 573-591. " Medico-legal evidence relating to the detection of human blood, presenting the 
alterations characteristic of malarial fever on the clothing of a man accused of the murder of 
Narcisse Arrieux, December 26th, 1876, near Donaldsonville, La.," by Joseph Jones, m. d. New 
Orleans Medical and Surgical Journal, August, 1878, pp. 101-123. "Yellow Fever Epidemic 
of 1878 in New Orleans, La.," by Joseph Jones, m. d. Neto Orleans Medical and Surgical Jour- 
nal, March, 1879, pp. 683-715; April, 1879, pp. 703-780; May, 1879, pp. 850-872; June, 1879, 
pp. 942-971. "Comparative Pathology of Malarial and Yellow Fevers," by Joseph Jones, m. d. 
Transactions of the Louisiana State Medical Society, Annual Session of 1879, New Orleans Med- 
ical and Surgical Journal, Vol. vil, New Series, July, 1879, pp. 106-217, p. 297. " Treatment 
of Yellow Fever," by Joseph Jones, m.d. New Orleans Medical and Surgical Journal, Septem- 
ber, 1879, pp. 344-365. "Medical and Surgical Memoirs," by Joseph Jones, m.d., New Orleans, 
La., 1876, p. 826; Vol. ir, 1887, p. 1348. 
« "Annual Reports of the Board of Health of the State of Louisiana to the General Assem- 
bly, 1880-'83," Joseph Jones, m.d., President. " Quarantine and sanitary operations of the Board 
of Health of the State of Louisiana during the years 1880-'83," by Joseph Jones, m.d., p. 377, 
New Orleans, 1884. "Measures for the prevention and arrest of contagious and infectious diseases, 
including smallpox and yellow fever," by Joseph Jones, m.d., New Orleans, Louisiana, 1884. SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
503 
APPLICATION OF THE RESULTS OF HIS CHEMICAL, MICROSCOPICAL AND PATHO- 
LOGICAL INVESTIGATIONS AS TO THE CHANGES OF THE BLOOD AND ORGANS IN 
THE VARIOUS FORMS OF MALARIAL PAROXYSMAL FEVER, TO MEDICAL DIAG- 
NOSIS AND MEDICAL JURISPRUDENCE. 
If it be true that the malarial poison produces distinct and specific microscopical 
changes in the blood of human beings, it is evident that we have in such changes 
valuable data for diagnosis. 
It will be admitted, by experienced and competent observers, that medico-legal 
investigations furnish the most difficult and important opportunities for the crucial 
test of the nature and value of changes of the human blood under the action of 
certain poisons, and in certain casualties, as revealed by chemical and microscopical 
analysis. 
The author, in the discharge of certain responsible duties imposed upon him by the 
legal authorities of Louisiana, was compelled to record his observations upon the 
changes of the blood in malarial fever. 
As far as our information extends, this is the only case in which the pathological 
changes of the blood found upon the garments of a man charged with the crime of 
murder was determined and announced officially, in advance of any knowledge of the 
history and condition of the murdered man. 
Regarding this subject as of importance to medical as well as to legal science, we 
reproduce it. 
MEDICO-LEGAL EVIDENCE RELATING TO THE DETECTION OF HUMAN BLOOD, PRESENTING THE 
ALTERATIONS CHARACTERISTIC OF MALARIAL FEVER, ON THE CLOTHING OF A MAN ACCUSED 
OF MURDER.® 
The value of life and property in every country depends not merely upon the num- 
ber and character of its laws, but chiefly upon a learned and incorruptible judiciary, 
supported by an intelligent, law-abiding and virtuous people. The great ends of good 
government, the security of life, liberty, property, and the pursuit of happiness to all 
alike, irrespective of birth, condition or occupation, can be secured solely by the 
impartial administration of just lawsand the certain and prompt punishment of their 
infraction. 
Holding these views, the writer has upon various occasions, in several Southern 
States, responded to the calls of outraged humanity and offended justice, and assumed 
the painful and responsible task of instituting those post-mortem examinations and 
chemical and microscopical processes which could best detect and reveal the modesand 
causes of death, and thus aid justice by furnishing an important link of evidence. 
Although, during the past twenty years I have been engaged in the investigation of 
over fifty cases of poisoning by various agents, as arsenious acid (arsenic), strychnia, 
morphia, opium and its preparations, lead and its salts, sulphate of iron, cyanide of 
potassium, the seeds of the Jamestown weed and other poisons, and although these 
medico-legal investigations have resulted in the conviction of a number of criminals ; 
as the processes employed were similar to those practiced by experienced toxicologists, 
and as the facts, as a general rule, are well known and carefully recorded, I have 
refrained from burdening the current medical literature with the details. I am 
induced, however, to publish the following details, under the belief that they will 
prove of interest to those who may conduct similar examinations, and also in two par- 
ticulars to the medical profession generally. 
The phenomena manifested by the deceased after the reception of the blows upon 
the head, as well as the detection of the. peculiar effects of malarial fever upon the 
blood spattered on the clothing of the accused, and also upon the floor, walls and fur- 
® The New Orleans Medical and Surgical Journal, August, 1878, pp. 139-156. 504 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
niture of the room in which the murder was committed, appear to be worthy of record 
and consideration. 
Circumstances of the Murder.-Narcisse Arrieux was found, on the morning of Decem- 
ber 28th, 1876, dead in his store, situated on the banks of the Mississippi, near the 
southwestern border of the town of Donaldsonville, Louisiana. The head, face, beard 
and clothing of the old man, Narcisse Arrieux, were covered with clotted blood. It 
was evident, from an extensive compound comminuted fracture of the cranium, extend- 
ing on the right side from the occiput across the right parietal bone and frontal bone to 
the internal canthus of the left eye, and from several other contused wounds on the 
head, that death had been caused by blows inflicted by heavy blunt instruments. 
The small house occupied by Narcisse Arrieux as a store and dwelling contained 
three apartments. The largest apartment, which faced the Mississippi river and opened 
by a door upon the common road or highway leading up and down the road behind 
the broad levee which protects this region from overflow, was used as a store for the 
sale and barter of various kinds of merchandise, food and spirits. This store was 
divided into two unequal portions by a counter running directly across in front of the 
door ; the space behind the counter was much less in area than that in front. 
Back of the counter and communicating with the main room or store were two 
smaller rooms, one of which was used as a sleeping apartment and the other as an 
office and sitting room. According to the testimony of the coroner and other witnesses, 
the dead body of Narcisse Arrieux was found, on the morning of the 28th of December, 
1876, lying near the stove, on an overturned chair in the small office. The doors com- 
municating between the store and the sleeping room and office, and between this office 
and the sleeping room, were open. The door opening from the street into the public 
road was shut and locked. A pool of blood lay on the floor behind the counter, near 
a barrel of alcoholic spirits. Traces of blood were also found upon the floor of the 
store, and marks of bloody hands were also upon the walls and upon the front door, 
and upon the floor of the office and sleeping room. Marks of bloody hands were found 
upon the walls and door posts and upon the bed. 
Blood was also found upon two desks and in the drawers, in w hich the deceased kept 
his money and books. Several four-pound iron weights containing blood and the gray 
hairs of the deceased were found behind the counter, in the office and sleeping apart- 
ment. One of these heavy iron weights, thrown at the head of the deceased, had 
crashed through a window in the back part of the sleeping room, and was picked up in 
the yard. According to the statement of Dr. John E. Duffel, an intelligent and accom- 
plished physician of Donaldsonville, who held the post-mortem at the Coroner's inquest, 
the wounds observed upon the head of Narcisse Arrieux were as follows :- 
Left Side.-Contused wound about one-half inch in length, near inner canthus of left 
eye. Contused wound one-half inch in length, at root of nose on the left side, pene- 
trating and fracturing the frontal bone. Great ecchymosis of both eyes. Contused 
wound over left eye, but extending diagonally toward the left temple, penetrating to 
the bone ; contused wound in left temple, in line with margin of left eye. Contused 
wound on posterior part of the head, penetrating to the bone. Contused wound four 
inches from left ear, extending backward toward occiput, two inches, fracturing and 
depressing the occipital bone. 
Right Side.-Contused wound on forehead, penetrating to the bone, about three 
inches across the root of the nose. Contused wound about one inch to the left of the 
ear penetrating to the bone. Contused wound starting from the outer margin of the 
eyebrows, ranging downward toward the temporal bone, about three inches in length, 
ending in a line with the top of the right ear, penetrating, fracturing and depressing 
the right temporal bone. 
Scalp Removed.-Extensive fracture, extending from the inner canthus of left eye, SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
505 
upward, in a curve, and ranging across the right side of the frontal hone, and around, 
across the temporal and parietal bones to the occiput. It appears, from the condi- 
tion of the premises at the time of the inquest, that, notwithstanding the extensive 
wounds and fractures of the cranium, the deceased, after the infliction of the injuries 
and after the flight of the assassins and robbers, had partially regained his senses and 
the use of his limbs; had closed his door, examined his money drawers, had attempted 
to light a fire in his stove, had placed a newspaper on the floor, unbuttoned and pulled 
down his pantaloons and evacuated his bowels, had staggered around the walls, steady- 
ing himself with his bloody hands, and after seating himself on a chair had died and 
fallen upon the floor, overtttrning the chair and lying upon the floor with his legs bent. 
He appears to have died in the sitting posture, and after death, and even after the 
establishment of the rigor mortis, the body had fallen upon the floor. It appears, from 
the testimony, that between the hours of 9 and 11 o'clock p.M., on the night of the 
27th (a dark and stormy night), four powerful, stalwart negro men entered the store of 
Narcisse Arrieux and called for ardent spirits. As the old man turned his back to 
draw the liquor from the barrel, he was struck by one or more of the robbers, with a 
four-pound iron weight, on the back of the head. This blow not having the effect 
desired by the assassins, the weights upon the counter were hurled in rapid succession 
against his head. The powerful leader of the robbers sprang over the counter and 
inflicted repeated blows upon his head with a short hickory stick armed with a leaden 
head, which had been carried concealed in the sleeve of his coat. It is probable that 
the victim lay unconscious during the robbery of the store, and after the assassins 
had withdrawn, the profuse hemorrhage (as shown by the large pool of blood behind 
the counter where he fell) relieved the congestion of the brain temporarily, and upon 
the return of consciousness he was able to stagger to the door and close it, and to visit 
his office and sleeping room, and even to examine the desks in which he kept his money 
and books. 
Prosecution of the Accused by the State.-Certain parties suspected of the murder 
were arrested; four negro men were incarcerated in the city jail charged with the mur- 
der of Narcisse Arrieux. Spots of blood were observed by the sheriff upon the coat of 
Wilson Childers, a powerful negro man, who was known to have been at the store of 
Narcisse Arrieux on the night of the 27th. Upon his arrest, on the 28th, Wilson 
Childers affirmed that these spots on his coat were caused by red paint, which was 
rubbed off from a barrel of whisky which he had handled for a merchant. By the order 
of the court an examination of these spots was made by physicians and druggists in 
Donaldsonville, on or about the 29th of December, 1876. 
There being no microscope of sufficient power in the town and its vicinity, the court 
ordered Mr. T. A. Landry to proceed to New Orleans with portions of the coat and 
shirt of the accused Wilson Childers, and to secure the services of a competent chemist 
and microscopist for their careful and thorough analysis. Early on the morning of 
January 2d, 1877, I received the following note from Dr. B. F. Gaudet, late President 
of the Board of Health, State of Louisiana:- 
New Orleans, January 2d, 1877. 
Joseph Jones, m.d., Professor of Chemistry, Medical Department, University of Louisiana, New 
Orleans. 
Dear Doctor:-Mr. T. A. Landry, of the Parish of Ascension, has been appointed custodian 
of a sealed package containing three pieces of woolen stutf cut from the coat of one Wilson 
Childers, accused of having, on Wednesday, 27th December, 1876, murdered a man, and he was 
ordered to proceed to New Orleans to submit the above to a chemist and microscopist of well- 
known reputation, for analysis and examination. The report must be officially made to the Judge 
of the Parish. I have, of course, suggested your name. You know that you must first take the 
oath before a Justice of the peace, and swear to the report which you will prepare. 
Very respectfully, your obedient servant, 
T. B. Gaudet. 506 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Result of Chemical and Microscopical Examination of Stains on the Coat and Shirt of 
Wilson Childers.-Upon careful chemical and microscopical analysis and examination, 
I determined that the stains on the coat and shirt of the accused were not paint, but 
were human blood. 
I also determined the fact that the blood was that of a human being who had suf- 
fered and was probably suffering at the moment when the blood was abstracted, with 
malarial or paroxysmal fever. 
My written statement of the general result of the chemical and microscopical analy- 
sis and examination, sworn to before a Justice of the peace, together with the pieces of 
cloth, carefully sealed, were forwarded, through Mr. T. A. Landry, to the Honorable 
Court, Fourth Judicial District, State of Louisiana. I did not introduce into this state- 
ment any allusion to the pathological state of the blood, but simply announced these 
results, namely:- 
1. That the stains were not due to red paint nor to any form of paint. 
2. That the stains were blood. 
3. That the blood presented all the characteristics of human blood. 
I informed Mr. Landry, however, of the conclusion to which I had arrived, that the 
blood was that of a human being who had suffered and was suffering at the moment of 
its abstraction, with malarial or paludal fever. 
On the 29th of June, 1877, I received a peremptory summons to appear in person in 
the Fourth Judicial District Court, Ascension Parish, State of Louisiana, signed by the 
Honorable M. Marks, Judge. I repaired forthwith, by steamer and railroad, to Donald- 
sonville, and found that the Honorable Court had continued the case. Subsequently, I 
was furnished, by John H. Hsley, attorney-at-law, with pieces of wood stained with 
blood, cut from the drawers which contained the money of Narcisse Arrieux. 
Chemical and microscopical analysis showed that this blood, which was beyond a 
doubt that of the deceased, presented the same pathological change as that found on the 
shirt and coat of Wilson Childers, the accused. 
After the examination, the particles of wood were carefully preserved about my 
person. 
On the 27th of May, 1878, I received at the hands of the Deputy Sheriff, in the city 
of New Orleans, the following:- 
The State of Louisianna c«. Wilson Childers, et al. 
The State of Louisiana, Parish of Ascension, 4th Judicial District Court. 
To Dr. Joseph Jones :- 
You are hereby summoned, in the name of the State of Louisiana, to appear before the 4th 
Judicial District Court of the Parish of Ascension, on the 29th day of May, in the year of our 
Lord 1878, at 10 o'clock, A. m., to testify the truth, according to your knowledge, in a certain case 
now pending before this Court, in which the State of Louisiana is plaintiff, and Wilson Childers, 
et al, is defendant; and hereof fail not, under penalty of the Law. 
Witness the Honorable H. D. Duffel, Judge of said Court, 23d day of May, 1878. 
L. E. Bentley, Clerk of said Court. 
In accordance with this summons, I appeared in the 4th District Court, Parish of 
Ascension, Wednesday, May 29th, but I was not placed upon the witness stand until 
9 o'clock, Friday night, May 31st. Through the courtesy of the accomplished 
clerk of the court, Mr. L. E. Bentley, I was furnished with the following report of my 
testimony as elicited by the examination of the State, represented by D. B. Earhart, Dis- 
trict Attorney, and R. N. Sims, Edward N. Pugh and John H. Hsley, Jr., Attorneys- 
at-Law, and of the defence as conducted by Col. Winchester, of St. James. In the fol- 
lowing report, the questions propounded by the State as plaintiff are indicated by the 
letter S, those by the defence, for the prisoner, by the letter D, and the answers wrhich SECTION XV PUBLIC AND INTERNATIONAL HYGIENE. 
507 
I returned relating to the chemical and microscopical examination of the blood found 
upon the clothing of the prisoner, in the house of Mr. Narcisse Arrieux, by the letter J. 
The counsel for the State, after a minute examination as to the time which I had 
practiced medicine, and devoted special attention to the chemical and microscopical 
examination of the blood of animals and man, proceeded :- 
Examination on Part of State of Louisiana.-S.-Was a sealed package, containing 
particles of a coat and shirt, at any time delivered to you officially by this Court for 
chemical analysis and microscopical examination ? 
J.-On or about the 2d of January, 1877, a small sealed package containing particles 
or pieces of cloth, was delivered into my hands, with an official warrant for a chemical 
analysis and microscopical examination, signed by Judge Marks, of this Honorable 
Court. 
S.-Is the following communication to this Court in your handwriting ? Is the sig- 
nature appended yours ? If so, read the communication to the Honorable Court. 
J.-The report is in my handwriting, and the signature is genuine. The paper reads 
as follows:- 
Medical Department, University of La., 
New Orleans, January 2d, 1877. 
On the 2d of January, 1877, a sealed package was placed in my hands by L. A. Landry, act- 
ing under the order of M. 0. Marks, Parish Judge, of the Parish of Ascension. Upon breaking 
the seal, two smaller packages were found, namely, one marked " from left sleeve of coat," con- 
taining two pieces of cloth; the other marked "from left breast,"containing three pieces of cloth. 
The said pieces of cloth contained spots of a red and brownish-red color. Careful microscopical 
and chemical examinations showed that the textures of the cloth in the discolored portions have 
been saturated with blood. The colored and colorless corpuscles were distinctly seen under a 
magnifying power of 420 diameters. The colored and colorless corpuscles resembled in size and 
structure those of man. Hæmatin and albumen were also present in the matters extracted from 
the discolored spots. Joseph Jones, m.d. 
Sworn to and subscribed before me, this January 2d, 1877. 
W. H. Holmes, Second Justice of Peace, Parish of Orleans. 
S.-Did you destroy the pieces of cloth containing the stains during your chemical 
and microscopical examination, or did you re-deliver them to Mr. Landry, duly sealed ? 
J.-I carefully preserved the pieces of cloth, and, after sealing them carefully, 
delivered them to Mr. L. A. Landry, in the presence of Wm. H. Holmes, Second Jus- 
tice of the Peace, Parish of Orleans. 
S.-Can you identify this package, with its seal, direction and contents? 
J.-I can; the direction is in my handwriting; the seal is mine; the particles of 
cloth resemble in all respects those which were delivered to me by Mr. Landry, and 
which I examined in my laboratory, on or about the 2d of January, 1877. 
S.- Did the pieces of cloth, when delivered to you by Mr. Landry, contain any 
spots, or present anything peculiar? 
J.-They did. Each piece of cloth contained spots of a red and reddish-brown 
color. 
S.-Were these spots caused by red paint? 
J.-They were not caused by paint of any color or description. 
S.-How would you detect spots of paint on any texture, as cloth or clothing? 
J.-Paint consists of oil mixed with metallic, earthy or vegetable or animal sub- 
stances, according to the nature of the paint and the purposes to which it is applied. 
The oil may be extracted from paint by certain agents, as sulphuric ether and sulphuret 
of carbon. The oil may be recognized by its physical and chemical properties, and also 
by the presence of globular masses of various sizes, under the microscope. The color- 
ing matters of paint, under the microscope, as a general rule, present a granular appear- 508 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
ance, and in no kind of paint do they resemble the colored blood corpuscles of man and 
animals. In the case of red paint, some form of the oxide of iron, or the oxide of lead, 
or the sulphuret of mercury (vermillion) may be used. After the extraction of the oil 
from the paint by sulphuric ether, these oxides specified may be rendered soluble by 
the action of the mineral acids, and especially by hydrochloric and nitric acids. The 
solutions thus obtained may be subjected to several tests. The salts of iron give blue 
and bluish-green precipitates with ferricyanide and ferrocyanide of potassium, and 
black with solution of tannic acid, and the per-salts of iron give a brownish-red precipi- 
tate with aqua ammonia, and a deep red color with sulpho-cyanide of potassium. If 
the color of the paint be due either to the oxide or the sulphuret of mercury, after the 
abstraction of the oil in the manner specified, the metallic mercury may be reduced by 
heat, or a nitrate, sulphate or chloride formed by the action of the respective acids, and 
the soluble salt thus formed may be subjected to various reagents, as iodide of potas- 
sium (green precipitate with proto-salt of mercury, and red precipitate with per-salt of 
this metal) ; lime water and solution of potassa, black precipitate with proto-salt and 
yellowish red with per-salt; a plate of polished copper plunged in solution of soluble 
salt of mercury is quickly coated with metallic mercury, which may be removed by 
sublimation, dissolved in the mineral acids and subjected to the test just specified. If 
the color be due to the red oxide of lead, the metal may be reduced from the paint by 
means of the blowpipe; the oxide may also be separated from the oil and subjected to 
the action of nitric acid, and the solution subjected to the action of various chemical 
reagents, as iodide of potassium (yellow iodide of lead), chromate of potassa (yellow 
chromate of lead), sulphureted hydrogen (black sulphuret of lead), sulphuric acid and 
soluble sulphate of lead (white sulphate of lead). 
S.-What did you determine these spots to be by chemical and microscopical exami- 
nation ? and state fully to this Honorable Court the groupd upon which your statement 
was based, and the processes by which you arrived at your conclusions. 
J.-Chemical and microscopical examination showed the spots to be those of blood. 
The presence of blood was determined by the following processes and reagents : When 
the stains were examined in a strong light, with a low power of the microscope, 
the fibres were not merely colored, but presented a shining, glossy appearance, 
and the individual fibres were observed to be invested with portions of dried 
coagulum or clot. Certain chemical processes, as the following, established pre- 
sumptively that the matter which imparted the color to the spots on the clothing 
of the accused was blood. 
It readily combined with cold distilled water, forming a bright red solution. This 
color was not changed to a crimson or a green tint by a few drops of a weak solution of 
ammonia, but when this agent, in concentrated form and large amount, was added, the 
red liquid acquired a brownish tint. The red liquid obtained from the particles of blood 
in the textures of the cloth, by means of cold water, coagulated when it was boiled, 
the color was destroyed and a muddy brown, flocculent precipitate was formed. When 
the coagulum was collected on a filter and dried, it formed a black resinous substance, 
quite insoluble in water, but readily dissolved by boiling caustic potash, forming a 
solution which was of a greenish color by reflected, and reddish by transmitted light. 
When the solution of the clots in cold water was subjected to the action of strong nitric 
acid, the red coloring matter of the blood and its albumen were coagulated and a dirty 
brown precipitate was thrown down. When examined under the microscope with 
various powers, ranging from 400 to 1800 diameters, the red matter causing red stains 
was found to consist of numerous circular, disc-like or flattened globules, having an 
average diameter of of an inch. The white or colorless corpuscles of the blood 
were also clearly distinguished. 
S.-Did you observe anything which would indicate the state of the health of the SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
509 
individual from whom the blood had issued upon the clothes of the accused ? and if so 
state your observations to this Honorable Court. 
J.-I observed changes in the blood obtained from the pieces of cloth which led 
me to infer that the person from whom it was abstracted had suffered and was most 
probably at that time suffering with paroxysmal, paludal or malarial fever. 
This opinion was based chiefly upon the following abnormal substances observed in 
connection with the colored and colorless or white blood corpuscles : Black pigment 
or melanæmic corpuscles, varying from to of an inch in diameter; con- 
glomerations of these melanæmic particles, in masses of various sizes; colorless corpus- 
cles or leucocytes which contained small granular masses of black pigment. Many of 
the particles of the melanæmic pigment were spherical, others irregular and angular, 
some entirely free, others incased in a hyaline mass; others incorporated with cellular 
elements which are more or less related to the white corpuscles of the blood. These 
black pigment particles indicated the destruction or alteration of the blood corpuscles 
and the escape of the hæmatin of the red globules which is characteristic of malarial 
fever. 
S.-How long have you been engaged in the microscopical and chemical investiga- 
gation of the blood of man in disease, and upon what facts do you base the preceding 
statement ? 
J.-My investigations upon the chemical and microscopical changes of the blood in 
fevers, and especially in malarial and yellow fevers, were commenced in 1856, and have 
been pursued continuously up to the present moment ; and during the past ten years I 
have treated, in the wards of the Charity hospital of New Orleans, over four thousand 
cases of various diseases, more than one-half of which were due to the action of the 
malaria of the swamps and marshes of the Mississippi valley. The blood in a large 
number of these cases has been subjected to microscopical and chemical examination, 
and in fatal cases post-mortem examinations performed. The result of these investiga- 
gations, which throw light upon the inquiries of this Honorable Court, are as follows: 
1. The malarial poison produces profounder alterations and more rapid destruction 
of the colored blood corpuscles than any other known febrile agent. 
2. The destruction of the colored corpuscles takes place chiefly in the spleen and 
liver. 
3. The black pigment resulting from this hæmatin of the blood corpuscles is fre- 
quently observed in the blood as it circulates in the vessels and capillaries, in masses of 
various sizes and in the form of cellular elements. 
4. The black pigment is deposited in the capillaries of various organs and tissues, 
as those of the liver, medulla of the bone, brain and subcutaneous tissue. 
5. The peculiar sallow, greenish-yellow and bronzed hue, which characterizes those 
who have been for a length of time subjected to the prolonged action of the malarial 
poison or to its powerful action in pernicious remittent fever and in malarial hæmaturia, 
is due not merely to hepatic and splenic derangement, but also to the deposit of pig- 
ment particles in the subcutaneous capillaries. 
S.-Did you make any further examinations of blood in this case or in connection 
with the deceased ? If so, state the result. 
J.-I examined bits of wood brought to New Orleans, and placed in my hands by 
John H. Ilsley, attorney-at-law and counsel for the State. These pieces of wood, the 
one of cedar and the other of mahogany, were spotted and coated upon the smooth side 
with blood. Microscopical and chemical examination revealed that it was human 
blood, and human blood presenting similar pathological alterations to that examined 
on the particles of cloth cut from the coat and shirt of the prisoner, and previously 
described. The blood, as in the first examination, contained numerous black particles, 
and pigment cells and colorless corpuscles, containing round, black pigment particles. 510 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Upon arriving in Donaldsonville, through the kindness of Dr. John E. Duffel, I visited 
the house formerly occupied by the deceased, and found that the particles of wood fitted 
exactly into the front portions of two drawers belonging to two desks. Undeniable 
testimony established the fact that the blood on these pieces of wood was that from the 
deceased after the infliction of the blows on the head. 
S.-Have you preserved these pieces of wood ? and if you have, produce them 
before the jury and fit them into the places from whence they were cut, in the drawers, 
which have been brought to this Court. 
J.-I have carefully preserved the pieces of wood upon my person, from their first 
reception to the present time. They correspond exactly to the missing portions of 
wood in the drawers exhibited by the Êjtate before this Honorable Court. 
S.-Have you examined the blood of various animals, as, for instance, reptiles, birds, 
and domestic animals ? And if you have, state the general results of your examinations, 
and if the blood of these animals can be distinguished from that of man. 
J.-I have examined microscopically and chemically the blood of a large number of 
the indigenous fish, amphiuma, sirens, batrachians, ophidians, saurians, birds and wild 
mammalia, and also the blood of domestic fowls and animals, and can state that in fish,* 
amphibians, batrachians, saurians and birds, the blood corpuscles can be distinguished 
at once and beyond all question under the microscope, on account of the elliptical shape 
and nucleated centre ; but in the case of the domestic and indigenous mammalia a more 
critical examination is required ; for in this class of animals the size of the globules 
varies within comparatively narrow limits ; they have a flattened or disc-like form, and 
with the exception of the camel tribe, the outline of the disc is circular. 
Examination on the part of the Defence.-D.-Are you absolutely certain that the 
stains on the pieces of cloth placed in your hands for microscopical and chemical 
analysis were caused by human blood ? 
J.-The substances causing the stains presented all the chemical and microscopical 
properties of human blood, and blood presenting a special pathological alteration. 
D.-Can you by means of chemical and microscopical examination of the blood 
determine any form of disease ? 
J.-By chemical and microscopical examination I am not able to determine every 
form of disease. 
D.-You would then be in doubt concerning the result, in certain diseases, of the 
chemical and microscopical examination ; please state, therefore, if there are any 
diseases, the nature of which may be revealed by the microscope ? 
J.-The microscope enables us to distinguish clearly the changes induced in the 
blood by malarial fever. That condition of the blood known as leucocythæmia or 
leukaemia can be accurately determined by microscopical examination. There was no 
doubt in my mind that the blood examined was human blood, from one who had suf- 
fered, and perhaps was at the time suffering with malarial fever. 
* The blood discs of fishes are commonly of a full, elliptic shape ; they present the largest size 
in the sharks, but are smaller in them in proportion to the body or mass of blood than in the 
batrachia. The white corpuscles are in less proportion in the blood of fishes than in saurians, 
birds or mammals. In my physiological and chemical researches, published by the Smithsonian 
Institution in 1856, I endeavored to establish the comparison of main physiological importance 
between the blood in different groups of vertebrates, namely, that which relates to the proportion 
of the organic matters contained in the water. It was then clearly shown that the blood varied, 
in the different classes of animals, in physical and chemical properties. The blood of reptiles has 
red corpuscles of a flattened, sub-biconvex, elliptical shape, proportionally smallest in ophidia, 
roundest in chelonia, and largest in batrachia. In birds the blood discs are more abundant than 
in the cold-blooded vertebrates ; they are nucleated, elliptic and flattened in form, averaging in 
size, in long diameter to of an inch. SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
511 
D.-What did you say was the average size of the colored blood corpuscles in the 
stains upon the cloth? and while giving this measurement, give those also of the dog, 
horse, rat, cat, rabbit, ass, ox, cow, sheep and goat. 
J.-The average of the diameter of the blood corpuscles from the stains, was about 
°f an inch. The corpuscles of human blood are larger than those of domestic 
animals. Thus, the average diameter in the dog is about of an inch ; horse, 
W(5tt an inch ; in the rat, °f an toch > the cat, °f an toch ; in the 
rabbit, of an inch ; in the ass, of an inch ; in the ox, of an inch ; 
in the cow, of an inch ; in the pig, °f an toch ; in the sheep, 
of an inch ; in the goat, of an inch. 
D.-Do not those individual blood corpuscles in man and animals vary in their 
diameter in the same specimen of blood ? and if so state to the Honorable Court the 
causes of these variations. 
J.-The blood corpuscles of man and animals vary in their diameters within cer- 
tain limits; thus, those of man may vary from to of the dog from to 
of the hare from to to ox from tftx to ïttïî to the sheep from 
TT3Ï to °f an inch. 
D.-Difficulty, therefore, exists in distinguishing between the blood of man and 
domestic animals; and in view of this fact do you assert absolutely that the stains in 
the pieces of cloth were human blood ? 
J.-I admit that difficulties exist in such examinations. I affirmed that the human 
blood corpuscles, upon an average, were larger than that of the domestic animals 
named. I also affirmed that the stains upon the pieces of cloth presented all the char- 
acteristics of human blood. I went a step further and affirmed that this blood pre- 
sented pathological appearances which, as far as my investigations extend, are peculiar 
to human blood in a certain diseased state, and that I have never observed such a con- 
dition in the blood of animals; and that the blood from the house in which the deceased 
was murdered presented similar chemical and microscopical characters. 
D.-Can the colored blood corpuscles be detected with accuracy in dried blood ? 
J.-They can be detected in many cases; and they were detected accurately in the 
case now before this Honorable Court. 
D.-Can you distinguish between the blood of a woman and the blood of a man ? 
J.-I cannot. 
D.-Can you distinguish the blood of a foetus from the blood of its mother ? 
J.-I cannot. 
D.-Can you distinguish the blood of the different races of men? for example, can 
you chemically and microscopically distinguish the blood of a white man from that of 
a negro ? 
J.-Different races are said to have distinct odors; sulphuric acid applied to blood 
will liberate the peculiar odor of the animal; I have, upon many cases, satisfied myself 
of the possibility of developing the peculiar odor of the blood in different animals by 
sulphuric acid. I cannot, however, speak positively with reference to the blood of the 
different races of mankind. 
VERDICT OF JURY. 
By the testimony of several witnesses, two of whom were practicing physicians, it 
was clearly established that, for some weeks before and up to the time of his murder, 
Narcisse Arrieux was suffering with intermittent malarial fever (chills and fever). The 
judgment of the jury rested, to a great degree, upon the presence of blood on the 
clothing of the accused, Wilson Childers. 
We have been informed by John H. Ilsley, Jr., one of the attorneys for the prosecu- 
tion, that an important witness testified as to the guilt of the four negroes accused of 512 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
the murder of Narcisse Arrieux. The jury rendered the verdict guilty of murder, with 
capital punishment. 
MICROORGANISMS OF MALARIAL FEVER. 
The microorganisms, which we have observed in the blood of patients suffering 
from malarial fever may be thus briefly enumerated:- 
(a) Minute globular bodies, from the ten-thousandth to the thirty-thousandth of an 
inch in diameter, having the general appearance and chemical characters of the spores 
of bacteria. 
(ö) Globular bodies of larger size than the preceding, often of a dark, opaque char- 
acter, found not only in the liquor sanguinis, but also in the colored blood corpuscles 
and in the colorless blood corpuscles. These bodies, most probably true spores, possess 
the power of invading and destroying the colored blood corpuscles. These micrococci 
or spores are often observed in the blood in groups, surrounded by protoplasm, consti- 
tuting zooglœa. 
(c) Ovoid, cylindrical and rose-shaped bodies, not destroyed by acetic acid and stained 
by aniline dyes. These bodies increase during the cold stage, and are most numerous 
in pernicious malarial fever. 
(d) Colorless blood corpuscles containing minute pigment granules, and dark spheri- 
cal bodies, resembling sporules; many of these pigmented corpuscles or aggregations of 
dark spherical bodies, surrounded by protoplasm, are about twice the diameter of the 
colorless blood corpuscles of normal blood; and their behavior under the action of 
reagents and also during the process of staining, leads to the view that a portion at 
least of these bodies must be regarded as vegetable organisms. The large pigment 
cells appear to be characteristic of malarial fever. 
(e) Masses of hæmatin of various forms, irregular in size and shape, but most gener- 
ally the sides and portions seen in profile are angular. The deposits of large pigment 
masses in the brain in malarial fever, and especially in cases of repeated paroxysm, 
find their origin in the changes of the colored blood corpuscles, induced by the morbific 
ferment or microorganisms of malarial fever. 
There is an actual destruction of the colored blood corpuscles in the living blood, 
and within the walls of the living capillaries and blood vessels in malarial fever; and 
this destruction is not referable, either solely or originally, to the action of the bile 
acids accumulated in the blood, as a consequence of biliary congestion, or obstruction 
during the febrile stages of malarial fever. 
We can detect the process of the disintegration of the colored blood corpuscles by 
the microscope, and detect the very inception of that great pathological change which 
constitutes one of the most distinctive features of malarial fever, and which must be 
carefully considered in any scientific and rational plan of treatment. 
(/) Marked variations in the size of the colored blood corpuscles. 
These variations, from small corpuscles to what may be called giant corpuscles, twice 
the diameter of normal blood globules, appear to be characteristic of malarial fever. 
The destruction of colored blood corpuscles does not take place with equal rapidity 
in all parts of the organism, but appears to be most marked in the spleen and liver. 
The blood pigment resulting from the hæmatin of the blood corpuscles is frequently 
observed in the blood as it circulates in the vessels and capillaries, in masses of various 
sizes, and in the form of cellular elements. 
Without doubt local congestions may be caused by obstruction of the circulation in 
the capillaries and by these pigment particles and cells; and such congestions may lead 
to local hemorrhages. The congestions and hemorrhages thus resulting are especially 
significant when occurring within the structures of the brain and spinal cord. 
The appropriation of a portion of the altered coloring matter (hæmatin of the SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
513 
colored blood corpuscles), by the leucocytes, is due to the physical and vital endow- 
ments of their elementary bodies. 
It is now generally admitted that the colorless corpuscles are elementary organisms 
which are endowed with the power of spontaneous motion, this power belonging to 
them in virtue of the protoplasm of which these bodies are composed. This motion is 
of two kinds, the change of form and the change of place; the latter resulting from 
the former. It has been demonstrated that the colorless blood corpuscles possess the 
faculty of taking, by virtue of their amoeboid movements, solid particles into their 
substance. 
This subject is of transcendent importance to the student of fevers, in giving an 
important point of diagnosis for malarial fever, which distinguishes it from all other 
forms, and especially from yellow fever. 
The author demonstrated during the progress of his pathological researches, extend- 
ing from 1856 to 1887, the power of the colorless corpuscles of human blood to feed 
upon and appropriate the haemoglobin, hæmatin and hæmin of the colored blood cor- 
puscles in the blood vessels of malarial patients, before physiologists had experiment- 
ally determined by employing either finely divided fatty substances, or coloring 
matter, the power of the colorless blood corpuscles to take solid particles into their 
substance. 
We have thus traced the pigmentation of the colorless blood corpuscles in malarial 
fever to- 
(а) The destruction of the colored blood corpuscles by the morbific ferment, or 
microorganism of malarial fever. 
(б) The separation of the haemoglobin, hæmin and hæmatin, and its appropriation 
by the colorless blood corpuscles, in virtue of their physical and vital properties and 
amoeboid movements. 
(c) The invasion of the colorless corpuscles by the colored spores of the malarial 
microorganisms. 
GENERAL RESULTS OF EXPERIMENTS INSTITUTED TO DETERMINE THE NATURE AND 
RELATIONS OF THE ORGANIC AND LIVING CONSTITUENTS OF THE ATMOSPHERE TO 
THE MICROSCOPICAL AND CHEMICAL CHANGES OF THE BLOOD IN YELLOW AND 
MALARIAL FEVERS, DURING THE YELLOW FEVER EPIDEMIC IN NEW ORLEANS, 
LOUISIANA, 1878. 
Eelying upon the fact that cold arrests yellow fever, I sought to condense and ren- 
der palpable to the eye and touch the poison, by passing large volumes of the yellow 
fever atmosphere of 1878 through ice and ice-cold water, by means of carefully con- 
structed bellows. In this manner I threw from 100,000 to 600,000 cubic centimetres 
of the yellow fever air of 1878 through ice and ice-cold water. The products of the 
condensation thus obtained were examined, both chemically and microscopically. The 
air was taken from rooms in the most infected localities containing those suffering with 
the various stages of yellow fever. 
I also endeavored to determine whether the living particles found in the air differed 
in accordance with the locality, whether malarious or non-malarious.* After a thorough 
examination of the minute spores, micrococcci and organic and inorganic matters of the 
air in which yellow fever was prevailing, it was observed- 
(a) In the well-paved and well-drained, non-malarious portions of New Orleans, the 
solid matters of the air examined, not only during the prevalence of the yellow fever, 
* " Yellow Fever Epidemie of 1878, New Orleans," by Joseph Jones, m.d. New Orleans Med- 
ical and Surgical Journal, March, 1879, pp. 683-715 ; April, 1879, pp. 763-780; May, 1879, pp. 
852-879 ; June, 1879, pp.933-942. 
Vol. IV-33 514 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
but also at various intervals during a period of six to eight months, I discovered no 
form which could be referred to such microscopical plants as the chlorococcum vulgare, 
protococcus viridis, palmella cruenta, coccochloris brebinonii and other confervoidæ, 
or unilocular algæ capable of producing chlorophyl. 
Certain granular cells observed in the blood of malarial fever resemble most nearly 
the resting spore of bulbochæte intermedia, and the granular cells of palmella cruenta ; 
but no such cells were observed in the atmosphere of the houses situated in well-paved 
and well-drained sections of the city. 
The forms of the non-malarial sick rooms (rooms containing yellow fever patients) 
were referable to those most nearly connected with putrefaction and fermentation, 
as the bacteria and torulæ, penicillus and micrococci and cryptococcæ. 
The absence of any of the known forms of algæ in the air of yellow fever collected 
in the non-malarious, well-drained and well-paved portions of the city of New Orleans, 
is important, in that this class of plants is thus excluded from the consideration of the 
question relating to the origin and causation of yellow fever. 
(&) The water obtained by passing the air through ice and melting ice and ice-cold 
water, was preserved, and portions added to solutions of sugar. The water from the 
rooms in which yellow fever patients lay caused the development in solution of sugar 
of a delicate fungus, the spores of which were distributed in regular rows, within the 
thallus. This plant, as well as that developed in the yellow fever blood, assumed a 
distinct yellow color. Both pénicillium and torulæ were observed in these solutions. 
For many years we have had, and taught essentially, the following- 
THEORY OF THE CAUSATION OF THE PATHOLOGICAL PHENOMENA IN THE LIVING 
HUMAN BEING, KNOWN AS MALARIAL FEVER. 
We are justified by our own observations, as well as those of observers who have 
recorded positive results, in the conclusion that malarial fever is caused by a specific, 
living, pathogenic microorganism. 
This microorganism and its spores exist in the soil, waters and atmosphere of mala- 
rial regions. It gains access to the blood of human beings, where it commits its greatest 
ravages, through the lungs and through the skin and alimentary canal, but it is chiefly 
through the respired air and the ingested water that it finds the media for its penetra- 
tion into the capillaries and circulatory fluids. 
The condition of the individual at the time of exposure, whether of health or ill- 
health, and the integrity of the pulmonary, alimentary and cutaneous surfaces, without 
doubt modify or influence the rapidity of the introduction and the subsequent action of 
the malarial pathogenic microorganism. After the introduction of the pathogenic 
microorganisms into the circulation they cause the splitting up of complex nitrogenous 
compounds (proteids, colloids, as well as crystalloid bodies) into compounds of compar- 
atively low or simple composition; they cause the disintegration of nitrogenous com- 
pounds by withdrawing from the compounds certain molecules of nitrogen, building 
up with these their own protoplasm. Similarly carbohydrates and inorganic salts are 
dissociated by them, inasmuch as they require a certain amount of carbon, phosphorus 
and potassium for building up their own bodies. The profound and remarkable 
changes of the amount and character of the constituents of the blood and urine, which 
we have detailed in the preceding pages, are thus shown to have their origin in the 
chemical changes excited by the life acts of the pathogenic malarial microorganism. 
In this process of decomposition, certain alkaloid bodies, closely related to the ptomaines, 
are produced and act upon the ganglionic centres of the nervous system, indicating 
aberrated nervous and muscular action, causing capillary congestion, deranged secre- 
tion and other toxic effects. It is probable that in the most malignant cases a compound 
or compounds resembling the septic poison (sepsin) is one of the products of decompo- SECTION XV PUBLIC AND INTERNATIONAL HYGIENE. 
515 
sition of animal substances. It will be readily admitted that putrid intoxication 
or poisoning may occur as a pyæmic affection in the human subject, when a large ulcer- 
ating surface exists, in which it is well known that large numbers of putrefactive 
organisms are growing and are producing the septic poison or sepsin, which can be 
isolated by various chemical processes destructive of every living microorganism. Gas- 
pard, Burdon-Sanderson, Panum, Bergmann, Billroth, Guttmann, Semmer and many 
others, have shown that sepsin injected into the vascular system of animals produces a 
marked febrile rise of temperature, and is capable of causing death with the symptoms 
of acute poisoning, showing vomiting and purging, spasms, torpor, collapse and death. 
On post-mortem there are found changes similar to those observed in the most malig- 
nant of fevers, and especially of hemorrhagic malarial fever and yellow fever; namely, 
severe congestion and hemorrhage of the stomach, duodenum and rectum ; hemorrhage 
in the pleura, lungs, pericardium and endocardium; congestion and hemorrhage in the 
peritoneum; congestion of the liver; congestion of the kidneys and bloody urine. This 
putrid infection leads to death in twelve to twenty-four hours, or even less. Ou inject- 
ing smaller quantities only a febrile disturbance is noticed, severe symptoms and death 
only following after injection of considerable quantities, such as several centimetres, of 
putrid fluid. Thus sepsin is known to be one of the products of the chemical changes 
excited in nitrogenous bodies by the multiplication, growth and life actions of septic 
bacteria. 
By holding that the microorganism of malarial fever develops or produces by its 
action on the proteid and morphological elements of the blood, bodies related to the 
animal alkaloids (ptomaines) and to sepsin, we have an explanation of the violent 
vomitings, sudden hemorrhages and profound coma characteristic of the severest forms 
of malarial disease. At the same time it should be observed that in the growth and 
chemical action of certain microorganisms, the products of the decomposition started 
and maintained by them have a most detrimental influence on themselves, inhibiting 
their multiplication; in fact, after a certain amount of these products has accumulated, 
the organisms become arrested in their growth, and finally, may be altogether killed. 
We have already dwelt upon the importance of the fact that indol, skatol, phenol, and 
other bodies belonging to the aromatic series, which are produced in the course of 
putrefaction of proteids, have a most detrimental effect on the life of many microorgan- 
isms. While it has not been as yet clearly determined whether in these instances the 
organisms produce the chemical effect by creating a special zymogen or ferment, and 
through it causing the chemical disturbance, or whether they merely dissociate the 
compounds by abstracting for their own use certain molecules ; it is, on the contrary, 
well established that in consequence of this chemical disturbance definite chemical 
substances are produced. 
In view of the fact that the microorganism of malarial fever acts with greatest 
energy and most destructive effects upon the colored blood corpuscles; and in view of 
the fact that there appears to be no practical limit to the alteration and destruction 
of the red globules; we must refer the temporary cessation of the actions of the micro- 
organism (the intermissions and remissions of malarial fever), not to the exhaustion of 
any special chemical substance in the blood and organs, but rather to the effects of the 
elevated temperature and the formation of antiseptic compounds, in arresting the 
development, and in destroying large numbers of the microorganisms. In certain dis- 
eases, as smallpox, vaccinia and typhus fever, the chemical changes resulting from the 
action of the pathogenic microorganisms, as well as the elevation of temperature, are 
such as to cause the complete destruction and elimination of the germs originally pro- 
ducing the disease. 
In the paroxysms of malarial fever, there is in like manner a destruction and elimi- 
nation of the pathogenic microorganisms, but in many cases the destruction and elimi- 516 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
nation of the germs of the disease is not complete, and these remaining in the blood 
reproduce their kind, and after a definite period the same phenomena are repeated. 
The paroxysm of malarial fever, with its elevated temperature and antiseptic products, 
must, to a certain extent, be regarded as curative in its effects ; and it is well estab- 
lished that a considerable number of cases of malarial fever end spontaneously and 
pass into recovery after one or more paroxysms, without the employment of any anti- 
septic or any remedies whatever ; in such cases the febrile changes excited by the 
pathogenic organisms have resulted in their death and elimination. On the other hand, 
the most destructive and incurable forms of malignant anæmia, ending finally in he- 
patic and splenic enlargement, general anasarca and failure of the heart and nervous 
centres, often result from the continuous and almost unobserved action of the malarial 
microorganism upon the constituents of the blood, and, more especially, upon the col- 
ored blood corpuscles; in such cases the antiseptic products of high fever have not been 
formed. 
We must look to chemical knowledge to guide us in our contests with the specific 
agents of malarial and other diseases, and we accept the doctrine, with but slight modi- 
fication, that no chemical or other agent can be rightly regarded as disinfectants, in 
respect of any disease, unless it can be shown to have the power of inhibiting or arrest- 
ing the development and growth of the particular species of microphyte which is the 
constant concomitant of the morbid process ; and that inasmuch as all specific micro- 
phytes are endowed with the power of multiplying in the blood and living tissues of 
the organism they infest, and of there playing their part in the morbid process ; all 
specific disinfectants must, in order to encounter the organisms they are intended to 
destroy, be of such a nature that they can, without prejudice, be mixed with the circu- 
lating blood, and come into direct contact with the tissues. 
In the case of malarial fever we have in quinine such a disinfectant, which is not 
only poisonous to the pathogenic microorganism of malarial fever but is also of such a 
nature that it can, without prejudice, be mixed with the circulating blood and come 
into direct contact with the tissues. Quinia may be taken in large doses without 
danger ; it is eliminated slowly, with little or no change, by the skin and kidneys ; it 
circulates freely in the blood, and passes into the organs, and is thus brought into con- 
tact with all pathogenic microorganisms; its action as a disinfectant is greatly increased 
by the rapidity of the circulation, and its action is also favored and supplemented by 
the antiseptic products developed during the febrile paroxysms. Professor Ceri, of 
Camerino, has shown that the infecting power of the organisms of malarial soils by the 
introduction of quinine into the infecting fluids, one part of quinia to 800 of the cul- 
ture fluids, prevented the development of the malarial spores, and arrested the putrid 
fermentation induced by them. Administered to healthy men, quinine reduces the 
urea twenty-five per cent, and the sulphuric acid forty per cent. ; it diminishes the 
amount of uric acid; it slightly increases the amount of water; it does not diminish 
the amount of carbonic acid excreted by the lungs. The spleen of warm-blooded ani- 
mals contracts under the influence of quinia within a few hours ; it becomes tougher 
and its surface is thrown into folds ; these phenomena are not prevented by the previous 
section of the afferent nerves. In healthy persons and in most febrile patients, it is 
not decomposed in passing through the blood, but is entirely excreted by the kidneys 
and bowels; notwithstanding that it doesnot directly take part in the chemical changes 
in the body, it produces giddiness and ringing in the ears, disturbances of hearing and 
vision, depression of reflex irritability, depression or impairment of the heart's action ; 
diminished frequency of the pulse; diminished arterial pressure, prostration and reduc- 
tion of animal temperature. Solutions of albumen are converted into peptones if 
shaken up in an atmosphere of nascent oxygen, but this change is prevented if quinia 
be present. Even in relatively small quantities it prevents the putrefaction of nitro- SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
517 
gencus substances, as well as several simpler fermentive processes, in both cases it acts 
directly on the protoplasm of which the substances or their germs are composed. On 
the other hand it is of importance, in the administration of quinine in large or continu- 
ous doses, that other amorphous ferments, such as ptyalin and pepsin, have their prop- 
erties very slightly or not at all arrested by quinia, and there are several protoplasmatic 
organisms on which it has no poisonous effects whatever, whereas it reacts on the other 
with unexpected vigor. 
The poisonous action of many putrid fluids upon warm-blooded animals may be 
neutralized, either completely or as far as certain symptoms are concerned, by the 
simultaneous administration of quinia. Owing to the energy with which it paralyzes 
certain kinds of protoplasm, quinia diminishes the absolute number of white blood 
corpuscles in the body; the lymphatic glands, under its action, become small, and are 
found, on section, to be abnormally dry, while splenic enlargements, due to hyperplasia 
of the lymphatic follicles, and to the increased tissue change within the organ by which 
it is accompanied, are reduced or prevented. 
The escape of white blood corpuscles from the vessels, and the suppuration which 
ensues, can be distinctly limited in animals by quinia ; its effect in this instance is, in 
the main, independent of the condition of actual pressure. It is due to a lowering of 
the affinity of the corpuscles for the oxygen of the hæmoglobin, this oxygen being the 
stimulus which excites the independent movements by which emigration from the veins 
and capillaries is partly effected. Fresh vegetable juices containing protoplasm, and 
also healthy pus-both of which ordinarily give the reaction of nascent oxygen with 
tincture of guaiacum or indigo-lose this property when mixed with relatively weak 
solutions of quinia, this alkaloid preventing the protoplasm from absorbing oxygen 
from the atmosphere and undergoing the special alteration to which the reaction is due. 
Phosphorescent infusoria, or those which are continually undergoing powerful oxida- 
tion, completely lose their phosphorescence on the addition of minute quantities of 
quinia. The *addition of quinia to blood which has been recently drawn not only 
diminishes the physiological production of acid which occurs immediately after its 
removal from the body, but also its power of transferring active oxygen to oxidizable 
bodies. This effect also takes place with pure hæmoglobin without its being possible 
to detect any decomposition of the latter spectroscopically during the presence of the 
quinia. On the contrary, when blood which contains quinia is heated, the lines which 
indicate oxygen disappear at a higher temperature than the same lines in pure blood 
used for comparison. The pénicillium fungus, when mixed with hæmoglobin outside 
the body, withdraws oxygen from it, and this process is arrested by quinia. 
From the preceding facts, established by the labors of eminent observers, as Dr. C. 
Binz, Mosier, Boeck, Rossbach and Preyer, and taking into consideration the altera- 
tions in size which the red blood corpuscles undergo under its influence, it seems prob- 
able that while the quinia renders certain cells within the human organism still less 
fitted than before for the absorption of oxygen, it binds that element more firmly to 
the hæmoglobin. The fall of temperature which quinia so frequently produces in fever 
(0.5°, 4.0°, and more, Centigrade) is independent of the heart, and also of those portions 
of the nervous system which take origin in the brain and pass downward through the 
spinal cord ; for it still takes place after the cervical portion of the latter has been com- 
pletely divided ; nor does it appear to depend upon an increased omission of heat from 
the skin. The reduction of temperature appears to be largely due to some inhibitory 
effect exerted by quinia over the functional activity of the protoplasmatic cells of the 
heat-producing organs. Even the normal cells become slightly depressed by its action, 
especially when they are producing an unusual amount of heat under the stimulus of 
pyretic substances; and those infective poisons (whether they be organized or merely 
in solution) which are capable of self-multiplication in the body after more or less of a 518 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
period of incubation, and of acting as irritants to their cells, are either rendered by 
quinia incapable of further development, as in malarial fever, or they have their energy 
paralyzed, as happens, to some extent, in typhoid fever. Quinia essentially differs from 
chemically allied molecules-such as morphia, strychnia, veratria-in the fact that it 
does not meet with any albuminous body in the nervous system on which it has a 
marked effect. Quinia circulates unchanged through the blood, and it is an error to 
attribute its specific antipyretic properties to its stronger affinity for one or more pyretic 
poisons, and especially for that form which malaria originates. The power of quinia to 
arrest malarial fever is due chiefly (a) to its antipyretic properties; (ft) its power to 
bind the oxygen more firmly with the colored blood corpuscles, and thus to avert the 
destructive action of the malarial germ or microorganism; (c) its poisonous effects upon 
the microorganisms of malarial fever; (d) its tonic effect upon the cerebro-spinal and 
sympathetic ganglia. 
PREVENTION OF MALARIAL FEVER. 
No subject is of greater importance to the inhabitants of tropical and temperate 
regions of the earth, than the destruction or removal of the cause or causes of malaria. 
The following propositions should be considered in the discussion of the measures 
which may be proposed for the destruction or removal of the causes of malaria :- 
1. Malaria inflicts a vast amount of disease and suffering upon the human race, and 
directly and indirectly causes a considerable portion of the mortality in tropical and 
temperate climates. Notwithstanding the modern civilizations had their rise and 
development in the most malarial portions of Africa, Asia and Europe, along the 
banks of the Nile, in its hot, malarious delta, we find the remains of an ancient and 
grand civilization, which gave birth to that of Greece and Rome, and the great commer- 
cial cities of the Phoenicians were located around the malarious borders of the land- 
locked Mediterranean. 
Even medicine had its first birth along the marshy waters of the Nile and in the 
temples of Isis and Osiris. • 
The works of Hippocrates (the father of European medicine) were based upon the 
knowledge which had crossed the Mediterranean from the shores of Africa, and the 
greater portion of the cases which he details relate to the various forms of malarial 
fever. Rome conquered the world with the sword and destroyed her citizens by malarial 
fevers, and through all her various changes, from universal empire to a contracted 
hierarchy, through all ages, she has retained her deadly malaria. In the malarious 
regions of Italy and Spain were born and reared Columbus, Cortez, Pizzaro, Ponce de 
Leon and Ferdinand de Soto. In the malarious regions of the Southern States were 
bred such men as Washington, Jefferson, Lee and Stonewall Jackson. 
The star of empire, which has been steadily passing from the east to the west, has 
halted in its progress in the great malarious valley of the Mississippi, where it will remain 
as the centre of political power, physical development and scientific advancement. In 
those regions in which the earth generates malaria, she also bestows her most boun- 
teous gifts, golden grain, luscious fruits, and every variety of animal and vegetable food. 
Thus the baneful effects of malaria are counterbalanced to a large extent by the mild 
and genial climate and the bounteous products of field, forest, river, lake and ocean. 
2. The labors of man in clearing the forests, opening and deepening the channels of 
rivers, draining and tilling the land, have altered the climate and changed the char- 
acter of the diseases of large portions of the earth's surface. 
The malarious belt of the earth has been thus progressively circumscribed by the 
labors of the agriculturist. In the present century the removal of the causes of mala- 
rial fever has been greatly facilitated by the extensive introduction of improved imple- 
ments and machinery and the use of steam. The drainage of lagoons, swamps and 
marshes, as well as of the land generally, has removed certain conditions favorable to 
the development of simply constructed organisms and morbific ferments. SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
519 
With the increase of the human race, and the advancement of agriculture and the 
mechanical arts, there will be a progressive diminution of the empire of malaria. The 
labors of the agriculturist have banished malarious diseases from the greater portions 
of England, France and Germany. In the early settlements of South Carolina and 
Georgia the clearing off of the dense virgin forests, even in elevated, hilly regions, was 
attended with the development of the severest forms of remittent and congestive 
fevers. At this day the old red clay hills of Carolina are comparatively free from 
malarial fever. 
3. Centuries must elapse before the low grounds, marshes, ponds, lagoons and 
swamps of the United States of America, and more especially of the great valley of 
the Mississippi, will be thoroughly drained and under cultivation. The rich returns 
yielded by sugar-cane, rice and cotton will ever tempt the laborer to disregard the 
effects of climate, and the gaps in their ranks will ever be speedily filled with new 
recruits. The question arises, what can be done to protect the laborers in the swamps, 
rice fields and marshes of the Southern States from the effects of malaria ? The author 
has witnessed, upon thousands of occasions, the destructive effects of malaria upon the 
human constitution. 
If the hardy sons of Ireland, England, Germany and France, and even the dark 
Latin races of Italy, Spain and Portugal enter the swamps and marshes and rice-fields 
of our Southern States as laborers, they are almost universally attacked with the various 
forms of malarial fever during the months of July, August, September, October and 
November. Many who escape the immediate fatal effects of the acute form suffer with 
diffuse parenchymatous hepatitis, malarial nephritis, anaemia, anasarca, ascites and 
prostration of the muscular and nervous forces. Vast numbers of men have perished 
from the effects of malaria and exposure in building the railroads of the United 
States. This subject should be thoroughly investigated by the National Government. 
At the present time vast numbers of men from all parts of the civilized world are 
suffering and perishing from the deadly effects of the malaria of the Central and South 
American States, and more especially from the fevers of the Isthmus of Panama. How 
to protect the laborer from the effects of malaria should call forth the earnest considera- 
tion of every civilized nation. 
Preceding the American Civil War, in 1859 and 1860, the author undertook an 
extended investigation of the diseases of the various geological and physical divisions 
of the Southern (slave States). The investigation of the soil, waters and diseases of the 
rice plantations, low grounds and swamps of Georgia first engaged his attention. Upon 
the present occasion we shall present only two results of these labors, namely, those 
facts which illustrate the poisonous nature of the stagnant water of the swamps and the 
rules formulated by the author for removing, at least some of the causes for malaria 
from among the laborers on the rice plantations. 
Poisonous Effects of the Stagnant Waters of the Swamps of Low Malarious Regions. 
Experiments on Living Animals.*-Water taken from a deep basin in the large canal 
which drains the rice fields-the swamp was entirely dry with the exception of the 
deeper portions of the canal-the waters of which had ceased to flow for at least three 
months, the season having been unusually warm and dry. The fish, terrapins, frogs, 
alligators and snakes had all collected in these pools of stagnant water, and the living 
catfish kept their mouths and feelers upon the surface of the water. As the eye rested 
upon the black and green, turbid waters, scarcely a spot could be discovered not occu- 
* "First Report to the Cotton Planters' Convention of Georgia, on the Agricultural Resources 
of Georgia," by Joseph Jones, m.d., pp. 269-272. Augusta, Ga., 1860. Analysis 43. Stagnant 
swamp water, Arcadia swamp, Liberty Co., eight miles from its junction with the North New Port, 
River, June 1st, 1860. 520 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
pied by the mouths and feelers of catfish moving tremulously about upon the surface 
of the water like so many spiders ; in fact, upon a general view, these pools resembled 
a dark surface of black and green liquid mud, upon which thousands of large spiders 
were dancing. Every now and then the monotony would be broken by the splash of a 
m udfish or garfish, or conger eel, or the plunge of a bull-frog. The catfish appeared, in 
their distress and anxiety to absorb the oxygen from the atmosphere, to disregard alike 
the presence of man and of the moccasins and water snakes which sluggishly moved in 
the stagnant pools among their feelers, apparently satiated and disgusted. These stag- 
nant pools, and in fact the whole swamp, under a burning sun emitted a most sickening 
and disgusting stench. Exposure to this atmosphere, contaminated with the gases 
arising from the decomposition of vegetable and animal matter, during the heat of the 
day, from ten o'clock in the morning until three o'clock in the afternoon, obtaining 
specimens of water and capturing the cold-blooded reptiles, was followed before night 
by an active diarrhoea. I have before suffered in a similar manner from exposure to 
these swamps in the summer season. Sulphate of quinia taken upon the appearance of 
the first symptoms of lassitude and of undue action of the bowels was the means of 
relieving the unpleasant effects of this exposure in two days ; and I have upon other 
occasions, when I have been similarly exposed in the prosecution of my inquiries, expe- 
rienced beneficial effects from sulphate of quinia used as a prophylactic. 
The power which quinia possesses of averting an attack of malarial fever is most 
valuable to the planters of these regions, who are often, during the harvesting of rice, 
necessarily exposed to the deleterious effluvia of the swamps. That the diarrhoea was 
caused by the effluvia of these swamps, inhaled during the collection of the waters and 
samples of the swamp mud and of the natural history specimens, was proved by the 
fact that my servant man (a strong, healthy negro, who resided on the plantation one 
mile from this swamp), who assisted in procuring the specimens, was also attacked at 
night with diarrhoea. I was anxious to test the effects of these waters when absorbed 
directly into the blood. They were placed in bottles hermetically sealed, and upon my 
return to Augusta, two days after, I injected several fluid ounces into the subcutaneous 
tissue of a large Newfoundland dog. The water was injected into the subcutaneous 
tissue of the back and right fore and hind legs. At the time of the injection the water 
had the same sickening smell of the swamp. No special symptoms were induced by 
the injection of the water at the time, but upon the next day there was a slight rise in 
the temperature of the dog, and the parts upon the back and legs where the swamp 
water had been injected were greatly swollen. Upon the third day the parts were 
lanced and discharged much green and yellowish-green, exceedingly offensive matter, 
together with much most foul and fetid air. The parts continued to discharge large 
quantities of foul matter and air for ten days. Tar was applied liberally around and 
within the orifices of the abscesses, to keep away the flies, which I am confident would have 
destroyed the dog. The dog lost flesh to a considerable degree, but recovered entirely 
in three weeks. At the end of one month he was killed by the subcutaneous injection 
of acetate of morphia, and a careful examination with the naked eye and with the 
microscope was made of all the viscera ; no lesions of the organs were discovered, and 
no alterations of the viscera were manifest, the color of the liver was natural, and the 
spleen was not enlarged. The swamp water was not injected directly into the blood- 
vessel system, for I felt confident that the animalcules and suspended matters which 
could not be removed by filtration would have produced death by interfering with the 
capillary circulation in the lungs, independently entirely of any direct poisonous effects. 
The highly complex nature of these waters will be seen in the following analysis : 
Specific gravity, 1000.661; solid residue in 100,000 grains, 23.400; suspended matters 
in 100,000 grains, 100.000 ; 100,000 grains contain suspended matters, 100 grains ; phos- 
phates of lime and magnesia, 22.224 ; phosphoric acid, 13.958 ; lime and magnesia, SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
521 
8.266 ; chlorides of sodium, potassium, calcium and magnesium, sulphates of soda, 
potassa, lime and magnesia, phosphates of soda and potassa, 5.733 ; organic matters, 
animalcules, microscopic plants, decaying animal and vegetable matters, urea, uric 
acid, salts of ammonia, crenic, apocrenic and humic acids, 15.101 ; silicates of alumina, 
potassa and lime, silicic acid, peroxide of iron, 56.892. Gases.-Sulphureted hydrogen, 
3.488 ; sulphur, 3.283 ; hydrogen, 205 ; phosphorated hydrogen, carbureted hydrogen, 
carbonic acid gas, carbonic oxide gas, atmospheric air, oxygen, nitrogen, and other gases. 
Solid residue, 23.400 ; carbonate of lime, 3.122 ; lime, 1.487 ; carbonic acid, 1.635 ; 
carbonate of magnesia, 0.455 ; magnesia, 0.217 ; carbonic acid, 0.238 ; chlorides sodium 
and potassium, 2.946 ; sodium and potassium, 1.350 ; chlorine, 1.596 ; sulphates soda 
and potassa, 4.223 ; soda and potassa, 2,050 ; sulphuric acid, 2.173 ; silicic acid, 0.213 ; 
phosphates of soda, potassa, lime and magnesia, trace ; chlorides of magnesium, calcium 
and aluminum, trace ; organic matters, humic, ulmic, crenic and apocrenic acids, ani- 
malcules, microscopic plants, ammonia, urea, uric acid, urate of ammonia, 2.450; 
putrefying vegetable and animal matters, undefined vegetable and animal matters. 
We thus demonstrated in 1860 the poisonous nature of the waters of swamps and their 
power to produce fever and dysentery in living animals when injected subcutaneously. 
During the treatment of 6311 cases of disease in the wards of the Charity Hospital 
of New Orleans, 1869-1886, nearly one-half of which were caused by the action of 
malaria, I have sought to investigate the proximate cause of the first and subsequent 
attacks. A large number of the cases of malarial fever and of acute and chronic dys- 
entery and diarrhoea can be traced to the drinking of swamp water and the waters of 
sluggish bayous and streams, and of wells sunk in low malarious regions. 
In the month of October, 1880, during a personal inspection of the cases of Oriental 
leprosy along the banks of the Bayou Lafourche, I was accompanied by my son, Stan- 
hope Jones, at that time a cadet of the State University of Baton Rouge (now doctor 
and assistant coroner). The water of the Bayou Lafourche (all that could be obtained 
for drinking purposes) produced a succession of violent hemorrhages from the bowels of 
my son, and had I not reached Lockport at midnight and secured the kind assistance 
of physicians and friends and the necessary remedies, death would have been inevit- 
able. A large number of ulcers of the lower extremities treated in my wards in the 
Charity Hospital have been traced to the action of the poisonous waters of the swamps 
and rice fields of Louisiana; and at the present time, November, 1886, I have under 
treatment a case of extensive ulceration of both lower extremities, complicated with 
anaemia, jaundice, enlarged liver, enlarged spleen and fever, occurring in the case of a 
man who had been cutting cypress logs in the swamps near Plaquemine, Louisiana. In 
dealing with such ulcers, the local treatment will not avail unless the constitutional 
treatment at the same time be carried on against the malarial fever and its effects. 
During my labors among the rice and cotton plantations of Georgia, in 1860, I was led 
to draw up the following rules with reference to the use of the waters and the general 
conduct of the laborers. 
Waters of the Wells and Springs of the First Tertiary Plain.*-The character of the 
waters of the springs and wells of the low lands bordering the sea, of Georgia, will 
depend upon the depth and character of the soil and their distance from the rivers and 
swamps. The springs and wells of water in sandy formations are of great purity, and 
their composition is correctly represented in analysis forty-one of Walthourville branch 
waters. In many of these springs and wells which are formed by the waters perco- 
lating through sand beds, which serve the purpose of natural filters, the saline matters 
are often not more than from one to three grains in the gallon. The waters of low, 
■s "First Report to the Cotton Planters' Convention of Georgia," etc., by Joseph Jones, m.d., 
Augusta, Georgia, 1860, pp. 285-289. 522 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
swampy lands and rice fields, on the other hand, are impregnated with organic matters 
w hich, in certain seasons and under certain conditions, exert most deleterious effects 
upon the health of the inhabitants. The great mortality upon rice places, many of 
which actually decrease instead of increasing, is due to the character of the waters, 
which induce bowel affections and derangement of the blood and low grades of fever. 
The relations of malarial fever to the organic matters of drinking waters demand a 
most searching and extensive investigation, and without hazarding an opinion at this 
stage of the investigation, we would simply state that we have been engaged in an 
examination of this complicated question as well as of the character and causes of these 
diseases of rice plantations, and hope to present a special report at some future day. 
Upon the present occasion I will point out a few practical rules which I know, by expe- 
rience, will greatly ameliorate the condition of the inhabitants of rice plantations:- 
1. Substitute cistern water for well and spring water. If this report should accom- 
plish no other result than the introduction of cisterns upon rice plantations and in the 
tertiary lime formation of Georgia, I shall feel myself to be rewarded for my labors. 
The surface exposed by the cotton gins, sheds and barns and dwelling houses upon 
plantations will prove amply sufficient for the collection of an abundant supply of 
water. 
2. If the cistern water should at any time fail, or if it be impossible to obtain the cis- 
tern water, then collect the well and spring water into large barrels or tanks, and add 
to the mass of water a solution of common alum. One pound of alum pulverized and 
dissolved in four gallons of water will be sufficient to purify the drinking water of a 
large plantation for six months. Of this solution a wineglassful may be added to 
every fifty gallons of water. The alum coagulates the organic matters, they settle and 
leave a clear, sparkling, wholesome water. The minute proportion of alum in the 
water will exert no inj urious effects whatever ; it will be only tonic in its action. 
3. Never commence work in the fields and low grounds before sunrise. 
4. Never allow the laborers to commence work upon empty stomachs. Establish a 
law, as unalterable as those of the Medes and Persians, that no one shall leave the 
quarters without having first cooked and eaten breakfast. Breathing in the morning in 
an atmosphere loaded with the noxious vapors of the swamps is the most fruitful of 
all sources of disease. 
5. Avoid, as far as possible, the dews of the mornings and nights. 
6. Avoid wet clothes, as far as possible. 
7. Clothe the feeble, during the fall and winter, in red flannel, worn next to the 
skin. 
8. Treat diseases of rice plantations and low grounds upon the stimulant plan. 
Avoid all depletion as far as possible, and in the climate fevers administer sulphate of 
quinia boldly, regardless of the symptoms of headache and delirium ; for this is the 
great remedy in the diseases of swamps and rice fields, even in the pleurisy and pneu- 
monia of the winter season, for they are, in this section of the country, modified by the 
slow action of malaria upon the system. 
9. Do not attribute the diseases of children in the summer and fall to worms. At 
this period of the year, when children are most liable to climate fever, it is the habit 
of so many planters to dose them with various drastic and disgusting mixtures, to rid 
them of worms, under the idea that the worms are the cause of the fevers of this season 
of the year, because, when the children are taken sick, the worms travel away from 
them through every avenue and in every direction. The explanation of this striking 
phenomenon, which, upon a superficial view, is liable to be taken for the disease, is 
simply this: during the attack of climate fever the secretions of the liver, and of the 
whole intestinal canal, are so altered that the worms, which have been quietly housed 
all winter in comfortable quarters, without exciting any injurious effects upon the SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
523 
unconscious landlords, are suddenly sickened and disgusted with their altered fare 
and habitations, and beat a precipitate retreat in the most convenient and natural 
directions. 
If you treat the disease for worms alone, the real disease, climate fever, will march 
steadily on, and you may purge the child until the last worm is evacuated, and only 
hasten the fatal end, because you are working in conjunction with the disease, all the 
tendencies of which are depressing. If, on the other hand, you administer a gentle 
purgative mixed with a full dose of sulphate of quinia, and follow up with gentle 
stimulants and sulphate of quinia, the termination of almost every case will be favor- 
able, and that, too, in a few days. We are persuaded that strict attention to these 
simple rules will be the means of materially diminishing the diseases and the rate of 
mortality upon rice plantations. 
Quinine as a Preventive of Malarial Fever. *-The following observations have lost 
none of their interest or value by the course of events; in fact, such inquiries are ren- 
dered more valuable than ever by the changes wrought by the war in the labor system 
of the South. The Southern States must do all in their power to promote and foster 
white immigration, and all facts are of interest which bear upon the health of white 
laborers in the cultivation of the rich swamps and rice lands, which in many places 
are now lying idle and rapidly reverting back to their original state. At the commence- 
ment of the recent war I prepared and published an article in the Southern Medical and 
Surgical Journal, entitled "Sulphate of Quinia administered in small doses during 
health, the best means of preventing Chills and Fever, and Bilious Fever, and Congestive 
Fever, in those exposed to the unhealthy climate of the rich low lands and swamps of 
the Southern Confederacy." Owing to the state of the country at the time, this publi- 
cation was not circulated in the manner designed. The climate of the rich, low plain, 
clothed with a luxuriant, sub-tropical vegetation, which forms a belt along the Atlantic 
Ocean and Gulf of Mexico of varying width, from thirty to a hundred miles, and which 
is intersected with numerous swamps, which discharge their waters into sluggish, muddy 
streams, surrounded on all sides by extensive swamps and marshes, is, necessarily, hos- 
tile to the white race. To the pestilential exhalations of stagnant swamps and rich 
river deposits, excited and disseminated by the burning rays of the sun in this hot 
climate during the summer and fall months, no process of acclimation has ever accus- 
tomed the white man. In the early settlement of South Carolina and Georgia, the 
inhabitants, in most instances, resided the whole year upon their rich rice and indigo 
plantations. Many, however, soon fell victims to the climate or dragged out a miserable 
existence, with constitutions broken and rendered prematurely old by repeated attacks 
of climate fever. The clearing of the forests, of the swamps and rich low lands, and 
the consequent exposure to the sun of the vegetable matter which had been accumulat- 
ing for ages, rendered the climate so deleterious to the white race that the planters were 
compelled to seek health during the summer and fall months in sea islands, or in pine 
barren or mountainous retreats; and with the most efficient precautions the mortality 
of these regions is far greater than in the elevated portions of the Southern States. 
The preceding statement has been fully illustrated in the fourth chapter of the 
present (second) volume of the "Medical and Surgical Memoirs," by reference to the 
mortuary records of Midway Congregational Church, of Liberty County, Georgia, and 
by the experience of the British officers in Africa. 
The facts which have now been fully presented are sufficient to justify the attempt 
to devise some means to ward off the climate fever. During the study of the relations of 
* " Quinine as a Prophylactic against Malarial Fever," being an appendix to the " Third 
Report on Typhoid and Malarial Fevers," delivered to the Surgeon-general of the late C. S. A., 
August, 1864. By Joseph Jones, m.d. 524 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
climate and soil to disease, the collection of the mortuary statistics and the investigation 
of the causes of diseases upon rice and cotton plantations, and during the discharge of 
the duties of chemist to the Cotton Planters' Convention of Georgia, the author has, 
necessarily, been greatly exposed to the agents which produce climate fever, and the 
results of his experience, now presented, cannot, therefore, be said to be wanting the 
test of actual experiment. Under these exposures, I have found the sulphate of quinia, 
taken in from three to five grains twice during the day, would, in most cases, prevent 
the occurrence of malarial fever, and if it failed to ward it off entirely, the attack 
would be of a very slight character. I have further observed that when the climate 
fever first appeared-with a sense of lassitude, headache and excitement of the pulse, 
with alternate flushings, it might be arrested by a dose of from five to ten grains of 
sulphate of quinia, in combination with bicarbonate of potassa and Hoffman's anodyne. 
From five to ten grains of the sulphate of quinia may be given, according to the urgency 
of the symptoms, united with fifteen grains of bicarbonate of potassa and two fluid 
drachms of Hoffman's anodyne, from five to fifteen grains of gum camphor; the whole 
to be dissolved in six fluid drachms of water. The feet should be placed in hot water 
immediately after or before the administration of the remedies, and the patient, after 
this bath, should be covered up in bed, so as to promote free perspiration and induce 
quiet sleep. I have frequently gone to bed in a feverish, restless state, with a severe 
headache, excited pulse, and pain in the limbs, and dry, warm skin, and, under the 
action of these remedies, arose in the morning refreshed and able to resume active 
operations. The bicarbonate of potash is here recommended instead of the proto-car- 
bonate (salts of tartar), which is in such common use during fever in the Southern 
country, because it is far less active in its effects upon the stomach, and may be taken 
in much larger doses, and accomplishes more effectually the neutralization of the acid 
which is so often abundant in the stomach at the commencement of malarial fever, and 
more effectually acts upon the liver and kidneys, and promotes the removal of all 
offending matters from the blood. 
We would recommend the use of quinia as a preventive of climate fever in the 
following manner:- 
R Sulphate of quinia gr. iij 
Dilute aromatic sulphuric acid drops, v 
Brandy tablespoonful, j 
Water wineglassful, ij. 
Drop the diluted aromatic sul phuric acid upon the sulphate of quinia, and then add 
the brandy and water. Administer twice during the day, after rising in the morn- 
ing and just before bedtime. 
To render the value of this means of warding off climate fever still more evident, 
we have cited in the fourth chapter the practice and success of the British surgeons 
upon the coast of Africa, premising at the outset, that the epidemic climate fever of 
Africa does not differ in any essential manner, except, perhaps in its severity, either in 
its causes, symptoms or effects, from the malarial fever of North America. The value 
of sulphate of quinia in warding off the climate fever of Africa, has been determined 
by instituting a comparison between the effects of the disease before and after the use 
of this medicine as a prophylactic. It is worthy of notice that in the instances in 
which the author has quoted from the experience of the British surgeons serving in 
Africa, when quinine wine was administered according to the instructions issued with 
it, no fever of any consequence followed exposure to land or swamp miasma ; but, on 
two occasions, when quinine purchased on the coast was substituted, and once when 
the wine was suddenly discontinued after the exposure, a considerable number of 
men were attacked, owing, it is to be supposed, to the discontinuance of the quinine SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
525 
wine in one instance, and to its bad quality in the other, for it is well known that, like 
other high-priced remedies, it does not escape adulteration when it falls into the hands 
of dishonest traders.* 
A comparison of these facts with the great sickness and mortality of the white 
explorers and residents and sailors of the African coast and rivers, demonstrates 
conclusively :- 
1. Quinine taken during exposure to the exhalations of miasmatic regions will, in 
most cases, ward off fever entirely. 
2. If fever attacks those to whom the quinine has been regularly administered, its 
severity and duration will be far less than in those who have not taken the quinine; it 
therefore not merely wards off disease, but renders it less powerful and destructive 
when present. 
3. To be entirely efficient the quinine must be administered for some time, at least 
ten days, after exposure to the causes of fever. Southern Medical and Surgical Journal, 
Augusta, Georgia, August, 1861, Vol. XVII, No. 8, pp. 593-614. 
The observations which I have been able to make during the late war have con- 
firmed the accuracy of the preceding statement ; and I am convinced that the health 
and efficiency of the troops in certain malarious localities of the Confederacy would 
have been greatly promoted by the daily use of quinine in the manner recommended. 
The value of quinine as a prophylactic in preserving the efficiency of troops serving in 
damp, unhealthy, malarious regions may be readily demonstrated by a direct calcula- 
tion. The following table illustrating the numerical relations of malarial fever to the 
other diseases, and its effect in reducing the strength of the command serving at Fort 
Jackson and the surrounding river batteries, situated in the low rice lands of the 
Savannah river, will furnish sufficient data for the calculation:- 
TABLE. 
CASES OF MALARIAL FEVER AND ALL DISEASES OCCURING DURING A PERIOD OF 
FIFTEEN MONTHS, OCTOBER, 1862, TO JANUARY, 1864, IN THE COM- 
MAND SERVING IN AND AROUND FORT JACKSON, ON THE 
SAVANNAH RIVER. 
Total 
October, 1862 
November, 1862 
December, 1862 
January, 1863 
February, 1863 
Marco, 1863 
April, 1863 
May, 1863 
June, 1863 
July, 1863 
August. 1863 
September, 1863 
October, 1863 
November, 1863 
December, 1863 
Month and Year. 
bO 
Congestive Fever. 
§ 
Intermittent Fever, 
Quotidian. 
i 
888883833888883 
Intermittent Fever, 
Tertian. 
g 
: : : : : : : : : g: : : : : 
Intermittent Fever 
Quartan. 
» 
o 88883 o to * to w ai 3 at S 
Remittent. 
3313 
88§5§§SS8§8838.8 
Total Cases of those 
Forms of 
Malarial Fever. 
1935 
38888SSS§feè3S!fcg 
Total Cases for all 
other Diseases. 
5218 
Total Cases of all 
other Diseases. 
Aggregate sick 
each month. 
Mean Strength of 
Command, 
Officers and Men 
* "Statistical Report of the Health of the Royal Navy, for the year 1857," ordered by the 
House of Commons to be printed, August 2d, 1859, pp. 78-85. 526 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
In an average command of 878 men, stationed at Fort Jackson and the surrounding 
river batteries, nearly one-half, or 410, on an average, were on the sick list each month; 
and the new cases of malarial fever averaged each month 220. During this period of 
fifteen months 3313 cases of malarial fever, in the form of congestive fevers, quotidians, 
tertians, quartans and remittents, occurred, while all other diseases, including also those 
diseases, as neuralgia, which might be traced in a measure to the action of malaria, 
numbered 1935 cases, or only a little more than one-half the number of the cases of 
malarial fever. 
Throughout the entire period more than one-fourth of the command were unfit for 
duty; and during the fall months more than one-half of the garrison was, on an 
average, incapable of performing military duty. In case of an attack during the sick- 
liest season of the year the effective force of the command, instead of being 878, would 
be less than 500. In using quinine as a prophylactic in such a command it would be 
necessary to administer the drug at least five months, namely, June, July, August, 
September and October. If three grains of quinine in a gill of whisky be adminis- 
tered daily to each soldier we may safely estimate the amount of quinine necessary to 
protect each man during these five months at about one ounce. This command of 878 
men would, therefore, require for its protection annually about 878 ounces of sulphate 
of quinia. 
During a period of twelve months, from October, 1862, to November, 1863, 2808 
cases of malarial fever were treated, and if we allow fifty grains of quinine as necessary 
on an average to the treatment of each case, very nearly 300 ounces of quinine would 
be consumed in the treatment of these cases. It is important also to bear in mind that 
this amount of quinine would in many cases produce only temporary relief, after the 
disease was once established, and would be powerless when thus occasionally used to 
prevent the serious lesions of the spleen and liver, and the disease would be liable to 
return again upon the slightest exposure to the original cause, or to cold and damp, 
even in healthy regions. It should be further considered that the process of acclimation 
in the white race is slow, if not altogether impossible in our Southern swamps and rice 
fields, and that an entire command might be gradually rendered unfit for service by 
the effects of malaria in such a locality as Fort Jackson; and even after the men are 
removed to healthy regions they are liable for many months, and even for years, to a 
recurrence of the various forms of malarial fever. 
Amount of quinine necessary to protect 878 men from malarious diseases, during 
twelve months, 887 ounces at an average cost of $5.00 per ounce $4390 00 
Amount of quinine necessary to trea t 2808 cases occurring among a command of 878 
men, during twelve months, at an average cost of $5.00 per ounce. 1500 00 
Difference of cost of quinine in protecting and treating these cases $2890 00 
According to this calculation the quinine necessary to protect the soldier from mala- 
rial fever would cost $2890 more than that assumed to be necessary to treat the cases 
of fever arising where no quinine had been used as a prophylactic. We must, however, 
introduce into this calculation the pay of the sick, officers and men, which may justly 
be considered as an unproductive expenditure. If we place the number of men con- 
stantly on the sick list and unfit for duty from malarial fever at 100, which is far below 
the actual number, and if we rate them as privates alone, each month $1100 would be 
expended in the payment of sick men, or $13,200 would be annually expended without 
any return whatever to the Confederacy. If we add to this the pay of sick officers the 
sum would reach a much higher figure ; but we simply desire to demonstrate the 
utility of the use of quinine as a prophylactic, beyond all cavil, even as a mere mat- 
ter of dollars and cents. SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
527 
Unproductive pay of 100 men for twelve months, laboring under the various forms of 
malarial fever ($10 per month for each man) $13,200 
Increased cost of quinine for the protection of the entire command during twelve months 2,890 
Difference in favor of the use of quinine as a prophylactic $10,310 
It should also be taken into the account that the expenses in food, nursing, hospital 
accommodations, other necessary medicines and transportation for the sick, are greater 
than the expenses of the supplies of the well soldiers; and it would be just, even to 
consider that the expenditures for the sick are a total loss, for they certainly add 
nothing to the defence of the country or the efficiency of the army. But, leaving this 
entirely out of the calculation, we have demonstrated clearly that the use of quinine 
as a prophylactic would be attended with an actual saving of expense, for in exposed 
malarious localities a less number of troops, properly protected, could be made to per- 
form more efficiently the duties of a much larger force. Surely the accomplishment of 
such a result is of value in a contest in which we are opposed to a powerful enemy, who 
outnumbers us in the ratio of three to one, and who, with almost exhaustless resources, 
has his ports open to the commerce of the world. The argument which might be urged 
on the score of humanity is even stronger than that based upon efficiency and economy. 
We must believe that the preservation of our soldiers from acute diseases, as well as 
from chrouic affections, with enlarged spleens, impoverished and watery blood, dropsies 
and innumerable nervous derangements, excites some interest and concern in the minds 
of their officers, as well as their relatives and friends at home. The difficulties of 
importing quinine at the present time are without doubt numerous, but they are not 
greater, and are perhaps far less, than the difficulties of the importation of the more 
bulky articles of clothing and luxury, which has been carried on to such an extent as 
to drain the country of gold, and to seriously endanger the moral and financial condi- 
tion of the Confederacy. With the large amount of cotton at the command of the 
people and the government, it would not be an impossibility to import a sufficient quan- 
tity of quinine to protect the troops exposed to malaria. Owing to the limited supply, 
quinine was not used to any extent as a prophylactic in the Confederate Army, and in 
several Instances where the attempt has been made to use it thus, it has failed to yield 
the most satisfactory results, from its irregular and unsystematic employment. It appears 
that it is very difficult to induce soldiers to take quinine in the state of powder. The 
proper mode would be to mix the quinine with whisky (a certain number of ounces to 
a barrel of whisky), and issue the medicated whisky at a certain hour each day, in the 
presence of officers charged with the duty of seeing that each man took his dose. As a 
general rule, soldiers will not refuse whisky, even when it contains quinine. Several 
instances have come under my observation where medical officers serving in malarious 
localities have taken quinine daily as a prophylactic, and while almost the entire com- 
mand have suffered with the various forms of malarial fever, they have escaped 
with impunity. In the summer and fall of 1863, during the great changes from the 
Military Department of Georgia and South Carolina to Piedmont, Virginia, and from 
thence back to Carolina and Georgia, and during considerable exposure to malarious 
influence in localities like James Island, acknowledged to be sickly, I protected myself 
with quinine. Doctor J. N. Warren, Assistant Surgeon of the Twenty-fifth Regiment, 
South Carolina Volunteers, stationed on James Island, S. C., in compliance with a 
request which I made him during a visit to the camps on James Island in the month of 
April, 1863, selected two hundred men from the regiment and administered four and a 
half grains to each man daily. This was continued regularly until the 1st of October, 
when Dr. Warren was transferred to Augusta. During this period, among this body of 
men only four cases of malarial fever and one case of typhoid fever occurred. The 
remainder of the regiment, between three hundred and four hundred men, did not take 528 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
quinine as a prophylactic, and the majority of these men were attacked by paroxysmal 
fever; and over three hundred cases of the various forms of paroxysmal fever, together 
with twenty-three cases of typhoid fever, occurred among them. During the service of 
this regiment at Battery Wagner, the men who took quinine daily bore the fatigue 
better and resisted the deleterious effects of the climate and the foul air of the bomb- 
proofs better than those who did not thus use quinine. 
I received from Surgeon Octavius White, C. S. A., in 1862, a report in favor of quinine 
as a prophylactic against malarial fever, and also from Surgeon Samuel Logan, Depart- 
ment of South Carolina and Georgia, C. S. A., contributing important facts illustrating 
the prophylactic powers of quinine, and from Dr. D. Du Pre, of Nashville, Tenn., in 
1867, in which he recorded instances of the prophylactic powers of quinine. * 
In the use of quinine as a prophylactic against malarial fever, the following questions 
are worthy of consideration :- 
1. To what extent can quinine be used daily as a prophylactic against malaria 
without inducing any injurious effects on the nervous system? 
2. How long can quinine be used daily as a prophylactic against the effects of mala- 
rial fever without losing its power or without inducing injurious effects upon the human 
system ? 
3. What proportion of the entire population in malarious regions could be preserved 
from malarial fever by the use of quinine as a prophylactic? 
4. What effect upon the total mortality, as well as upon the number and character 
of various diseases, would the prophylactic use of quinine induce during given periods 
of time in malarious regions ? 
5. To what extent can arsenic (arsenions acid) and the compounds of arsenicum be 
substituted for quinine for the prevention of malarial fever? 
6. What effect upon the human organism and upon the character and number and 
mortality of various diseases will arsenic produce when used as a prophylactic? 
The preceding questions are of great importance, and their investigation should 
demand the attention of the medical profession in all malarious regions. Scientific 
commissions of experienced and accomplished medical men should be appointed by the 
leading powers of the civilized world for the thorough investigation of the origin, 
nature, propagation and prevention of the morbific ferment of malarial fever. To be 
properly constituted, each commission appointed by the individual nations, as Great 
Britain, Germany, Spain, Italy, Austria, Portugal, Turkey, Russia, France and the 
United States should be constituted thus : Chemist, microscopist (bacteriologist), 
botanist, physiologist (experimental), hygienist, therapeutist, physician (practicing, of 
enlarged experience as to malarious diseases). The first duty of the State is to protect 
the lives of the laboring classes from all causes of preventable diseases. To what extent 
the cause of malaria may be removed and its effects modified or avoided, can only be 
determined by the careful investigations of competent, honest, conscientious, scientific 
men, liberally supplied with all the instruments, reagents and processes of the Nine- 
teenth century. Whatever the results of such labors might be, they will illustrate the 
humanity as well as the science of the civilization of the present day. 
DISCUSSION. 
Dr. Reed, of Mansfield, 0., said, in referring to Dr. Jones' paper, in which he 
said he injected swamp water hypodermically in animals, producing fever, desired 
to ask the question whether the drinking of the water would produce the same 
results as those produced from the use of the hypodermic syringe. 
* See " Medical and Surgical Memoirs." By Joseph Jones, m. d., Vol. n, pp. 1122-1126. New 
Orleans, 1887, pp. 1348. SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
529 
529 
Dr. Jones replied in the affirmative. 
Dr. A. N. Bell, of New York.-I have heard this valuable and exhaustive 
paper relating to the investigations of the author during the past thirty years, and 
am gratified to know their history, as they have, to a large extent, been unknown to 
the American profession. 
I have been especially interested in those parts which relate to the following sub- 
jects : namely- 
1. The chemical and microscopical characters of the blood in malarial fever. 
2. The microscopical appearances and changes of the blood in malarial fever. 
3. The comparison of the chemical and microscopical changes of the blood and 
organs in yellow and malarial fever. 
4. The results of injecting swamp water subcutaneously in living animals, in the 
years 1859 and 1860, thus anticipating the labors of subsequent investigators and 
demonstrating its poisonous effects. 
5. The extensive labors relating to the microscopical, physical and chemical pro- 
perties of soils of various localities, and to their relations with the origin and preva- 
lence of malarial fever. 
6. The discovery in 1863, during the siege of Charleston, S. C., of the microbe 
of typhoid fever. 
Dr. Bell said that this paper is replete with chemical and microscopical investiga- 
tions and original observations of great practical importance, not hitherto placed 
within reach of the medical profession. 
Dr. Bell proposed that the thanks of the Section on Public and International 
Hygiene be tendered the President for his elaborate and valuable paper. 
The motion was put to the Section by Dr. Bell and unanimously adopted. 
Vol. IV-34 530 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
FOURTH DÀY. 
NATURE OF MALARIA AND PROPHYLAXIS IN MALARIAL 
REGIONS. 
NATURE DU POISON PALUDEEN ET LA PROPHYLAXIE DANS LES PAYS 
INFECTÉS. 
ÜBER DAS WESEN DES MALARIAGIFTES UND DIE PROPHYLAXE IN SUMPFGEGENDEN. 
BY CORRADO TOMMASI CRUDELI, M. D., 
Of Rome, Italy. 
Extracts and Translation from the Italian, by Dr. Felix Formento, of New Orleans, La.* 
CAUSE OF MALARIA. 
It is well known that eight years ago Klebs and Tommasi Crudeli announced to the 
scientific world that the cause of malaria was a bacillus, diffused on the surface of the 
earth, capable of retaining its vitality for a long while in the interior of the ground, 
and of vegetating in soils of varied geological composition, sometimes paludal, offener 
non-paludal, provided it should be moderately damp in the hot season and in imme- 
diate contact with atmospheric air. During these eight years speculations in regard to 
the above microorganisms have greatly varied. At first, there were many confirma- 
tions of its existence. Prof. Cuboni found it in the air; Prof. Ceci in the soil of mala- 
rial regions; Marchiafava, Lanzi, Perronci to, Sciammana, Fenaresi and Terrigi found it 
in the blood of fever patients. 
At first, the bacillus malaria was always found, even at times when it did not 
exist, confounding with it accidental products in the blood, due to alterations of blood 
globules (pseudo-bacilli). 
" These pseudo-bacilli," Crudeli says, "I have always considered as effect, and not 
cause, of malarial infection, and can be produced artificially. In fact, these alterations of 
red blood globules were obtained forty-five years ago. Dujardin described and designed 
perfectly well the so-called plasmodium as far back as the year 1842, producing it arti- 
ficially, either by preventing evaporation of blood, or by adding to it weak saline solu- 
tion. 
' ' By injecting directly into the abdominal cavity of chickens and pigeons the blood of 
a dog, after three days there will be found in its red globules all the regressive metamor- 
phoses which have been interpreted as progressive evolutions of a plasmodium. These 
pseudo-plasmodium result from a degeneration of the red globules, which may be deter- 
mined by a variety of causes, and are sometimes found in typhus fever, progressive 
anaemia, etc. 
' ' The accurate microscopical researches of Marchiafava and Celli induced me to 
believe that the constant presence, in notable quantity, of black pigment, which is found 
in the degenerated globules of malarial patients, could be considered as a pathognomonic 
* Translation into English by Dr. Felix Formento, Italian Secretary. SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
531 
sign of malarial infection, and I had the opportunity to illustrate, in 1884, at the Inter- 
national Congress of Copenhagen, the microscopical preparation of Marchiafava and 
Celli." 
The discoveries of Klebs and Crudeli are confirmed by the researches of Mosso and 
Schiavazzi, and more recently by Prof. Ferdinand Cohn, of Breslau. The production 
of malaria is not necessarily connected with the existence of marshes or stagnant 
waters. The malarial germ is entirely different from the putrid germ ; it does not 
develop in water, but in the ground. In hot weather it develops in the soil, provided 
it is damp and in contact with the air, while there is no trace of putrefaction going on 
in said soil ; once carried in the air it loses its virulence by being diluted, and cannot 
be infectious beyond a short distance. 
Tommasi Crudeli prefers filling low lands with dry sand or earth to mechanical 
■drainage. Experiments made by large plantations of eucalyptus (as prophylaxis) have 
not given the results that were expected, as has been demonstrated by the experiments 
made in the agricultural colonies of The Fontana. 
In spite of unfavorable conditions, Rome becomes healthier every year, on account 
of the new method of paving streets, which is gradually being extended to all parts of 
the city. 
The same result is obtained in the country around Rome by cultivation of artificial 
prairies covered with thick, dense grass, which protects the soil from immediate contact 
of air, which condition seems indispensable to the development of malaria, being at the 
same time a great advantage to agriculture. Where the quality of the soil permits the 
cultivation of wheat and the vine, malaria still continues to prevail, in spite of the 
improved hydraulic condition, on account of the surface of the soil not being sufficiently 
protected. 
As individual prophylaxis in malarial countries, Crudeli recommends the con- 
tinued use of small doses of arsenic, and the best possible alimentation. Also, the 
daily use of decotion of lemons, made with the whole fruit and taken on an empty 
stomach. 
He alludes to the curative properties of lemons, and mentions the fact that Professor 
Coloranti and Drs. Leopold Taussig and Oreste Ferreire have used it with excellent 
results in cases of malaria, which had resisted quinine, some in their own families. 
He mentions that it has also been tried by Dr. Shakespeare, in the Philadelphia Hospi- 
tal. 
In presenting to the Royal Accademia dei Lincei of Rome numerous specimens 
of cultures of microorganism, invariably found by Dr. Bernardo Schiavazzi in the 
malarial atmosphere around Pola (Istria) and, indicating the methods of observation 
followed by him (Koch's apparatus for microphytic investigations of the atmosphere, or 
simply causing the air to pass through a tube containing five centimetres of sterilized 
gelatine), he gives as follows the results of Dr. Schiavazzi's researches :- 
1. The constant presence of a bacillus, morphologically identical to that described 
by Klebs and Crudeli, under the name of bacillus malaria, in the malarial atmosphere 
of Pola, and its absence in the atmosphere of non-malarial regions. 
2. That inoculation of pure cultures of the bacillus in rabbits produces fever with 
all the characteristic anatomical and clinical symptoms of malarial fever. 
3. That the blood, spleen and lymphatic abdominal glands of these rabbits, being 
placed in favorable conditions of development, furnish an abundant vegetation of 
Bacilli morphologically identical to those which infected the rabbit. 
4. That in animals infected by pure cultures of the bacillus, the red blood globules 
undergo those alterations described by Marchiafava and Celli as characteristic of 
malarial infection. 
5. That the bacillus has been found in the waters of intensely malarial regions. 532 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
From the above, Schiavazzi draws the conclusion that the bacillus found by him is 
precisely identical with the bacillus discovered by Klebs and Crudeli in 1879, and that it 
is really and positively the cause of malaria. 
He further declares that malaria increases in proportion to the development and 
presence in the air of this bacillus. 
Crudeli passes in review the different prophylactic agents that have been recom- 
mended against malaria, particularly quinine, the alkaline salicylates and the tincture 
of eucalyptus. Quinine is expensive for the poor peasants, and in the long run, disturbs 
the digestive and nervous functions. The salicylates, when pure, are also expensive, and 
observation has not yet proved their real efficacy. Tincture of eucalyptus is useful 
(like all alcoholic stimulants), rendering more active the circulation, and may have 
succeeded in regions of country where malaria is not very severe, but does not succeed 
in badly infested localities, such as The Fontana, where terrible epidemics prevailed in 
the years 1880, 1882 and 1886, in spite of generous, free distribution among the people 
of a well-prepared tincture. 
He gives the preference by far over all other prophylactic agents to arsenic (arse- 
nious acid), which possesses more permanent anti-malarial action, costs but very little, 
improves nutrition, and can be administered without difficulty to all, even to young 
children. 
The preparation which is recommended, especially among ignorant persons, is that 
of accurately dosed gelatin tablets, each containing two milligrammes of arsenious 
acid, and which can be easily detached, one from the other, somewhat like our postal 
stamp sheets. These gelatin tablets, or wafers, are easily dissolved in coffee, wine or 
soup, as we all know arsenic should never be given on an empty stomach. It should 
be given at the dose of two milligrammes a day for adults, gradually increased to twelve 
and more milligrammes. It can be given without danger, for three and four months at a 
time, with occasional short intervals, during the whole period of danger, from June to 
September, inclusive. Arsenic may be administered under a different name. Its 
efficacy as a prophylactic has been demonstrated by numerous observations (over one 
thousand) among the Contadine soldiers or garrisons, railroad employés living in the 
Agro Romano. 
DISCUSSION. 
Dr. R. Walker, of Ind.-I would like to ask whether Prof. Crudeli means to 
say that the stagnant water of malarial districts does not contain the bacilli of malaria 
and is incapable of producing that disease when used for drinking purposes ? 
Dr. Felix Formento, of New Orleans, La. (translator).-The Professor dis- 
tinctly says that the bacillus of malaria, the cause of the disease, found in the air of 
malarial regions, has also been found in water. 
Dr. M. K. Taylor.-I have a word to say in this matter. My experience at 
military posts on the plains and at high altitudes has led me to regard impure water 
as one of the principal means by which the malarial poison is conveyed into the 
system. 
Dr. D. R. Walker, of Ind.-I have found that the cause of malaria in my 
section is due to the presence of stagnant pools of water, at least this was so some 
years ago, but now, upon the draining off of this foul water, malaria has almost dis- 
appeared, although the same drinking water is in use now as formerly. 
Dr. Joseph Jones, of New Orleans, La.-I discovered many years ago that the 
injection of swamp water into animals produced febrile symptoms, and the same 
changes in the blood as noticed in malarial fevers. SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
533 
Dr. B. D. Taylor.-My experience in the Northwest has led me to adopt the 
opinion expressed by Dr. M. K. Taylor, for I have been stationed in high altitudes 
where there was no possible way to account for the malaria, except by its introduc- 
tion through foul drinking water. 
Dr. A. R. Milner, of New Orleans, La.-I believe that the emanations from 
the water may be hurtful, but not the water itself. 
Dr. R. K. Fox, Jesuits' Bend, La.-I am confident that the bacillus of malaria 
does not exist in the water ; but is present in the decaying vegetable matter under 
the water, and when this dries up the emanations from the filth produce the 
disease. 
Surgeon M. K. Taylor, m.d., of the United States Army, said he would not 
occupy the attention of the Section for one moment, did he not think, indeed feel 
certain, that the paper supported by the great name of the author was calculated to 
mislead and create a false impression in respect to drinking being a source of malarial 
poisoning. The history of our military posts shows, it seemed to him, conclusively, 
that potable water is frequently a cause of the malarial fevers of every form. This 
is apparent at stations which are located at such altitudes as, in the estimation of the 
profession, and in popular beliefs, are free from these maladies-fallacies of the 
greatest import. 
The records of the army show the following facts :- 
Fort Lewis in S. W. Colorado, at an elevation of 8000 feet above the sea, has 
a yearly prevalence of malarial fevers, embracing both intermittent and remittent 
fevers, above the average of the whole army. Fort Stanton, in New Mexico, situ- 
ated in a region of country known for its arid character, has had these fevers in large 
numbers, from its establishment. They have equaled, for years, anywhere from 20 to 
30 per cent, of the main strength, and often of great severity. The character of the 
water supply is thus described by the post surgeon : " Water insufficient, offensive 
and deficient. It is taken from the Rio Bonito, which in the summer runs nearly 
dry, and which is contaminated with organic matter." 
Fort Assinniboine, in Montana, nearly 4000 feet above the sea and close to the 
Canadian line, is another station where these fevers prevail. The water supply is 
from a creek, and reported by the Port Surgeon very low, deteriorated, shows organic 
matter present, deficient and very offensive ; water should be boiled. The presence 
of malarial fevers is reported at Forts Bayard, Bridger, D. A. Russell and many others 
ranging from 3000 to 6500 feet above the sea and taking the water supply from 
streams known to be contaminated by the wash of extensive prairies, and often 
contaminated by Indian camps and cattle herds. The most notoriously malarial 
posts are those taking the water supply from streams. Forts situated in the 
Indian Territory are examples in point. Fort Union, New Mexico, taking its water 
supply from the Arkansas river, is situated on a terrace 30 feet above the river 
bottom and upon land absolutely barren of vegetation except, by irrigation, in 
small amount, and Fort Bliss, in northern Texas, taking its water from the Rio 
Grande and situated at an elevation of nearly 4000 feet above the sea, have had 
malarial fevers very prevalent, at the latter post equaling in 1873 the rate of over 800 
per thousand of mean strength. 
The records show further that whenever there has been a change of water to a 
better quality there has been a corresponding lessening of the prevalence of these 
fevers, more than 50 per cent. At Fort Sill, in the Indian Territory, the change 
reached over 50 per cent, in changing from creek water to a fine quality of spring 534 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
water, while at Fort Ringgold, on the lower Rio Grande, in the change from the 
natural river water to distilled and aerated water the fevers were reduced almost 
identically in the same ratio. 
The facts appearing in the history of our military posts are overwhelming in 
proof that potable waters may be a cause of miasmatic disorders. 
THE INFLUENCE OF CLIMATE IN THE PRODUCTION OF CHOLERA 
INFANTUM. 
L'INFLUENCE DU CLIMAT DANS LA CAUSALITÉ DU CHOLÉRA DES ENFANTS. 
ÜBER DEN EINFLUSS DES KLIMAS IN DER ÄTIOLOGIE DER CHOLERA INFANTUM. 
BY GEORGE TROUPE MAXWELL, M.D., 
Of Oeala, Florida. 
I acknowledge a feeling of embarrassment in treating, before an International Congress, 
a subject which, in its practical relations, is of national interest chiefly. But I would 
feel greater hesitation in presenting it for the consideration of this august body, com- 
posed of sages from every civilized country, did I not know that a disease which so 
deeply affects the welfare and happiness of a large portion of the human family must 
have at least a scientific attraction for all medical philosophers. 
The cause and prevention of a disease which, though it assails only one class- 
children of the tenderest ages, and does its deadly work principally in a single month, but 
which, in the long catalogue of " ills that flesh is heir to " stands sixth in the order 
of fatality, and annually numbers as its victims more than thirty thousand in the 
United States, demand the earnest attention of philanthropists, and are worthy of the 
most careful consideration of scientists. 
Nothing, perhaps, more clearly demonstrates the fact that familiarity with danger, 
suffering and death, as with vice, blunts human sensibility, than the conduct of men in 
contact with disease. In the presence of yellow fever, for instance, the inhabitants of 
towns and cities within the territorial area to which it is indigenous display compara- 
tively little terror in the midst of its work of destruction, while even suspicion of its 
probable invasion of communities unused to its ravages affrights them into unseemly 
and even tumultuous panic. 
We had an illustration of this the last summer, when entire communities in parts 
of our country were thrown into hysteroid tremors because of a few cases of yellow 
fever upon a small island nearly a hundred miles from the main; while the better 
classes of the little town that had stirred this commotion were energetically engaged in 
laudable efforts to suppress gambling and other vices that were rampant in the atmos- 
phere of pestilence. 
And while that exhibition of indifference to yellow fever-the summer scourge of 
low latitudes-was being given in the southern extreme of our country, and Key West 
was being shunned as a plague-spot, cholera infantum-the summer scourge of high 
latitudes-was daily counting its victims among the innocents by thousands, with little 
more remark than as a news item in the daily papers. 
Pestilence, in whatever garb it assumes, is appalling, seemingly, only to those who are 
unaccustomed to its devastation; while in communities which are often its field of 
slaughter, it is regarded as a matter of course, -not calculated to excite especial wonder. SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
535 
I have thought that, in this way, perhaps, the routine and perfunctory style of 
writers in general upon cholera infantum may be explained. With rare exceptions the 
doctrines of recent writers have come down to us from former generations without 
change or modification ; and the same sad unsuccess which resulted from the treatment 
practiced by the fathers follows the same inadequate measures which are employed by 
the wisest of to-day. Familiar with its destruction, as with the recurring years it 
heralds the approach of black-winged death to thousands of households, it is too gener- 
ally regarded as an inevitable evil which, as it "can't be cured, must be endured." 
An instance of marching out of the beaten track in dealing with the aetiology and 
prophylaxis of cholera infantum, was furnished by Dr. Davis, of Chicago, the distin- 
guished president of this Congress, in an instructive essay which he read before the 
section on " Diseases of Children," of the American Medical Association, at Detroit, in 
1882. Not satisfied with the theories commonly accepted as orthodox, that careful 
observer and sagacious physician showed by facts and figures that the causes usually 
assigned as chiefly instrumental in the production of cholera infantum exert, if they 
operate as factors at all, only a "minor influence." 
Said he : " Nearly all the recent writers on practical medicine and diseases of children 
class the cases of serous diarrhoea and cholera morbus in children under two years of age, 
usually called summer complaint and cholera infantum, with the local inflammations, 
under the general head of catarrhal gastro-enteritis. And while they all assert that 
these forms of disease are most prevalent and fatal during the warmest months of 
summer, they set forth as the chief causes, improper feeding, impure and changed milk, 
impure and confined air, the progress of dentition or 'teething,' and overworked, 
badly fed and unhealthy mothers and nurses. All these causes are set forth as pro- 
ducing either gastric or intestinal indigestion, or both. It will be noted that indigestion 
is very generally alleged as the immediate cause of the so-called catarrhal irritation and 
excessive discharges, while the indigestion is, in turn, regarded as the result of bad feed- 
ing, impure air, teething, and unhealthy mothers and nurses. Dr. Flint and others have 
placed much emphasis on the influence of adulterated and poor quality of milk dis- 
tributed in our large cities. That the milk so distributed is often of poor quality, and 
is often productive of gastric and intestinal derangements, and that all the other causes 
enumerated are often the occasion of similar derangements, I freely admit. But I am 
quite certain that a more careful and extended clinical study will show that some of the 
causes usually enumerated rarely exert more than a minor influence over the so-called 
summer complaint and cholera infantum that prove so destructive to infantile life in 
many of our large cities and populous towns every summer. For instance, a moderate 
degree of attention will show that the errors in feeding infants, the adulterations of milk 
and impurities of other food, and the unsanitary condition of dwellings are quite as 
prevalent in all communities during the winter as the summer. It is quite certain that 
on the average there are in all communities as many children cutting their teeth 
in December and January as in July and August, and I have been wholly unable to 
find any larger proportion of unhealthy, badly fed, or overworked mothers or nurses at 
one part of the year than another. It is very certain that if any one or all of these 
agencies exercised a prominent or controlling influence in determining attacks of serous 
diarrhoea and cholera infantum, such attacks would be met with frequently at all 
seasons of the year. Yet both the records of commencements of attacks and the statis- 
tics of mortality show that the prevalence of all grades of these two forms of disease is 
restricted almost entirely to the ninety days intervening between the last week in June 
and the last in September. 
" Thus, in Chicago, in 1877, only two deaths from cholera infantum are reported in 
the statistics of the Health Department during the months of November, December, 536 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
January, February and March, eight in April, six in May, 23 in June, 246 in July, 163 
in August, 69 in September, and 13 in October. • 
" Again in 1875 aud 1876 I obtained the date of the commencement of 351 cases of 
serous diarrhoea aud cholera infantum, of which 61 commenced in June, 197 in July, 
66 in August, and 27 iu September, and none during the remaining months of these 
years. The ratio of prevalence thus found to exist in the various months of 1875-6-7, 
in Chicago, will be found to fairly represent the ratio every year, and in all the northern 
and eastern cities of our country. 
" If we turn our attention in another direction, we will be met by still greater diffi- 
culties in accounting for these bowel affections, on the supposition that they are produced 
by the causes to which they have usually been attributed. For instance, the mortuary sta- 
tistics show that the diseases under consideration prevail but little in cities so located that 
there is only a short range of temperature between the warmest days of summer and the 
coldest days of winter, and where from sea breezes, or otherwise, the summer nights are 
cool. 
" There is no evidence, within our knowledge, which shows that the milk distributed 
in San Francisco and New Orleans, is any purer or of better quality than in Boston and 
Chicago. Neither are nursing mothers any more free from mental and physical infirmi- 
ties, nor the sanitary condition of the dwellings, sewers, etc., more perfect, in the former 
than in the two last named cities. Yet an examination of the mortality statistics shows 
a ratio of only about five deaths from cholera infantum, annually, for every 10,000 
inhabitants in San Francisco; and seven in New Orleans; while Boston gives 25 and 
Chicago 30 deaths, from the same cause, for every 10,000 inhabitants. 
"The foregoing facts show conclusively that there must be some efficient cause or 
causes which determine the prevalence of the disease under consideration that are not 
common to all large cities, and all aggregations of civilized people. Their prevalence 
at certain seasons of the year only, and chiefly in certain climatic regions, shows con- 
clusively that they are dependent on causes which are operative under some circum- 
stances not common to all civilized communities." 
Dr. Davis began years ago an investigation to ascertain what those circumstances 
are. The most important of his conclusions are : 1. " That the disease commences with 
the first wave of atmospheric heat that continues day and night for five successive 
days." 2. " That the date of the initial symptoms, or beginning of the disease, in three- 
fourths of all the cases is in July, very few originating in August." And 3, " that if in 
addition to high heat, the air be stagnant, as from lack of winds, or from obstructions, 
as in large and compactly built cities, or from defective ventilation of dwellings, the 
morbific effects are greatly increased." 
I have drawn freely upon the admirable essay of Dr. Davis, because his utterances 
on all medical subjects carry with them the weight which belongs to supreme authority, 
but principally because his statement of facts, as they bear upon the aetiology of cholera 
infantum, and the inferences he draws from them, are in precise accord with my own 
experience with the disease and my deductions from observation of it in its chosen 
"climatic regions," during nine years. Dr. Davis has, I think, conclusively demon- 
strated the fallacy of the prevailing theories, and I have, for convenience, appropriated 
his demonstration. But, while I am in agreement with him in detracting from the 
alleged importance of the agencies enumerated by writers in general as productive of 
cholera infantum, and in attributing to them a minor influence, if any, I find it impos- 
sible to coincide with him in the hypothesis which he has constructed, and offered as a 
substitute. Clearly and conclusively as Dr. Davis has proven that not improper feeding, 
adulterated and changed milk, but hygienic conditions, impure air, overworked, diseased, 
improperly and insufficiently fed mothers and nurses, teething and indigestion, one, or 
all, will satisfactorily account for the general prevalence and appalling fatality of cholera SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
537 
infantum annually in the northern sections of our country, the proof is equally absolute 
that intense heat, long continued, and low range of temperature, even when reinforced 
by so-called "stagnant air," are not the efficient causes. Dr. Davis has shown by 
mortuary statistics, and by his personal investigations, that July is the especial delin- 
quent-more than three-fourths of the cases beginning in that month. This is not, so 
to speak, accident. It is the rule; and there must be reason for it. If continuous, 
high heat, through successive days and nights, associated with stagnant air, is indeed 
the causa causans of cholera infantum, it must appear that such meteorological condi- 
tions are distinguishing characteristics of that month. Is that the case ? Let us see. 
There were, at Chicago, in 1886, 13 days in which the temperature reached 80° and 
above; in August there were 14. In July there were two groups of three successive 
days in which the temperature reached 80° and above, one being of five days 
duration ; in August there were three similar groups of successive hot days, 
one continuing four days and another five. The longest continuance of hot 
days, with a break of a single day, was, in July, six, the mercury descending one day 
to 76.3°; in August, ten, the mercury falling one day to 79°. The sum of the temper- 
ature of the (13) hottest days in July is 1114.2°; in August, the sum of the (14) hottest 
days is 1198.4°, a difference of 84°. The mean daily range of temperature was, in July, 
13 9°; in August, 12.2°. The least daily range of temperature was, in July, 5.6°; in 
August, 4.2°. August was, therefore, the hotter month, with a greater number of and 
longer lasting groups of successive hot days; with lower mean and daily range of tem- 
perature; and followed June and July with their protracted, intense heat. Besides, 
the records show that there was more movement of wind in July than in August ; or, 
in other words, that the air was more stagnant in the latter than in the former month. 
There having been 5472 miles of movement in July, and 5439 in August. 
With higher, and longer continuance of heat, and a calmer air in August than in 
July, the former ought, according to Dr. Davis' hypothesis, to furnish a larger mortality 
list; but, on the contrary, the statistics show 285 deaths from cholera infantum in July, 
and 201 in August, a difference of 84, which disparity would be greatly increased if 
three-fourths of the cases that died in August were charged to July, when they 
undoubtedly had their beginning. It is logically impossible to explain the high 
annual mortality from cholera infantum in July, and the great and sudden decrease in 
the number of deaths in August, by the hypothesis of Dr. Davis. 
Again, if we attribute the comparative immunity of San Francisco, New Orleans 
and other large cities in warm climates, to their locations near the coast, and the 
hygienic effect of sea breezes by day, and cool breezes at night, how will we account 
tor the great mortality from cholera infantum in Boston, New Haven, New York, 
Brooklyn and all other towns and cities of the Eastern and Middle States similarly 
situated. Statistics are abundant to show that the cities named have an annual experi- 
ence of the prevalence and fatality of cholera infantum which is common to all the 
townsand cities within certain " climatic regions." 
And again, if it be true that the range of temperature between the hottest days of 
summer and the coldest of winter enters as an element in the production of cholera 
infantum, that, as asserted, the higher the range the greater the prevalence and mor- 
tality, and vice versa; St. Paul and Denver, with their much higher range than 
Chicago and Cincinnati, ought to exhibit a correspondingly great ratio of prevalence 
and fatality. But the reverse obtains. The deaths from cholera infantum in St. Paul, 
for the year 1880, were 17; in Denver, 27 ; while they were for the same year, in 
Chicago, 555; in Cincinnati, 204. No; I repeat, not improper feeding, changed and 
adulterated milk, bad hygienic conditions, impure air, overworked, diseased, improp- 
erly and insufficiently fed mothers and nurses, teething and indigestion, nor long con- 
tinued, intense heat with stagnant air, one, or all, satisfactorily accounts for the preva- 538 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
lence and fatality of cholera infantum in the northern sections of our country. The 
cause has yet to be discovered. 
But the most flagrant error which Dr. Davis, in common with all writers upon the 
subject, makes, is that cholera infantum is less prevalent and less fatal in rural districts 
within the climatic regions to which it belongs than in large and densely populated 
cities. This error is the more important and serious because it has led to all the mis- 
takes that have been committed on the questions of aetiology and prophylaxis. 
I had practiced medicine twenty-three years in the extreme Southern section of the 
United States, when, in June, 1871, I moved to the State of Delaware. During that 
time I had only occasionally seen cases of cholera infantum. I located at Middletown, 
a village of about one thousand inhabitants, the centre of prolific peach orchards, in 
a beautiful, thickly-settled, highly-improved farming country, midway between the 
Chesapeake and Delaware Bays. I soon discovered that my practical knowledge of 
cholera infantum was meagre and imperfect ; for I believe I am within the bounds of 
truth when I say that I saw a greater number of cases in that village and its vicinity 
within three months than I had previously seen in twenty-three years. 
The town of New Castle, Delaware, is located on the Delaware River, at the head 
of Delaware Bay. It is not compactly built, has neither over-crowded, illy-ventilated 
tenement houses nor squalid, filthy poor, and is freely exposed to river and sea breezes. 
With a population of about two thousand, there were buried in its cemetery in the 
month of July, 1873, forty-one children under three years of age, victims of cholera 
infantum. In comparison with these figures, Boston's twenty-five and Chicago's thirty 
to ten thousand inhabitants pale into insignificance. In a letter from Dr. Benjamin 
Lee, the distinguished Secretary of the State Board of Health of Pennsylvania, of July 
27th, 1887, he says: "I was informed, when recently in the Wyoming Valley, this 
State, by a leading physician in large practice in the mining villages that cholera 
infantum was very prevalent, and often rapidly fatal, in that region." 
Nothing like what I have related of Middletown and New Castle, Delaware, facts 
of my personal observation, and what has been said by Dr. Lee, has ever been known 
in any Southern city or town. And it is only by contrasting those facts with our 
experience in the far South that we can approach a just conception of what a fearful 
scourge cholera infantum is at the North. 
Ocala is located in the centre of the peninsula of Florida. It is about equidistant 
-fifty miles-from the Atlantic and the Gulf. It has about 2500 inhabitants, and, 
without special favoring circumstances as to breezes and hygienic conditions, it is 
entirely exempt from cholera infantum. During the last six summers I have resided 
and practiced medicine there, and have not seen or heard of a case of that disease. 
Nor is the experience of Ocala peculiar. Dr. Hicks, the health officer of Orlando, Fla., 
wrote to me that ' ' cholera infantum is almost unknown here. ' ' And from personal 
knowledge I can say the same of Fernandina and Tallahasse. At Jacksonville the 
proportion of deaths from cholera infantum, to 10,000 inhabitants, was, in 1880, 6; in 
1881, 12; and in 1882, 5. At Savannah, Ga., the mortuary report, as published in 
The Savannah Journal of Medicine, Sept., 1876, shows only one death, in July and August 
each, from cholera infantum; and the cemetery records of Thomasville, Ga., from 1881 
to August 27th, 1887, show but two deaths from that disease. 
It thus appears that cholera infantum has its chief home in certain climatic regions, 
and within the territorial area which furnishes the conditions for the production of its 
cause it prevails among the rich as well as the poor, in palatial residences as well as in 
crowded tenements and filthy cabins, in towns, villages, hamlets and isolated farm- 
houses, as well as in compactly built, densely populated, insanitary cities. More; in 
the territorial area within which cholera infantum prevails neither topographical nor SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
539 
other physical features of localities exert appreciable restraining influence; for its deadly 
work is done at the seashore, on elevated plateaus and upon mountains. 
The cause has yet to be discovered; but the patent, significant fact remains-that, 
whereas it is a terrible scourge at the North, it is an infrequent and comparatively 
trifling affection at the South; and, as Dr. Davis has said, " Its presence at certain 
seasons of the year only, chiefly in certain climatic regions, shows conclusively that it 
is dependent upon some circumstances not common to all civilized communities." 
What are those causes ? 
Cholera infantum, like yellow and typhoid fevers, Asiatic cholera, etc., is a specific 
disease, and has a special and peculiar cause. It is not a gastro-enteritis, such as results 
from indigestible or fermented food, or from acrid poisons, like arsenic and tyrotoxicon. 
It is the effect of a specific poison which produces cholera infantum, and nothing else. 
In the present status of ætiological science it is a reasonable assumption that the special 
cause is a microorganism which exists and propagates under suitable conditions of cli- 
mate, such as are present during the summer in the Northern, Eastern and Middle 
States of the United States. 
As the germ of yellow fever finds its favorite home in tropical and semi-tropical 
America, and the germ of Asiatic cholera its appropriate nidus in India, so the germ of 
cholera infantum makes its habitat in the Northern and Eastern States of our Union. 
That their appearance is synchronous with the approach of the " heated term," that 
their numbers and power for evil should culminate in July, or midsummer, is not more 
remarkable, or inconsistent with natural laws, than for flowers to have their time to 
bloom, and fruits theirs to mature; and it would be easy to find analogies throughout 
the animal kingdom. 
As the theories of the chemical origin of the malarial poison have been made to 
give place to the microscopic demonstrations of the malarial bacillus, by the world- 
renowned Tomassi Crudeli, so the chemico-physical hypotheses of the aetiology of 
cholera infantum must, in their turn, be supplanted by the soon-to-be-discovered bacil- 
lus of cholera infantum. By this suggestion, if it has not been done before, the way is 
opened to some enterprising American to share, with Klebs, Tomassi Crudeli, Koch and 
others, the distinguished honor which the world is ever ready to bestow upon those who 
are at once discoverers and benefactors. 
The immunity from cholera infantum which, as the records show, the Gulf and the 
Pacific States enjoy, must arrest attention, and whether the explanation I have given 
is the correct one, or not, the fact-patent and significant-remains; and I believe that 
when the fact is known and appreciated, the South will become to the innocents what 
the "cities of refuge" were to the Levi tes, to which thousands will be brought, to escape 
the merciless child slayer ; for as certainly as the middle-aged, with weak or diseased 
respiratory organs, are now induced to come in winter, will parents be influenced by 
their medical advisers to take their infants and young children to the far South in the 
summer, to avoid the ravages of this cruel pestilence. 
There is one point which I ask permission to refer to before concluding, simply as a 
suggestion to those who have more industry and better facilities for investigation than 
I. It is this : During my observation of cholera infantum, circumstances led me to 
suspect that the fatality of the disease has been appreciably increased by the introduc- 
tion and universal use of the child's carriage. Every one knows-by observation, if not 
by experience-how aggravating to every form of irritation of the stomach and bowels is 
agitation of the body; yet who has not seen-and often in the dead hours of the night 
heard-the incessant rolling of the carriage, with its restless, suffering cargo, over the 
uneven sidewalks of cities ? I am quite sure that I have seen fatal results hastened, if not 
caused, by a single night of such kindly-intended but, nevertheless, rough treatment. 
In no class of diseases is the benign influence of rest more imperatively demanded. 540 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
DISCUSSION. 
Dr. R. Harvey Reed, of Ohio.-It is well known, Mr. President, that children 
nursed on the bottle are much more liable to cholera infantum than those nursed by 
their own mothers. The nursing bottles with long tubes are especially liable to 
produce this affection, from the fact of the difficulty experienced in cleaning them. 
I never allow anything to be used except an open bottle with a rubber nipple pulled 
over the top, and which can readily be cleaned. The Doctor speaks of the disease 
being most prevalent-contrary to the popular idea-in the country; but who knows 
that, as far as the cleanliness of the milk is concerned, the same conditions may not 
prevail in the small hamlet as in the crowded city. 
Dr. B. D. Taylor.-I would like to ask the Doctor how, on his theory, he 
accounts for the prevalence of cholera infantum in Texas? I have seen it frequently 
in the summer months, both at Brackettville and Rio Grande City, Texas. 
Dr. G. Troupe Maxwell, of Florida.-I am not able to give a satisfactory 
answer to that question, as I have no statistics from Texas. 
Prof. Victor C. Vaughn, of Michigan.-I have not specially attached myself 
to this Section, but I am compelled to make a few remarks on this question. It is 
one of the best-established facts of the profession that children nursed by their own 
mothers or wet nurses seldom have cholera infantum, while it is well known that 
infants raised on the bottle suffer the greatest mortality. I am unable to see how 
it can be disputed that the decomposition of the milk and the formation of a 
ptomaine is the chief and most potent cause of cholera infantum. The post-mortem 
appearances after poisoning by a ptomaine and death from this disease are precisely 
similar, particularly the appearance of the stomach. Take away the milk from the 
child and give it beef tea and it at once improves, and, as a rule, ultimately recovers. 
It is easy for men who have seen little of this disease to formulate theories as to its 
nature and origin ; but it is with those who have treated and are treating it by hun- 
dreds of cases every summer to frame rational ideas of its ætiology and practical 
ideas as to its treatment. 
Dr. Joseph Jones, of New Orleans, La.-I consider the irritation of the teeth 
pressing against the dental nerves, and causing reflex action to the spinal column and 
sympathetic nerve centres, to be one of the causes of cholera infantum. In every- 
thing concerning the origin and cause of cholera infantum, we must carefully consider 
the peculiar state of the nervous system in this disease. The irritation of the dental 
nerves causes by reflex action the irritation of the stomach and bowels, resulting in 
enfeebled digestion and diarrhoea. Even the kidneys show the influence of reflex 
action from the spinal cord in the increased flow of urine, which sometimes contains 
grape sugar. We are all familiar with the celebrated experiments of Claude Bernard, 
in the production of diabetes mellitus in animals by the artificial irritation of the 
medulla oblongata and spinal cord. Dr. Jones had frequently demonstrated the truth 
of Bernard's statements by experiments on living animals. The frequency and fatality 
of convulsions in teething children is also another proof of the irritated and deranged 
condition of the cerebro-spinal and sympathetic systems in this troublesome and fatal 
form of disease. 
Dr. Jones suggested that the cause of the greater virulence of the disease in July 
might be referred to the debilitating effects of high heat upon the deranged and 
debilitated system of teething children. The first spells of high and protracted heat 
usually occur in this month, and the feeblest children soonest succumb to its well- 
known effects. As the summer wears on, the system becomes accustomed to its effects SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
541 
Along the Atlantic and Gulf coasts of our Southern States, with their insular cli- 
gnâtes, the cold of winter and the heat of summer are modified, and the seasons glide, 
as it were, into each other by almost insensible degrees. In New York, Philadelphia, 
Cincinnati and Chicago, the extremes of heat and cold are much greater and more 
rapid, and hence the effects of great extremes of heat are more marked. In Cincin- 
nati and Chicago especially we have a true continental climate, with very cold winters 
and intensely hot summers. 
Dr. Jones fully admitted the truth of much which had been said by the speakers 
as to the effects of crowding, foul emanations, imperfect feeding, sour milk, putrid 
and poisonous milk, inducing this disease, and he fully endorsed the rules laid down 
as to the necessity of the greatest care in the treatment of cholera infantum. He 
had listened with great interest to the paper of his friend-Dr. Maxwell, of Florida 
-who, as far as his information extended, was the original inventor of the laryngo- 
scope. He also knew him as an eminent and successful practitioner and teacher of 
medicine. 
Dr. Thomas Hebert, of New Iberia, La.-I have seen cholera infantum in 
Louisiana during July and August, but not to any great extent. 
CLINICAL HISTORY AND TREATMENT OF MALARIAL CONTINUED 
FEVER, ESPECIALLY AS OBSERVED IN TEXAS, AND ITS 
DIFFERENTIATION FROM ENTERIC FEVER. 
HISTOIRE CLINIQUE ET TRAITEMENT DE LA FIÈVRE PALUDÉENNE CONTINUE 
SPÉCIALEMENT COMME ELLE EST OBSERVÉE AU TEXAS, ET SA 
DIFFÉRENCE D'AVEC LA FIÈVRE TYPHOIDE. 
KLINISCHE GESCHICHTE UND BEHANDLUNG DES CONTINUIRLICHEN MALARIAFIEBERS, 
MIT SPECIELLER HINSICHT AUF BEOBACHTUNGEN IN TEXAS, UND DIE 
DIFFERENTIALDIAGNOSE ZWISCHEN DEMSELBEN UND 
DEM ENTERISCHEN FIEBER. 
BY BLAIR D. TAYLOR, M. D., 
Of Columbus Barracks, Ohio. 
In common with other observers in the South, I can devise no name for this variety 
of "continued fever" more appropriate than the one given in the title of this paper. 
While it is chiefly of malarial origin, it is, at the same time, partly a fever of "acclima- 
tization," and is undoubtedly aggravated, and to some extent caused, by the intense 
and long-continued heat prevailing in those States in which it is most prevalent. 
It is never seen except in localities subject to malarial emanations, and, to my 
knowledge, is not found north of the thirty-sixth parallel ; while the southern portion 
of Texas, some parts of Mississippi, Louisiana and Arkansas may be looked upon as its 
natural home 
It is regarded by some as identical with the " typho-malarial " fever of Woodward ; 
but it is simply adynamic without abdominal symptoms, and seems to depend for its 
origin, much less than that disease, upon over-crowding, filth, poor food or other unsani- 
tary conditions. New residents are oftenest attacked, many of them being in military 
posts of unusual cleanliness ; while Mexicans, existing in the midst of dirt, foul water 
and general untidiness, are seldom affected. Many physicians not familiar with this 
disease will often pronounce it enteric fever upon sight ; but, as I hope to show, it has 542 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
well-marked diagnostic symptoms, by means of which it can be readily distinguished 
from that affection. 
With regard to my opportunities for the study of this disease, I will state that I 
served from 1881 to 1885, two years at Fort Ringgold, on the lower Rio Grande, and 
the same length of time at Fort Clark, which is twenty-five miles from the river, and 
about one hundred and thirty miles west of San Antonio, Texas. During this period 
I had sole charge of numerous cases, and saw many more under the care of others. At 
Fort Ringgold I experienced two attacks in my own person, the first in June, 1882, 
lasting four weeks, and the second in January, 1883, nearly six. 
lu a paper of this kind, intended to embody only conclusions and opinions derived 
from personal experience, it would be tiresome to recapitulate verbatim et literatim 
records of the numerous temperature charts, and clinical histories of the cases pre- 
served ; and I am persuaded that an account of the average symptoms noticed in the 
majority of instances would better convey to the profession my own knowledge of the 
subject, and better enable them to estimate that knowledge at its true value. 
Malarial continued fever rarely occurs before the*month of June and seldom after 
the month of November. My o,wn second attack and that of one of my family took 
place in January ; but I never saw a case of this disease in either February, March, 
April or May. The latter part of July, the months of August, September and October 
cover the time of its greatest prevalence. 
The average temperature in the shade for the whole of this period collectively will, 
at Ringgold, seldom fall short of 75° F., and I have seen the maximum during July 
reach 110° F. and over for every single day in the month. 
The onset of this disease is almost typical of its malarial origin. The chill is sudden 
and well-marked in the majority of cases, without having been preceded by any feeling 
of malaise. This is accompanied and followed by muscular and arthritic pains, head- 
ache, yawning, stretching, nausea, and often vomiting, with a general feeling of lassi- 
tude and weariness. The temperature at once rises to 103°-104° F., seldom less. 
I have frequently seen this train of symptoms followed by sweating and a subsidence 
of the temperature, with a complete intermission, and on the next day, at the same 
hour, a repetition of the attack, which would then become continuous. The tongue 
appears flabby, broad, thick, covered with a heavy white coating, and showing the marks 
of the teeth around its edges. This is what I call a malarial tongue, and may also be 
found in remittent and intermittent fevers. 
The bowels are generally constipated, although occasionally diarrhoea is present, 
which is usually due to some preceding error of diet or to a large dose of quinine. As 
already mentioned, nausea and vomiting of green or yellow bile are common occurrences, 
frequently accompanied by tenderness over the liver, spleen or stomach. The urine is 
scanty and high colored. There may be epistaxis early in the disease, but it seldom 
occurs before the end of the first week, and then continues at intervals during the 
remainder of the attack. 
The pulse, as a rule, is in the beginning full but soft, and rarely exceeds 100-112 
per minute during the progress of the disease. I have seen it reach 125 a few times in 
casas ending in recovery, but this is uncommon. 
The temperature is seldom less than 103°-104° F. at the outset. I remember one case 
in which the thermometer never registered lens than 104° at any time during the twenty- 
four hours for seven days ; nevertheless, the patient regained his health. As a rule the 
temperature varies from 2°-4° F. between morning and evening, the morning pyrexia 
being the lowest. In some instances, however, this rule is reversed. There is not 
nearly the same regularity in the rise and fall of the mercury in malarial continued 
fever as in its enteric rival ; and this is not only true as to the daily variation, but 
also from week to week. The temperature is liable to make sudden and erratic SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE, 
543 
excursions, up or down, without any apparent cause and without ever becoming 
normal. 
The body heat and pulse do not seem to correspond in this disease. In some cases 
I have seen the thermometer over 105° F. and the pulse under 100. A peculiar feature 
is the fact that for some days after convalescence is established the temperature seems 
to swing back like a pendulum, just in proportion to its former excursion in the opposite 
direction, until a minimum of 97°, 96°, and even 95.6° F. is reached. This may seem 
an extraordinary statement, but these extremely low temperatures have been verified 
by myself, and with thermometers corrected either at the Yale or Washington observa- 
tories. Temperatures below 96° F. I have seen in only a few instances, but 97° F. or 
less is the rule, in my experience, during the early stages of recovery. 
I would also state, in this connection, that the thermometer in all of my cases was 
placed under the tongue. When the temperature falls to the normal at any time, the 
patient may be regarded as having very nearly reached the limit of his illness. From 
this time on there is no continued fever, but intermittent, the thermometer registering 
98.6° F. or less in the morning, and reaching 101°-102 in the evening. This condition, 
however, only lasts a few days before the pyrexia entirely disappears. 
Headache, as mentioned above, is always present, but in some casesit is a prominent 
symptom, amounting to cerebral congestion, accompanied by delirium, sleeplessness and 
hallucinations. 
The tongue changes its appearance after the second or third week, more or less, 
according to the severity of the attack, becoming dry, brown, and cracked, with sordes 
on the lips and teeth ; in fact, it presents a typhoid appearance, so called, but which can 
be found in other varieties of continued fever as well, and also in dysentery. This state 
of the tongue, however, is unaccompanied by an eruption or abdominal symptoms 
referable to the right iliac region. Tenderness over the liver or spleen, with more or 
less enlargement of the latter, may be concomitants of the condition referred to. 
Among the sequelæ of this fever may be enumerated great muscular and mental 
weakness, the former almost amounting to paralysis, while the latter may result in 
temporary mania, though oftenest in melancholia. The patient previously mentioned, 
whose temperature remained so high for a week, was affected with suicidal mania for 
ten days after his pyrexia had disappeared, and the thermometer registered below the 
normal. Being prevented from destroying himself, he begged me, on each visit, to "cut 
his head off with a hatchet. ' ' 
In another case, occurring at Little Rock, Ark., the soldier had to be discharged 
the service for weakness of intellect, melancholia and peculiar eccentricities, following 
an attack of malarial continued fever which lasted over forty days. I have no doubt, 
however, that he completely recovered within eighteen months or two years. 
Differential Diagnosis.-The only fever of a continued type with which the disease 
under consideration might be confounded is enteric fever. I use the term ' ' enteric ' ' 
instead of "typhoid," as more clearly defining the natural and anatomical lesions of 
that affection. The strongest point of resemblance between the two diseases is found 
in the dry, brown, cracked tongue of the third week of malarial continued fever. This 
appearance of the tongue, however, is more or less common in the latter stages of all 
continued fevers of an adynamic type, and of over twenty days' duration. Another symp- 
tom in which an agreement may be discovered is the cephalalgia and delirium; but the 
former is, in my experience, most severe in malarial continued fever, while the latter 
is seldom ever of the low, muttering character so often found in enteric. In this connec- 
tion, I may mention that all of the few cases of enteric fever seen by me in Texas died; 
generally about the twenty-first day, and of perforation and peritonitis. One peculiar 
case, and the only one occurring at Fort Ringgold, was fatal on the fourteenth day. The 
eruption was well marked on the head (which was bald), and on the neck, arms and 544 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
breast, with very few spots on the abdomen. In this case, the temperature was 106.2° F. 
just before death, and the autopsy revealed extensive ulceration of Peyer's glands, as far 
as they extended in the commencement of the ileum, with perforation, hemorrhage and 
peritonitis. 
With the appearance of the tongue late in the continued fever of malarial origin, 
and the symptoms referable to the nervous system, the resemblance between the two 
diseases ceases. 
The points of difference are much more prominent. In the first place, the onset of 
malarial continued fever is either sudden, the chill being marked and immediately fol- 
lowed by a high temperature, or it is preceded by one or more attacks of quotidian or 
tertian intermittent. In enteric fever the chilly sensation is, as a rule, slightly pro- 
nounced, and the initial symptoms may be prolonged for several days before the patient 
feels it necessary to take to his bed. In my experience, the temperature in enteric 
fever seldom rises above 102°-102.5° F. until the end of the first week, while in the 
malarial affection the body heat rises at once to 103°-104° F., or even more. The 
appearance of the heavy white coating on the broad, thick and indented tongue is 
highly characteristic of the beginning of malarial continued fever, while my own obser- 
vation of the enteric affection has generally shown a narrow, pointed, red tongue, with- 
out indentations from the teeth, and with a slight fawn-colored or brownish fur, rather 
than white. 
The most radical difference, however, is to be found in the complete absence of the 
typhoid eruption, and of all those abdominal symptoms so characteristic of enteric fever. 
In malarial continued fever there is seldom diarrhoea-rather constipation-no tender- 
ness on pressure in the right iliac fossa, no tympanites, no gurgling, and no rose-colored 
lenticular spots, disappearing under pressure, and after death. 
In malarial continued fever there may be present tenderness over the liver, spleen 
or stomach, but not elsewhere in the abdominal cavity. Seventeen years ago I was 
taught by Dr. Alfred L. Loomis that there could be no case of typhoid fever without 
the characteristic eruption, and my subsequent experience has confirmed this state- 
ment. I believe the spots can always be found between the seventh and twelfth days, 
if carefully looked for. 
The erratic behavior of the temperature in the Texas fever is still another distin- 
guishing feature. For instance, it may rise to its maximum in the first week, and may 
fall as suddenly below 100° F. in the second; these excursions, however, only occupy a 
few hours. Seldom a whole day passes with the thermometer below 102°, unless the 
pyrexia has been artificially reduced, i. e., until convalescence is established. Some- 
times the thermometer will vary less than one degree in the twenty-four hours for days 
at a time. I have known it to remain steadily above 104° F., and not over 105° F., 
for a whole week. 
The regular daily fall and rise of the temperature in enteric fever, as well as its 
steady increment from week to week to the maximum, and its no less steady decrease 
toward recovery, have been observed so often as to be considered one of the diagnostic 
features of this disease. 
I have not dwelt on epistaxis as common to these maladies, as it also occurs in other 
fevers of continued type, and in relapsing fever. There is no special character of the 
pulse by means of which these two diseases may be distinguished, other than the fact 
of its greater rapidity in enteric fever, while at the same time it lacks the soft fullness 
so frequently observed in the malarial affection. 
The prognosis is favorable with proper treatment, much more so than the high tem- 
perature, brown, dry, cracked tongue, delirium, duration of the disease and general 
appearance of the patient would lead one to expect. Of the numerous cases under my 
immediate charge during the four years of my service in Texas, only one died, and he SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
545 
was treated in his own house, where there were no conveniences for baths, and he was, 
moreover, a new comer and of a very delicate constitution. Of the cases mentioned, the 
average duration of the pyrexia was 28 days ; in none was it less than 21, and in only 
a few over 42. 
Of pathological appearances I can say little, as no autopsy was permitted in my own 
fatal case, and I had no opportunity of witnessing a post-mortem in those of others. 
The patient who died under my care succumbed on the twenty-eighth day of the 
disease, from heart failure, and according to my observation, the tendency to death is 
in that direction. 
Treatment.-When I was an interne of Bellevue Hospital, 1869 and 1870, we gave 
large doses of quinine to every patient affected with malaria in any form, and very 
properly, too, in the class of cases seen in New York, which were either of the-inter- 
mittent or remittent type, with occasionally a congestive chill. We used this remedy 
antiperiodically, antipyretically and heroically, if necessary. In consequence of this 
previous experience and prejudice in favor of large doses of quinine, the first few cases 
of the disease in question were treated by me on the principle that if thirty or forty grains 
of quiniæ sulph. did not break up this malarial continued fever, sixty grains would. 
I tried it and failed, not only to break up the fever and reduce the temperature to any 
appreciable extent, but succeeded in making the patient so deaf, blind and wild that 
nothing could quiet him. After trying this remedy on several patients, I abandoned it 
altogether as an antipyretic, and used it only as an antiperiodic when convalescence 
was just beginning and there was a complete intermission. I do not dispute the fact 
that quinine in large doses will reduce the temperature from -.5°-1.5° F., but it does 
this, in this disease, at the expense of the already overstrained and oxidized nervous cen- 
tres, and when used to such an extent is liable to produce permanent deafness, and 
more or less injury to other special senses. Another strong objection to its use is the 
nauseating and disagreeable effect it has on the stomach, rendering the administration 
of nourishment or medicines almost impossible. 
I must register, also, my protest against the early use of stimulants in malarial con- 
tinued fever. They seldom become necessary before the third week of this affection, and 
most of the fatal cases I have seen and heard of were treated in the beginning of the 
disease with large doses of brandy and quinine. 
Some of the best surgeons who have served in Texas do not agree with me in the 
opinions above expressed; others do; nevertheless, lam obliged to draw my own deduc- 
tions from observed facts, and judge of the efficacy of treatment by its results. I have, 
moreover, taken great interest in this disease, and made somewhat of a special study of 
it, not only in others, but also in my own person. 
Having entered my protest against the quinine and brandy treatment, I will now for- 
mulate an opinion as to what I consider the proper management of this disease. The 
indications for treatment appear to me to be as follows :- 
1. To keep the secretions and excretions free. 
2. To build up the patient with proper nourishment, and stimulants when required 
by the condition of the pulse. 
3. To quiet the excited brain and procure refreshing sleep. 
4. And above all, to reduce the body heat and keep it down, as far as practicable. 
To meet the first indication, I have used as a routine, and certainly harmless pre- 
scription, 10 kb each of syr. rhei. arom., liq. ammon. acetat. and spts. ætheris nitrosi, 
administered, diluted, every four hours. For this special combination I am indebted 
to Dr. A. Heger, Lieutenant-Colonel and Surgeon, U. S. Army, then stationed at Fort 
Clark, Texas, and whose four years of experience with this disease had independently 
led him to adopt very nearly the same views as myself. 
The combination above mentioned appears to me to benefit by its gentle stimulating 
Vol. IV-35 546 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
effect upon the excretory function of the skin, kidneys, liver and intestinal tract. In 
the beginning of the disease, when the constipation was a prominent symptom, I have 
often derived benefit from the exhibition of six grs. each of calomel and mass, hydrarg., 
in the pilular form, and followed, if necessary, in six hours by a Seidlitz powder or 
moderate dose of magnes, sulph. I prefer, however, one of the saline cathartics, as a 
rule. 
During the further progress of the disease, when the bowels are inactive, I use 
either an enema of warm water and soap or a laxative pill composed of podophyllin, 
gr. I; extr. coloeynthi. co., gr. 4; extr. hyoscyami, extr. nucis vomicæ and extr. ta- 
raxaci, ää gr. |. Strong purgatives are to be avoided. 
The second indication may be best met by such easily digestible nourishment 
as suits the patient's stomach and is especially desired by him. 
In my experience, milk has served the purpose better than anything else. I have 
very little faith in the various forms of "meat juice" and "beef extracts," except 
possibly as stimulants. As to the latter, they should only be used when the pulse first 
fails in strength. I generally begin with sherry and egg in small quantities, frequently 
repeated, and progress to whisky or brandy, in the form of milk punch, as the case 
appears more serious. When the heart's action becomes excessively weak, I have found 
much benefit from the administration of 10 rq, doses of tinct. digitalis, repeated as 
required. 
The nervous excitement of the third indication can be best controlled by 15 to 20 
grs. each of chloral hydrat. and potass, bromide, given at bedtime. In some few 
instances, however, this prescription seems to aggravate the restlessness and delirium 
In such cases | gr. morph, sulph., administered hypodermically, will generally produce 
quiet and sleep. 
The above statement was illustrated in my own person, the bromide and chloral 
acting well in the first attack, while in the second morphia had to be substituted. Do 
not understand me to recommend the daily use of these remedies ; they are only 
required occasionally. 
With me, nothing has fulfilled the fourth indication so well as cool baths and cool 
sponging. 
I had the temperature of each patient taken every two hours, from 6 A. M until 10 
P.M., and when the thermometer indicated 103° F. or more, he was at once placed in a 
bath-tub of water kept constantly standing by his bed. These tubs were long enough 
to admit of the immersion of the whole body except the head, and the latter was 
drenched with a sponge during the entire time of the bath. 
The patient was allowed to remain in the water until he complained of feeling 
chilly, when he was immediately removed. The times of immersion varied from five 
to fifteen minutes-the average being about eight minutes. 
There was no ice at Fort Ringgold, and the lowest temperature obtainable for water 
during the fever season was 74° F. I preferred the bath, however, at 80°-84° F., as 
the shock of colder water was too great for feeble patients. There is not the slightest 
danger in this mode of treatment if the rule given above is observed, i. e., to take the 
patient out of the bath as soon as he complains of feeling chilly ; reaction will invari- 
ably occur under these circumstances. When the temperature is over 100° F. and not 
more than 103° F. I use sponging instead of the bath. 
With regard to the antipyretic effect of this treatment, I will state that in the fewest 
number of instances has it failed, in my hands, to reduce the temperature from 2°-4° F. 
Often have I seen the thermometer fall from 104.5°-99.6° F. Frequently, in severe 
cases, five or six baths a day are required, and the amount of difficulty experienced in 
reducing the temperature may be taken as a measure of the severity of the attack. 
It is true that this lowering of the body heat is not permanent, but it frequently SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
547 
lasts as much as an hour, and these hours added up for the whole period of the disease 
correspond to a long season of rest from oxidation and waste of the tissues, which is of 
incalculable benefit to the patient. 
An additional advantage of the water treatment is the perfect cleanliness of the 
skin thus secured, while the pores are kept open and transpiration encouraged. More- 
over, the bath calms and quiets the brain, and I have often seen patients go off into 
a natural sleep afterward without any necessity for anodynes or soporifics. I must 
mention, before concluding, that in some cases the symptoms referable to the brain 
and nervous system are replaced by excessive irritability of the stomach, rendering 
it very difficult to administer either food or medicine. In the case of an officer at 
Fort Clark, he could retain nothing but very small quantities of iced champagne, and 
occasionally a little cold milk. I succeeded, however, in subduing this annoying state 
of affairs by drawing a blister, about an inch and a half in diameter, over the epigas- 
trium, and keeping it open for several days. 
During convalescence I have found ferri et quiniæ citras, in five-grain doses three 
times a day, the most suitable and beneficial tonic. Quinine alone I seldom give, except 
at the termination of the continued pyrexia, when there is a complete intermission in 
the morning. I may also state that I have tried quinia in small doses-4 grs. ter die 
-during the whole disease, but abandoned it, because I could not observe that the 
malady was at all influenced by its exhibition, except for the worse, as far as the 
brain and stomach were concerned. 
In presenting these views of "malarial continued fever" and its treatment, no 
claim to originality is made, but I have simply recorded clinical facts as they appeared 
to me, and the natural deductions therefrom as to the nature of the disease and its man- 
agement. 
It may seem strange to speak of a malarial fever and then deny the efficacy of qui- 
nine in its treatment. This opinion, however, applies only to its antipyretic and not 
at all to its antiperiodic action. According to my observation, this remedy is more 
potent, even in remittent or intermittent fevers, if administered when the temperature 
is at or near the normal and the excretions free. 
In conclusion, I must apologize for having presented nothing new or strange, but as 
each little drop adds something to the ocean, so the truly recorded experiences of us att 
are required to complete the mighty structure of our noble science. 
DISCUSSION. 
Dr. Thomas Hebert, of New Iberia, Louisiana, said that his experience in 
Louisiana coincided, with reference to the clinical history and treatment of mala- 
rial continued fever, with that observed by Dr. Blair D. Taylor, in Texas. 548 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
ON THE SANITARY INSPECTION OF PASSENGER COACHES. 
SUR L'INSPECTION SANITAIRE DES VOITURES DE VOYAGEURS. 
ÜBER SANITÄTSAUFSICHT ÜBER EISENBAHNWAGGONS. 
BY R. HARVEY REED, M.D., 
Of Mansfield, Ohio. 
In the collection of material for the preparation of this report it has been our aim 
to be as careful and thorough as circumstances would permit; we have also tried to 
procure all the facts possible pertaining to sanitary matters connected with passenger 
coaches, and, so far as possible, have tabulated them in a convenient form for reference. 
We have also tried to collect enough of each to enable us to arrive at general conclu- 
sions, based on the facts collected. 
For the collection of these facts we have chosen four fairly typical American rail- 
roads-roads that we thought would unquestionably represent the general condition of 
first-class railroads throughout our land-on each of which we inspected the coaches of 
only first-class passenger trains, all of which were subjected to the same scrutiny 
throughout. 
For aiding me in this task I am indebted to Mr. G. M. Beach, Manager of the 
Cleveland, Columbus, Cincinnati and Indianapolis Railroad; Mr. Wm. Baldwin, Man- 
ager of the Pittsburgh, Cincinnati and St. Louis Railroad (known as the Pan Handle), 
and the Pittsburgh, Fort Wayne and Chicago Railroad (known as the Fort Wayne),- 
and Mr. W. W. Peabody, Manager of the Baltimore and Ohio Railroad, each of whom 
furnished me valuable assistance in the way of transportation and the collection of 
facts pertaining to our investigations. 
I am also indebted to Prof. C. C. Howard, chemist for the Starling Medical College, 
Columbus, Ohio, for the chemical analysis of the air and water, and his report of the 
same, found herewith ; and to Dr. J. Harvey Craig, of Mansfield, Ohio, for necessary 
and needed assistance in the collection of facts. 
Different times of the year, with their corresponding changes of weather, were chosen, 
as well as roads running in different cardinal directions and under different kinds of 
management, and representing different styles of coaches and various kinds of car 
furniture, such as stoves, heaters, washstands, water tanks, urinals, etc., in order that 
our report might be as complete and practical as possible, and our deductions based on 
as many general facts as circumstances would admit. 
TEMPERATURE. 
In taking the temperature, we used tested thermometers, of Fahr, scale, and first 
ascertained the condition of the atmosphere outside the car, the character of the weather, 
direction of the wind, and general trend of the train. 
Six thermometers were used in each car, which were numbered from one to six, 
always commencing with the right front side of the car, and counting around the coach 
and ending with the sixth, at the left front end of the same, thus placing two ther- 
mometers at each end and two in the middle of each car (see Fig. 1), which were hung 
at the sides of the car as near the level of the heads of the passengers while sitting in 
their seats as was practical, and always placing the thermometers in the same relative 
position in each car. 
The temperature was then noted carefully while the train was in full motion, at 
intervals of from twenty minutes to half an hour, and in a few instances as much as an SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
549 
hour apart, and also taken while standing at different stations, usually making the 
observations immediately before the train left the depot ; and, finally, the thermometers 
were placed on the floor in the same relative positions and the temperature again care- 
fully noted. 
Fig. 1. 
Diagram of a passenger car, showing the relative position of the thermometers with reference to the 
front, rear and sides of the car. 
The general results of these observations will be seen by the following tables :- 
Table No. 1.-Greatest, least and average difference of temperature observed between 
the inside and outside of coaches while running, during the winter season- 
Greatest. Least. Average. 
80° 37° 54° 
The same observations made in summer showed- 
Greatest. Least. Average. 
7° 0° 4° 
Table No. 2.-Greatest, least and average difference observed between the extremes 
of temperature in coaches while running, during the winter season- 
Greatest. Least. Average. 
27° 0° 7j° 
The same observations made in summer showed- 
Greatest. Least. Average. 
3° 0° 2° 
Table No. 3.-Greatest, least and average difference observed between extremes of 
temperature in coaches while standing, during the winter season- 
Greatest. Least. Average. 
27° 1° 7° 
The same observations made in summer showed- 
Greatest. Least. Average. 
4° 2° 2j° 
Table No. 4--Greatest, least and average difference observed between extremes of 
temperature in coaches running and standing, during the winter season- 
Greatest. Least. Average. 
29° 5° 13j° 
The same observations made in summer showed- 
Greatest. Least. Average. 
4° 3° 3j° 
Table No. 5.-Greatest, least and average difference observed between the tempera- 
ture at the bottom of cars and the level of the head, while sitting in a running car, at 
full speed, during the winter season- 
Greatest. Least. Average. 
30° 12° 18° 550 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
The same observations made in summer showed no appreciable difference, as might 
be expected. 
By reference to temperature chart No. 1, you will find that the greatest difference of 
temperature between the outside and inside of a car occurred in a smoking car, on 
December 16th, 1886, with the mercury at 4° above zero, and the least difference occurred 
on both a smoker and sleeper, of the same date, March 28th, 1887, with the mercury 
outside at 27° and 30° respectively. 
It will also be observed that the greatest difference between the extremes of tempera- 
ture on a car while running occurred on a sleeper, March 28th, 1887, with the mercury 
outside at 27° above zero, and the least difference between the extremes of temperature 
of a car while running was on a smoker, on December 29th, 1886, with the mercury 
outside at 22° above zero. 
The greatest difference of temperature while standing occurred on a sleeper, March 
28th, 1887, with the mercury outside at 27° above zero, while the least difference of 
temperature while standing occurred on a sleeper, December 29th, 1886, with the 
mercury outside at 16° above zero. 
Again referring to chart No. 1, it will be observed that the greatest difference between 
extremes of temperatures on a coach running and standing was on a sleeper, March 28th, 
1887, with the mercury at 27° above zero, and the least difference occurred on a sleeper, 
December 16th, 1886, with the mercury outside at 4° above zero, the coldest day we 
were out making these inspections. 
The greatest difference found between the temperature at the bottom of a car and 
the level of the head, occurred on a sleeper, March 29th, 1887, with the mercury at 
12° above zero; and the least difference was on a ladies' coach, two of which registered 
the same, the one December 29th, 1886, with the mercury at 18° above zero, and the 
other on March 29th, 1887, with the mercury outside at 12° above zero. 
HEATING. 
Again, by referring to chart No 1, it will be seen that 6| per cent, of the cars were 
heated by stoves ; 36| per cent, by hotair; and 56 j per cent, by hot water, in the form 
of the Baker heater. 
In all our examinations, only two cars were heated by common stoves, and one of 
those was found in summer, which was useless for our purpose in this direction. 
In the one found in use in the winter, it will be observed that the temperature out- 
side the car was 10° above zero, and that the difference between the extremes of tem- 
perature in the car while running was from 5° to 6°, and the same while standing, 
while the greatest difference of temperature on the same car, between running and 
standing, was 8°, while that between the bottom of the car and head was 17°. 
In cars heated by hot air, the difference between extremes of temperature while 
running, was from 2° to 14° with the mercury outside at 30° and 15° respectively. 
The extremes of temperature between cars heated by hot air, while running and 
standing, was from 8° with the thermometer outside at 30° above zero in one instance, 
and 15° above zero in another, to 18° with the mercury outside at 4° at one time, and 
15° above zero at another. 
In cars heated by hot water, there was found a difference of temperature while run- 
ning, varying from 0° to 27° with the mercury outside at 22° and 27°, respectively, above 
zero, and a difference of temperature between running and standing, varying from 5° 
to 29°, with the mercury outside at 4° and 27° respectively, above zero, while the differ- 
ence between extremes standing varied from 1° to 27°, with the mercury outside at 16° 
and 27°, respectively, above zero. 
By the same methods of heating a variation of temperature between the bottom of 
the car and level of the head while sitting was found, varying from 12° with the met- SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
551 
cury outside at 18° above in one instance and 12° above in another, to 30°, with 
the mercury outside at 12° above zero. 
We found 43| per cent, of the cars ventilated with the " drop-sash " ventilators (see 
Fig. 2); 23J per cent, with "registers"; 13| per cent, with "side-sash"; 65 per cent, 
with "transoms"; and 131 per cent, without any ventilators at all. 
By "drop-sash " ventilators we mean where the little sash at the top of the car is 
attached below by hinges, and so arranged as to drop inward and downward when it is 
desired to ventilate the car (Fig. 2, a) ; and by a " side-sash " ventilator we mean where 
VENTILATION. 
Fig. 2. 
Diagram of different kinds of car ventilators. ' a a a, drop sash ; b b b, side sash ; c c, transom. 
the sash at the top of the car are hung on hinges at their ends, and so arranged as to 
open outward and backward when it is desired to ventilate the car (see Fig. 2, &). 
By ' ' registers ' ' we mean that method of ventilation by which the air is allowed to 
escape near the top of the car by means of a valvular arrangement on each side of the 
car, which can be opened or closed at will (see Fig. 3, c). 
Ventilation by transoms is where an opening is usually made in each end of the car, 
and generally a short distance above the door, and is so arranged as to be opened or 
closed by means of a sash or wooden arrangement, capable of being swung on its centre 
at will (see Fig 2, c). 
By "pipe " ventilators we mean simply a pipe running through the roof of the car 
Diagram of different car ventilators, a, common pipe ventilator; b, pipe ventilator with funnel-shaped 
top ; c, common register. 
from the inside, and ending either with a simple cover or funnel-shaped arrangement 
on its top, and was usually found in the toilets and water closets (see Fig. 3, a and Z>.) 
The circulation of air through the car was tested by means of a wax candle, so arranged 
as to protect the flame from all draughts, excepting the one to be tested. 
The cars were all examined just as found, and the tests made when the car was run- 
ning at or near the schedule speed of the train. 
Each window was tested separately, and the direction of the currents of air carefully 
noted and mapped down on a blank diagram, prepared for that purpose (see Fig. 4, a), 
on which was also kept the date, No. of car, kind of car, etc., which corresponded 
with the record kept on other blanks, prepared for that purpose, on which the temper- 552 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
ature, direction of wind, kind of heating apparatus and other general facts were 
recorded. 
After testing the windows for draughts, the openings at the top of the cars, of what- 
ever character, were carefully tested, ami the direction of the currents of air again noted 
and mapped down on suitable blanks. (See Fig. 4, &.) In the same manner the ven- 
tilators of each of the toilets, water closets and urinals were in turn examined. 
Fig. 4. 
Jfoltoin of Car 
fajj vj- Ccu~ 
Almost the universal result of these investigations showed that in the winter 
season, when the cars were heated artificially, a constant draught of cold air came 
in around the windows, notwithstanding they were closed and many of them double. 
(Fig. 6.) These currents first dropped downward toward the centre of the car, then 
arose and passed out at the ventilators at the top of the car. They were, of course, 
Fig. 5. 
A diagram of the upper part of a car, showing the circulation of the air while running, in winter. &, b, 
cold air entering the car at front transom; c, c, hot and foul air escaping at top of car through the 
open ventilators at the side and transom at rear end. 
more or less modified by the force and direction of the air outside the coaches, also by 
the number and location of open windows, or transoms, and ventilators. (See Fig. 5. ) 
In those cars in which hot-air heaters were used, and which, as a rule, are usually placed 
at each end of the car, with a hot-air conduit running along each outer side and bottom 
of the car, there was found to be a great uncertainty in the supply of warm, fresh air. SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
553 
As a rule, they were found to have a good draught from the registers of those con- 
duits (which are usually placed at the bottom of the car, opposite each seat) which 
came from the heater at the front end of the car, while from those coming from the heater 
at the rear end of the car, there was usually little or no draught. 
In those coming from the heater at the front end of the car, the draught was often 
so strong, and the air so hot, as to necessitate the closing of the register by the party 
sitting next to it, while his neighbor on the opposite side of the car was as much too 
cold as he was too hot. 
In cars heated by hot water, which usually consisted in a heating apparatus placed 
at one or the other end of the car, with an arrangement for heating salt water very hot, 
usually by the means of a coil of pipe, which was continued from the heater around 
the entire car, running back and forth under each seat, as it encircled the car, and finally 
connecting with the other end of the coil at the heater. 
By this ingenious arrangement a constant current of hot water was intended to be 
kept circling around the car, which, as fast as it became cool, would return to the heater, 
and be reheated again. 
Under many circumstances these were found inadequate to properly heat the coaches 
in cold weather, and failed to keep up an even temperature even when pushed to their 
utmost, which, in turn, would modify the currents of air throughout the car, and often 
necessitated the closing of the ventilators in order to keep the passengers comfortably 
warm, and were utterly useless so far as ventilating the car was concerned. 
Fig. 6. 
A diagram showing the entrance of air at the closed windows of a running car in winter, a, a, Cold air 
entering the car at the windows. 
In those cars provided with registers at the top, the ventilation was found very 
defective; in fact, there were but few of these registers in which there was the faintest 
draught perceptible passing either out or in. 
Occasionally one would have a feeble draught out, which always seemed to be of a 
spasmodic character. 
The same may be said of the pipe ventilators, excepting in those with a funnel- 
shaped top, which, by being constructed so that the draught made by the moving train 
would always throw the large end of the funnel backward, producing, occasionally, a 
slight draught from the inside of the car out. 
In the little inch and a half to two-inch pipes intended as ventilators for the hop- 
pers and urinals, there was little or no draught found at all. 
The cars in which the best circulation of air was found, everything else considered, 
were those provided with the side-sash ventilators, and hot-air heaters; in all of the 
former there was found to be quite a remarkable regularity in the draught, which was 
always found outward, except when changed by a strong outside current, which was 
seldom the case. 
In those ventilated with the drop-sash the circulation of air was fair, but they were 
susceptible to the impressions from the outside air, which changed the currents back 
and forth accordingly. 554 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
In the summer time, when there was no fire in the cars and nearly all the windows 
open, there was found to be an inward draught at the rear side of each window, with 
an outward draught at the front side of the same ; while in the same cars ventilated 
with registers there was a constant outward current through them; in the cars, how- 
ever, provided with drop-sash ventilators, there was almost a constant inward draught 
Fig. 7. 
Diagram showing the general circulation of air through a running coach in winter. 
through the ventilators and a more constant outward draught through the open 
windows. 
In the accompanying diagram (see Fig. 7), I have endeavored to show, as near as 
possible, the prevailing direction of the air currents in and out of a majority of the 
cars I have inspected. 
LIGHTING. 
In not a single instance did we find candles used for lighting the coaches; lamps 
being used entirely; gas having also been abandoned by the roads that used it a few 
years ago. 
The number of lamps used for lighting the coaches varied from four to twenty-seven 
in a single car. 
AIR AND WATER. 
For the following report of the chemical analysis of the air in the coaches, and the 
drinking water used by the different roads inspected, I am indebted to Prof. C. C. 
Howard, of Columbus, Ohio, who accompanied me in these inspections, and made all 
his observations on the running train. (See Tables No. 6 and 7. ) 
In addition to Prof. Howard's reports of the air and water analysis, made at the 
author's request, he adds the following :- 
' ' The apparatus used in the determination of the carbon dioxide was essentially 
that proposed by Pettenkofer. A glass bottle containing 3828 cubic centimetres was 
filled with the air under examination, by filling it with water and removing the water 
with a syphon. 50 cc. of barium hydroxide colored with phenol-phthalein were added 
and shaken with the contained air until absorption of the carbon dioxide was complete, 
and this titred to exact discharge of color with a standard solution of oxalic acid, of 
which 1 cc. is equivalent to 1 milligramme of carbon dioxide. 
' ' The relation between the strength of the barium hydroxide and oxalic acid solu- 
tion had been accurately determined. 
' ' The temperature of the air under examination and the barometric pressure were 
taken and the volume of air reduced to normal conditions of temperature and pressure 
(0° C. and 760 mm.). 
"From the diminished alkalinity of the barium hydroxide the weight of the carbon 
dioxide present was calculated, and this expressed in parts per 10,000. 
' • The fact that the apparatus was to be used on a running train required that it 
should be of the simplest form. 
" Comparative tests were made by the aid of the apparatus described by Van Niiys, SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
555 
TABLE NO. 6. 
DETERMINATION OF CARBON DIOXIDE IN AIR OF PASSENGER COACHES ON THE 
FOLLOWING RAILROADS AND CARS. RATE PER 10,000. 
Date. 
No. 
R. R. 
No. of Car. 
Condition. 
No. of 
Passengers. 
Carbon Dioxide. 
Parts per 10,000. 
Dec. 29,1886. 
1 
C. C. C. & I. 
Smoker, 153. 
Front. 
8 
7.34 
2 
1C c « 
Smoker, 153. 
Middle. 
8 
7.62 
cc << 
3 
Coach, 356. 
Front. 
32 
14.26 
ll ll 
4 
(C It 
Coach, 356. 
Middle. 
29 
13.68 
ll ll 
5 
ll ll 
Coach, 356. 
Rear. 
27 
11.53 
ll tt 
6 
ll ll 
Sleeper, 40, 
Front. 
11 
8.52 
II U 
7 
11 ll 
Sleeper, 40. 
Middle. 
11 
8.84 
CC ll 
8 
ll ll 
Sleeper, 40. 
Rear. 
11 
8.92 
It ll 
9 
ll ll 
Coach, 356. 
57 
18.33 
It ll 
10 
Smoker, 153. 
23 
10.97 
March 28,1887. 
11 
Pan Handle. 
Smoker, 51. 
14 
5.60 
«C ' It 
12 
ll ll 
Coach, 36. 
18 
5.45 
ll ll 
13 
ll ll 
Coach, 36. 
25 
8.39 
ll ll 
14 
ll ll 
Sleeper, 406. 
14 
11 36 
It ll 
15 
ll ll 
Sleeper, 319. 
12 
13.35 
ll ll 
16 
ll ll 
Coach, 36. 
22 
6.37 
It ll 
17 
ll ll 
Smoker, 153. 
15 
8.73 
ll ll 
18 
ll ll 
Coach, 36. 
Closed for 35 minutes. 
23 
10.78 
ll I. 
19 
Coach, 36. 
Doors opened 2 minutes. 
21 
4.22 
March 29, 1887. 
20 
Ft. Wayne. 
Sleeper, " Metis." 
10 
10.54 
ll ll 
21 
ll 9 ll 
Smoker, 38. 
6 
6.81 
ll ll 
2! 
ll ll 
Coach, 16. 
24 
7.64 
ll ll 
23 
ll ll 
Coach, 26. 
23 
9.93 
ll ll 
24 
cc u 
Sleeper, 383. 
30 
12.28 
ll ll 
25 
ll ll 
Smoker, 38. 
14 
6.13 
July 20, 1887. 
26 
B. & 0. 
Smoker, 457. 
7 
4.87 
<> » 
27 
C( 4» 
Coach, 453. 
11 
4.41 
U ll 
28 
»» ll 
Coach, 469. 
15 
4.66 
ll ll 
29 
ll ll 
Sleeper, 505. 
12 
4.26 
ll ll 
30 
ll ll 
Coach, 457. 
29 
4.42 
ll ll 
31 
44 ll 
Coach, 431. 
24 
4.90 
ll ll 
32 
It 44 
Coach, 350. 
17 
4.48 
TABLE NO. 7. 
CHEMICAL EXAMINATION OF WATER (WITH ICE) FURNISHED FROM THE FOLLOW- 
ING RAILROADS, CARS AND PLACES. RATE PER 100,000. 
Date. 
No. 
R. R. 
No. of Car. 
Source. 
I Oxygen 
| Required. 
Free 
Ammonia. 
Albuminoid 
Ammonia. 
Nitrous Acid. 
| Chlorine. 
| Total Solids. 
Dec. 29, 1886. 
1 
C. C. C. & I. 
Coach, 356. 
Cleveland. 
.17 
.001 
.003 
Trace. 
.21 
9.0 
Dec. 29, 1886. 
2 
C. C. C. & I. 
Coach, 301. 
Cincinnati. 
.15 
.005 
.016 
.001 
2.41 
26.3 
March 28, 1887. 
3 
Pan Handle. 
Coach, 36. 
Columbus. 
.16 
.001 
.005 
Trace. 
.28 
6.6 
March 28, 1887. 
4 
Pan Handle. 
Sleeper, 406. 
St. Louis. 
.13 
.0005 
.002 
None. 
.18 
2.5 
March 29, 1887. 
5 
Ft. Wayne. 
Coach, 26. 
Sleeper, 383. 
Alliance. 
.18 
.001 
.004 
Trace. 
.50 
14.2 
March 29, 1887. 
6 
Ft. Wayne. 
Washington. 
.11 
.001 
.006 
Trace. 
.39 
8.4 
July 20, 1887. 
7 
B. & (). 
Coach, 453. 
Sandusky. 
.09 
.001 
.003 
None. 
.25 
2.1 
July 20; 1887. 
8 
B. & 0. 
Sleeper, 505. 
Chicago. 
.19 
.001 
.004 
Trace. 
.28 
9.5 
July 20, 1887. 
9 
B. & 0. 
Coach, 350. 
Wheeling. 
.22 
.001 
.005 
.001 
1.60 
12.4 
(American Chemical Journal, Vol. VIII, page 190), and the fact learned that the simpler 
form gave results closely comparable, but slightly higher than those obtained by the 
more elaborate apparatus. 
" The samples of water obtained from the various cars were submitted to the usual 
examination for organic impurities. 556 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
"The oxygen required for oxidation, free and albuminoid ammonia, nitrous acid, 
chlorine, and total solids were determined in each sample. ' ' (See page 555. ) 
By again referring to chart No. 1, it will be seen that 71| per cent, of the cars 
inspected used disinfectants of some kind, and that the water closets in 60 per cent, of 
these cars had a bad smell. 
In the majority of the cases the bad smell came from the urinals. 
In 865 per cent, of the cars examined there were found tool boxes, consisting usually 
of an ax, sledge and saw, placed in some convenient part of the car, while 76| per cent, 
carried water buckets, and only 40 per cent, carried fire extinguishers. 
83| per cent, have some form of an air-brake attachment, usually consisting of a 
cord running along the side of the car, so arranged that in case of an emergency any 
person can pull it and apply the air brakes to the train. 
Fifty per cent, of the coaches have toilets (by this we mean a washstand and towel, 
which, in the common coaches, are found in the water-closet apartment, while in the 
sleepers they are kept separate). 
Of the toilet apartments and water closets- 
86j per cent, were ventilated, 
66$ " of washstands were clean, 
26$ " " " medium, 
6$ « " " dirty; 
70 " of towels were clean, 
13 " " " medium, 
17 " " " dirty; 
70 " of hoppers were ventilated, 
60 " " " clean, 
10 " " " medium, 
30 " " " dirty ; 
37 " of urinals were Ventilated, 
64 " " " clean, 
23 " " " medium, 
13 " " " dirty; 
38 " of drips to urinals were clean, 
24 " " " " medium, 
38 " " " " dirty ; 
45 " of water tanks were clean, 
34 " " " medium, 
21 " " " dirty. 
ladies' toilets. 
100 per cent, were ventilated, 
100 " clean, 
100 " of towels were clean ; 
100 " of water tanks were clean. 
64 " of hoppers " ventilated, 
82 " " " clean, 
9 " " {< medium, 
9 " " " dirty; 
73 " of toilets were disinfected, 
100 " " had no odor, 
100 " " were carpeted, 
CONCLUSIONS AND SUGGESTIONS. 
The results of these investigations have called our attention to a number of inter- 
esting points relative to railroad sanitation. 
In first-class passenger coaches, constructed with the greatest of mechanical care, at 
large expense, there should not be such extreme changes of temperature as our investi- 
gations have shown to exist. 
We must either attribute it to the faulty construction of the cars or to improper or 
defective heating and ventilating; with such universal variations of temperature as SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
557 
were found to exist in cars of first-class construction, made of first-class material, by 
skilled workmen, for enterprising and progressive companies, we are led to the natural 
and legitimate conclusion that the fault must lie with our present system of heating 
and ventilating coaches. 
It is true that the currents of air outside the cars, together with the external tem- 
perature, have their influence; but is there no way whereby these influences may be 
overcome ? and these extremes of temperature, so conducive to acute diseases, be greatly 
modified ? 
Putting double doors, with a sort of an ante-room, at each end of our common 
coaches, similar to that of the sleeping-cars, would, no doubt, be an improvement over 
the present methods of constructing them; yet, if you will refer to chart No. 1, you will 
find as much as 29° difference between the extremes of temperature in even a sleeper, 
with all the improvements of construction science has suggested, which clearly indi- 
cates that there is something else at fault than the mere construction of the car alone. 
If you will go a little further into this matter, you will find the greatest and really 
most important difference of temperature is between that at the level of the head and 
that at the surface of the floor. By referring to chart No. 1, you will find there 
was found to be as much as 30° difference in one instance between these two extremes, 
and that, too, in a sleeper, which is supposed to be the best and most comfortably 
equipped car we have, for the privilege of riding in which we are compelled to pay an 
extra fee; and yet in this traveling palace the minimum difference between these two 
extremes of temperature was found to be 12° (that is by taking the lowest temperature on 
the floor from the highest at the level of the head), and the average difference estimated 
from twenty-four cars, in ordinary winter weather, was found to be as high as 18°. 
With these facts staring us in the face, is it any wonder that people take colds and 
contract severe acute diseases while traveling in our passenger coaches, as they are 
heated and ventilated at the present day ? 
By referring to the air analysis, table No. 6, you will find that in these same cars 
above referred to there is not only a great variety of temperature, but also a polluted 
atmosphere. 
For example, in referring to chart No. 1, car No. 319 (Pan Handle R. R.) will be 
found to be a sleeper, and only contained twelve passengers, but showed a difference 
between the temperature at the bottom of the car and the level of the head of 29°, and 
at the same time the atmosphere in the car showed 13.35 parts per 10,000 of carbon 
dioxide present in its atmosphere, the highest in proportion to the number of passen- 
gers of any car examined, which certainly demonstrates, without a question, a decidedly 
imperfect system of heating and ventilating; and yet this car had the ordinary provi- 
sions for ventilating found in the majority of such cars, and was heated by a Baker's 
hot-water heater, of which there are more used, as shown by our investigations, than 
of any other one kind. 
Another example of this character will be found by referring to car No. 356 (C. C. C. 
& I. R. R.), which was a ladies' car, heated with a Baker heater, of which there was 
one transom and eleven drop ventilators open; in which car there were three analyses of 
the air made, one at the front end of the car, when there were thirty-two passengers in 
it, which showed 14.26 parts per 10,000 of carbon dioxide present; another at the mid- 
dle of the car, when there were twenty-nine passengers in it, which showed 13.68 parts 
of carbon dioxide present, and finally one at the rear end of the car, when there were 
twenty-seven passengers in it, which showed 11.53 parts of carbonic acid per 10,000. 
At the same time in this car, the thermometer showed a difference of 14° between 
the level of the head and the surface of the floor, with a variation of 6° between the 
extremes running and standing, with the mercury outside at 15° above zero. 
The horrifying accidents that have occurred, alone have demonstrated to the public NINTH INTERNATIONAL MEDICAL CONGRESS. 
558 
mind the imperative necessity for some other, safer, and if possible, a more efficient plan 
for heating our passenger coaches, than the systems now in use. 
Almost universally the stoves or heaters are set at one end or the other of the car, or 
both, and in the case of a wreck they are among the first things that are smashed 
up; not only setting fire to the car, but cutting off all means of escape from it, excepting 
through the windows; saying nothing of the valuable space they occupy in every car. 
It seems to me that all these grave objections could readily be remedied by a system 
of heating in which the fire-box of the heating apparatus would be inclosed in a steel 
case, placed underneath the middle of each car, which steel case could easily be con- 
structed to serve as a hot-air chamber, as well as a protection against fire in case of an 
accident; to this hot-air chamber can easily be attached a pipe, leading from an air- 
pump on the engine, from which any amount of pressure desired could easily be 
obtained, and, at the same time, by a suitable arrangement with a stop-cock attach- 
ment, the fire could be supplied with any amount of fresh air, at will, from this air 
pipe or the hot-air chamber, and yet not expose it in any way to the car, even in case 
of an accident; then by placing two air conduits of suitable size along the entire length 
of each side of the car, underneath the windows, say eight or ten inches apart, the 
upper one of which should be in direct connection with the air-pump, and the lower 
Fia. 8. 
Diagram showing proposed system for heating and ventilating passenger coaches. 
a a, hot-air chamber, b, blower for fire, c c, registers to be used in case of accident to air-pump. 
d d, cold-air conduit, e e, hot-air conduit. //, short conduits connecting hot and cold conduits with 
stop-cock and opening for exit of air into car. g g, place for ventilating attachment for urinal or hopper. 
one connected with the hot-air chamber; then, by connecting these two conduits opposite 
each seat by a small conduit, at each end of which there should be a stop-cock, one of 
which should be marked " cold air," and the other one " hot air; " then by having an 
opening in the middle of each of these short conduits leading into the car, and by apply- 
ing a light pressure from the air-pump, say eight or ten pounds to the square inch, a 
regular supply of fresh air could be forced into every car, regardless of the direction the 
car was running, or whether it was running at all, or the condition of the external 
atmosphere. (See Fig. 8.) 
At the same time, to insure perfect heating of the car, and the removal of the cold, 
foul air at the bottom of the car, a foul-air ventilator should be placed at each end of 
every car, and so constructed as to be opened or closed at will. The one at the front end 
of the car should always be kept closed, and the one at the rear end always kept open. 
These ventilators should be placed at a level with the floor, and open into a foul-air 
conduit that should pass out of the car, say a foot above the top, and be large enough 
to receive all the foul air as fast as it would accumulate, and being at the floor would 
not only remove the foul air, but also the cold stratum of air that always accumulates 
at the bottom of the car. 
By means of a stop-cock, and a connecting conduit with one of the pressure-air 
pipes, a constant ascending current could be insured, if found necessary in the foul-air 
conduit, which I am satisfied would seldom, if ever, be needed. 
With this arrangement there should be no ventilators of any kind at the top of any 
car, and no windows should be allowed open, for just as soon as a ventilator is open at SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
559 
the top of a car, it allows the warm, pure air to escape, and thus not only wastes the 
heat, but allows the cold, foul air at the bottom of the car to remain, to the discomfort 
of the passengers. 
By such a plan each seat would be supplied with a fresh supply of either warm or 
cold air, or a mixture of both, by a simple turning of the stop-cock opposite each seat, 
not only giving individual ventilation, which is especially so essential in sleeping cars, 
but at the same time ventilating and heating the whole car, at the will of its occupants, 
regardless of external influences, which should be governed, so far as the heating of the 
car is concerned, by thermometers, kept at suitable points in each coach, with printed 
instructions accompanying them as to the proper average temperature the car should be 
kept at. 
By such a method it will be readily seen that a constant supply of warm, pure air 
coming in at the sides of the car would soon heat it evenly all over, and by its pressure 
would constantly drive the cold, foul stratum of air at the bottom of the car out 
through the foul-air ventilators, and thus not only ventilate, but heat the car perfectly 
and scientifically throughout, and thus avoid all unnecessary draughts from open win- 
dows or ventilators, such as are now found in almost every coach you enter, whether 
first-class or the lowest grade of emigrant cars. 
For emergencies, in case of failure of the air pump, or the detachment of the engine 
from the train, two hot-air pipes, leading from the hot-air chamber into the car, with 
suitable registers, can easily be arranged for, by which each car could be heated directly, 
the same as from an ordinary furnace, until the defects in the air pressure, 
they might be, were remedied, when the registers could be closed air tight, and the 
pressure from the air pump again applied. 
Such a system for heating and ventilating would certainly have several advantages 
over the plan now in use. 
1. It would provide for an equal distribution of heat throughout the car, regardless 
of the weather outside, or whether the train be running or standing. 
2. It would furnish a constant supply of fresh air to each seat, regardless of the 
external atmospheric pressure or the direction the train be running, and in such amounts 
and at such a temperature as the occupant might desire, and thus avoid the very 
objectionable habit of opening the windows or, doors for a supply of fresh air. 
3. It would be decidedly safer than having a heater at each end of a car should a 
wreck occur, and much cheaper and more efficient than either hot water or steam from 
an engine, and equally as safe and much better practically. 
4. By this method the water closets, as well as the urinals and hoppers in them, 
could be constantly and thoroughly ventilated, at a trifling expense. 
5. While, last, but not least, by this system the room now occupied by heaters in 
each car would be vacated and could be used for a better purpose. 
The use of lamps, gas, and even candles, for the lighting of coaches, should be 
promptly abandoned. Candles are not only dangerous in case of a wreck, but trouble- 
some, dirty and inefficient ; while gas, owing to its bulk and dangerous properties in 
the case of a wreck, where it is liable to either smother people (for which reason it has 
already been abandoned by some roads) or explode and set fire to surrounding struc- 
tures, make it a dangerous element to use in railroad service. 
Although lamps are in general use throughout the country for the lighting of rail- 
road coaches, yet I consider them even more dangerous than either candles or gas in 
case of an accident. They are almost certain to become broken, and the oil spilt over 
the car, which is easily ignited, and in an instant gets beyond all control. 
The safety and efficiency of the incandescent light for the lighting of railroad coaches 
should certainly place it, without a question, beyond all doubt the ideal method for 
lighting railroad cars. Its success for this purpose has, to my own knowledge, already 
been thoroughly demonstrated on the cars of the electric street railroad in my own city, 560 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
and besides, I have been informed that its use on one or more of our Eastern railroads 
has proven successful and satisfactory. 
Then, if it is safe, efficient, reasonable in price, does not burn up the oxygen of the 
air in the car, and goes out immediately when impaired by an accident, without the 
least danger of igniting the surrounding structures, why should we hesitate to adopt it, 
and do away with the use of lamps, which are certainly as expensive, much more dirty 
and troublesome, less efficient and decidedly more dangerous ? 
AIK AND WATER ANALYSIS. 
In regard to the air and water analysis, Prof. Howard remarks that "an examina- 
tion of the results obtained shows several points of interest. The results obtained in 
summer, when doors and windows are open, show that under these circumstances the 
air of the car contains slightly more than the normal quantity of carbon dioxide. The 
proportion is from 4.26 to 4.90 parts in 10,000, while the air in the surrounding fields 
probably contained about 3 parts in 10,000. 
"In winter, with closed doors and windows, the results are quite different. It may 
be noted that the quantity of carbon dioxide present is largely proportional to the 
number of passengers in the car. The smokers, which generally contained a less num- 
ber of passengers than the ladies' cars, had an atmosphere that contained less carbon 
dioxide than that in the more crowded ladies' cars. The odors in the smokers were 
frequently more offensive, for reasons that will readily suggest themselves. 
' ' The air of the sleepers was not generally found to be lower in carbon dioxide than 
that of the coaches, as might be expected,to be the case, both from the smaller number 
of passengers and from the presumably better means of ventilation. A large part of 
the ventilation of the coaches is obtained by the opening of the doors at stations, and 
in the sleepers, where this prevails to a less extent, there is less change of air from this 
cause and the carbon dioxide rapidly rises. 
" An instructive experiment, as showing the ventilation obtained by doors and win- 
dows, was made on the Pan Handle R. R. The doors and windows of Coach 36, with 
twenty-three passengers, had remained closed for thirty-five minutes. The carbon 
dioxide rose to 10.78 parts. The doors were opened for two minutes; a current of fresh 
air swept through the car, and the carbon dioxide sank to 4.22 parts, or but little more 
than the normal quantity. 
"This proves that the present system of ventilation in coaches, and even in sleepers, 
is far from satisfactory. 
"The mixture of ice and water gave fairly satisfactory results, and it is probable 
that the quality of the water was, in many cases, improved by the mixture with the ice. ' ' 
The assertion made by Prof. Howard, in regard to the ice improving the water, is 
no doubt true where the water is very bad and the ice very good; but where you have 
good water to start with, the addition of commercial ice will certainly not improve it. 
The objectionable habit of using roller towels, or those in common use, for a promis- 
cuous lot of patrons, should be speedily done away with, and nothing but small, indi- 
vidual towels be allowed used under any circumstances. 
In the protection against emergencies, we found that 83j per cent, of the coaches 
w'ere supplied with an air-brake attachment, described heretofore in this paper, and 
which, practically, I consider of little real value. 
In fact, the air brake itself, although in almost universal use, has, in my opinion, 
seen its best day, so far as the real safety of passengers is concerned, in emergencies, 
unless improved upon. 
It is true, when air brakes work at all, they usually work well ; but it is also too 
true that when it fails on a single car, it fails on the whole train connected with that car. 
Its great liability to fail, and fail often when most needed and least expected, makes 
it a dangerous element in railroad service; for when depended upon, and it fails, as I SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
561 
am informed was the case only a few weeks ago in this very city, a whole train load of 
lives is suddenly placed in imminent peril. 
When we stop to consider that a very large percentage of all the railroad accidents 
occurring to passenger trains are, directly or indirectly, the result of defective air 
brakes, we are led, as sanitarians, to look for something better, safer and more reliable. 
From the most reliable information I can obtain on this subject, I am informed that 
a good automatic brake is much more reliable and equally as efficient, and much more 
simple in construction, and when the brakes on one or more cars in a train get out of 
order, it does not impair the usefulness of the brakes on the remainder of the cars in 
the train; and thus it makes them decidedly the safer and more reliable brake for rail- 
road service, from a sanitary standpoint, than any other now in use, so far as it has been 
possible to practically demonstrate this question. 
You will notice that 36f per cent, of the urinals have ventilators, and, further, that 
nearly all the bad smell in the water closets came from either the urinals or their drips, 
of which there were 60 per cent, of the whole number examined giving off a bad odor. 
In this direction I would recommend less plumbing work about the urinals than is 
found at present, simply making a large opening similar to that of the hoppers, which, 
like the hoppers, would have free ventilation, and no place for stale urine to accumu- 
late, which, with the moderate use of some good, reliable disinfectant, would soon do 
away with all these disagreeable odors, when the gentlemen's water closet would show 
as good a record as the ladies' does now. 
I cannot close this paper without referring to the water tanks as usually found in 
our coaches, of which 20| per cent, were found dirty, among which was discovered one 
with a baby's soiled diaper in it. 
Many of the tanks are placed so as to open inside of the water closet apartment, and 
I am credibly informed by railroad employés, who have had abundant opportunities 
for knowing, that it was not an infrequent occurrence to find babies' diapers, dirty rags 
and filth of that character dumped into the water tanks of our passenger coaches. 
So frequently was this the case that some of the railroads have made their cars more 
recently with the water tanks opening on the top of the car, while others have placed 
them in plain view in the car, where filth of that character could not be so easily intro- 
duced into them without being detected. 
The analysis of the water, with a few exceptions, shows that a very fair quality of 
water was supplied the passengers on the roads examined ; yet the custom of dumping 
the ice used into the water should be dispensed with, and, instead, a water tank used 
that was so constructed as to permit of the ice being packed around the outside of the 
water can proper, which should be porcelain lined, and so arranged as to be easily got 
at and cleaned, which is the great objection to those opening at the top of the car; 
while the tops to these refrigerators should not only be double, but locked on, and no 
person furnished with a key except the proper railroad employés, and they should be 
held responsible for their sanitary condition. 
With such an arrangement the drinking water could be kept clean and free from 
"foreign or domestic" filth, the water kept cool, but not ice cold, and at the same 
time free from the many impurities so frequently found in commercial ice. 
On the whole, however, we think the railroads examined will compare very favor- 
ably with the great mass of American railroads, which, in turn, will compare just as 
favorably with those of the world. 
Yet there are many things pertaining to the sanitary interest of our passenger coaches 
which can still be very much improved upon, and if this investigation, crude and 
imperfect as it was, will only be the means of calling attention to and remedying any 
one of these sanitary imperfections, I will feel that I am amply paid for all my trouble, 
and that my labors in this direction have not been in vain. 
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TEMPERATURE CHART NO. 1, FAHRENHEIT'S SCALE. 
562 Dec. 29th. 
P.M. 
c. c. c. 
&I. 
84 
Wagner's 
Sleeper 
Baker's 
Drop Sash 
22 
above ° 
47 
55 
47 
69 
70 
64 
66 65 66 
66 65;77 
66 
70 
64 
66 
66 
64 
4 
12 
5 
14 
66 
70 
68 
65 
66 
64 
64 
64 
63 
66 
68 
64 
66 
69 
67 
M 
69 
68 
2 
6 
5 
58 
57 
56 
56 
57 
51 
16 
Cloudy and 
Cold. 
Easterly 
North 
64 
69 
68 
Dec. 29th. 
c. c. c. 
301 
Smoker 
Baker's 
None 
22 
66 
82 
80 
88 
86 
86 
88 
8 
82 
82 
84 
84 
85 
84 
3 
70 
71 
72 
74 
74 
75 
18 
Cloudy and 
Easterly 
North 
P.M. 
♦ I. 
above ° 
66 
86 
86 
87 
88 
87 
87 
2 
80 
80 
78 
80 
80 
79 
2 
Cold. 
64 
86 
86 
86 
86 
86 
86 
0 
13 
76 
76 
76 
75 
76 
78 
3 
Dec. 29th. 
C. C.C. 
346 
Ladies' 
Baker's 
Transoms 
18 
59 
77 
76 
76 
75 
75 
77 
2 
78 
74 
76 
76 
76 
74 
4 
68 
66 
65 
66 
65 
67 
12 
Cloudy and 
Easterly 
North 
P.M. 
&I. 
at both 
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56 
74 
73 
71 
72 
71 
72 
3 
73 
71 
72 
74 
75 
71 
4 
Cold. 
ends of car 
52 
70 
68 
68 
70 
69 
68 
2 
10 
74 
72 
74 
77 
74 
72 
5 
1887. 
Mar. 28th. 
Pan 
51 
Smoker 
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Side Sash 
30 
41 
71 
69 
69 
68 
68 
69 
3 
76 
75 
81 
78 
76 
75 
6 
60 
60 
59 
59 
60 
59 
13 
Cloudy with 
Northerly 
East 
A.M. 
H ndle 
above ° 
37 
67 
65 
67 
66 
66 
66 
2 
Raw Wind 
37 
67 
64 
66 
65 
64 
66 
3 
42 
68 
68 
72 
70 
68 
68 
4 
17 
Mar. 28th. 
Pan 
36 
Ladies' 
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30 
50 
80 
76 
74 
80 
74 
80 
6 
76 
74 
74 
81 
74 
80 
7 
65 
66 
65 
70 
64 
72 
16 
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Northerly 
East 
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Handle 
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48 
74 
72 
72 
78 
70 
75 
8 
76 
71 
70 
76 
76 
74 
6 
Windy 
Stove 
46 
72 
70 
72 
76 
71 
73 
6 
11 
74 
72 
72 
76 
70 
75 
6 
Mar. 28th. 
Pan 
53 
Ladies' 
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30 
47 
72 
73 
75 
77 
73 
75 
5 
76 
76 
78 
79 
74 
77 
5 
62 
61 
67 
65 
65 
66 
16 
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East 
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50 
76 
74 
76 
78 
74 
80 
6 
74 
74 
76 
78 
72 
76 
6 
Stove 
48 
71 
74 
76 
78 
73 
74 
5 
78 
77 
Ï 6 
so 
76 
so 
4 
50 
76 
75 
78 
80 
76 
76 
5 
8 
76 
75 
76 
78 
76 
76 
3 
Mar. 28th. 
Pan 
319 
Sleeper 
Baker's 
Drop Sash 
27 
37 
64 
64 
62 
62 
64 
14 
20 
65 
61 
64 
65 
65 
44 
21 
55 
56 
56 
57 
56 
40 
29 
Blowing and 
Northerly 
East 
P.M. 
Handle 
above0 
42 
67 
69 
67 
66 
67 
42 
27 
68 
70 
68 
6S 
67 
43 
27 
Snowing 
40 
67 
66 
66 
67 
66 
41 
26 
29 
Mar. 28th. 
Pan 
406 
Sleeper 
Baker's 
Drop Sash 
28 
40 
62 
68 
58 
62 
64 
52 
16 
62 
66 
68 
69 
62 
53 
16 
51 
53 
50 
54 
55 
50 
18 
Blowingand 
Northerly 
East 
P M. 
Handle 
above ° 
40 
62 
62 
68 
60 
62 
52 
16 
Snowing 
39 
63 
62 
67 
58 
62 
52 
15 
17 
Mar. 28th. 
Pan 
392 
Sleeper 
Baker's 
Drop Sash 
28 
38 
58 
61 
66 
62 
58 
54 
12 
58 
60 
62 
62 
67 
53 
14 
19 
50 
51 
50 
48 
44 
22 
Blowingand 
Northerly 
East 
P.M. 
Handle 
above ° 
38 
58 
60 
62 
66 
58 
40 
26 
27 
60 
60 
62 
63 
67 
55 
12 
Snowing 
Mar. 29th. 
Fort 
"Metis" 
Sleeper 
Baker's 
Drop Sash 
12 
48 
60 
56 
55 
56 
53 
59 
.7 
63 
54 
55 
56 
54 
57 
9 
49 
51 
52 
50 
57 
50 
12 
Blowingand 
N.W. 
West 
A.M. 
Wayne 
above0 
49 
61 
57 
56 
56 
52 
59 
9 
Snowing 
49 
61 
56 
56 
51 
51 
59 
7 
11 
Mar. 29th. 
Fort 
383 
Sleeper 
Baker's 
Drop Sash 
12 
55 
67 
65 
50 
62 
61 
62 
17 
60 
62 
56 
60 
58 
58 
6 
56 
55 
11 
50 
51 
52 
30 
Blowing and 
N. W. 
West 
A.M. 
Wayne 
above ° 
58 
69 
70 
54 
63 
62 
64 
16 
65 
61 
50 
60 
60 
60 
15 
Snowing 
59 
71170 
54 
64 
62 
64 
17 
21 
67 
67 
52 
64 
62 
63 
15 
Mar. 29th. 
Fort 
291 
Sleeper 
Baker's 
Drop Sash 
13 
51 
60 62 
62 
64 
62 
44 
20 
62 
62 
62 
64 
60 
44 
20 
50 
51 
51 
53 
50 
39 
27 
Blowingand 
N.W. 
West 
A.M. 
Wayne 
above ° 
52 
60 64 
65 
65 
62 
18 
17 
64 
64 
60 66 
62 
52 
14 
Snowing 
53 
64 66 
65 
66 
61 
46 
20 
61 
62 
63 64 
62 
44 
20 
51 
60160 62 
64 
62 
50 
14 
22 
68 
65 
64165 
65 
46 
19 
563 July 20th, 
July 20th, 
P.M. 
July 20th, 
P.M. 
July 20th, 
M. 
July 20th, 
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CO 00 
bP CD 
standing. 
CO 
© 
bP 
© 
1st. 
© 
© 
© 
3 
2d. 
Temperature taken at bot- 
Cn 
© 
© 
3d. 
tom of car, while running, at 
six different relative points. 
© 
3 
4th. 
© 
X 
© 
3 
5th. 
© 
© 
6th. 
Difference between ex- 
tremes of temperature at bot- 
tom of car and level of the 
head, while sitting in a run- 
ning car. 
eo 
02 
o 
3 
® 
* 3 
p's 
ST 
p 
"S 
rtf 
p 
5* 
p 
-s 
2 
■ 
*1 
X 
o 
1 
s' 
CO 
o' 
S 
lowingai 
Snowing 
Kind of Weather. 
I 
&> 
!?! 
« 
* 
® 
fl? 
® 
Direction of the Wind. 
00 
e* 
00 
e* 
CD 
•d 
B 
M 
8 
oo 
CO 
di 
General direction the train 
® 
p 
m 
S 
® 
■ 
e* 
was running. 
TEMPERATURE CHART NO. 1, FAHRENHEIT'S SCALE.-Continued. 
564 CHART NO. 2. 
A TABLE SHOWING THE GENERAL SANITARY CONDITION OF THIRTY PASSENGER CARS INSPECTED. 
1st. 
2d. 
3d. 
4th. 
5th. 
6th. 
7th. 
8th. 
9th. 
10th. 
11th. 
12th. 
13th. 
14th. 
15th. 
16th. 
17th. 
18th. 
19th. 
20th. 
21st. 
22d. 
23d. 
24th. 
25th. 
26th. 
27th. 
28 th. 
29 th. 
30th. 
General Remarks. 
Name of the Railroad 
C. C. C. 
C. C. C. 
C. C. C. 
c. c. c. 
c. c. c. 
ctcua 
c. c.c 
c. c. c. 
c. c. c. 
C. C. C. 
C. C. C. 
C. C. C. 
Pan 
Pan 
Pan 
Pan 
Pan 
Pan 
Ft. 
Ft. 
Ft. 
Ft. 
Ft. 
Ft. 
Wayne. 
B. & O. 
- 
Number of the Car 
& 1. 
355 
& I. 
148 
& I. 
42 
Wagner 
A I. 
146 
&I. 
346 
Al. 
& 1. 
153 
A I. 
356 
&I. 
40 
& I. 
84 
& I. 
301 
& I. 
346 
Handle. 
51 
Handle. 
36 
Handle. 
Handle. 
319 
Handle. 
406 
Handle. 
392 
Wayne. 
" Metis." 
Wayne. 
Wayne. 
Wayne. 
Wayne. 
B. AO. 
B. A (). 
B. & O. 
B. & O. 
B. A O. 
Kind of Car 
53 
383 
291 
26 
16 
38 
457 
453 
469 
431 
505 
350 
Ladies'. 
Smoker. 
Smoker. 
Ladies'. 
»V agyer 
Smoker. 
Ladies'. 
Sleeper. 
Sleeper 
Smoker. 
Ladies'. 
Smoker. 
Ladies'. 
Ladies'. 
Sleeper. 
Sleeper. 
Sleeper. 
Sleeper. 
Sleeper. 
Sleeper. 
Ladies'. 
Ladies'. 
Smoker. 
Smoker. 
Sleeper. 
Sleeper. 
Ladies'. 
Ladies'. 
Ladies'. 
Sleeper. 
July 20, 
1887. 
Ladies'. 
Date of Inspection 
Dec. 16, 
Dec. 16, 
Dee. 16, 
Dec. 16, 
Dec. 16, 
Dec. 16, 
Dec. 29, 
Dec. 29, 
Dec. 29, 
Dec. 29, 
Dec. 29, 
Dec. 29, 
March 28, 
March 28, 
March 28, 
March 28, 
March 28, 
1887. 
March 28, 
1887. 
March 29, 
March 29, 
1887. 
March 29. 
1887. 
March 29, 
1887. 
March 29, 
1887. 
July 20, 
1887. 
July 20, 
1887. 
July 20, 
1887. 
July 20, 
1887. 
July 20, 
1887. 
1886. 
1886. 
1886. 
1886. 
1886. 
1886. 
1886. 
1886. 
1886. 
1886. 
1886. 
1886. 
1887. 
1887. 
1887. 
1887. 
1887. 
1887. 
A.-Protection against Emergencies. 
1. Is there an air-brake attachment?. 
Yes 
Yes 
Yes. 
Yes. 
Yes. 
Y'es. 
Yes. 
Yes. 
Yes. 
Yes. 
Yes. 
Yes. 
Yes. 
Yes. 
Yes. 
Yes. 
Yes. 
Yes. 
Yes. 
Yes. 
Yes. 
Yes. 
Yes. 
No. 
This has reference 
to a special air- 
No. 
No. 
No. 
No. 
Yes. 
brake attachment to 
2. Is a tool box carried? 
3. Are fire extinguishers carried? 
Yes. 
Y es. 
Yes. 
No. 
Yes. 
Yes. 
Yes. 
Yes. 
Yes. 
Yes 
Yes. 
No. 
No. 
Yes. 
Yes 
Yes. 
Yes. 
Y'es. 
Y'es. 
No. 
Yes. 
Yes. 
No. 
Yes. 
Yes. 
Yes. 
Yes. 
Yes. 
Yes. 
Yes. 
Yes. 
No. 
Yes. 
Yes. 
No. 
Yes. 
Yes. 
No. 
Yes. 
No. 
Yes. 
Yes. 
Yes. 
Yes. 
Yes. 
Yes. 
Yes. 
Yes. 
Yes. 
No. 
No. 
Yes. 
No. 
Yes. 
Yes. 
Yes. 
Yes. 
No. 
No. 
No. 
Yes. 
Yes. 
Yes. 
Yes. 
Yes. 
Yes. 
each car. 
4. Are water buckets carried? 
No. 
No. 
Yes. 
Yes. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
Yes. 
No. 
Yes. 
No. 
Yes. 
No. 
Yes. 
No. 
Yes. 
No. 
Yes. 
B.-Artificial Lighting of the Car. 
1. Are candles used ? 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
Candles are sei- 
No. 
No. 
No. 
No. 
No. 
dom used on first- 
2. Are lamps used ? 
Yes. 
Yes. 
Yes. 
Yes. 
Yes. 
Yes. 
Yes, 
Yes. 
Yes. 
Yes. 
Yes. 
Yes. 
Yes. 
Yes. 
Yes. 
Yes. 
Yes. 
Yes. 
Yes. 
Yes. 
Yes. 
class trains. 
Yes. 
Yes 
Yes. 
Yes. 
Yes. 
Yes. 
Yes. 
Yes. 
3. Is gas used 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
Gas was used a 
No. 
No. 
No. 
No. 
No. 
No. 
few years ago on the 
Penn'a Road. 
C.-Toilets. Gentlemen's Toilet, or in com- 
mon use, for both Sexes. 
1. Is there a toilet attachment to the car? 
No. 
No. 
Yes. 
No. 
Yes. 
Y>s. 
5 ts. 
Pipe. 
Marble. 
Cleian. 
Roller 
No. 
Yes. 
Yes. 
Yes. 
No. 
Yes. 
No. 
No. 
No. 
Yes. 
Yes. 
Yes. 
Yes. 
Yes. 
Yes. 
No. 
No. 
No. 
This has reference 
Yes. 
No. 
No. 
No. 
Yes. 
No. 
to a washstand in 
2. Is it ventilated? 
3. How is it ventilated? 
Yes.* 
Pipe. 
None. 
None. 
Yes* 
Pipe. 
None. 
None. 
Yes. 
Pipe. 
Marble. 
Clean. 
Roller 
and indi- 
vidual. 
No. 
No. 
Yes.* 
Pipe. 
None. 
None. 
Yes. 
Pipe. 
Marble. 
Clean. 
Roller. 
Yes. 
Drop. 
Marble. 
Clean. 
Indi- 
Yes. 
Drop. 
Marble. 
Clean. 
Indi- 
Yes* 
Pipe. 
None. 
None. 
No. 
No. 
Yes.* 
Pipe. 
None. 
None. 
Yes.* 
Pipe. 
None. 
None. 
Yes. 
Drop. 
Marble. 
Clean. 
Indi- 
Yes. 
Yes. 
Drop. 
Marble. 
Clean. 
Single. 
Yes. 
Drop. 
Marble. 
Fair. 
Roller 
and indi- 
vidual. 
Yes. 
Drop. 
Marble. 
Clean. 
Roller 
and indi- 
vidual. 
Yes. 
Yes. 
Yes.* 
Yes.* 
Yes* 
Yes.* 
Yes* 
Yes* 
Yes. 
Yes* 
addition to a closet. 
4. What kind of washstand is used? 
5. In what condition is it? 
G. What kind of towels are supplied ? 
Marble. 
Medium. 
Roller. 
Marble. 
Medium. 
Roller. 
None. 
None. 
Drop. 
Marble. 
Medium. 
Indi- 
Drop. 
Marble. 
Clean. 
Roller 
and indi- 
vidual. 
Pipe. 
Marble. 
Dirty. 
Pipe. 
None. 
Pipe. 
None. 
Pipe. 
None. 
Pi pe. 
None. 
Pipe. 
None. 
Pipe. 
None. 
Drop. 
Marble. 
Clean. 
Roller 
Pipe. 
None. 
sin 
Igle. 
vidual. 
vidual. 
vidual. 
vidual. 
Roller. 
None. 
None. 
None 
None. 
None. 
None. 
and indi- 
vidual. 
None. 
7. In what condition are they ? 
Clean. 
Dirty. 
Cl 
e!an. 
Medium. 
Clean. 
Clean. 
Medium. 
Clean. 
Clean. 
Clean. 
Clean. 
Clean. 
Dirty. 
dirty. 
Clean. 
8. What kind of water tank is used? 
Zinc. 
Zinc. 
Zinc. 
Zinc. 
Zinc. 
Zinc. 
Zinc. 
Zinc. 
Zinc. 
Zinc. 
Zinc. 
Zinc. 
Zinc. 
Zinc ; 
filled at 
Zinc. 
Zinc. 
Zinc. 
Zinc. 
Zinc. 
Zinc. 
Zinc ; 
filled at 
Zinc ; 
filled at 
Zinc ; 
Porcelain 
This only refers 
to the tanks for 
filled at 
Zinc. 
Zinc. 
Zinc. 
Zinc. 
Zinc. 
1 
top of car. 
top of car. 
top of car. 
top of car. 
lined. 
carrying drinking 
water. 
9. In what condition is it? 
Clean. 
Clean. 
Clean. 
Medium. 
Clean. 
Medium. 
Clean. 
Dirty. 
Medium. 
Medium. 
Medium. 
Medium. 
Medium. 
Medium. 
Dirty. 
Clean. 
Clean. 
Dirty. 
Dirty. 
Medium. 
Clean. 
Medium. 
Clean. 
Clean. 
Clean. 
Clean. 
10. What kind of hopper is used? 
Porcelain. 
Porcelain. 
Porcelain. 
Porcelain. 
Porcelain. 
telain. 
Porcelain. 
Porcelain. 
Porcelain 
Porcelain. 
Porcelain. 
Porcelain. 
Porcelain. 
Porcelain. 
Porcelain. 
Porcelain. 
Porcelain. 
Porcelain. 
Porcelain. 
Porcelain. 
Porcelain. 
Porcelain. 
Porcelain. 
11. Is it ventilated? 
and iron. 
Porcelain. 
Porcelain. 
Porcelain. 
Porcelain. 
Porcelain. 
Porcelain. 
Porcelain. 
No. 
No. 
Yes. 
Yes. 
No. 
No. 
No. 
No. 
Yes. 
No. 
No. 
No. 
No. 
No. 
Yes. 
Yes. 
Yes. 
Yes. 
No. 
No. 
No. 
Yes. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
12. Tn what condition is it? 
Clean. 
Medium. 
Clean. 
Dirty. 
Clean. 
Clean. 
Clean. 
Dirty. 
Clean. 
Clean. 
Medium. 
Very 
Dirty. 
Dirty. 
Dirty. 
Dirty. 
Clean. 
Dirty. 
Clean. 
Dirty. 
Clean. 
Clean. 
13. What kind of urinal is used ? 
14. Is it ventilated? 
dirty. 
Clean. 
Clean. 
Clean. 
Porcelain. 
No. 
Metallic. 
No. 
Porcelain. 
Yes. 
Porcelain. 
No. 
Porcelain 
No. 
Pore 
Y 
plain, 
es. 
Porcelain. 
No. 
Porcelain. 
Yes. 
Porcelain. 
Yes. 
Porcelain. 
Yes. 
Porcelain. 
No. 
Porcelain. 
No. 
Porcelain. 
No. 
Porcelain. 
No. 
Porcelain. 
No. 
Porcelain. 
Yes. 
Porcelain. 
Yes. 
Clean. 
Porcelain. 
Clean. 
Yes. 
Porcelain. 
Yes. 
Clean. 
Porcelain. 
Clean. 
Yes. 
Porcelain. 
Yes 
Porcelain. 
Yes 
Porcelain. 
Yes. 
Medium. 
Porcelain. 
Dirty. 
Porcelain. 
No. 
Dirty. 
Porcelain. 
Dirty. 
Porcelain. 
No. 
Clean. 
Porcelain. 
Clean. 
Porcelain. 
No. 
Clean. 
Porcelain. 
Dirty. 
Porcelain. 
No. 
Clean. 
Porcelain. 
Medium. 
Porcelain. 
No. 
Clean. 
Porcelain. 
Dirty. 
Porcelain. 
No. 
Clean. 
Porcelain. 
Clean. 
Porcelain. 
Porcelain. 
Porcelain. 
10. What kind of drip to urinal? 
17. In what condition is it? 
18. Are disinfectants used 
Medium. 
Porcelain. 
Medium. 
Yes. 
Dirty. 
Metallic. 
Dirty. 
No. 
Clean. 
Copper. 
Clean. 
Yes. 
Filthy. 
Zinc. 
Dirty. 
No. 
Medium. 
Zinc. 
Medium. 
No. 
Cl 
Pore 
Clt 
Jan. 
elain. 
Jan. 
es. 
Filthy. 
Zinc. 
Filthy. 
Yes. 
Clean. 
Porcelain. 
Medium. 
Yes. 
Clean. 
Copper. 
Clean. 
Yes. 
Medium. 
Porcelain. 
Medium. 
Yes. 
Clean. 
None. 
No. 
Medium. 
Zinc. 
Dirty. 
No. 
Medium. 
Porcelain. 
Dirty. 
In 
Medium. 
Porcelain. 
Medium. 
No. 
Clean. 
Porcelain. 
Dh ty. 
No. 
Clean. 
Porcelain. 
Clean. 
Clean. 
Porcelain. 
Clean. 
Yes. 
Clean. 
Porcelain. 
Medium. 
No. 
Clean. 
Porcelain. 
Dirty. 
No. 
Clean. 
Porcelain. 
Clean. 
No. 
Clean. 
Porcelain. 
Clean. 
summer. 
Yes. 
No. 
Yes. 
Yes. 
Yes. 
Yes. 
Yes. 
Yes. 
Yes. 
Yes. 
Yes. 
Camphor 
Yes. 
19. What kind? 
Carbolic 
Lit 
nid. 
Carbolic 
Carbolic 
Liquid. 
Granules. 
Ice. 
"Star." 
"Star." 
" Star." 
"Star." 
"Star." 
Ice. 
Ice. 
20. How often? 
soap. 
Daily. 
No. 
Daily. 
No. 
soap. 
soap. 
Ice. 
Ice. 
Ice. 
Ice. 
Ice. 
Ice. 
Da 
b 
ily. 
io. 
Daily. 
Yes. 
Daily. 
Yes". 
Daily. 
No. 
Daily. 
No. 
Daily. 
Yes. 
Daily. 
No. 
Daily. 
No. 
Daily. 
No. 
Daily. 
Yes. 
Daily. 
Daily. 
Daily. 
Ice. 
21. Is there any smell? 
Yes. 
Yes. 
Slight. 
Yes. 
Yes. 
Yes. 
Urinal 
and 
hopper. 
No. 
Yes. 
Slight. 
Daily. 
Daily. 
Daily. 
Daily. 
Daily. 
Yes. 
Daily. 
No. 
Daily. 
No? 
No. 
Yes. 
Slight. 
Yes. 
Slight, 
Yes. 
No. 
22. From what cause ? 
Urinal. 
Urinal. 
Urinal. 
Drip. 
Urinal. 
Urinal. 
Drip and 
urinal. 
Drip. 
Urinal. 
Urinal. 
General. 
Urinal. 
General. 
Urinal. 
Urinal. 
Drip. 
Drip. 
23. Is the toilet carpeted? 
No. 
Yes. 
No. 
No. 
y 
es. 
No. 
No. 
Yes. 
Yes. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
Yes. 
No. 
Ladies' Toilet. 
1. Is it ventilated 
Yea 
Yes. 
Pipe. 
Marble. 
Clean. 
Yes. 
Pipe. 
Marble. 
Clean. 
Yes. 
Pipe. 
Marble. 
Clean. 
Yes. 
Yes. 
Yes. 
2. How is it ventilated? 
Pipe. 
Marble. 
Clean. 
P 
Ma 
Cl 
Yes. 
Pipe. 
Yes. 
Yes. 
3. What kind of washstand is used? 
rble. 
ean. 
Pipe. 
Pipe. 
Drop. 
Pipe. 
Pipe. 
Marble. 
4. In what condition is it? 
Marble. 
Marble. 
Marble. 
Marble. 
Marble. 
Clean. 
Clean. 
Clean. 
Clean. 
Clean. 
5. What kind of towels are supplied ? 
Indi- 
vidual. 
Sii 
igle. 
Indi- 
vidual. 
Indi- 
vidual. 
Indi- 
vidual. 
Indi- 
vidual. 
Indi- 
vidual. 
Roller 
and indi- 
Roller 
and indi- 
Indi- 
vidual. 
Roller 
and indi- 
6. In what condition are they? 
Clean. 
Cl 
ean. 
Clean. 
Clean. 
Clean. 
Clean. 
Clean. 
vidual. 
vidual. 
. * 
Clean. 
Clean. 
Clean. 
Clean. 
7. What kind of water tank? 
<x> 
Zinc. 
z 
"o 
Zinc. 
Zinc. 
2 
'S 
Zinc. 
Zinc. 
Zinc. 
<D 
CD 
0) 
This only refers 
o 
o 
o 
o 
Zinc. 
Zinc. 
Zinc. 
- 
Double 
to the t a n k s for 
8. In what condition is it? 
H 
H 
o 
H 
o 
H 
H 
top ; zinc. 
o 
carrying drinking 
00 
Clean. 
Cl 
ean. 
Clean. 
Clean. 
Clean. 
Clean. 
Clean. 
Clean. 
*co 
» 
Id 
water. 
o 
<D 
<D 
a> 
<x> 
Clean. 
Clean. 
CO 
CO 
« 
<x> 
Clean. 
9. What kind of hopper is used? 
'Ö 
Porcelain. 
Yes 
T5 
Port 
elain. 
To. 
ean. 
res. 
Porcelain. 
No. 
Clean. 
Yes. 
Porcelain. 
Yes. 
Medium. 
Yes. 
i-l 
r-* 
Porcelain. 
Pan 
hopper. 
Porcelain. 
10. Is it ventilated ? 
J 
(3 
3 
c3 
CÖ 
Q 
CÔ 
CÖ 
CS 
Porcelain. 
Porcelain. 
Porcelain. 
Is 
8 
o 
ft 
a 
►-4 
o 
ft 
i 
o 
ft 
03 
Porcelain. 
8 
h-1 
o 
ft 
11. In what condition is it? 
12. Are disinfectants used? 
A 
A 
Clean. 
Yes. 
A 
o 
£ 
ci 
I 
o 
o 
ft 
o 
ft 
o 
ft 
o 
ft 
o 
o 
Yes. 
Clean. 
No. 
Clean. 
les. 
Clean. 
Yes. 
Clean. 
Yes. 
Clean. 
Yes. 
Dirty. 
o 
ft 
o 
ft 
o 
No. 
Clean. 
13. What kind? 
No. 
Yes. 
" Star. 
No. 
No. 
Yes. 
Yes. 
Lit 
uid. 
Liquid. 
Crane's. 
Camphor 
" Star." 
"Star." 
14 How often ? 
Daily. 
No. 
lily. 
Io. 
Dailv. 
No. 
Daily. 
No. 
Daily. 
Ice 
15 Is there any smell ? 
No. 
Daily. 
Daily. 
Daily. 
No. 
16 From what cause ? 
No. 
No. 
No. 
No. 
No. 
17. Is the toilet carpeted ? 
Yes. 
I 
jE 
Yes. 
Yes. 
Yes. 
Yes. 
Yes. 
- 
- 
- 
- 
- 
- 
Yes. 
Yes. 
Yes. 
Yes. SECTION XV PUBLIC AND INTERNATIONAL HYGIENE. 
565 
DISCUSSION. 
Dr. A. N. Bell, of New York.-In traveling on railroads I always keep my eyes 
about me, to find out what can be seen. In traveling once, my wife was wi me, 
we stopped at a small village, not the regular place for supplying the water tanks 
in the sleepers. I saw one of the porters go out and fill bucket after bucket, and 
empty them into our drinking-water tank, from a foul and filthy little rivulet carrying 
the drainage and sewerage from some of the houses of the hamlet. I am in favor 
of this most important matter being brought to the attention of our legislators, 
as well as the criminal carelessness with which the modern railroad is conducted, 
resulting in disease and deaths, whose numbers are appalling. 
Dr. Scott, of Cleveland, Ohio.-This subject is of vast and national importance. 
I have traveled on cars to a considerable extent, and generally notice what is going 
on. I have seen soiled baby's diapers thrown into the water tank, i. e., not seen 
them thrown in, but found them there. The privies on the cars, and especially in 
some of the stations, notably Pittsburg, are filthy beyond conception. A man may 
carry home the seeds of lifelong infection from these sources. The use of the roller 
towel is abominable ; individual towels should invariably be furnished and the other 
abolished. With regard to air-brakes, their day has nearly passed we must have 
an automatic brake. In coming down the mountain the other day, it was desired to 
stop the train at a certain point in order to allow the passengers to see some object 
of interest ; the engineer found that the air-brakes would not work, and he could not 
check the train at the desired point. If this had been a sôo/Ze-track road and another 
train approaching, we would, in all probability, have been hurled down a precipice 
one hundred feet high. This matter should be prominently agitated until some safe 
and reliable brake can be adopted. 
THE HISTORY, PRACTICAL APPLICATION AND EFFICIENCY OF 
STEAM AS A DISINFECTANT. 
L'HISTOIRE, L'APPLICATION PRATIQUE ET L'EFFICACITE DE LA VAPEUR 
COMME DESINFECTANT. 
DIE GESCHICHTE, PRAKTISCHE ANWENDUNG UND WIRKSAMKEIT DES DAMPFES ALS 
DESINFEKTIONSMITTEL. 
BY A. N. BELL, A.M., M.D., 
Of Brooklyn, N. Y. 
The occurrence and attending circumstances of my first knowledge of the practical 
application of steam as a disinfectant have been already published, but under such 
limitations as to abundantly j ustify the following synopsis in connection with more 
recent observations. 
While I was an assistant surgeon in the Navy, and in service in the Gulf Squadron 
during the epidemic of yellow fever which prevailed there during the summer and 
autumn of 1847, the United States steamer " Vixen " was one of the earliest infected 
vessels of the fleet. Being of small draft she had been chiefly confined to the coast 
and river service in the war with Mexico, and was, consequently, filthy and infested 566 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
with cockroaches and other vermin. I first joined the " Vixen" in December of that 
year. 
During the season of the " northers " there was a cessation of yellow fever, though 
there was a continuous large sick list composed of tedious convalescents and frequently 
recurring febrile complaints. On the return of hot weather in the following May 
(1848), and in anticipation of an early recurrence of yellow fever in our then condi- 
tion, it became expedient to break out as far as practicable while in service, and paint 
ship. Preliminary to this proceeding, on the suggestion of the commander, the late 
Jas. E. Ward, Esq., a final effort was determined upon to destroy the vermin with 
steam. Everything thought to be susceptible of injury by its use was taken on deck, 
the hatchways were carefully closed and covered with tarpaulins, with opening for the 
passage of a leather hose only, connected with the steam-cock of the boiler. Steam was 
turned on and continuously poured in below decks for about two hours, until the 
leather hose in immediate connection with the coupling could be no longer maintained. 
On removing the hatch coverings there was a forcible, gush of steam, but not scalding 
hot, and the first surprising effect noticeable on going below was the complete dryness 
of all the exposed surfaces; not a particle of moisture remained. Some of the thinner 
bulkheads were cracked, and the paint on them generally blistered; and the lower deck 
was covered with dead cockroaches, aZZ, apparently, driven from their hiding places to 
die in the "country." The steam had driven them from their inmost recesses-had 
penetrated every crevice. Having no registering thermometers, these were the only 
evidences of high temperature. After this there was a thorough scraping and painting 
and an abundant use of whitewash on all rough surfaces, both above and below decks. 
From this time forward to the end of the cruise there was a decided improvement in 
the health of the crew-no more fever cases occurred ; indeed, so complete was the 
change in the health of the crew (of about sixty), three weeks subsequently, that there 
was no sick list. The inference was manifest. 
About one month subsequent to the steaming of the "Vixen," the gunboat " Ma- 
hones," Lieutenant Commander Wm. D. Porter, returned from a surveying expedi- 
tion up the Tuxpan river, and made signal for my services. (I was the only medical 
officer at the time attached to a gunboat squad off the mouth of the Tuxpan river. ) 
There I found three cases of yellow fever, and within a few days four additional, out of 
a crew of eighteen. The "Mahones" was a vessel captured from the Mexicans, had 
never been off the coast,' was old and in rotting condition, and evidently had never 
been cleansed from the time she was launched ; she was filthy in the extreme, and, like 
the "Vixen," was, before steaming, infested with vermin. The salutary effect of the 
steaming of the "Vixen " was so apparent that I at once advised it for the " Mahones," 
and it was forthwith applied by bringing her alongside, and by means of the ' ' Vixen's ' ' 
engine, steam was injected and kept up for about two hours; and, as in the first case, 
vermin and fever were both destroyed. 
These vessels continued in service in the vicinity of Vera Cruz until early in the 
following July, when they proceeded to Norfolk, Va., where they arrived in the height 
of hot weather. After three weeks, the "Vixen" was transferred to Coast Survey 
Service in the Chesapeake Bay for the remainder of the summer. The "Mahones" 
was found to be unseaworthy ; she was laid up at the Portsmouth Navy Yard during 
the summer, and subsequently sold and broken up as refuse. In neither of these ves- 
sels was there any return of the fever subsequent to having been steamed. 
About the same time that the "Vixen " and " Mahones " arrived at Norfolk, the 
Frigate "Cumberland" and the Steamer "Scorpion," arrived at New York. The 
"Scorpion" was at once put in quarantine, on account of recent cases of yellow fever 
on board ; and the "Cumberland " not having had any cases since the previous sum- 
mer, was, after a few days' detention, permitted to go up to the Navy Yard, but at the SECTION XV PUBLIC AND INTERNATIONAL HYGIENE. 
567 
very beginning of the work of " breaking out " and the exposure of new hands, yellow 
fever appeared ; she was placed in quarantine, and there kept until November follow- 
ing. 
The "Cumberland " and " Scorpion " were of the same squadron as the " Vixen" 
and '1 Mahones, ' ' but were more commodious, better ventilated, more easily kept in 
cleanly condition and, apparently, in every respect in a more healthful condition than 
either the " Vixen" or "Mahones," except that they had not been steamed. 
The next application of this knowledge with which I am acquainted was by the late 
Elisha Harris, M. d. , at the time of his death Secretary of the State Board of Health of 
New York, whose active cooperation I had in the care of yellow fever patients at Bay 
Ridge and at Fort Hamilton, in 1856, and who was at the time Physician in Chief of 
the Quarantine Hospital. He had occasion to observe the danger of yellow fever to the 
women who washed the clothing from hospital patients and infected vessels in the 
ordinary way. I had related to him my observations on the use of steam and sug- 
gested its adoption. Under his direction steam tubs for boiling, and a steam-heated 
chamber for drying the clothing were introduced, with the result of wholly preventing 
any further recurrence of the disease among the washerwomen. 
Again in 1859, after the quarantine structures on Staten Island had been destroyed, 
and the practice of burning all clothing, bedding etc., from infected vessels, in an iron 
scow in the open bay, by the direction of the Health Officer at that time, a ' ' floating 
hospital ' ' was provided, consisting of the hulk of an old steamboat without fitting, 
anchored in the lower bay awaiting the arrival of patients. Fortunately, Dr. Harris 
was placed in charge. Proper protection of the washerwomen and other employés was 
his first consideration. A copper steam generator, capacious steam vats and wash- 
tubs were erected on the projecting framework of one of the side wheels. Into the vats 
every infected article of clothing and all hospital bedding worth preserving were 
thrown. All articles from infected vessels were received directly from the boats into 
the steam chamber, without exposing the hospital ship or any of its inmates to the 
danger of contact. And from the hospital wards, every article of soiled clothing or bed- 
ding, as soon as soiled, was at once removed and thrown into the steam vats, and there 
immediately subjected to the highest degree of steam heat of which the apparatus was 
capable.* Successors to Dr. Harris in the same service, myself among the number, 
practiced the same means for fourteen years, 1856 to 1869, during the whole period from 
the time it was first introduced to the time when the floating hospital for the care of 
infectious diseases in the lower bay of New York was discontinued ; and, so far as I 
have been able to learn, without the communication of a single case of infectious dis- 
ease to any inmate. Among the first acts of my official connection with the New York 
Quarantine, in 1870, was to have constructed a steam disinfecting chamber and vat, in 
connection with the Hospital. 
While myself in charge of the Floating Hospital, during the first summer of the 
War, 1862, of all the infected vessels that arrived at the Port of New York, the Quar- 
termaster's Steamer "Delaware" was probably the worst; at any rate, the malig- 
nancy of the fever from that vessel was greater than that from any other. The ' ' Dela- 
ware ' ' had proceeded from the Tortugas in the early part of August, with invalid sol- 
diers on board, stopped at Key West, Fernandina, St. Augustine and Port Royal, where, 
in consequence of having yellow fever on board, she was kept in quarantine twelve 
days, and then sent to New York. She arrived there September 21st, having lost one 
man with the fever on the passage from Port Royal. On arrival, her Commander, Cap- 
tain James S. Cannon, and two of the crew were sent to the floating hospital, and with- 
in five days afterward seven of the invalid soldiers, all well marked cases of yellow 
* Fourth National Quarantine and Sanitary Convention, Boston, 1860, p. 224. 568 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
fever, and some of them so malignant as to have hlack vomit supervene within a few 
hours from the time of attack and to die within forty-eight hours. One died on board 
the "Delaware" within 24 hours, his case being so malignant that the boarding offi- 
cer deemed it useless to transfer him. In this state of affairs, at my urgent request, 
the remainder of the invalid soldiers (18), were transferred to the (yellow fever) float- 
ing hospital, for safety. They all escaped the disease ; and I have not the least doubt 
that if all the soldiers had been removed immediately on arrival, several lives might 
have been saved instead of lost by depending upon the effects of " fumigation." During 
the convalescence of Captain Cannon, I recommended to him the use of steam for the 
purpose of effectually disinfecting his vessel. I subsequently received the following 
letter :- 
U. S. Transport " Delaware," New York, November 30th, 1862. 
Dr. Bell:- 
Dear Sir-During my confinement in Quarantine Hospital with yellow fever, last summer, 
you suggested the idea of disinfecting my vessel by steam. In accordance with the suggestion, 
before my recovery the engineer steamed the lower cabin, where nearly all the sick had been con- 
fined. After my recovery I more effectually steamed the vessel by closing her up below and 
driving the steam through her lower hold and bilges. This I did by attaching a hose to the 
boiler and leading it below through an aperture left for that purpose. Although we remained 
in quarantine three weeks after the first steaming, we had no sickness among a crew of twenty 
persons ; and since that time the steamer " Delaware " has been in a perfectly healthy state. 
After refitting, the "Delaware " was sent to Port Royal with soldiers and encountered a heavy 
gale; of course everything was damp, but no sickness occurred on board and the troops remained 
perfectly healthy after landing. On my return, over a hundred invalid soldiers came North 
with me, but there was no sickness among them except that which they brought from the hospi- 
tals. The only injury resulting from the use of the steam was to the paint, which it stained; 
and, the first time charring the leather, and the second time melting the rubber hose. In using 
steam, hose which cannot be affected by heat easily ought to be provided especially for the pur- 
pose, by a copper coupling about ten feet long attached to the cock where the steam comes directly 
from the boiler, and the heat is most intense. Much injury might otherwise result from the 
cracking of the hose, if leather, or melting it, if rubber, by the escape of steam. 
I am so well satisfied of the beneficial effects of steam on shipboard, that I would be sure of 
clearing my vessel of that dread disease, the yellow fever, by its use, in a very short time. 
I am very respectfully, your obedient servant, 
James S. Cannon, 
Master U. S. Transport " Delaware." * 
In reporting my experience of that year, 1862, to the Medical Society of the State 
of New York, I formulated at the time, among others, the following conclusions:- 
2. That inasmuch as a temperature of 145° Fahrenheit, which coagulates albumen, 
effectually disinfects the worst fomites, we have in this fact alone 
strong evidence of the identity of virus with organic matter. 
3. That the necessary degree of heat for disinfection may be applied in some form 
to almost every article of commerce or apparel liable to the virus of infection or con- 
tagion, without injury. 
4. That the examples furnished are an amply sufficient guide for the application of 
heat under the most variable circumstances. 
During the excitement attendant on the retention of persons on board cholera 
infected ships in the lower bay of New York, in the month of June, 1866, I was invited 
by Dr. John Swinburne, health officer of the port, to institute certain experiments at 
Seguin's Point, Staten Island, for the purpose of demonstrating to him the applicabil- 
ity and utility of steam to infected clothing and vessels. The means at command con- 
* Transactions of the Medical Society of the State of New York, 1864. SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
569 
sisted of a small engine, so nearly worn out as to be incapable of sustaining a pressure 
of more than thirty pounds, and which, starting at this pressure, could keep up steam 
for only ten minutes at a time ! However, after considerable hesitation, the experi- 
ments were undertaken. A coiled pipe, of 356 feet in extreme length, was connected 
with the steam pipe of the engine, and around it a furnace chamber of ordinary 
cellar size, bricked up, to superheat the steam escaping from the engine. Over this 
furnace, with the pipe communicating, a chamber of 500 cubic feet capacity was 
constructed. 
This chamber was formed in the jamb of an old factory chimney, two sides of brick ; 
the other two sides, roof and floor of unplaned pine boards. Although this chamber 
was far from being air tight, an opening was made on one side into the chimney flue, 
covered by a trap door to which a string was fastened and leading to the outside, so as 
to provide for the escape of air on first letting in steam, and to admit of closure at will. 
Thus provided, three thermometers were placed : one, a registering, midway from the 
floor to the roof, suspended on a pine board six inches from the back wall ; a second 
penetrated near the top, and a third near the floor-both being bent tubes with free 
bulbs in the chamber and scales outside. In the chamber were placed two basins of 
water of two quarts each, one on the floor, and the other on a bench nearly midway, 
from floor to roof-in the centre of the room; a few clams, oysters, eggs, and small fish; 
also a pair of linen pantaloons, and a shirt nicely done up. The initial temperature of 
the water in the basins was 75° and of the room 80°. Some of the clams, eggs and 
oysters were wrapped with several folds of wet blanket, others with dry; and others 
were left free, in different parts of the room. Thus arranged, with a good fire in the 
furnace under the pipe, and the boiler of the engine under a pressure of thirty pounds, 
steam was turned into the chamber and allowed to escape from the engine slowly, till 
the head of steam was exhausted, which occupied ten minutes. At the end of this 
time, the door was opened, and in two minutes, the chamber entered. The thermom- 
eters meanwhile, having run up, the one at the top of the chamber, to 224°; the one 
at the bottom, 205°, and the self-registering stood at 210°. Ou first opening the cham- 
ber the floor was quite wet, but it was so hot that in less than ten minutes the mois- 
ture had all evaporated. The water in the basin on the floor was heated to 162°. On 
the bench, 150°. The fish, eggs, oysters and clams, that were not enveloped, were all 
well cooked. Those that were wrapped in the blanket, both wet and dry, were only 
partially cooked-and about equally. The clothing was perfectly dry and stiff, and in 
every respect in as good condition as when it was placed in the chamber. It was only 
very hot. 
The experiment was repeated, and the temperature taken every minute, as follows: 
Time. 
Pressure 
of Steam 
Pounds. 
Upper 
Therm. 
Degrees. 
Lower 
Therm. 
Degrees. 
Self-regis. 
Therm. 
Degrees. 
30 
96 
112 
95 
1st minute-... 
27 
160 
135 
2d " .... 
24 
176 
165 
3d " .... 
22 
186 
180 
4th " .... 
16 
192 
190 * 
5th " .... 
15 
199 
195 
6th " .... 
14 
212 
198 
7th " .... 
13 
217 
201 
8th " .... 
10 
220 
202 
9th " .... 
10 
222 
204 
10th " .... 
10 
224 
205 
210 570 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
The experiment was several times repeated, sometimes covering a period of five 
minutes only, and at others, as in the foregoing, ten minutes, which is a fair example 
of the result. 
July 9th, 1886. Having obtained the temporary use of a Metropolitan fire engine, 
capable of sustaining a steam pressure of 100 pounds, and having the privilege of using 
a room that had been used as a dog kennel, adjoining the engine house on Centre street, 
New York, the following experiments were made : The cubic capacity of the room 
was 4240 feet, and over the floor was an accumulation of not less than a cart-load of 
straw rubbish, saturated with moist dog filth, offensive in the extreme. At each end of 
the room were large folding doors, about twelve feet square, the back ones, being half 
glass, presenting a large radiating surface. Around the doors were large crevices, in some 
places of more than an inch in width. Horse blankets were hung over the worst places, 
however, and thermometers placed, one three feet from the floor, projecting a foot from 
the side of the room; one near the top and centre; one self-registering, free, and three 
feet from the floor; and one self-registering, wrapped in eight folds of heavy horse 
blanket, laid on the floor. Half an ounce of liquefied carbolic acid was added to the 
water in the boiler. The following is the table of observations :- 
Time. 
Steam 
Press. 
Pounds. 
Lower 
Thr. 
Degrees. 
Up. Ther. 
Degrees. 
Free 
Self-reg. 
Ther. 
Degrees. 
Env. Self- 
reg. Thr. 
Degrees. 
Initial, 4.30.... 
160 
80 
80 
4.35..., 
60 
147 
140 
4.40.... 
40 
145 
144 
4.45.... 
45 
138 
138 
4.50.... 
65 
138 
140 
4.55.... 
100 
138 
142 
5.00.... 
120 
138 
144 
5.05.... 
160 
138 
140 
5.10.... 
120 
153 
158 
5.15.... 
75 
162 
152 
5.20.... 
90 
158 
146 
5.25.... 
90 
147 
158 
5.30.... 
100 
166 
162 
5.35.... 
90 
170 
166 
5.40.... 
120 
166 
158 
5.45.... 
145 
166 
170 
5.50.... 
80 
186 
176 
5.55.... 
40 
191 
178 
177 
155 
On throwing open the doors the room was entered immediately, and when the steam 
had sufficiently cleared away to see, in four or five minutes, the floor alone was wet (as 
it was before the beginning of the experiment), the side walls and ceiling perfectly 
dry. It may be here remarked that the room was ceiled up with painted pine boards, 
from the floor, four feet high ; the remainder plastered wall. The paint on the wood 
was blistered, and the resin *was running from the pine knots. There was no disagree- 
able odor whatever in the room, and but a very faint odor of carbolic acid. The filth, 
now rendered inoffensive, was removed. 
A second experiment, with the same appurtenances and a super-heating coil of pipe 
attached, as in previous experiment, was made on the next day. In ten minutes' time 
the temperature was raised to 160°, and kept steadily above that, gradually rising to 
the close, at the end of an hour, at which time the lower thermometer was at 186°, the SECTION XV PUBLIC AND INTERNATIONAL HYGIENE. 
571 
upper one, 180° ; the free self-registering, 188° and the enveloped one 190°. The same 
could have been maintained indefinitely. 
A third experiment with the same appurtenances obtained in the same length of 
time the temperature of lower thermometer 190°, upper 200°; self-registering, wrapped 
in sixteen folds of heavy, dry horse blanket, 190°; do. in sixteen folds, wet, 175°. 
A fourth experiment gave nearly the same results. The record made at the time 
states that the only apparent benefit of the superheater in these experiments, over wet 
steam, consists in the maintenance of a more steady high temperature and greater pene 
trability of the heat into clothing. 
In whatever degree these experiments, in the aggregate, may appear unfavorable, it 
is scarcely necessary to again allude to the imperfection of the appurtenances in order 
to account for it. It will suffice to state that the appurtenances were accepted with all 
of their imperfections, because of the experimenter's wish to show the adaptability of 
steam as a disinfectant, even under the most unfavorable circumstances. And further, 
that almost any degree of temperature can be obtained to satisfy the skeptical that it 
may be high enough to destroy all organic matter of whatsoever nature, though the 
facts before adduced conclusively show that the temperature of wet steam kept for two 
or three hours, has, in yellow fever, at least, proved to be sufficient for the complete 
and speedy disinfection of a ship. With an engine equal to the fire engine used in 
these last experiments, or such as those commonly used in the tug-boats in the harbor 
of New York, the writer has no question whatever, that in three hours' time a sufficient 
degree of steam heat can be thrown into any room or ship to disinfect it of yellow 
fever, and, a fortiori, all other infections. 
The next practical illustration was the following, furnished me by the Secretary of 
the Navy :- 
Copy of the official report of Commander Chandler, of the U. S. Steamer "Don," 
on the disinfection of his vessel by steam. 
U. S. Steamer " Don " (4th Rate), Santa Cruz, W. I., December 16th, 1867. 
Hon. Gideon Welles, Secretary of the Navy :- 
Sir-I have the honor to inform the Department that yellow fever broke out on board this 
vessel on the 16th of November, in its most virulent form. Seven men were taken down, but the 
symptoms did not at first seem alarming, and the fever was light. Soon, however, delirium took 
place, followed in a few hours by black vomit and death. I was, by order of Rear-Admiral 
Palmer, examining the Island of St. John's, as reports had been circulated that the recent earth- 
quake had destroyed a portion of it. These reports were groundless. I immediately returned to 
St. Thomas, when the fever became malignant, and was ordered to Santa Cruz. On arriving here 
the ship was anchored with a spring, and was always broadside to the wind. The sick were at 
once landed, Commodore Bissell kindly sending his launch for that purpose, and clothing and 
bedding aired. Some time ago one of the members of the Board of Health of the City of New 
York gave me the pamphlet which I have the honor to enclose, in relation to overcoming miasma 
by heat or steam, and I resolved at once to test it. The ship was thoroughly impregnated with 
yellow fever. I caused the hatches of the berth deck and ward room to be securely closed and 
battened down. One joint of the steam heater on the berth deck was disconnected, and the same 
operation performed in the ward room. A thermometer was lowered through a small slit in the 
tarpaulin, and after two hours' steaming in the ward room it indicated 205°, and on the berth 
deck 172°. I am under the impression that the true temperature was at least 10° above these 
figures, as the act of bringing the thermometer in contact with the air above caused it to fall too 
quickly for an accurate observation. The hatches were then opened, decks dried down, the joints 
of steam heaters replaced, and steam turned through the heaters, and in two hours there was no 
indication of the extreme heat those places had been exposed to, except blistered paint, and a few 
articles of furniture that were glued together had fallen apart. The berth deck had previously 
been scraped, ready for a new coat of whitewash, which was soon put on, and it affords us much 572 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
happiness to state that no new cases of fever occurred. Several men afterward complained of 
pains in the head and back, with a little fever, showing that, although the heat had mortally 
affected the disease, yet it was still struggling for existence. We had twenty-three cases on board, 
and seven died. I have the honor to inform the Department that I am fully persuaded that heat 
eradicated the disease on board this vessel as effectually as a severe frost could have done, and I 
would respectfully recommend that vessels of war destined to cruise on the West India station be 
provided with means of steaming the lower decks and holds. 
The medical officer, A. A. Surgeon Thomas Owens, has made a detailed report to the Bureau 
of Medicine and Surgery. The fire department, as usual, suffered most, owing, I think, to im- 
prudent exposure in coming from the hot fire-room to a cool draft on deck, and also from exces- 
sive drinking of cold water while in a heated state. This is the third yellow fever ship that I 
have served on board of, but I have never before seen the disease in so violent a form. 
Very respectfully, your obedient servant, 
(Signed) R. Chandler, Commander U. S. Navy.* 
Besides the examples above given there have been several other instances of the 
application of steam to American men-of-war, for the purpose of disinfection, but so 
imperfectly, or in conjunction with other means to such an extent, as to divest steam 
of the credit it deserves. 
Sanitarians, as other persons who have not observed the proper application of steam 
under such circumstances, are loath to accept it, on the false assumption that it will 
cover the surrounding walls and saturate everything into which it is forced with mois- 
ture, a fallacy which actual observation wholly dispels. On the contrary, steam under 
pressure, it should be borne in mind, is always above that given off from the surface 
of boiling water, and when properly applied, it so quickly and effectually heats what- 
ever substances with which it comes in contact as to render them repellant of moisture 
and adjuvants in its dissipation ; an excess of moisture on the surface, or even in the 
substance of things, such as baled rags, to which it has been applied, is an indication 
of insufficiency of temperature. Under 20 lbs. pressure the temperature of steam is 
230° F. ; under 25 lbs., 240° F. ; and under 30 lbs., 250° F. The lowest of these tem- 
peratures is found to be sufficient to destroy the most resistant spores in twenty minutes; 
while the highest is effective almost immediately. But to practically apply the requi- 
site temperature, the nature of the fomites, the space and the character of the surround- 
ings, all have to be taken into consideration. 
Heat has long been known to be the most powerful of all disinfectants, but since the 
general belief in the germ origin of infectious diseases, the desideratum has been-how 
to apply it with a sufficient degree of intensity to destroy the germs, without at the 
same time destroying, or at least injuring, the material infested by them : because bi- 
ologists have been wont to teach-what many sanitarians have erroneously believed - 
that the only safe test was the resisting power of certain organisms found in boiling 
springs and under other circumstances, with no known relation to disease germs or the 
contagium of disease under any circumstances whatsoever. The impracticability of this 
effort has finally had the effect of diverting the attention of biologists from dry heat to 
the effect of steam on disease germs, and they have recently discovered the correctness 
of that for which I have contended for twenty-five years, and practically demonstrated 
in the manner above described, nearly thirty years ago, that " a temperature of 145° F. 
effectually disinfects the worst fomites." 
George M. Sternberg, M.D., Major and Surgeon, U. S. Army, in a contribution to 
the American Journal of Medical Sciences for July, 1887, p. 146, cites the conclusions 
of Koch and Wolff hugel on the effects of dry heat, as follows :- 
* Transactions of the Medical Society of the State of New York, 1868, p. 91. SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
573 
1. A temperature of 100° C. (212° F.), maintained for one hour and a half, will de- 
stroy bacteria which do not contain spores. 
2. Spores of mould-fungi require for their destruction in hot air a temperature of 
from 110-115° C. (230-239 F.), maintained for one hour and a half. 
3. Bacillus spores require for their destruction in hot air a temperature of 140° C. 
(284° F.), maintained for three hours. 
He then proceeds to relate the results of his own experiments with moist heat on the 
bacilli of typhoid fever, cholera, swine plague, tuberculosis and on numerous other 
microorganisms. His conclusions are, that- 
' ' The temperature required to destroy the vitality of pathogenic organisms varies 
for different organisms. 
' ' In the absence of spores, the limits of variations are about 18° F. 
' ' A temperature of 132.8° F. is fatal to the bacillus of anthrax, the bacillus of 
typhoid fever, the bacillus of glanders, the spirillum of Asiatic cholera, the erysipelas 
coccus, to the virus of vaccinia, of rinderpest, of sheep-pox, and probably of several 
other infectious diseases. 
"A temperature of 143.6° F. is fatal to all of the pathogenic or non-pathogenic 
organisms tested, in the absence of spores (with the single exception of sarcina lutea, 
which, in one experiment, grew after exposure to this temperature). 
"A temperature of 212° F. maintained for five minutes destroys the spores of all 
pathogenic organisms tested. 
"It is probable that some of the bacilli which are destroyed by a temperature of 
140° F. form endogenous spores, which are also destroyed at this temperature. ' ' 
It is important to notice in this connection that, according to the same writer, ' ' the 
cholera germ of Koch does not form spores, and there is good reason to believe that the 
same is true as regards the germs of yellow fever, of scarlet fever, and of smallpox, 
which have not yet been demonstrated. This inference is based upon evidence obtained 
in the practical use of disinfectants, and upon certain facts relating to the propagation 
of these diseases."* 
Dr. Parsons, in his ' ' Report to the Local Government Board, ' ' London, April 27th, 
1887, remarks that- 
' ' The disinfection of rags by heat otherwise than by boiling requires special apparatus. 
Dry heat penetrates so slowly into non-conducting materials, such as rags, that it is 
impracticable to disinfect them in the bale by this agency in any reasonable time, 
unless, perhaps, with the aid of currents of hot air or exhaust apparatus. 
"A machine for the preliminary disinfection of woolen rags has been patented by 
Mr. Illingworth, rag-flock manufacturer, of Batley. It consists of a cylindrical cage 
revolving within an iron steam-jacketed cylinder, closed at the end by a door. The rags 
have to be unpacked from the bale, and are placed inside the cage, where, as the cage 
revolves, they are caught and turned over by projecting prongs. The steam in the 
jacket stands at seventy pounds pressure, equal to a temperature of 316° F., but it does 
not ordinarily enter the interior of the cylinder. The action of the heat is, however, 
supplemented by the fumes of burning sulphur. A charge of rags is 1 cwt. to 1J cwt., 
and I found that one and a half hour's exposure was necessary in order to raise such 
charge to a temperature of 217° F. By the introduction of a jet of steam the time 
necessary to attain a like temperature was shortened to thirty-five minutes, the rags not 
being ipade appreciably damp ; indeed, they had lost weight. 
" A machine has also been invented by Mr. Illingworth for the disinfection of rags 
in the bale. It is a steam-jacketed chamber, with a tightly fitting door ; the cold air 
* " Disinfection and Individual Prophylaxis against Infectious Diseases " (Lomb Prize Essay). 
By George M. Sternberg, m.d., Major and Surgeon, U. S. Army, p. 108. 574 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
in the interstices of the bale being displaced by exhausting the chamber with an air 
pump, and replaced by chlorine or sulphurous acid gas, let in by opening a valve. The 
use of this machine, however, appeared to have been abandoned. 
" Some experiments on bales of rags made in Lyon's patent disinfector are recorded 
in my report on ' Disinfection by Heat ' (Annual Report of the Medical Officer of the 
Local Government Board, 1884). This apparatus is a steam-jacketed chamber, with a 
tightly-fitting door, steam being admitted both into the jacket and into the interior. 
The pressure of the steam in the jacket is kept above that in the interior, so as to avoid 
condensation. The steam in the interior is let off from time to time, and re-applied, so 
as by the alternations of pressure to displace the cold air remaining in the interstices. 
"In a bale of packed cotton rags weighing 500 cwt. a hole was bored with an auger; 
into this a registering thermometer was inserted and the hole plugged with a wooden 
plug. The bale was then exposed in the machine for four hours, to steam at 15 lbs. 
pressure, relaxed every half hour, the pressure in the jacket being 30 lbs. At the end 
of the time the thermometer was found to register 252° F. The bale had gained in 
weight 27 lbs. or 4.8 per cent. In the centre of a bale of woolen rags (not press-packed) 
weighing 549 lbs., a temperature of 255° F. was by similar means obtained after two 
hours, the increase in weight through condensation of moisture being 25 lbs. or 4.4 per 
cent. ' ' 
This last and a dozen other kinds of disinfecting apparatus-including that of Parker 
and Blackman, in use at the New York Quarantine, with which, in conjunction with 
Dr. William M. Smith, Health Officer of the Port of New York, and, in part, with Dr. 
H. M. Biggs, of the Carnegie Laboratory, New York, my most recent experiments and 
observations, covering a period of nearly two years, have been conducted, chiefly in the 
disinfection of baled rags-meet the necessity of obtaining the requisite degree of tem- 
perature throughout the bale in the shortest possible time without causing combustion 
of the rags. 
The apparatus is erected on a floating scow, and consists of an ordinary engine, of 
sufficient power and boiler strength, with an attached superheater. To this is appended 
a series of iron boxes of about the shape of, and large enough to admit, a bale of rags 
pushed in endwise. Each one of several boxes has penetrating through, from the rear 
end, a gimlet-bit screw, or several such screws, nearly as long as a bale of rags, enlarged 
from a point to about two inches in diameter, and when more than one is used, at such 
a distance apart as to about equally divide the end of a bale. These screws are hollow 
and perforated in their whole circumference and length, and each one is the terminus of 
a steam-escape cock to which it is coupled. The screws are rapidly revolved by the 
machinery. On pushing in a bale of rags, it no sooner comes in contact with the points 
of the screw or screws than it is drawn in with great rapidity. The box is now closed 
by a flap door in front, hinged at the top, and the steam turned on, through the screws, 
and around the bale. In two or three minutes the temperature of the bale, as thus 
exposed, can be raised to the necessary degree of temperature throughout and sustained 
for any desired length of time. 
The experiments were as follows :- 
1. Steam at seventy-five pounds : exposure five minutes. Thermometer at supply 
heater 320° F., followed by sixty-five pounds pressure at same exposure to 550° F. 
Result, 220°. 
Result. 
Thermometer at opposite end under the same conditions 220°. 
under wrapper of the bale, same conditions 220°. 
three inches beneath top of bale, same conditions..235°. 
2. Steam at eighty pounds ; exposure six minutes. Thermometer at supply heater 
360° F., and 420 F. SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE 
575 
Result. 
Thermometer at screw end 280°. 
" in opposite end 220°. 
four inches beneath the top 219°. 
" on top of bale 220°. 
3. Steam at eighty pounds ; exposure seven minutes. Thermometer at the supply 
heater 490° F. 
Result. 
Thermometer in top of bale 218°. 
in screw end near top 235°. 
in the side under the band 410°. 
near bottom in the end opposite the screw 305°. 
Several vaccine points, number ninety-eight, in a vial wrapped in rags and under 
cover on top. Several vaccine points number eighty-nine, in a vial in the side of bale. 
Twenty-four vaccine points were submitted to the test. Twenty-three primary vac- 
cinations were made with the disinfected virus, all of which were failures. 
The same day twenty-eight vaccinations were made with non-disinfected virus, 
twenty-seven being successful. Both the disinfected and non-disinfected virus were 
taken the same day, from the same calf. (Report of Dr. J. B. Taylor, New York, 
Board of Health. ) 
4. Steam at eighty pounds; exposure, eight minutes. Thermometer at supply heater, 
490° F. 
Result. 
Thermometer in under side, middle of bale 335° 
" " upper " " " 235° 
" " end opposite screw 220° 
" " " where screw enters 355° 
Several vaccine points in a vial marked "C," with thermometer at top of bale, 
wrapped in rags. Several vaccine points (2d No. 98), with thermometer at end of bale. 
5. Steam at eighty pounds; exposure, six minutes. Thermometer at supply heater, 
380° F. 
Result. 
Thermometer in bale at end 239° 
" on top, five inches inside of bale 220° 
" " outside of bagging 220° 
(Five screws.) 
6. Steam at eighty-five pounds; exposure, six minutes. Thermometer at supply 
heater, 405° F. 
Result. 
Thermometer in bale at end 245° 
' ' on top, five inches inside of bale 230° 
" " outside of bagging 225° 
(One screw. ) 
7. Steam at one hundred pounds; exposure eight minutes. Thermometer at supply 
heater, 500° F. 
Result. 
Thermometer on top, inside of bale 280° 
" hung at end of bale 220° 
(Five screws) 
8. Steam at one hundred pounds; exposure, five minutes. Thermometer at supply 
heater, 500° F. 
Result. 
Thermometer on top, inside of bale 390° 
" hung at end of bale 233° 
(Three screws. ) 576 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
9. Steam at one hundred pounds; exposure, five minutes. Thermometer at supply 
heater, 500° F. 
Result. 
. f 490° 
Thermometer on top inside of bale < 480° 
{ 320° 
hung up at end of bale 22qO 
(One screw. ) 
During the progress of these experiments the time was frequently cut short by evi- 
dence of scorching or combustion of the rags, by the odor. The liability to combustion 
depends, to a considerable extent, upon the character of the rags, it being by no means 
uncommon to find in the bales fragments of tarpaulin, oakum and other easily combus- 
tible material. But to avoid this liability, as well as to secure the more certain and 
uniform diffusion of the temperature, at my suggestion a new coupling was added, for 
the primary injection of wet steam, before passing it through the superheater, for five 
or six minutes, and immediately thereafter, for an equal period, superheated steam. 
This effectually estopped the liability to combustion. The following are examples of 
the record:- 
10. Steam pressure, eighty pounds; initial temperature of supply heater, 390° F. ; 
time, ten minutes-five each of wet and dry steam. 
Result. 
Thermometer on bale, near back end.. 220° 
" " " " front end 220° 
" in " fifteen inches from front end, near 1 „„co 
the centre. f 
11. Steam pressure, seventy-five pounds; initial temperature of supply heater, 360° 
F. ; time, twelve minutes-six each of wet and dry steam. 
Result. 
Thermometer on bale, middle 220° 
" in " fifteen inches, front end 220° 
" " " between the screws, back end 280° 
It is manifest that in the whole series of experiments above detailed, for the disin- 
fection of rags in bale, the degree of temperature attained is much higher than necessary, 
except with reference to the greatest possible dispatch in disinfecting such merchandise. 
It should be remembered, however, that the apparatus was constructed, and the engine 
adapted to its use (although less than three years ago), under the erroneous impression 
that it was necessary to apply " a temperature of not less than 330° Fahrenheit, forced, 
under a pressure of four atmospheres," by direction of the Hon. Secretary of the 
Treasury (McCulloch), 100° higher than recommended by the committee of the con- 
ference of the representatives of the State Boards of Health, held in Washington, Decem- 
ber lOth-llth, 1884. February 24th following (1885), Dr. Sternberg communicated 
the results of tests he made with the same apparatus to Dr. Wm. M. Smith, Health 
Officer of the Port of New York, as follows:- 
' ' Moist heat proves to be a most certain and practical method of destroying germs, 
and the most resistant spores are quickly destroyed by a temperature of 230° F., 
which is 100° below the temperature exacted by the Treasury Department. The spores 
of anthrax are destroyed by a temperature of 221° maintained for two minutes, and 
all micrococci and bacilli not containing spores are quickly destroyed by a temperature 
much below the boiling point of water."* 
But under Dr. Sternberg's more recent conclusions (ante) and the now general 
* "Report on Contagious Diseases Propagated by Rags, to the Health Department of New 
York," October 16th, 1885. SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
577 
acceptation of the practical results that steam, at a temperature of 145° F., is 
amply sufficient, it is clear that the disinfection of baled merchandise may be effected 
with great facility and without the possibility of combustion or other injury, by the use 
of the same machinery. 
It would not be well, however, to restrict the power of the steam machinery for 
quarantine purposes to the special necessities for which it appears to have been, in the 
first place, particularly adapted-the disinfection of baled merchandise. As before 
demonstrated, steam can be applied with equal certainty to infected ships, and it is 
sometimes necessary to disinfect both ship and cargo before breaking bulk-for the pro- 
tection of the stevedores-and this can be done with the utmost facility and certainty 
by the use of steam without injury to either ship or merchandise; but, manifestly, a 
large head of steam, some additional appurtenances-flexible hose of sufficient resist- 
ing power to heat-and considerable more time are required to insure the plenary 
injection of steam into the bilge, throughout the limbers and all other recesses; and the 
more time, especially if an iron ship, because of the greater capacity for heat. 
It might go without saying, perhaps, that water in the bilge can be quickly raised 
to a boiling temperature by the injection of steam, and kept so ad libitum. 
It affords me special pleasure to add to the foregoing the following communication 
from Dr. Joseph Holt, President of the State Board of Health of Louisiana, describing 
the disinfecting apparatus devised by him, and successfully used at the Mississippi 
Quarantine Station by his direction. 
Board of Health, State of Louisiana, New Orleans, August 28th, 1887. 
A. N. Bell, m.d., Editor The Sanitarian, New York, N. Y. :- 
Dear Doctor-In reply to your letter requesting of me a description of the "Steam Super- 
heating Chamber " in use in the quarantine station of this port, I have the honor to make the 
following statement :- 
The quarantine system of the port of New Orleans is essentially one of disinfection; detention, 
except in the case of actually infected vessels, never exceeding five days. 
There are two stations ; one completely isolated and intended for the reception of infected ves- 
sels only; the other, for general inspection and sanitary treatment of all vessels (except those 
known to be infected) coming from quarantined ports. The latter (called the "Upper Station") 
is the one at which the greater part of the sanitary work is accomplished. 
The sanitary treatment consists in the concurrent application of three (3) processes; first, the 
wetting of all available surfaces of the vessels (excepting cargo, but including bilge, ballast, hold, 
saloons, forecastle, decks, etc., with a solution of the bichloride of mercury of a strength of 
1:1000. The hatches are then closed and the entire atmosphere of the hold is displaced by 
sulphurous dioxide. 
While this is going on, all bedding, ship's linen, cushions, mattresses, flags, mosquito nets, 
curtains, carpets, rugs, and all personal baggage and wearing apparel of whatever description, are 
removed from the ship to a commodious building in close proximity, in which these articles are 
treated by " moist heat," at a temperature of not less than 230° F. 
The apparatus for this work consists in a steel 40-horse power steam boiler (Fig. 1), connected 
with a superheating chamber a few feet distant, and which I will now describe. 
The dimensions of this chamber taken interiorly, or inside measures, are 60 feet long, 11 feet 
wide and 7 feet high. The framework is composed of 3x3-inch seasoned pine lumber, joined 
just as in the construction of a wooden house. Upon this, outside, excepting the front, is 
nailed, tongued and grooved flooring material, if-inch thick by 6 inches wide. The interior of the 
ends, rear side and top are ceiled with the same material, and a flooring of the same is also laid. 
Upon these interior surfaces is tacked "heavy Russian hair-cloth or felting," and upon this, at 
intervals of three feet, are nailed parallel strips of wood, ljx2 inches thick, and in turn again 
upon these strips is fastened another layer of planking as already described. This secures an air 
space between the hair-cloth and the inner planking. Upon this now smooth surface of wood is 
finally tacked, and held in place by broad-headed nails, or, better, by nails supplied with tin 
Vol. IV.-37. 578 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
washers, a double layer of " asbestos building felt," well lapped and securely tacked, thus render- 
ing the interior of the chamber fire-proof, a most essential provision. By the foregoing described 
construction it will be seen that the walls of the chamber, which are eight (8) inches in thickness, 
consist of seven (7) non-heat-conducting media: First, the outer layer of planking; second, three 
(3) inches of air space; third, an inner ceiling of planking; fourth, one (1) inch thickness of 
Russian hair-cloth; fifth, one and one-half (1|) inches of air space; sixth, a third layer of i-inch 
planking, and seventh, a double layer, or interior lining of heavy asbestos felting. 
The front wall is divided into forty (40) panels, eighteen (18) inches wide each, which repre- 
sent that number of racks contained within the chamber. Upon the bars of these racks the cloth- 
ing, etc., is hung for exposure to disinfection by moist heat. These racks are constructed with a 
front and rear panel, united by horizontal bars, five to each side. Each rack is suspended over- 
head on traveling rollers upon an iron rod which extends from the rear wall of the chamber to a 
support, ten feet in front of the chamber; the rod, therefore, being twenty (20) feet in length. 
By this arrangement the racks may be drawn out and pushed in. When drawn out the full 
length of ten feet the rear panels of the racks as securely close the chamber as the front panels do 
Fig. 1. 
when the racks are pushed in, thus admitting the heating of the chamber during the process of 
hanging the articles of clothing, etc., on the rack bars for disinfection. 
The interior surface of each front panel is lined with a layer of Russian hair-cloth, over which 
is applied a double layer of asbestos felting. 
At intervals of seven and one-half (7J) feet a bulkhead of one (1) inch tongued and grooved 
flooring material is placed, subdividing the chamber into eight (8) compartments. These bulk- 
heads are made fire-proof by a covering of a double thickness of asbestos felting. The object of 
this arrangement is to provide against the spread of fire in the event of its occurrence. In 
addition to this provision, there is a double lead of one-inch fire hose connected with a steam 
pump near the boiler, and at all times ready within fifteen seconds' notice to turn on two streams 
of water upon any rack on which fire might have originated. 
The superheating of this chamber is so provided as to furnish at will dry or moist heat, or 
both. 
Within and at the end of the chamber next to and connected with the boiler are two (2) mani- 
folds, one above the other, to which are connected a system of forty-five (45) J-inch iron steam 
pipes (aggregate 5500 lineal feet) placed horizontally near the floor of the chamber, running its 
full length, and supplied with a bleeder for carrying off the water from condensed steam. This SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
579 
furnishes the dry heat. Above and in close proximity to this system of pipes is extended a hori- 
zontal layer of galvanized iron l -inch mesh, to catch and so prevent the coming in contact with the 
superheating pipes of any article accidentally falling from the racks. 
The moist heat is supplied by a 1-inch steam pipe laid centrally in the midst of the above 
described dry heat pipes, which also runs the entire length of the chamber, constituting a steam 
main connected with the boiler and controlled, as the others, by a ball-valve on the outside. This 
pipe is perforated by forty (40) |-inch holes, so placed as to furnish steam to each rack. 
During the process of hanging the articles of clothing, etc., on the racks, the dry heat is turned 
on and the temperature of the chamber raised to about 190° F., made known by a thermometer 
suspended near the centre of the chamber, working on a slide, which is drawn forward to a glass 
panel when it is desired to make a reading; this thermometer has a scale of 285° F. 
As each rack is filled, it is pushed back into place. By the time the last of the articles have 
been hung on the racks, the entire mass of the material within the chamber has attained the 
Fig. 2. 
PERSPECTIVE, LOOKING TOWARD BOILER-ROOM OF SUPERHEATING CHAMBER, ALL THE RACKS PUSHED IN, 
a. Exterior view of front panels of racks, b. Traveling rods overhead, c. Fire-hose. 
above mentioned temperature, and the free steam is turned on ; the thermometer speedily rises to 
a point varying between 230° and 240° F., at which it is maintained for a period of twenty (20) 
minutes. The steam pressure in the boiler, at the beginning of this process, registers between 
100 and 110 lbs. by the steam gauge ; at the end of the process of blowing in steam, the pressure 
will have fallen to about 60 lbs. The steam is now entirely cut off from the chamber and the racks 
are drawn out and their contents removed. During the process of steaming every article is per- 
ceived to be saturated and intensely hot ; but so great is the heat in the texture of the fabrics as to 
immediately expel all moisture upon drawing the racks and exposure to the open air. Shirts, 
collars, etc., instantly resume the crisp dryness they possessed before exposure. Silks, laces, the 
most delicate woolen fabrics, show no signs whatever of the treatment. 
Of course, articles of leather, rubber and whalebone would be injured by the heat, and 580 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
are therefore disinfected with the mercuric solution and not permitted to go into the heating 
chamber. ' 
Time required to charge chamber with apparel for disinfection, thirty (30) minutes; time 
required for moist heat, twenty (20) minutes, and for removal of articles fifteen (15) minutes, a 
total of sixty-five (65) minutes. 
A large steamship, particularly a passenger vessel, may require two or three charges of the 
chamber. 
Amount of coal consumed from 2 to 4 barrels per vessel. 
In the summer of 1885, 1 devised and put into operation a chamber, exactly of the above speci- 
fications, but wholly inadequate for the requirements of our service. This was replaced by one of 
the same kind, but 50 feet in length and supplied with a 20 horse-power boiler, which latter proved 
too small for rapid operation. This apparatus was burned last spring. Our present chamber and 
supply boiler are of the dimensions and capacities given. The cost of the chamber, supply boiler 
and fixtures is $2500.00. 
Fig. 3 
All expressions of opinion on our part touching the relative and special values of disinfectant 
agents, in " Maritime Sanitation," are the deductions of elaborate and expensive experimental work. 
While in practice we have found the mercurial solution the most efficient for the treatment of 
ships' surfaces, and the sulphurous acid gas or sulphur di-oxide for the displacement of atmos- 
phere contained within the ship's hold, our chief difficulty has been the disinfectant treatment of 
baggage and other textile fabrics expeditiously, efficiently and without injury to the articles. 
The application of chemical agents, in any form suggested, has been slow, laborious and inju- 
rious, or even destructive to the articles disinfected. 
The use of such agents has cost us many heavy bills of indemnity. 
Schooled by necessity, we have been compelled to seek in moist heat a satisfactory remedy. In 
adopting this agent we were greatly enlightened and facilitated by the published official reports 
and papers emanating from yourself and appearing from time to time in The Sanitarian. 
Your experience in regard to the efficacy of moist heat as applied by yourself in the disinfec- 
tion of yellow fever infected vessels of the U. S. Navy, and dating as far back as 1848, has fur- SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
581 
nished us a substantial groundwork of ascertained fact, upon which we have been enabled to 
build our present, and we believe perfected, method of applying steam as a disinfectant agent 
in one of the most important departments of " Maritime Sanitation," regarding heat thus used as 
the most reliable, economical and unobjectionable germicide available in practice. 
Yours very truly, 
Joseph Holt, m.d., 
President Board of Health, State of La. 
The conclusions fairly deducible from the foregoing are that- 
1. Steam at a temperature of 220° F. for ten minutes, or at 145° for two hours, is 
fatal to all known disease germs. 
2. The various devices and facilities for the application of steam for the purpose of 
disinfection are abundant, and may be safely left to the direction of those whose duties 
require their exercise. 
DISCUSSION. 
Dr. Joseph Jones said that he regarded the paper of the distinguished sanita- 
rian as one of great value and importance to sanitarians, and he regarded Dr. Bell as 
the first American to apply steam for the disinfection of infected ships. The results 
obtained by Dr. Bell have stood the test of time and experiment. I am convinced 
that steam is more efficacious and far less dangerous and destructive than dry heat. 
If the disinfecting apparatus is defective in its structure, and without proper 
control of the heat and proper increase of the air, dry heat may injure the articles 
subjected to it, charring, and even setting fire to them. 
The recent accidents at the Mississippi Quarantine Station illustrate the import- 
ance of regulating the degree of heat. The thermometer suspended in the air does 
not always give accurate information with reference to the temperature of the wood 
and metal of the apparatus or drying room, and they may gradually attain a tem- 
perature above that of the more mobile air. 
Dr. M. P. Red ARD, of Paris.-I desire, with my honorable confrère, Bell, to 
insist before the Congress upon the value of disinfection by steam. From many 
experiments made by me the past two years, it results :- 
1. Chemical disinfectants recommended and generally employed are absolutely 
uncertain. Certain virulent substances do not lose their virulence after prolonged 
immersion in antiseptic liquids. 
Carbolic acid is no more efficacious than sulphate of zinc and chloride of zinc. 
These last two disinfectants may attenuate some viruses after long contact. Nitro- 
sulphate of zinc and sulphur have shown themselves absolutely inefficacious. 
2. Disinfection by means of steam, not over-heated and not above 110° C., is 
inefficacious. Steam at a temperature of 90°-100° C. produces attenuation of virus. 
3. Absolute disinfection-destruction of virus-can only be obtained by super- 
heated steam at 110° C. As to the practical side of the question, it is necessary to 
build simple and cheap apparatus, giving superheated steam at 110° C. We are 
now studying new, simple apparatus, and hope soon to present new models for the 
disinfection of railroad coaches, rooms, etc. 
Dr. J. A. S. Grant-Bey, of Egypt.-I read a paper at the Congress in Copen- 
hagen on disinfecting rags, and recommended that the bales should be broken up. 
I have now changed my mind, and believe it is safer not to bring them into the 
country at all. 
Dr. A. N. Bell, of New York.-My paper shows that steam at 225° F. for ten 
minutes, or 145° F. for two hours, will destroy any germs. 582 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
ON SOIL DRAINAGE, AND OTHER METHODS, IN THEIR RELA- 
TIONS TO THE DEVELOPMENT OF MALARIAL FEVER. 
SUR LE DESSÈCHEMENT DU SOL, ET SUR LES AUTRES METHODES RELATIVES 
AU DEVELOPPEMENT DE LA FIÈVRE PALUDÉENNE. 
ÜBER BODENDRAINAGE UND SONSTIGE METHODEN IN IHREN VERHÄLTNISSEN ZU DER 
ENTWICKELUNG DES MALARIAFIEBERS. 
THOMAS HEBERT, M. D., 
Of New Iberia, La. 
By this communication to the cause of public and international hygiene, the author 
will feel amply repaid for his labors if he succeed in successfully soliciting discus- 
sion, and bringing out the latest thoughts and views upon the important subject of the 
prevention of malaria. I disclaim the least intention of being exhaustive, as my pur- 
pose is only that which has just been mentioned. No elaborate treatment will even 
be attempted by me in the inadequate and cursory view of the subject here presented. 
Two practical questions of primary and pressing importance arise in the considera- 
tion of malaria and its manifestations. One of these is the efficacious treatment of the 
disease in persons of indi viduals, and its prevention either in regard to its return after cure, 
or its outbreak in persons subject to its occurrence. The other is the correction of such 
influences as favor its evolvement, which arise in climate and conditions of soil, as far 
as may be practicable to us by our short and inadequate measures of sanitary ameliora- 
tion. The first reference belongs to the domain of therapeutics and personal hygiene; 
the second is fitly embraced under the head of general hygiene, or sanitation of com- 
munities. Several well-established facts in regard to the behavior of the malarial 
poison, which relate more especially to its physical properties as a form of matter, have 
long been matters of observation to the profession, of which we may take a passing 
view before arriving at the heart of the questions herein considered. 
We know, for instance, from facts too well known to be doubted, that malaria, in its 
specific sense, is an outcome or emanation from the soil, receiving its production and 
development from conditions existing in the soil, and probably from matter in an 
organized state, as a necessary factor in its production. 
Its telluric origin would be impossible without the concomitant cooperation of heat, 
air and moisture. 
We are aware of the fact that the morbific material, of whatever nature or form it 
is, finds its avenue of dissemination generally in the atmosphere, or in water or other 
liquids which have become impregnated, primarily or secondarily, with the poison, and 
that through the atmosphere the disease breeding agent may spread over an extent of 
country miles away from its locality of origin. 
Its material nature and more or less ponderous character is demonstrated by the 
fact that a line of forest or densely aggregated trees, or sufficient rise of ground, may 
prevent its propagation in the direction barred thereby. 
This fact suggests another of considerable importance relative to the occurrence of 
an outbreak of the disease in certain defined localities favorably situated for the occur- 
rence of the phenomenon, which exists in the obvious relation between the greater pre- 
valence of the disease and the direction of winds which blow over the localities where 
malaria is being generated. I have observed, and others no doubt have had a similar 
opportunity, that, for example, when the winds are prevalent from the southern and 
eastern quarters, as is the case most of the time in spring and summer in the northern 
hemisphere, with some exceptions, maybe, the spread of malaria is generally to a SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
583 
greater extent upon the north and west side of streams and marshes ; and although in 
most instances the relative preponderance of cases in certain localities in communities 
affected may not, under circumstances alluded to, be well marked or sharply defined, 
I have, nevertheless, made it a matter of well-authenticated and corroborated observa- 
tion that such a relation as here expressed does exist between the prevalence of winds 
and the propagation of malarial fever. 
These facts and others not mentioned here, going to prove or demonstrate that 
malaria is something originating in the soil or in decaying vegetable matter, the pro- 
duct of the soil, the practical question to which they lead, for us to consider specially, 
is in regard to the feasibility of methods by which the origin and prevalence of malarial 
disease may be more or less effectually prevented. A matter of observation may be 
scientifically important or interesting, and yet, for the utilitarian or worker in the lines 
and avenues of every-day practical life, may not be worth the trouble or labor of its 
acquisition. But there is a lesson in this subject of the origin of malaria which bears 
for us an important significance, and which may enable us to formulate and exercise 
efficient methods by which the manifestations of this pathological agent may some- 
times be more or less effectually stamped out of existence or very materially modified 
in communities subject to its pernicious influence. 
When the drainage of a marsh or low-lying locality reeking from moisture is 
possible, its noxious properties may be obviated. In this plain method we have indi- 
cated the readiest and generally the most efficacious and economical means by which 
malarial disease may be obliterated from a locality where it is prevalent. The question 
of drainage is one which rises to the attention of the sanitarian as belonging to the 
alphabet or first principles of Hygiene. But to be efficacious or successful in the 
attainment of its object drainage must be thorough and complete. Partial drainage of 
a marsh, pond, low-lying place, or basin for moisture, which abstracts the bulk of 
the water and allows more or less to remain indefinitely, stagnant in pools, or as sat- 
urating the spongy soil, is worse than useless, since such water remains, to disappear 
slowly by evaporation, giving time and the best conditions, I believe, for the malarial 
poison to be generated. If the soil, in other words, by such drainage cannot be ■ left in 
a condition to be desiccated by the sun heat in the ordinary time required, for instance, 
to dry up high ground after heavy rains, or if after a certain reasonable length of 
time, it will be exactly in the condition most favorable for the development of the 
malaria] poison. Of course, if such drainage can ultimately leave the soil in such 
condition as to achieve the purpose of thorough drainage, then it may be classed as effi- 
cacious and beneficial, although its effects may not be immediate. 
After heavy rains which completely cover with water low places and help to purify 
the atmosphere by precipitating floating particles therefrom, and which also cause a 
repletion of small streams, the soil of marshy places or the damp edges of streams may 
cease for the time being from generating miasms. When such an occurrence takes 
place to an extent sufficient in degree to cover totally a marshy soil, or fill to repletion 
the streams of a locality, I have noticed a cessation in the occurrence of new cases of 
malarial fever sufficiently well marked to demonstrate decidedly a close relationship 
between the amount of rainfall and the degree of prevalence immediately afterward 
(not for a season) of cases of malarial fever. 
The theory here intimated or understood is that where and when the ordinary forms 
of vegetation, applying the statement universally, which have their roots necessarily 
in the soil for the possibility of growth, cannot find the necessary conditions for their 
germination and growth, malaria, which is a product of the soil, which seems to require 
essentially heat, air, and moisture for its production, will also fail to find the circum- 
stances favorable to its growth and propagation. If (and this has been a matter of com- 
mon observation to all physicians familiarized with the manifestations of the disease 584 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
dependent upon its evolution and dissemination), under these circumstances, malaria 
will not be generated, no new cases, or, as stated before, but few will occur during the 
time that the atmosphere remains free from the poison. But as soon as these waters 
drain off or are evaporated and the heat of the sun begins to set up fermentative and 
germinative action in the damp, exposed edges and stretches of the surface of the soil 
inadequately drained, malaria is generated anew, and we have in localities subject to 
its influence a fresh outbreak of cases of the disease, attendant upon its presence in the 
atmosphere. 
From this series of phenomena I have been able to determine approximately the 
time that is consumed in the production or generation of the malarial poison, its dis- 
semination in the atmosphere and the outbreak of the disease in persons most directly 
subject to its influence. This period varies from a few hours or five or six days to 
fifteen. The first factor in the production of this period, that of the production of the 
poison and the contamination of the atmosphere, is, all things being equal, more or less 
fixed and constant, I presume, in comparison to the second, the incubation of the germ 
in the blood, which is variable. 
Knowing this, the possibility of effectively preventing the prevalence of malaria 
by a system of quick and thorough drainage and drying of the soil producing it is 
apparent. In the spring of the year, when the farmers prepare the soil for cultivation 
and rains are generally frequent, the upturned soil remains damp and loose for a con- 
siderable length of time, and our vernal fevers are the result. They are generally uni- 
versal in the region being thus prepared for tillage, thus showing their dependence to 
be, one of effect to cause, upon the changes produced by the plow in the condition of the 
soil. But after some time these fevers cease, to give place later to severer forms of the 
disease. 
Theoretically, the question of perfect drainage of the soil, so that its thorough desic- 
cation is the work of the shortest possible time, is undoubtedly the best solution to the 
problem of the readiest and most economical method of preventing, as much and as far 
as lies in our power, the formation and the outspreading of the malarial poison. No 
doubt this question of drainage is the explanation of the fact that, as this country has 
gradually been reclaimed from the wilderness, improved, tilled and drained, malarial 
fever has proportionately become less virulent and less universally prevalent. But there 
remains a vast amount of territory to which the methods of sanitary care and treatment 
might be applied, where practicable, with great and lasting benefit to those human 
beings who are suffering from the effects of malarial toxæmia. 
There are low basins, however, especially in the strictly alluvial districts of this 
country, to which no economical system of thorough drainage could effectively be 
applied. There are ponds and marshes which cannot be effectually drained, as there 
are such places to which no system whatever, of sanitary treatment, can practically be 
applied as a whole. The immense low swamps of Louisiana and other States are an 
example of this inability of the sanitarian to meet the requirements of the case. For 
such regions the only practicable plan is, that they should gradually be reclaimed, 
where possible, settled and tilled. Again, however, localities in question exist which 
cannot be effectually drained, but to which other measures may sometimes be applied, 
achieving the same end as drainage. I refer in this connection to two procedures which 
naturally occur to the mind as succedanea, or even, where more economical, or under 
circumstances preferably favoring their application, more efficacious and more to be 
desired than drainage. One of these methods, to which only a short reference need be 
made, is the filling up on a level with surrounding higher ground of low places and 
shallow ponds, etc., when practicable, so as to leave no depressions or hollows to retain 
water or moisture. This method must of necessity be very limited in its application, 
as the work necessary to accomplish the obliteration of localities of any considerable SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
585 
extent bearing the characters in question would cost more in the payment of labor, 
etc., than most communities would be able to pay. There are, however, innumerable 
localities, foci of generation, which embrace but a small area of surface, shallow ponds, 
as in southwestern Louisiana, over the prairies, and, almost invariably there adjoining 
residences, which are hotbeds of malaria for those persons who inhabit their immedi- 
ate neighborhood, and also for some considerable distance away. In the hot season of 
July, August and September such depressions are tor the most of the time in a semi- 
dry condition, affording the opportunity for malaria to find its most favorable conditions 
of development. Obviously, the filling up or obliteration of such places is the readiest, 
most efficacious and economical means of dealing with them, from a sanitary point of 
view, judging by the topographical conformation of the regions in question. 
Whether malaria finds its nidus in the soil directly, or in decaying vegetable matter, 
the product of the soil, it is certain that its prevention in localities where it is rife 
would greatly conduce to the mental and material welfare of those who habitually are 
laboring under its repeated visitations. In countries subject to overflow, or in those 
sections where the flooding of rice fields offers opportunities for study, malaria does not 
affect, to any great or appreciable extent, the inhabitants of these localities as long as 
the water is not receding from the surface of the ground. But it makes its appearance 
upon the heels of the waters in their recession, and is manifested, ' ' cæteris paribus, ' ' 
most universally and virulently when the greatest amount of damp soil covered with 
decaying vegetable matter is exposed to the sun, and is strongest in such manifestations 
when the recession of waters takes place in the hottest season of the year. 
Localities to which the foregoing methods can be applied will be found to exist in 
all malarial districts, and in any case the choice of a method by which the sanitary 
condition of a locality may be improved will mostly be a question of financial economy 
and material aptitude. Under certain natural arrangements of the topographical fea- 
tures of a locality, we may sometimes find that the malarial focus of generation is 
limited to a well-defined and comparatively small area of surface, and that the neigh- 
borhood of an abundant supply of water will facilitate the application of the principle 
of flooding, as illustrated by the natural phenomena alluded to above, in freshets and 
rice flooding. Where practicable, this means of arresting the generation and diffusion 
of malaria is as efficacious, may be, as either of the two others already alluded to in 
the preceding remarks. But, of necessity, this means, as that which effects the oblit- 
eration of small malarial-bearing ponds, marshes and other damp and noxious places, 
by filling them up, is one which falls short of an aptitude for general application. So 
few, indeed, may be the opportunities of having recourse to this measure of preven- 
tion, that the sanitarian may be called upon but seldom to advise and enforce its appli- 
cation. 
No stagnant water, in case of such flooding, must be allowed to lay upon the soil, 
and the presence of the water must be maintained until the arrival of the cold 
season shall put a stop to the processes by which the malarial bacillus is generated. 
With these general methods the sanitarian, whose field of inquiry and operation is 
embraced within the bounds of malarial districts of country, will be concerned, for the 
welfare of humanity and the advancement of race will demand of him an increase of 
knowledge and a further perfection of means and measures as the enlightenment and pro- 
gress of communities advance, for there can be no doubt that malaria is a factor in the 
retardation of mental, material and physical progress, and that its production and 
effects are to be deplored and arrested, as far as our limited means will permit us. 
In conclusion, a general view of this subject, embraced in three propositions, will 
serve to give a clearer understanding of the subject, one which is of vital importance 
to a very large proportion of the inhabitants of this country and others, and which 
merits the serious attention of the guardians of the public health. 586 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
The first of these is as follows: Drainage, free, complete and thorough, by which a des- 
iccation of the soil and decaying vegetable matter may be achieved in the shortest pos- 
sible time, and the effects of which are to remain as permanent as the circumstances of 
the case will allow. 
2. In localities which permit its economical and thorough application, the filling up 
or obliteration of low-lying places may sometimes be the readiest and most efficacious 
means at the choice of the sanitarian. 
3. Where neither of these measures may suitably be applied, flooding, where the 
natural conformation of the surface of the earth and a free supply of water may be 
drawn upon when favorably situated for the purpose, is a rare means which might 
sometimes be found applicable to the arrest of the growth and dissemination of the 
miasmatic emanations from the soil. 
Unfortunately, a large area of disease-breeding soil will always remain inaccessible 
to the sanitarian, a part of which can ultimately be improved by the changes produced 
in the condition of a country by its settlement, habitation, tillage and drainage for the 
purposes of cultivation and the needs of civilized life. 
I have not, in the consideration of the sanitary treatment of malarial localities, 
taken cognizance of all the points of interest and utility suggested by the subject. 
Cleanliness of habitations and their surroundings, and prophylaxis in person, although 
so very important, belong to other divisions of the general subject. The cleanliness of 
malaria-bearing localities, embracing the removal of vegetable matter which, in a 
decaying condition, offers food, if I may so say it, for the poison, is of sufficient import- 
ance in itself to merit serious attention, and should, of course, be attained as much as 
possible. The details of any particular system of sanitation are not to be considered 
here, and would, if introduced, stretch this paper beyond the limits of your patience, 
for which, in conclusion, allow me to express my thanks. 
DISCUSSION. 
Dr. A. Nash, of Illinois.-The gentleman has advanced the idea that drainage 
will check the malaria. In our section I have found that draining of the standing 
water during the summer, or malarial season, is invariably followed by an outburst 
of remittent and intermittent fevers. The ultimate drainage of the soil is necessary 
and proper, but it should never be uncovered during the hot months ; there is left 
then a half-dried slime, from which malarial emanations poison the neighborhood. 
Dr. James A. Martin, of Kansas.-In my opinion the malaria in our country 
proceeds chiefly from standing pools of stagnant water. 
Dr. W. L. Schenck, of Osage City, Kansas.-I know that none of you will agree 
with me ; but who has seen this concealed organism which is so much talked about? 
It is beyond the microscope. I believe the heat and great changes from heat to 
cold, warm days and cool nights, cause congestion-congestion of internal organs ; 
this brings on fever and the other symptoms which we call malaria. I know you do 
not agree with me, but the great authority, Stokes, I may refer to for some of my 
opinions. SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
587 
FIFTH DAY. 
THE NECESSITY FOR TEACHING HYGIENE IN SCHOOLS. 
L'ENSEIGNEMENT NÉCESSAIRE DE L'HYGIENE DANS LES ECOLES. 
ÜBER DIE NOTHWENDIGKEIT DES HYGIENISCHEN UNTERRICHTES IN DEN SCHULEN. 
BY W. C. COOK, M.D., 
Of Nashville, Tennessee. 
Notwithstanding the efforts of sanitarians in recent years to enlighten the world 
upon the importance of public hygiene, as a most economic and essential element in 
human progress and happiness, the sad fact still remains that the greatest obstacle in 
the way of advancement is ignorance and consequent indifference of the masses upon 
this vital question. This is truly shown by the opposition with which vaccination is 
met by a large per cent, of every community, although for nearly a century it has 
been demonstrated to be an unfailing preventive of a most loathsome and dangerous 
disease. This was clearly evident among the negroes at Nashville, during a fearful 
epidemic of smallpox, in 1882-4. 
They have but little fear of smallpox, believing it to be a God-given disease. The 
more superstitious of them regard it as an evidence of religious courage, mortification of 
the flesh and acceptance with God, to bravely face it, as a direct visitation of Divine 
Providence. Hence, they firmly believe and say, when the vaccinator proposes to 
protect them by the operation, "Go 'way from here wid your scratch pins. You 
can't keep off smallpox. God gibs us dat, and you can do no good wid your baccinate. 
If I's gwine to hab de smallpox, I's gwine to hab it." Some affect to believe that the 
doctor vaccinates with smallpox matter, or some poisonous substance, which gives them 
disease and kills. So a large per cent, of the lower class of the negroes, and many of 
the same class of whites, have never submitted to the operation, and never will. It is 
frequently the case, when smallpox appears in a family, and all the other members are 
unvaccinated, that they refuse to heed the admonition of the doctor, and be protected. 
Hence, the contagion spreads from one to another. 
Another reason why the disease has been so difficult to manage is the refusal of the 
afflicted families to maintain isolation of cases. So, from ignorance and superstition 
mainly, a large portion of the sick people refused to enter the hospital, or to be vaccin- 
ated or isolated, and its ravages were continued for more than two years. 
As knowledge has extended, other diseases have alike been proved to be caused by 
or dependent upon such conditions as are certainly avoidable. Typhoid fever, dysen- 
tery, diarrhoea, and other forms of bowel troubles, have many times been demonstrated 
to be caused by contaminated drinking water. Klein has shown that scarlet fever is a 
disease derived from the cow through the medium of the milk. Measles, diphtheria, and 
possibly all infectious diseases, in most instances are controllable or preventable. Much 
of the ill health of all communities is known to result from the unsanitary conditions 
which are found to exist, and yet how impossible, often, it is, under the prevailing 588 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
insubordination and general lack of information upon the necessities of hygiene among 
the masses, for health officers to induce, or enforce, a compliance with rules and regu- 
lations for their removal. 
This lack of information and consequent indifference as to sanitary methods is not 
confined to the people only, but is often as striking among those who are called upon to 
represent them in the legislatures of the country. Like them, they have not yet been 
brought to the proper study of the problem. 
An intimate acquaintance with a number of Tennessee legislatures enables me to 
state that most members will only endorse and promote such measures, as they say, 
"as my people want," with a natural disposition not to encourage anything new, unless 
there is a manifest demand for it. 
My observation, with much evidence besides, goes to show that in large communi- 
ties the food supply, especially live stock and dressed meats and sausages, offered for 
sale, should receive not only closer inspection by health officers and boards of health, 
but with a view of securing a purer supply should be the subject of special legislation. 
I am informed by butchers, and the inspection of our sanitary officers, that often sick, 
poor, bruised and tired beef cattle are received or offered for sale as food in our market. 
Adulteration of many of the chief articles of diet, such as butter, syrups, teas, canned 
goods, spices, etc., are known to exist, especially in large cities, as New York, Phila- 
delphia, Boston, and elsewhere. In the recent Legislature of our State a well-prepared 
bill was introduced with the view of securing the proper inspection of live stock, 
dressed meat and sausages intended for food in cities of over 70,000 population at least, 
but the ready defeat of the measure showed conclusively how little sympathy or inter- 
est the average legislator has in sanitary affairs. The bill was voted down in the Senate by 
twenty to four, upon the presumption, as an honorable Senator remarked to the writer, 
" that it was a slap in the face of the farmer, and was thought to operate against his inter- 
est," as if the farmer in offering his meat for sale in the market has greater rights than 
those who buy and eat it. Many States in this and other countries protect public 
health and trade by rigid laws upon the subject. The active opposition displayed by 
our law makers as to the bill clearly shows how far behind we are in the progress and 
enlightenment of the age. 
Health officers, boards of health, physicians, and sanitarians should feel an especial 
obligation resting upon them to renewed effort in educating the masses upon this and 
kindred subjects, by a more thorough dissemination of sanitary knowledge. It is 
said that when the people of Great Britain discovered that more than one hundred 
articles were adulterated, the British Parliament, as long ago as 1815, passed the best 
law extant, and since known as the "Foodand Drugs Act." The present Legislature 
passed a law looking to the manufacture of a purer article of candy, which, while it is 
to be certainly approved, it is nevertheless difficult to see that a similar bill to secure 
pure and wholesome meats is less important. We are liable to be imposed upon by 
having placed upon our market cattle afflicted with Texas fever, pleuro-pneumonia, 
tuberculosis, and other contagious diseases among cattle in the absence of authorized 
inspection, which are calculated to prejudice the health of the people. 
The popular mind should be brought to realize the fact that in divers ways they are 
being imposed upon, either by ignorance or the greediness and unscrupulousness of 
vendors of articles supposed to be necessary for their health and comfort. Medicines 
even, the first and last means to which we resort for the relief of suffering humanity 
and the prolongation of life, are alike subject to adulteration, or else placed upon the 
market, with flaming advertisements, in the shape of some worthless elixir, a panacea 
for some or all the ills to which human flesh is heir. Krauss, chemist of Memphis 
recently analyzed a specimen of a proprietary medicine under the extravagantly adver- 
tised name, " Tasteless syrup of quinine," highly recommended, he states, by two very SECTION XV PUBLIC AND INTERNATIONAL HYGIENE. 
589 
reputable physicians of my own town (Nashville), and " found it to be not quinine, but 
pure commercial cinchonine, the basest of all cinchona alkaloids." This is only one 
instance of thousands similar that have come to light. In these degenerate days the 
proper thing to do would be to have all articles intended for food or medicine for man 
subjected to authorized and competent inspectors. To do so, the people must be 
taught the necessity. Once thoroughly informed, all needed legislation and compli- 
ance therewith would follow. 
In order to secure with greater efficiency necessary laws and to promote in the high- 
est degree public hygiene in all of its departments, every effort should be made to 
instill its principles into the popular mind. 
For this the first class to whom we should appeal is the medical profession itself. 
They are by nature, education and practice the guardians of the health of the commu- 
nities in which they live, and from every consideration better acquainted with the sani- 
tary demands which surround them than any other class of people in their midst. 
Moreover, they are usually faithful workers for the public, without money and without 
price. They only need to recognize a little more sharply the fact, and act accordingly, 
that preventive medicine is the medicine of to-day, and, as Dr. Brunton says, perhaps 
in the near future doctors will be paid rather to keep people well than to treat them 
when sick, observing that ' ' this branch of medicine has been greatly aided by the 
recent increase of our knowledge of the life history of microbes, and their action in 
causing disease. Our power to prevent disease will become greater when we know 
accurately the action of various drugs in destroying these microbes, or preventing their 
growth." 
Medical practitioners are invaluable coadjutors to health officers, in that they con- 
stitute a vast army of thinkers and readers, who are therefore enlightened and efficient 
instructors, or may become so, of the modern gospel of sanitation among the people. 
Instead of becoming alienated, they should be more cooperative in all that tends to 
lessen human suffering and lengthen human life. Sanitation or preventive medicine 
is of recent growth, but in this country, as elsewhere, like all new enterprises, has had 
to withstand old customs, habits and ignorance of the people, from whom, under our 
form of government, all laws must spring and be sustained, in order to be effective. 
The prime duty, then, of health officers and medical men is to educate the masses as to 
the importance of statutes providing for the successful application of all measures neces- 
sary for the removal of all causes operating prejudicially to the public health. 
In my field of operation as county health officer, I have been compelled to observe, 
with regret, a large measure of laggardness and indifference in sanitary measures among 
my professional brethren, as is shown by their neglect in reporting the existence of 
infectious disease, as urged, as well as in many other things. They should realize that 
to prescribe sanitation is as much their duty as to prescribe calomel, and that, therefore, 
they have the same right to take a fee. It does not follow, therefore, that in urging 
the application of sanitary principles, they necessarily destroy the chances for income. 
If so, upon the same principle they should continue to keep the patient sick. The doctor 
thrives best and longest who, with any and all measures, restores his patient quickest. 
Such considerations of selfishness should be abandoned by them, and they at once become 
leaders in sanitary progress. As Hartshorne remarks, ' ' practitioners of medicine have 
need to be thoroughly versed in hygiene, for its uses in the treatment of their patients, 
and that air, water, food, sunlight and other natural agencies, as they are dealt with, 
war either for or against them." The same author says in "Annals of Hygiene :"- 
' 'One cause for the insufficient interest of physicians, so far, in sanitary science, has 
been the general absence of instruction upon hygiene in the medical schools. Until 
the University of Pennsylvania established a chair of hygiene, for a three months' 
course, in 1886, there was, except a less distinctly professional course in Harvard 590 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
College, nothing of the kind in this country. In hardly any other medical school 
in the United States is there to-day more than a nominal inclusion of hygiene, under 
the wing, so to speak, of physiology." 
This ought not so to be ; hygiene, coming naturally between physiology and path- 
ology on the one hand and therapeutics on the other, ought to have a full place in every 
medical curriculum. It should be granted a professorship to itself, in the winter course, 
with examinations compulsory for every graduate. Only when this is done, and the 
whole acquaintance of the physician with the subject is no longer postponed till after 
graduation, then to be picked up as it may be here and there, only then will it be 
possible for the members of the medical profession fully to maintain the place which is 
theirs of right-that of thoroughly equipped, scientific and practical leaders in sanitary 
progress. 
The time may indeed, and ought to, come when sanitary counsel may be called for 
and professionally given, in a manner analogous to that of legal advice, to prevent, 
instead of only to remedy, disaster. If a careful man has property to bequeath, he 
consults a lawyer about his will. When he has a house or a farm to sell, or proposes 
to buy one, a lawyer or conveyancer inspects the title and sees to the proper and safe 
conduct of the transaction. So, why should not the family sanitary adviser be con- 
sulted about the situation, construction, drainage and ventilation of a proposed new 
dwelling to be built or bought? 
All medical colleges should set the example by establishing regular professorships 
on public hygiene, and thus assume a prominence and advantage to which, in the nature 
of their calling, they are justly entitled. 
Not only in medical colleges should public hygiene be taught, but also in the uni- 
versities and literary colleges of the country ; it should be embraced in their curricula. 
Systematic and thorough text-books upon the subject should be introduced, and a faith- 
ful study of the subject be enjoined upon the pupil. It would be better for all such 
institutions to employ a thoroughly educated physician and practical sanitarian as the 
instructor and lecturer in this department, and at the same time supervise and direct 
the sanitation of the institution; a subject of the greatest moment to schools, where, at 
the tender age of youth, so many are thrown together. Anatomy and physiology have, 
to a limited extent, been taught in many schools for years, but in this country I have 
been unable to learn that text-books upon hygiene and instruction thereon have been 
added, to any considerable extent. The subject, however, here and there seems to 
have received some attention. In a recent letter to the writer from Dr. Henry B. 
Baker, Secretary of the Michigan State Board of Health, he states : - 
"In Michigan we have for some time had lectures on sanitary science in our uni- 
versity, at Hinsdale College, Albian College and the State Agricultural College. Some 
of our high schools are becoming interested in the subject." As a further means of 
enlightenment, leading universities of different States could not do better than to imitate 
the energy, intelligence and liberality of Michigan, by securing in some way the means 
necessary to establish a laboratory of hygiene and physics. He says, "We are now 
breaking ground for a thirty thousand dollar building in Ann Arbor, which will be 
given up to the laboratory of hygiene and the laboratory of physics. Five thousand 
dollars have been appropriated for their equipment. " While in European countries 
such laboratories are numerous, in the United States, perhaps, there are none, except 
at the University of Harvard, John Hopkins University, and prospectively at Ann Arbor. 
Public Schools.-Another means for further and more rapid and effective diffusion 
of a knowledge of hygiene would be to teach it in the public and private schools of the 
country, especially to the advanced classes. Latin, Greek, Hebrew, Algebra, Rhetoric, 
Logic, High Art and Music and many other things are taught in such schools, that in 
after life are found to be comparatively useless to the masses in their struggles for SECTION XV PUBLIC AND INTERNATIONAL HYGIENE. 
591 
bread. Could not a knowledge of hygiene be imparted in these schools, by systematic 
teaching, which in the serious march of life would be equally if not far more import- 
ant ? Is it not as practicable to instill a knowledge of hygiene into the minds of pupils 
as that of dead languages, philosophy or political economy ? Is it more valuable or 
productive of more happiness to possess a knowledge of belles-lettres than to under- 
stand how the human body is dependent upon, and affected for life or death by, sur- 
rounding elements and conditions? Is a knowledge of logarithms, trigonometry, or cal- 
culus more conducive to health and wealth than a knowledge of house construction, 
home sanitation, or prevention of epidemics ? I would not be understood as underrat- 
ing the knowledge acquired by pursuing the usual curricula of our schools, but sub- 
mit that the minds which grapple so successfully with their intricate and ornamental 
problems can as easily and with far more practical advantage master the principles of 
sanitary science. 
According to the census of the United States, in 1880 there were attending the vari- 
ous schools of the country 9,946,160 pupils. Suppose this number, or even half, with 
graded and suitable text-books, were being instructed, as in other studies, in the princi- 
ples of hygiene; who could compute the wonderful revolution that would inevitably 
follow upon the subject of public health, within a dozen years, in this country ? What 
a diffusion of knowledge and influence for good would be wrought all over the land as 
they would enter upon the pursuits of life ! What more potent method could be 
adopted fpr the dissipation of the incubus of ignorance which prevails as to the anatomy, 
physiology and hygiene of the human body ? I once asked an intelligent lawyer, as we 
were viewing a manikin, to point to the place where he thought the stomach was. 
Placing his finger on top of the sternum, he said, ' ' There, there it is. " I replied, "You 
are mistaken." "Well," said he, "there is where I feel sick when I puke." As 
truthfully remarked by the Rev. J. L. Patton, of Michigan, "There is scarcely any 
subject of human knowledge of which the mass of men know so little, as their own 
proper selves. " It is hard to illustrate. Here is a man of mature years, who, when 
asked the other day what the thorax is, said that it is a big vein that runs down the 
backbone. But that man is a practicing surgeon, had performed an autopsy on the 
body of a murdered woman, and made this answer on the witness stand of the Circuit 
Court. What, then, must be the condition of laymen ? 
Further, it is said-and there is a good show of authority for it-that knowledge 
is power. George Eliot asks why nobody ever speaks of the power of ignorance. 
Ignorance is not properly power. It cannot tunnel a mountain ; it is the mountain to 
be tunneled, that lies in the way of every proper accomplishment by power. It is weak- 
ness to the mind and weakness and death to the body. This ignorance of men in mass 
as to the anatomy of their own persons, and of the physiology and hygiene pertaining 
thereto, means ignorance of the laws of health, and their consequent violation and 
penalty. Sanitary reform will make no headway worth mention through such igno- 
rance. It is not enough that some physicians and a few experts and specialists be 
intelligent as to sanitary science. The people will not gather themselves up and do 
these things merely because they are told that this will be best for them. To the end 
that they may live long and to best purpose-the object to be attained-people must 
themselves become intelligent as to how to build their homes and cities, how to eat and 
how to sleep, how to work and how to rest, how to keep the earth clean where they are, 
and the air, and the water, also themselves and everything about them. They must 
know how best to keep up the wholesome balance between the activities of the physical 
man and those of the mind. They must also know how best to keep every part of their 
own animal economy at its own proper work and fully up to the requirements upon it 
of the whole man. They must also see how these things are necessary. All this may 
be the work, properly, of the common schools of the land, but it is the province of 592 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
sanitarians to call for it. If our boys and girls, at the age of sixteen years, could chart 
the arterial and venous systems of the human body, and have sufficient knowledge of 
its functions and hygiene, they could well afford to be ignorant of the river systems of 
Europe, Asia and Africa; and if they could also have knowledge of the nervous system, 
the system of digestion and nutrition, the respiratory system, and the mechanics of the 
bones, with their several functions and hygiene, they could afford, even as a means of 
mental discipline, to leave out the rest of their geography, their definitions of dictionary 
words and part of their mathematics. This would give foundation for sanitary reform 
such as might, in time, bring human life up to its natural duration of a hundred 
years. 
In a recent letter from Dr. Ezra M. Hunt, Secretary of the State Board of Health, 
New Jersey, and teacher of hygiene in the Normal School at Trenton, he says, with 
reference to teaching hygiene in the public schools : "I have thought much upon the 
subject upon which you speak, and have the conviction that we will not reach great 
reforms in the care of public health until our children are taught in the schools what 
are the conditions of health. This will not come by the mere teaching of physiology. 
We must directly teach hygiene. " " One of the first things is to teach teachers. " "I 
do not believe any text-book takes the place of a teacher." "My own classes enjoy 
it as much as any study they have, and get out of it science and mental training, as 
well as practical facts." 
In view, therefore, of the benefits to be derived from a diffused knowledge of hygiene, 
may it not be pertinently suggested that sanitarians throughout the land arouse them- 
selves to increased efforts to have the subject embraced in the curricula of the schools, 
and advise the teaching of the subject be intrusted to thoroughly competent physicians 
and practical sanitarians? In this way there will be indelibly impressed upon the 
minds of youth valuable facts pertaining to the conservation of health, which is, indeed, 
individual, as well as public wealth. 
Should this paper contribute in any wise to the agitation, or adoption, by the various 
school authorities of the land, of the views herein imperfectly presented, then would I 
feel conscious that having thus complied with an invitation to write upon the subject 
of Public Hygiene for the Ninth International Medical Congress my labor had not 
been wholly in vain. 
DISCUSSION. 
Dr. Benjamin Lee, after commending the paper of Dr. Cook, offered the fol- 
lowing resolutions, which were unanimously adopted :- 
Resolved, That this Section cordially endorses the suggestions contained in the 
paper of Dr. Cook, of Nashville, "On the necessity for teaching hygiene in schools, " 
and recommends to the Congress the passage of the following resolutions :- 
Resolved, That it is the sense of the Fifteenth Section,Public and International 
Hygiene, of the Ninth International Medical Congress- 
1. That every medical college should place the chair of hygiene in its curriculum, 
and on an equal footing with the other regular branches of instruction, 
2. That in all universities, colleges and high schools, hygiene should form a part 
of the compulsory course of study, and should be taught, not simply by text-books, 
but by educated physicians. 
3. That in all public schools the teaching of hygiene should form a prominent 
and essential feature. 
4. That every State Legislature should establish a museum and laboratory of 
hygiene. 
5. That these resolutions be transmitted to the Ninth International Medical 
Congress, in general session, for its action and endorsement. SECTION XV PUBLIC AND INTERNATIONAL HYGIENE. 
593 
Dr. R. C. Davis, of Seneca, S. C.-I wish to express my heartfelt thanks to the 
gentleman for this paper. This is a grand and all-important subject. We all agree 
that hygiene should be taught in all medical colleges, and also in universities, col- 
leges and common schools. How we can attain this object is the question. How 
can we induce those having power to take the proper steps to have it taught in all 
schools. We should recommend it, as a Section, and as a Grand International Medi- 
cal Congress. I wish to second the resolutions offered, recommending such a course 
of instruction in all schools and colleges. 
The President of the Fifteenth Section placed in Hie hands of Dr. N. S. Davis, 
President of the Ninth International Congress, the foregoing resolutions of Dr. 
Benjamin Lee, for the formal consideration and action of the Congress. 
A NEW METHOD OF TESTING THE GERMICIDAL AND ANTISEPTIC 
POWERS OF CERTAIN MINERAL AND VEGETABLE SUBSTANCES 
EMPLOYED EXTERNALLY AND INTERNALLY IN THE TREAT- 
MENT OF WOUNDS, TUMORS, ENLARGED GLANDS, ULCERS 
AND SYPHILIS; AND IN CERTAIN SANITARY OPERATIONS OF 
DOMESTIC AND PUBLIC HYGIENE. 
UNE MÉTHODE POUR ÉPROUVER LE POUVOIR GERMICIDE ET ANTISEPTIQUE 
DE CERTAINES SUBSTANCES MINÉRALES ET VÉGÉTALES DANS LE TRAITE- 
MENT EXTÉRIEUR ET INTÉRIEUR DES BLESSURES, TUMEURS, RENFLEMENT 
DES GLANDES, ULCÈRES ET SYPHILIS; ET DANS CERTAINES OPÉRATIONS 
SANITAIRES D'HYGIÈNE PUBLIQUE ET DOMESTIQUE. 
ÜBER EINE NEUE METHODE ZUR PRÜFUNG DER GERMICIDEN UND ANTISEPTISCHEN 
KRÄFTE GEWISSER MINERALISCHER UND VEGETABILISCHER SUBSTANZEN, WELCHE 
ÄUSSERLICH UND INNERLICH IN DER BEHANDLUNG VON WUNDEN, GESCHWÜLSTEN, 
• GESCHWOLLENEN DRÜSEN, GESCHWÜREN UND DER SYPHILIS, UND IN GEWISSEN 
SANITÄREN VERRICHTUNGEN DER HÄUSLICHEN UND ÖFFENTLICHEN HYGIENE 
ANGEWANDT WERDEN. 
JOSEPH JONES, M.D., 
New Orleans, La. 
GENERAL OBSERVATIONS ON PUTREFACTION AND ZYMOSIS, ILLUSTRATING THE 
PRESENT STATE OF SANITARY SCIENCE. 
The access of air, together with a moderate amount of warmth and of moisture, are 
necessary to the occurrence of the putrefactive changes which consist essentially in the 
breaking up of the complex organic material and the formation of new and simpler 
combinations among its constituent elements. During the process various vapors and 
gases are evolved, and the lower forms of animal and vegetable life are observed to 
grow and multiply in the putrefying substance. The exciting causes of putrefaction 
have long formed a subject of scientific discussion, two widely different theories being 
maintained respecting them. By the one, the changes which occur during the process 
are held to be from the first the result of chemical decomposition in the organic sub- 
stance, whose atoms are in a state of motion or activity, which is capable of being com- 
municated by catalytic action to other organic material in contact with it (Liebig) ; 
while, further, it is asserted that minute living organisms may be evolved from the 
dead material as the result of these chemical transformations. 
Vol. IV-38. 594 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
By the other theory, which is founded mainly upon the researches of Pasteur, the 
putrefactive changes are ascribed to the agency of organized germs ever present in the 
atmosphere, which, finding a suitable nidus in the putrescible material, grow and mul- 
tiply, producing the chemical decompositions as the result of their action. Putrefaction, 
it is further maintained, may be entirely prevented by means which exclude the access 
of germs. The subject derives much interest and importance from its relation to the 
doctrines of the origin of life, as well as to questions concerning the sources of contagion 
and epidemic disease, and continues to the present time a matter of keen inquiry and 
experiment among physiologists. Various opinions are entertained regarding the 
modus operandi of antiseptics. By those who hold the purely chemical theory of putre- 
faction they are believed to operate in different ways, according to their chemical pro- 
perties ; thus, sulphurous acid is said to act by deoxidizing the putrescible matter; the 
mineral acids and metallic salts by combining with the substance, and forming a per- 
manent compound ; and the tar acids in a similar manner. On the other hand, the 
supporters of the germ theory maintain that carbolic acid, and indeed all true antisep- 
tics, produce their effect by acting as poisons to the infusorial organisms which are held 
to be essential to the occurrence of the putrefactive process. 
We accept the preceding facts and statements of the theories with reference to the 
origin of diseased germs without further comment, and proceed at once to the detail of 
the results of our investigations. 
SCOPE OE THE PRESENT INQUIRY. 
It is of importance that the relative value of the agents used in the local and con- 
stitutional treatment of wounds, tumors and ulcers, contagious diseases, as syphilis, 
should be determined by well-devised and easily manipulated and comprehensive 
experiments. If certain diseases be caused by microorganisms, bacteria and fungi, it is 
of importance to the physician and surgeon that the relations of the therapeutic agents 
to the pathogenic organisms should be carefully and thoroughly determined. Inves- 
tigations upon the relations of disinfectants and antiseptics demand the most profound 
and protracted investigation with the higher powers of the microscope, and more or less 
obscurity necessarily attaches to results thus obtained. Besides, it is important to 
demonstrate the results beyond cavil to those unacquainted with the use of the micro- 
scope. Science demands a method of research at once simple and open to the obser- 
vation of the naked eye, and to all observers, whether skilled or not in the use of the 
microscope; only those who have labored for any length of time in the field of bacteri- 
ology with the higher powers of the microscope can form any accurate judgment as to 
the effect of the continual strain upon the organs of vision. If there be any tendency 
to inflammation of the eyes or to neuralgic hemicrania, great suffering, if not irreparable 
damage of the eyes, may result. 
In order to determine experimentally the relative value of the agents employed 
locally and internally in the treatment of wounds, ulcers and of syphilitic affections, in 
such a manner as to omit tedious and doubtful labors with the higher powers of the 
microscope, it was necessary to select the larger germs, whose evolution could be 
observed by the naked eye. Of course, such a line of experiment was applicable to all 
medical agents and poisons, whether or not included under the divisions of antiseptics 
or disinfectants. 
METHOD OF EXPERIMENTS WITH POISONS, ANTISEPTICS AND DISINFECTANTS. 
The plant selected for these experiments was rice (Oriza sativa). If grains of rice 
be placed in water, they will, if the water be of the proper temperature, germinate, and 
the plants will grow several inches in water without the addition of any extraneous 
matter. During the period of the germination and growth of the rice, we have a favor- SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
595 
able opportunity of testing the effects of various poisons, simply by adding them to the 
water. It will be of some interest to consider briefly the history and nature of the 
plants which we have selected for this series of experiments. 
Rice, Oriza sativa-General Observations.-Rice has been known and cultivated from 
the earliest records of the human race, and it is believed to furnish food for a greater 
number of human beings than any other of the cultivated cereals. Of this plant there 
has usually been held to be but one species-Oriza sativa, common rice. But there are 
sub-species or varieties, so greatly different in their habits and characters that they may 
be rather, perhaps, regarded as specifically distinct. They may be all referred to two 
general types-the common rice, so termed, and the mountain rice, Oriza mutica of 
many botanists, which differs from the other in its general aspect and habits. 
The common rice grows from one to six feet in height, terminating in a pinnacle, 
the seeds of which are armed with long arms. It is cultivated in marshes, and for a 
great part of its growth is partially under water. The mountain rice grows on moun- 
tains and dry soils. A plant of this class has been recently found growing high on the 
range of the Himalayan mountains. The rice is spread over all the warmer regions of 
the Old World, and has been carried to the New, where it flourishes in great luxuriance. 
The common rice is cultivated in the south of Europe, and the mountain rice has lately 
been extended to the more northern parts of it, to Westphalia, and even to the Low 
Countries. Rice seems to be a plant fitted in a remarkable degree to accommodate 
itself to different situations. It is a considerable period since it was introduced into 
the countries north of the Mediterranean, Greece, Italy and Spain. It is more recently 
that it has extended to Hungary and Central Europe. 
Historical Notes on the Cultivation of Rice.-Rice, according to the testimony of botan- 
ical and agricultural writers, has been cultivated from time immemorial in tropical coun- 
tries. The fact of its having been used in a Chinese ceremonial as early as 2800 years B. c., 
induced Alphonse de Candolle to consider rice as a native of China. It was very early 
cultivated in India, in some parts of which country, as in tropical Australia, it is, as we 
have seen, indigenous. It is not mentioned in the Bible, but its culture is alluded to in 
the Talmud. There is no evidence of the existence of rice in Egyptian remains, nor is 
there any trace of it as a native plant among the Greeks, Romans or ancient Persians. 
There is proof of its culture in the Euphrates valley and in Syria, 400 years before 
Christ. Crawford, on philological grounds, considers that rice was introduced into 
Persia from southern India. The Arabs carried the plant into Spain under the name 
"aruz," the arros of the Spanish, the rizo of the Italian, whence our word rice. 
Rice was first cultivated in Italy, near Pisa, in 1468. It was not introduced into 
Carolina until 1700, and then, as it is said, by accident, although at one time the 
southern United States furnished a large proportion of the rice introduced into com- 
merce. Rice, says Crawford, sports into far more varieties than any of the corns 
familiar to Europeans, for some varieties grow in the water and some on dryland; 
some come to maturity in three months, while others take four and six months to do so. 
The Hindus, however, are not content with such broad distinctions as might be derived 
from these obvious sources, but have names for varieties, the distinctions between 
which are unapplicable by Europeans; besides terms for this corn founded on variety, 
on season, and on mode of culture, the grain itself bears one name in the straw, another 
when threshed, one name in the husk and another when freed from it, and a fifth when 
cooked. A similar abundance of terms is found in the languages of the Malay and 
Philippine islands. Such minute nomenclatures seem to point to a great antiquity in 
the culture of this cereal. 
Botanical, Microscopical and Chemical Characters of Rice, and its Nature as an Article 
of Food.-According to Roxburgh, the cultivated rice, with all its numerous varieties, 
has originated from a wild plant, called in India newaree, or nivara (Oriza sativa). It 596 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
is said to grow on the borders of lakes in the Circars and elsewhere in India, and is 
also native in tropical Australia. The rice plant is an annual grass with long, glab- 
rous leaves, each provided with a long, sharply-pointed ligule. The spikelets are 
borne on a compound or branched spike, erect at first, but afterward bent downward. 
Each spikelet contains a solitary flower with two outer small glumes and two inner, 
larger and folded lengthwise, the outer one of the two rather larger and sometimes 
provided with an arm. Within these are six stamens, a hairy ovary, surmounted by 
two feathery styles which ripen into the fruit (grains), and which is invested by the 
husk formed by the persistent glucess. The cultivated varieties are extremely numer- 
ous, some kinds being adapted for marshy land, others for growth on the hill sides. 
The cultivators make two principal divisions, according as the sorts are early or late. 
Other subdivisions depend upon the habit of the plant, the presence or absence of an 
arm, the color of the grain and other particulars. Rice constitutes one of the most 
important articles of food in all tropical and sub-tropical countries, and is one of the 
most prolific of all crops. The rice yields best on low lands subject to occasional inun- 
dations, and thus enriched by alluvial deposits. An abundant rainfall during the grow- 
ing season is also a desideratum. Rice is sown broadcast, and in some districts is trans- 
planted after a fortnight or three weeks. No special rotation is followed ; indeed, the 
soil best suited for rice is ill adapted for any other crop. In some cases little manure 
is employed, but in others abundance of manure is used. No special tillage is required, 
but weeding and irrigation are requisite. Rice in the husk is known as "paddy." In 
cutting across a grain of rice and examining it under the microscope, first the flattened 
and dried cells of the husk are seen, and then one or two layers of cells elongated in a 
direction parallel to the length of the seed, which contains the gluten or nitrogenous 
matter. Within these, and forming by far the largest part of the seed, are large poly- 
gonal cells filled with numerous and very minute angular starch grains. Rice is not so 
valuable as a food as some other cereals, inasmuch as the proportion of nitrogenous matter 
(gluten) is less. Payeu gives only seven per cent, of gluten in rice as compared with 
22 per cent, in the finest wheat, 15 in oats and 12 in maize. The percentage of potash 
in the ash is as 18 to 23 in wheat. The fatty matter is also less in proportion than in 
other cereals. Rice, therefore, is chiefly a farinaceous food, and requires to be com- 
bined with fatty and nitrogenous substances, such as milk or wheat gravy, to satisfy 
the requirements of the system. 
EXPERIMENTS ILLUSTRATING THE EFFECTS OF CERTAIN POISONS, GERMICIDES, ANTI- 
SEPTICS AND DISINFECTANTS UPON THE GERMINATION, GROWTH AND PRESER- 
VATION OF THE SEEDS OF RICE (ROUGH RICE). 
Experiments with Hydrogen and Potassic Cyanide.-1st Series. Experiments upon the 
Action of Prussic Acid {Hydrocyanic Acid) and Cyanide of Potassium upon Plants {Rice. Oriza 
sativa), at Maybank, Georgia, in the summer of 185f 
Experiment 1.-Hydrocyanic acid was added to half a fluidounce of spring water, 
in which the rice seeds had been placed, in an open glass vessel. The hydrocyanic acid 
retarded germination for several days, but did not arrest the final development of the 
young plants. The degree of retardation was determined by conducting simultaneously 
experiments with rice and pure water. 
Experiment 2.-Action of Hydrocyanic Acid upon Rice in Closed Vessels. 
When the rice seeds and dilute solutions of prussic acid were put in a partially cov- 
ered glass vessel, with sufficient atmospheric air for germination, they did not ger- 
minate. When the grains were removed from this solution, with very few exceptions, 
they were incapable of germination, although originally perfect. The experiments 
were performed in the month of June, in an upper, well-ventilated room, where the SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
597 
temperature and light were most favorable for « a rapid and vigorous germination and 
growth, and were repeated upon more than one hundred grains of rice. 
If we compare the two experiments and consider the surrounding circumstances, it 
is evident that the different results were due to the fact that when the rice was subjected 
to the action of dilute prussic acid in open vessels, the poison, from its volatile nature, 
was evaporated, in a great measure, before it produced any deleterious effects upon the 
rice; in the confined space, on the other hand, while the seeds had all the essential con- 
ditions of germination, viz., heat, moisture and a sufficient, if not abundant, supply of 
oxygen in the confined air, still, the absorption of the prussic acid continued unimpeded 
and arrested the process of germination in its earliest stages, for the seeds, in almost 
every instance, presented upon the exterior an unaltered appearance. 
Experiment 3.-Action of Hydrocyanic Acid upon Germinated and Growing Rice. 
When dilute hydrocyanic acid was added to the water in which the young shoots 
were growing, it arrested the growth and caused death in periods of time corresponding 
with the amount of acid added. This experiment was repeated upon more than one 
hundred stalks of growing rice, with similar results. 
Second Series. Action of Cyanide of Potassium upon Plants.-In the experiments with 
this salt, as well as in those of hydrocyanic acid, rice was the plant selected, and the sur- 
rounding conditions of temperature were the same. 
Experiment 4.-Action of Cyanide of Potassium upon the Germination of Rice. 
Both in closed and unclosed vessels, solutions of cyanide of potassium arrested com- 
pletely the process of germination. The word arrested is here used because it is diffi- 
cult in such experiments to affirm that not a single change took place in the organic 
elements before the complete arrest of the process. It is certain, however, that if any 
of the numerous changes of germination took place, they did not proceed far when the 
seeds thus acted upon by cyanide of potassium were transferred to pure water. In no 
instance did germination take place, they simply underwent slow decay. This experi- 
ment was repeated with the same result upon more than one hundred rice seeds. Cor- 
responding experiments were carried on at the same time with pure water. 
Experiment 5.-Action of Cyanide of Potassium upon Growing Rice. 
Solutions of cyanide of potassium in every instance arrested the growth and caused 
the death of the growing rice; and the rapidity of its action corresponded with the 
amount of the poison added. These experiments were, in like manner, repeated upon 
more than one hundred stalks of growing rice. The following conclusions may be 
drawn from the preceding experiments :- 
1. Plants as well as animals may be destroyed by certain mineral and vegetable 
substances denominated poisons. 
2. As the vegetable kingdom is without nerves, muscles, or any special circulating 
apparatus similar to the automatic apparatus of animals, it is evident that these poi- 
sons must act upon the individual living cells composing the vegetables. 
3. As the living component cells of the vegetable kingdom are capable of elaborating 
distinct products from the surrounding nutritive materials, and as this power is 
destroyed by poisons, we must conclude that the functions of secretion, growth and 
nutrition may be influenced directly by poisons, without the intervention of the ner- 
vous system. 
4. As therefore poisons may act directly upon the individual living cells of vege- 
tables, arresting the process of the acts of germination in the seed, and of the acts of 
secretion, nutrition and growth in the fully-formed cells; it is reasonable to infer that 
poisons may act upon the individual living cells of animals. Thus poisons may act 
directly upon the muscular fibres, or upon the ganglionic cells of the sympathetic and 
cerebro-spinal system, or upon the secreting and excreting cells of the liver and kidneys, 
or upon the colored and colorless corpuscles of the blood. 598 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
EXPERIMENTS ILLUSTRATING THE RELATION, POWERS AND EFFECTS OF CERTAIN 
ANTISEPTICS, DISINFECTANTS AND GERMICIDES. 
Definition of terms, and a general outline of the present state of our knowledge 
with reference to disinfectants and antiseptics appear to be a useful introduction to the 
following experiments:- 
Definition of Terms and Brief Outline of Established Facts Relative to Disinfectants 
and Antiseptics.-Disinfectants are agents or substances employed to prevent the spread 
of contagious or infectious diseases. Recent investigations all tend to demonstrate that 
the efficiency of any disinfectant is due to its power of destroying, or rendering inert, 
specific poisons or disease germs which possess in themselves an independent existence, 
and which, when introduced into the animal system under favorable conditions, increase 
and multiply, thus producing the phenomena of special diseases. Therefore, antisep- 
tic substances generally, which check or stop putrefactive decay in organic compounds, 
by preventing the growth of these minute organisms which produce putrefaction, are 
on that account disinfectants. So also the deodorizers, which act by oxidizing or 
otherwise changing the chemical constitution of volatile substances disseminated in the 
air, or which prevent noxious exhalations from organic substances, are, in virtue of 
these properties, effective disinfectants in certain diseases. A knowledge of the value 
of disinfectants, and the nse of some of the most valuable agents, can be traced to very 
remote times; and much of the Levitical law of cleansing, as well as the origin of 
numerous heathen ceremonials and practices, are clearly based on a perception of the 
value of disinfection. The means of disinfection and the substances employed are 
very numerous, as are the classes and conditions of disease and contagion they are 
designed to meet. Nature, in the oxidizing influence of freely circulating atmospheric 
air, in the purifying effect of water, and in the powerful deodorizing properties of com- 
mon earth, has provided the most potent, ever-present and acting disinfecting media. 
Of the artificial disinfectants employed or available,' three classes may be recog- 
nized :- 
1. Volatile or vaporizable substances which attack impurities in the air. 
2. Chemical agents for acting on the diseased body or on the infectious discharges 
therefrom ; and 
3. The physical agencies of heat and cold. 
In some of these cases the destruction or the formation of new chemical compounds 
by oxidation, deoxidation or other reaction, and in others the conditions favorable to 
life are removed or life is destroyed by high temperature. Of the first class, aerial dis- 
infectants, those most employed are the gaseous sulphurous anhydride, the fumes of 
nitrous acid, with chlorine gas and vapors of bromine and iodine. The use of sulphurous 
anhydride, obtained by burning sulphur, is of great antiquity, and it still is unequaled 
as a disinfectant of air, on account both of its convenience and its general efficacy. 
Camphor and some volatile oils have also been employed as air disinfectants, but their 
virtues lie chiefly in masking, not destroying, noxious effluvia. In the second class, 
non-gaseous disinfecting compounds, all the numerous antiseptic substances may be 
reckoned, but the substances principally employed in practice are oxidizing agents, as 
potassic manganates and permanganates. 
One of the most important applications of antiseptics has been their introduction 
into medical and surgical practice. Although their internal administration, with the 
view of counteracting diseases believed to be due to morbid poisons, has not hitherto 
yielded any marked practical result, their employment in the treatment of wounds has, 
in the hands of Professor Lister, of Edinburgh, attracted much interest, and has exer- 
cised an important influence on surgical practice during the past ten year's. Professor 
Lister, adopting the germ theory of putrefaction, and regarding many of the evils arising 
in connection with open wounds as the result of putrid discharges, produced by the SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
599 
agency of atmospheric germs, seeks to exclude the access of these to wounded surfaces 
by the employment of antiseptics, particularly carbolic acid, the power of which in 
destroying living organisms is undoubted. Dressings of gauze made antiseptic by pre- 
vious treatment with strong carbolic acid, are applied to wounds. The acid well diluted 
with water is likewise employed as a lotion, and during the dressing of wounds and the 
performance of operations is also applied in the form of spray to the surrounding 
atmosphere, with the object of preventing all access of germs. Boracic acid is also 
employed by Mr. Lister as an antiseptic. The chief benefits claimed for the method of 
treatment are, that wounds, however extensive, may heal without the occurrence of 
putrefaction in the discharges, and that thereby the risks of blood poisoning (pyæmia, 
etc.), are reduced to a minimum. 
Bichloride of mercury (corrosive sublimate) has, to a certain extent, recently super- 
seded carbolic acid in surgical and sanitary operations ; but the relative value of both 
agents as disinfectants, antiseptics and germicides must be still further investigated, as 
we shall endeavor to demonstrate by the method of experimentation which we have 
indicated. In medical, surgical and sanitary practice the relative poisonous properties 
of the various agents employed should always be most carefully and thoroughly tested 
and considered. Thus the poisonous properties of corrosive sublimate benefit it for use 
in many sanitary operations, and necessitate the utmost precaution in its use in medi- 
cine and surgery. We cannot separate the poisonous properties of any agent from its 
antiseptic powers when the foul water and air are concerned, and when human life may 
be jeopardized by their careless or ignorant use in the sick room, on shipboard, or in 
hospital. 
Third Series-Water.-Experiment No. 6.-Ten grains of well-formed, healthy, 
rough rice, grown by Col. Favrot, in the neighborhood of Baton Rouge, Louisiana, 
loosely enclosed in ordinary clean cotton wool, were placed in the upper portion of a 
test tube, five and a half inches in length and about one-half inch in diameter, con- 
taining 350 grains of rain water, on the 11th of May, 1886, at 3 o'clock p.m. Tem- 
perature of the surrounding atmosphere in my practical laboratory, 36 Dryades street, 
84° F. On the 14th of May (fourth day of the experiment) the rice had commenced to 
germinate, each grain showing signs of life, sending up a delicate white sprout through 
the meshes of the cotton into the air, and below, into the water, a delicate white root. 
The rice continued to grow; the upper sprouts, or stems, presented a delicate greenish 
hue, while the straight white roots sent out numerous delicate white rootlets through 
the water. The delicate white roots passed to the bottom of the glass test tube, attain- 
ing a length of five inches, and the stems grew to a similar height above the layer of 
cotton in the upper portion of the tube. 
The maximum growth was attained in about three weeks, and the green color of the 
upper sprouts or plants gradually faded, and on the 14th of June the plants, as far as 
the upper sprouts or plants were concerned, presented a withered and dried appear- 
ance. On examination, I found that only 100 grains of water remained in the test 
tube ; 250 grains of water had been consumed by the growing rice and by evaporation. 
The loss of vitality appeared to be due to the absence of the necessary saline constitu- 
ents for the perfect development of the plants after the transformation of the organic 
elements and compounds (starch, sugar, albumen or gluten) into cellular elements, and 
by the exhaustion of the greatest portion of water. 
Experiment No. 7-Repetition of Experiment No. 6.-Ten grains oC rough rice 
placed in cotton wool in mouth of test tube, containing 350 grains of water, at the same 
time and upon the same day (11th of May, 1886), and in the same room. The grains 
sprouted, and followed the same course of development as described in the preceding 
experiment (No. 6). The individual plants attained the same size, and perished about 
the same time. At the expiration of both experiments, on the 14th of June, 1886, 600 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
although the upper plants were withered and apparently dead, the roots were soft and 
white, and the remaining parts of water (100 grains in each test tube) were clear and 
odorless, and the plants gave forth no bad odor. 
Fourth Series-Corrosive Sublimate (Mercuric Chloride, Bichloride of Mercury)- May 
11th, 1886; temperature of the atmosphere, 84° F.-Ten grains of rough rice were loosely 
enclosed in cotton wool and placed in the mouth of a test tube of similar size and capacity 
as that used in the preceding experiments. Five small lots of rice were thus prepared, and 
assigned to five test tubes. These test tubes were charged with solutions of corrosive 
sublimate (mercuric chloride), one grain dissolved in 100, 200, 400, 800 and 1600 grains 
of water. The relative properties of mercuric chloride to the water is illustrated by 
the following fractions: jggg. The following are the results of the 
individual experiments:- 
Experiment No. 8.-Ten grains of rice in one per cent, solution of bichloride of 
mercury (one grain in 100 grains of water). No germination by the seeds of rice at 
the end of three weeks. 
Experiment No. 9.-Ten grains of rice immersed in solution of corrosive sublimate, 
one grain dissolved in 200 grains of water. Grains of rice remained unchanged; no 
germination at the end of three weeks. 
Experiment No. 10.-Ten grains of rice immersed in solution of corrosive sublimate, 
one grain dissolved in 400 grains of water. The grains of rice showed no signs of germi- 
nation at the end of three weeks. 
Experiment No. 11.-Ten grains of rice immersed in solution of corrosive sublimate, 
one grain dissolved in 800 grains of water. Eight grains of rice showed no signs of ger- 
mination ; two grains in the second week of the experiment showed signs of feeble ger- 
mination, and finally attained a height of one and three-quarter inches above the surface 
of the cotton and presented a pale, withered, sickly appearance ; the grains also sent 
small roots into the solution, which did not exceed three-tenths of an inch in length. 
These two grains occupied an extreme portion of the upper part of the cotton. The 
exact date of the commencement of germination in this experiment was May 18th, 
and all signs of life gradually ceased before June 10th. 
Experiment No. 12.-Ten grains of rice immersed in solution of one grain of cor- 
rosive sublimate in 1600 grains of water. Four grains showed no signs of germination; 
six grains germinated, sending up sickly, pale-green sprouts, which finally attained, 
on the 18th of May, a length of from one to one and three-quarter inches, and then 
ceased to grow and gradually withered. The whole imperfectly formed roots varied in 
length from one-tenth to four tenths of an inch in length and did not penetrate the 
water to any depth. The products of the germination were pale and stunted in the 
preceding experiments with corrosive sublimate. 
Numbers 8, 9, 10, 11 and 12 wrere concluded in June, 1886. The weather was warm 
and at times the thermometer stood near 90° F. The water was clear in the five test 
tubes, and free from odor or deposits; the grains of rice presented a clean, undecomposed 
appearance. They were firm upon pressure and had not undergone putrefaction. The 
loss of water in each test tube was about 100 grains, about 250 grains of the solution 
of mercuric chloride remaining in each test tube. On the contrary, the experiments 
with water unadulterated, 250 grains were lost and only 100 grains remained in the 
test tube ; it would appear, therefore, that about 150 grains of water were consumed or 
exhausted by the growing rice. The preceding experiments demonstrated that mer- 
curic chloride is both germicidal and antiseptic. On the 18th of June the grains of 
rice employed in the experiment with corrosive sublimate just detailed were placed 
in clear w ater and allowed to remain for one month. During this period there wrere 
no signs of germination. 
Fifth Series.-Carbolic Acid.-New Orleans, May 11th, 1886; temperature of atmos- SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
601 
phere 84° F. The carbolic acid employed in these experiments was the crystallized 
Calvert No. 1 ; regarded as the purest sample of carbolic acid offered in this market. 
Ten test tubes (with ten grains of rice) enclosed in cotton wool, as in the preceding 
experiments with corrosive sublimate, were charged with solutions of carbolic acid of 
the following strengths : one grain of carbolic acid to 100 grains of water ; one grain 
to 200 grains of water 400, 800 and 1600 grains of water. 
Experiment No. 13.-Ten grains of rice immersed in solution of one grain of car- 
bolic acid in 100 grains of water ; up to the 18th of June no germination, grains of rice 
sound, no putrefaction, water gave a distinct odor of carbolic acid. 100 grains of water 
lost out of the original 350 grains. When transferred to pure water the grains did not 
germinate. 
Experiment No. 14.-Ten grains of rice immersed in solution of carbolic acid, one 
grain in 200 grains of water. Grains did not germinate up to end of experiment, June 
18 ; at the latter date, water clear with odor of carbolic acid, and grains of rice not 
decomposed, but presenting a normal appearance; 100 grains of water lost from the ori- 
ginal 350 grains of carbolic solution in the test tube. 
Experiment No. 15.-Ten grains of rice in solution of one grain of carbolic acid in 
300 grains of water. 
Experiment No. 16.-Ten grains of rice in solution of one grain of carbolic acid in 
400 grains of water. 
Experiment No. 17.-Ten grains of rice in solution of one grain of carbolic acid in 
800 grains of water. 
The results obtained in each of the foregoing experiments (Nos. 15, 16, 17) were 
similar in all respects with those of experiment No. 9, namely, no germination of the 
rice, no putrefaction, no bad odor of the water, and the loss of about 100 grains of water 
in each test tube. Experiments closed on the 18th of J une, and the grains transferred 
to fresh rain water; no subsequent signs of life or germination. 
Experiment No. 18.-Ten grains of rice, immersed in solution of one grain of car- 
bolic acid in 1600 grains of water. The grains of rice germinated and sent up a stem 
about two inches in height. At the end of the experiment the grains of rice were 
black and soft and emitted a putrid odor; the water was turbid and emitted a putrid 
odor. It is clear, from these experiments, that carbolic acid possesses equal if not 
greater germicidal powers than corrosive sublimate, while its antiseptic properties 
appear to be less. 
Sixth Series.-Red Iodide of Mercury (Mercuric Iodide), Biniodide of Mercury.-New 
Orleans, June 20th, 1886. Temperature of the atmosphere, 88° F. 
Experiment No. 19.-Ten grains of rice enclosed in cotton wool and immersed in 
rain water; germination of each grain rapid, and the results similar to those secured in 
experiment No. 6, third series. 
Nine test tubes, of similar length, diameter and capacity with those employed in 
the preceding experiments, and furnished each with ten grains of rice on the necessary 
tufts of cotton wool, and charged with the following solutions of the red iodide of mer- 
cury dissolved in water, by'the aid of the iodide of potassium. The amount of iodide 
of potassium employed was just sufficient to make a perfectly clear solution of the red 
iodide of mercury. 
Experiment No. 20.-Ten grains of rice wrapped in cotton wool and immersed 
in solution of red iodide of mercury of the strength of ten grains dissolved in 100 
grains of water ; ten per cent, solution. No germination of rice on the 23d of August, 
1886, when the experiment closed; the grains of rice presented a sound, unaltered 
appearance, with no marks of putrefaction, although the thermometer was frequently 
near 100° F. 
Experiment No. 21.-Ten grains of rice immersed in solution of mercuric iodide 602 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
of the strength of five grains in 100 grains of water. No germination of rice. On 
23d of August, rice grains unaltered and apparently undecomposed. 
Experiment No. 22.-Ten grains of rice immersed in solution of mercuric iodide 
of the strength of 2.5 grains in 100 grains of water. The result was the same as in 
the preceding experiment-no germination ; on the 23d of August rice grains presented 
an unaltered appearance. 
Experiment No. 23.-Ten grains of rice immersed in solut'on of mercuric iodide 
of the strength of 1.25 grain to 100 grains of water. Result the same as in the pre- 
ceding experiments-no germination ; on the 23d of August rice grains appeared to be 
unaltered and not decomposed. 
Experiment No. 24. Ten grains of rice immersed in solution of 0.5 grain of 
mercuric iodide dissolved in 100 grains of water ; no germination. August 23d, no 
change to the naked eye in the grains of rice. The proportionate strength of this solu- 
tion was one grain of the mercuric iodide dissolved in 200 grains of water, 
Experiment No. 25.-Ten grains of rice immersed in solution of 0.25 grain of mer- 
curic iodide in 100 grains of water; the strength of this solution was one grain of 
mercuric iodide in 400 of water and expressed by the fraction No germination ; 
on the 23d of August rice had not sprouted and the grains appeared to be unchanged 
and without marks of putrefaction. 
Experiment No. 26.-Ten grains of rice immersed in a solution of mercuric iodide 
of the strength of 0.125 to 100 of water ; one grain of mercuric in 800 of water, 
No germination ; on the 23d of August grains of rice presented an unchanged appear- 
ance. 
Experiment No. 27.-Ten grains of rice immersed in solution of mercuric iodide, 
0.0625 in 100 grains of water; relative strength, one grain of red iodide of mercury in 
1600 grains of water. No germination; August 23d, no appearance of change in the 
rice grains. 
Experiment No. 28.-Ten grains of rice immersed in solution of mercuric iodide, 
0.03175 grain dissolved in 100 grains of water. Relative strength, one grain mercuric 
iodide dissolved in 3500 grains of water, Result the same as in the preceding 
experiments ; no germination, and no putrefaction of the rice grains. The preceding 
experiments, sixth series (experiments 19-28), demonstrate in the clearest manner 
the germicidal and antiseptic properties of the red iodide of mercury, which appears to 
possess superior powers in these results to mercuric chloride (corrosive sublimate). 
Seventh Series-Blue Vitriol {Sulphate of Copper, Cupric Sulphate), June 29th, 1886.- 
Temperature of the atmosphere, 88° F. Six test tubes provided each with ten grains of 
rice and the necessary amount of cotton wool, and the following solutions of cupric 
sulphate were used:- 
Experiment No. 29.-Ten grains of rice immersed in solution of ten grains of cupric 
sulphate in 100 grains of water, ten per cent, solution. No germination and no putre- 
faction up to close of experiment, August 23d. 
Experiment No. 30.-Ten grains of rice immersed in solution of five grains of cupric 
sulphate in 100 grains of water. No germination and no putrefaction up to close of 
experiment, August 23d. 
Experiment No. 31.-Ten grains of rice immersed in solution of 2.5 grains of 
cupric sulphate in 100 grains of water. The results were similar to those of 29,30. 
No germination and no putrefaction. 
Experiment No. 32.-Ten grains of rice immersed in solution of cupric sulphate in 
1.25 grains in 100 grains of water. No germination or putrefaction up to August 23d, 
1886. 
Experiment No. 33.-Ten grains of rice immersed in solution of cupric sulphate 
0.625 in 100 grains of water. No germination and no putrefaction. SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
603 
Experiment No. 34.-Ten grains of rice immersed in solution of 0.3125 grains of 
cupric sulphate. No germination and no putrefaction. 
The preceding experiments (series 7, experiments 29, 30, 31, 32, 32, 34) establish 
the germicidal and antiseptic properties of the sulphate of copper, even in small pro- 
portions and in very dilute solutions. 
Eighth Series-Green Vitriol, {Sulphate of Iron, Ferric Sulphate').-June 19th, 1886, 
temperature of the atmosphere, 88° F. 
Experiment No. 35.-Ten grains of rice, immersed in solution of ten grains of ferric 
sulphate (green vitriol) dissolved in 100 grains of water; rice did not sprout or putrefy. 
Experiment No. 36.-Ten grains of rice immersed in solution of ferric sulphate, 
five grains dissolved in 100 grains of water; rice did not sprout or putrefy. 
Experiment No. 37.-Ten grains of rice immersed in solution of ferric sulphate, 2.5 
grains in 100 grains of water. 
The germination of the rice was somewhat retarded, but all the grains sprouted, 
developed vigorous roots and leaves, the leaves presented a light green color and 
attained the height of about six inches. 
Experiment No. 38.-Ten grains of rice immersed in a solution of ferric sulphate, of 
the strength of 1.25 grains dissolved in 100 grains of water. The germination was 
slightly retarded, but the rice sprouted and grew luxuriantly, the leaves reaching 
about eight inches in length and of a bright green color. 
From the preceding experiments, 35, 36, 37 and 38, it is evident that the sulphate 
of iron (green ferric sulphate) is germicidal and antiseptic only in strong solutions, 
from five to ten per cent. In weaker solutions the ferric sulphate retards but does not 
arrest germination. 
Ninth Series-The Citrate of Iron, Quinia and Strychnia.-Compound crystalline salt, 
as prepared by Powers & Weightman, was employed in the following experiments:- 
Experiment No. 39.-Ten grains of rough rice immersed in a solution of ten grains 
of compound salt, citrate of iron, strychnia andqninia, dissolved in 100 grains of water. 
Germination retarded, but was not arrested, and the plants of rice finally presented a 
green appearance. 
Experiment No. 40.-Ten grains of rice immersed in a solution of five grains of the 
citrate of iron, strychnia and quinia; germination slightly retarded, but not arrested; 
growth of rice vigorous. 
Experiment No. 41.-Ten grains of rice immersed in solution of 2.5 grains of the 
citrate of iron, strychnia and quinia; germination prompt and vigorous; blades of rice 
well formed and of a decided green color. 
In the preceding experiments, which, like those with the ferric sulphate, were per- 
formed simultaneously and in the same room and atmosphere with those of the corrosive 
sublimate, carbolic acid, mercuric iodide, and cupric sulphate, we observe that the com- 
pound salt of the citrate of iron, strychnia and quinia did not arrest the germination 
of the seeds of rice. 
PRACTICAL APPLICATION'S AND GENERAL CONCLUSIONS WITH REFERENCE TO THE 
ANTISEPTIC AND GERMICIDAL PROPERTIES OF SOME OF THE AGENTS STUDIED. 
First.-Substances may be Germicidal but not Antiseptic.-Thus, hydrocyanic acid and 
cyanide of potassium promptly arrest vegetable and animal lite, but do not arrest 
putrefaction. 
Second.-Mercuric chloride and mercuric iodide, which are powerful germicides and 
antiseptics, are also powerful anti-syphilitic remedies. If syphilis be due to a specific 
microorganism, the value of the preparations of mercury may be due, in part at least, 
to their power to destroy syphilitic germs and to prevent germination. 
The author has employed the mercuric chloride and mercuric iodide in the treat- 604 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
ment of syphilis during the past thirty years with successful results, and has found the 
red iodide of mercury easily administered in solution, by means of the iodide of potas- 
sium, in about the proportions indicated. We have employed the various preparations 
of mercury as blue mass (pil. hydrargyri), calomel (mercurous chloride), corrosive sub- 
limate (mercuric chloride), green iodide (mercurous iodide), red iodide (mercuric 
iodide), black oxide (mercurous oxide), yellow oxide (mercuric oxide), in the treatment 
of the various forms of syphilis dur.ng the past thirty years, and have been led to 
assign the first place to the red iod'de of mercury. The best results were achieved by 
the use of the following formula:- 
R. Biniodide of mercury, red iodide of mercury gr. iv 
Iodide of potassium 
Tincture of iodine fiij 
Peppermint water f£ viiss. M. 
One teaspoonful in four tablespoonfuls of water, three times a day. 
Each dose in the preceding mixture contains about one-sixteenth of a grain of the 
red iodide of mercury, held in solution by the iodide of potassium; the strength of the 
solution was about in the mixture, and less than when diluted for internal 
administration. In the preceding prescription the red iodide of mercury is held in 
solution by the iodide of potassium, and the iodine exists in the free state, and in virtue 
of its physiological and therapeutical properties in this condition excites profound 
effects upon the glandular system. Iodine is also a potent antiseptic, disinfectant and 
germicide. Such a combination as that just given is not merely a powerful alterative, 
but is also an effective antiseptic and germicide. I have seen a large number of 
patients in hospital and in private practice, the latter greatly outnumbering the former, 
relieved of the most threatening and distressing symptoms and restored to good health 
and preserved for years in good health, by the use of the above combination in the 
treatment of constitutional syphilis. The natural tendency of the syphilitic poison to 
induce profound anæmia may be met by the following formula:- 
R. Red iodide (biniodide of mercury) gr. iv 
Iodide of potassium 5j 
Tincture of iodine ij 
Syrup of iodide of iron 
Syrup of ginger f.5 ivss 
Peppermint water iij. M. 
Dissolve the iodide of potassium in the peppermint water, then add the red 
iodide of mercury and tincture of iodine, and, finally, the syrups of the 
iodide of iron and ginger. 
Dose.-Teaspoonful in four tablespoonfuls of water, three times a day. 
We have the same dose of the red iodide of mercury in each teaspoonful of both 
formula, namely, the one-sixteenth of a grain. 
As tested in over five hundred cases of constitutional syphilis, the effects of the red 
iodide of mercury held in solution by the iodide of potassium are to reduce glandular 
swellings, heal sore places on the head and limbs, remove syphilitic eruptions, alleviate 
or cure syphilitic sore throat, remove the early symptoms of paralysis, promote the 
decided increase of the red globules and restore the enfeebled muscular and nervous 
powers. 
We must attribute the great value of the red iodide of mercury in the treatment of 
syphilis not merely to its power of destroying the syphilitic microorganisms, but also to 
its power as a vigorous germicide or alterative to the glandular enlargements and abnor- 
mal growths, gummata, tumors, and mucous and cutaneous eruptions, tertiary and 
osseous degenerations, characteristic of this disease. 
The power of the red iodide to arrest germination and cell proliferation must play SECTION XV PUBLIC AND INTERNATIONAL HYGIENE. 
605 
a most important part in its arrest and eradication of the action of the syphilitic 
poison. 
In like manner we may attribute its wonderful powers, when locally applied, in con- 
junction with free iodine, to goitres, enlarged glands and indolent tumors, to its power 
of arresting and preventing proliferation of the cellular elements. I have used the 
red iodide of mercury in combination with free iodine and iodide of potassium and 
the extract of ergot, with beneficial results, in the treatment of cancers of the womb 
and niammæs, before the appearance of ulceration, and also in fibrous tumors of the 
uterus. The following combination appeared to arrest the growth of malignant and 
non-malignant tumors in some cases :- 
R. Red iodide of mercury gr. ij 
Tincture of iodine f 3 ij 
Iodide of potassium 5j 
Syrup of the iodide of iron f?j 
Squibb's fluid extract of ergot f'5 iij 
Peppermint water fgij 
Dissolve the iodide of potassium, red iodide and tincture of iodine in the pep- 
permint water, and then add the syrup of the iodide of iron and the 
fluid extract of ergot. 
Dose.-30 to 60 drops in teaspoonful of water, three times a day. 
The effect of the ergot upon the circulation is supplemented by the germicidal 
powers of the red iodide of mercury and free iodine. The syrup of the iodide of iron 
tends to alleviate the profound anæmic characteristics of the cancerous diathesis. We 
have been led, by extended experience, to regard the red iodide of mercury as superior 
to the bichloride of mercury, both as an antiseptic and as a germicide. 
Mercuric Chloride: Its Value as an Antiseptic for the Destruction of the Microorganisms 
of Contagious and Infectious Diseases.-Mercuric chloride is not merely a violent poison, 
destructive alike to plants and animals, but it also clearly belongs to the class antiseptics. 
Antiseptics {anti, against, and putrid, from agibiç, to make rotten), substances 
which have the property of preventing or arresting putrefaction in dead animal or 
vegetable matter. 
In virtue of its power to coagulate albumen, mercuric chloride may be regarded as 
a corrosive and most destructive agent to all forms of vegetable and animal protoplasm, 
and in virtue also of its germicidal power may be regarded as a potent disinfectant. 
Antiseptic, disinfectant and germicidal properties are not necessarily inseparable, as 
may be shown by the following well-established facts : Prussic acid and cyanide of 
potassium, even in small quantities, destroy animals by altering the composition of the 
blood and by acting upon the ganglionic centres of the sympathetic and cerebro-spinal 
systems, and more especially upon the ganglionic centres of the medulla oblongata, which 
preside over respiration, and upon those of the heart, which regulate its actions. 
But hydrocyanic acid and potassium cyanide possess no antiseptic properties ; rapid 
putrefaction may ensue in animals destroyed by these agents. 
Putrefaction may be prevented by removing one or more of the conditions essential 
to its occurrence. Thus, by exclusion of the atmosphere, dead matter, which would 
speedily undergo decomposition, may be kept intact for an indefinite length of time, as 
shown in the method of preserving meat by hermetically sealing the jars after the 
expulsion of the air by heat. Again, the preservative influences of a low temperature 
are well known, and extreme cold is a powerful antiseptic, as proved in the case of the 
frozen mammoth of northern Asia. Furthermore, the abstraction of moisture will 
prevent corruption in dead matter. 
In warm and dry climates animal food may be preserved by exposure to the sun. 
In the ancient practice of embalming the dead, which is the earliest illustration of the 606 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
systematic use of antiseptics, the moister portions of the body were removed before the 
preservative agents were added. Numerous chemical substances have the power of 
counteracting the putrefactive process. Many of these have been long known and used 
for this purpose. In embalming, besides the application of various aromatics and resins, 
the body was washed with cedar oil and natron (soda), and pitch or tar were used as 
antiseptics. Pitch was used by the Romans in wine making, to control the fermentative 
process. The fames of sulphur were largely employed by the ancients for purposes of 
purification, while common salt has been known and used for ages as one of the best 
preservatives from decay. The mineral acids possess antiseptic properties, as do also 
many of the metallic salts, the chloride of zinc, in the form of Sir W. Burnett's disin- 
fecting fluid, being one of the most potent of them. Alcohol is well known for its 
power of preserving animal substances from decay. Quinine has been found to possess 
strong antiseptic properties. The tar products, notably carbolic acid, are among the 
most approved and extensively used of all antiseptic agents. 
The various substances named possess the power of preventing putrefaction in dead 
animal or vegetable matter, and to a greater or less degree of arresting it when already 
begun. They likewise exert a similar action on the analogous process of fermentation. 
They differ from mere disinfectants which destroy the emanations from putrescent 
material, but do not necessarily arrest the progress of decay. Some antiseptics, how- 
ever, such as sulphurous acid, are powerful disinfectants also, while others, such as 
quinine, have no disinfectant properties at all. Mercuric chloride not merely coagu- 
lates the albumen of living germs, and in all organic fluids and solids containing this 
substance, but is in itself, in virtue of its inherent properties, a most potent poison to 
man and animals, whether administered internally or applied externally. Corrosive 
sublimate induces in man symptoms of the most violent character, which cannot wholly 
be explained by its power of coagulating albumen. In the present state of knowledge 
we cannot give a rational explanation of the fact that a few grains of corrosive subli- 
mate, or of arsenious acid, or of strychnine, are capable of destroying the most powerful 
human being. On the contrary, why are many mineral substances which have no 
established relations, chemical or physical, to the human system completely inert ? It 
is evident that corrosive sublimate, even in minute quantities, is, independently alto- 
gether of its chemical and physical properties, a direct and most potent poison to all 
the various forms of animal and vegetable life. The poisonous properties of this agent 
must, therefore, be considered in its use as an internal remedy and as an antiseptic and 
disinfectant. In its use in hygienic and sanitary operations the following facts should 
be carefully considered :- 
1. When mercuric chloride is used in solution for the disinfection of clothing, fur- 
niture and floors, in private houses, hospitals or ships, the potency of the solution used 
will decrease in a ratio corresponding with the amount of animal and vegetable albumen 
present. Of course, the coagulation and chemical alteration of albuminoid substances 
is a powerful means of destroying the germicidal powers and arresting the life acts of 
pathogenic organisms, and of altering and arresting the process of septic fermentation 
or putrefaction. But that portion of the disinfectant which accomplishes these changes 
must be regarded as having accomplished a definite result, and, therefore, as being 
withdrawn from the further process. In other words, sanitary officers should bear 
these facts continuously in mind, and use in their operations large and efficient quan- 
tities of the bichloride. In the practical operations of disinfecting clothing, houses and 
ships, the solution of bichloride should be more concentrated than those usually recom- 
mended by writers who base their view upon the experiments of Koch, Miquel, Croix 
and others. In sanitary operations it must also be considered that the influence of 
certain substances and conditions on microorganisms may be twofold- 
(a) The condition may be unfavorable to the growth of the organism. SECTION XV PUBLIC AND INTERNATIONAL HYGIENE. 
607 
(&) The condition may be fatal to the existence of the microorganism. 
2. In the disinfection of drains, yards and privies by corrosive sublimate, it 
must be borne in mind (a) that the salt is immediately decomposed by lime, ammonia 
and all alkalies; (&) when not thus decomposed, the poisonous mercuric chloride may find 
its way into wells and springs, and thus induce poisonous effects upon human beings. 
The ordinary strength of the solution of corrosive sublimate recommended by sanitarians 
for disinfection, one part to 1000 of water, is entirely inadequate to the proper and 
thorough disinfection of foul privies and to the foul bilge water and ballast of infected 
ships. 
If the ballast of a ship be composed of carbonate of lime, the bichloride will neces- 
sarily suffer chemical change. In foul privies, sulphuret of ammonia and carbonate 
of ammonia are present in large quantities, and large quantities of the bichloride will 
be decomposed, the sulphuret of the peroxide of mercury, which possesses little or no 
germicidal properties, being formed. 
3. The careless use of such a deadly poison as mercuric chloride in sanitary and 
quarantine operations may indirectly or directly lead to fatal accidents, and will afford 
an easy opportunity for the commission of murder by poisoning. Since the establish- 
ment of the preparations of arsenic for the destruction of the cotton worm and other 
vermin, about twenty cases of arsenical poisoning of planters and their families by 
negro servants and laborers, as well as a large number of mules, horses and cattle, have 
come under my observation and been subject to my examination. This country has 
suffered much from the unrestrained and uncontrolled use of poisons. 
4. When a solution of mercuric chloride comes in contact with metal it is decom- 
posed, metallic mercury being deposited. Thus, when iron, copper or brass pumps are 
used in the disinfection of ships, by means of weak solutions of the bichloride of mer- 
cury, a certain portion of the salt is decomposed, to the injury of the apparatus. And 
when the solution of free mercury is squirted over the walls of the cabins and vaults, 
all gilded surfaces, all articles of jewelry, watches, etc., metallic buttons on male or 
female attire, alter in like manner and receive a film of metallic mercury. 
5. The bichloride of mercury is volatilized by heat, but it is erroneous to suppose 
that any large area can be pervaded by its fumes, unless the closed chamber or oven 
containing the clothing to be disinfected is elevated to a degree of heat destructive of 
the textile fabrics. 
6. When the attempt is made to charge steam with the bichloride of mercury by 
boiling the solution, the salt will remain in the boiler and will not, to any extent, 
escape with the steam. 
7. The solution of the bichloride of mercury is unfitted for the disinfection of car- 
goes of coffee, or of grain or any kind of food, in that it imparts poisonous properties to 
all articles of food with which it comes in contact. 
CARBOLIC ACID : ITS VALUE AS AN ANTISEPTIC AND GERMICIDE; COMPARISON 
WITH MERCURIC CHLORIDE. 
The experiments which are here detailed, illustrating the influence of certain agents 
upon the germination and growth of rice, have shown that carbolic acid possesses ger- 
micidal powers similar to those of mercuric chloride. These results are at variance 
with those obtained by Koch, Miquel, Davaine and other experimenters, and it is evi- 
dent that we must exercise great care in arriving at any settled conclusions from experi- 
ments made upon one organism with reference to the amount which may be necessary 
to prevent the development of another. 
The method of experimentation, also, as well as the time consumed in the perform- 
ance of the experiments, and the vital endowments of the organisms experimented on, 
must be carefully considered. With reference to the experiments with carbolic acid, 608 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
we observe that Koch found a one per cent, solution to be without effect in anthrax 
spores after fifteen days' exposure; a two per cent, solution retarded the development 
of spores, but did not completely destroy their vitality, in seven days; a three per cent, 
solution was effective in three days; in the absence of spores, a one per cent, solution 
quickly destroys the vitality of anthrax bacilli. Koch recommends a five per cent, 
solution in the destruction of the comma bacillis of Asiatic cholera, and a two per cent, 
solution for the disinfection of surfaces and articles soiled by such discharges. 
While acting as President of the Board of Health of the State of Louisiana, 1880- 
1884, the author employed carbolic acid effectively as a disinfectant, in strength varying 
from two to ten per cent. Dr. Sternberg has found that in the proportion of one to two 
hundred, these agents destroy bacterium termo, a septic micrococcus (M. Pasteur) in 
active growth, while one to twenty-five failed to destroy the bacteria in putrid beef tea. 
A micrococcus obtained from the pus of an acute abscess was destroyed by 0.8 per cent., 
while five per cent, failed. In all of these experiments by Dr. Sternberg, the time of 
exposure was two hours-a time far too short to afford results applicable to practical 
sanitary operations. According to Simon, the micrococcus of swine plague multiplies 
abundantly in urine containing one per cent, of carbolic acid; while the micrococcus of 
fowl cholera is destroyed by six hours' exposure in a solution of this strength (one per 
cent.), and two per cent, destroys the bacterium of symptomatic anthrax (dried virus) 
in forty-eight hours. According to the researches of Antoin, Cornevin and Thomas, 
Davaine showed by inoculation experiments that anthrax bacilli in fresh blood are 
destroyed by being exposed to the action of a one per cent, solution for one hour. 
Schill and Fischer found that the infecting power of tuberculous sputum, as shown 
by inoculation into Guinea pigs, is destroyed by twenty-four hours' exposure to a twenty- 
five per cent, solution of carbolic acid. The same result was obtained with a three per 
cent, solution, while one and two per cent, solutions failed. 
The experiments which the author has detailed with rice assign more strongly anti- 
septic and germicidal powers to carbolic acid than those just quoted, while, on the other 
hand, they indicate that the mercuric chloride is much less potent than would appear 
from the following statements. 
Many experimenters regard corrosive sublimate as the most powerful antiseptic, 
since even solutions as weak as 1 to 300,000 are said to inhibit the growth of bacillus 
anthracis. According to Koch, mercuric chloride, in the proportion of 1 to 1000, destroys 
all spores in a few minutes, and that the vitality of anthrax spores is destroyed by 
much weaker solutions (1 to 10,000) when the time of exposure is prolonged. The 
experiments of Sternberg, repeating those of Koch and other observers, have given 
similar results. 
NECESSITY FOR MORE CAREFUL AND SIMPLER EXPERIMENTS TO DETERMINE THE 
ACTUAL VALUE OF-DIFFERENT ANTISEPTICS IN THE DESTRUCTION OF 
PATHOGENIC ORGANISMS. 
In dealing with the causes and prevention of such fearful scourges as yellow fever 
and Asiatic cholera, those charged with the sanitary operations necessary to an effectual 
system of Public and International Hygiene need exact data with reference to the 
relative value and most effective methods of employing antiseptics and disinfectants. 
Professor E. Klein, M.D., F.R.S., has placed in a clear light the imperfection of the 
knowledge of sanitarians with reference to the actual power of such antiseptics as car- 
bolic acid and mercuric chloride to destroy the microorganisms which are regarded as 
intimately associated with certain diseases and diseased processes. This acute observer 
says: "By sowing any microorganisms into a nourishing solution to which has been 
added a certain substance, as carbolic acid, to the amount of one per cent., and exposing 
this medium to the conditions of temperature and moisture otherwise favorable to the SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
609 
growth of the organism, it is found that, after the lapse of a due period, the growth is 
retarded or altogether inhibited ; the conclusion is reached that this substance-namely, 
carbolic acid of one per cent.-is an antiseptic." 
There is nothing more fallacious than this mode of reasoning; a great many micro- 
organisms can be exposed to a one per cent, solution of carbolic acid for hours without 
in the least being affected ; for on being then transferred to a suitable nourishing medium, 
they grow and thrive well. Similarly, by placing the spores of bacillus anthracis in a 
proteid medium containing perchloride of mercury of the strength of 1 to 300,000, it 
is found (as Koch has shown) that the spores are absolutely incapable of germinating. 
But from this the conclusion is drawn that perchloride of mercury of the strength of 
1 to 300,000 is a germicide. Dr. Klein most strongly dissents; for perchloride of mer- 
cury, even of the strength of one per cent., is not a germicide any more than vinegar; 
for on placing the spores of bacillus anthracis in a proteid medium to which so much 
vinegar, or any other acid, has been added as makes it decidedly acid, it will be found 
that the spores do not germinate. In order to pronounce a certain substance an anti- 
septic, in the strict sense of the word, it is necessary to place the organisms in this sub- 
stance for a definite time, then to remove them thence, and to place them in a suitable 
nourishing medium. If they then refuse to grow, the conclusion is justified that the 
exposure has injured or destroyed the life of the organism. In the case of pathogenic 
organisms, a substance, to be pronounced a germicide, must be shown to have this 
power, that when the organism is exposed to the substance, and then introduced into 
a suitable artificial medium, it refuses to grow; and it must also be shown that when 
introduced into a suitable animal, it is incapable of producing the disease which the 
same organism, unexposed to the substance in question, does produce. 
Dr. E. Klein has made many observations on microorganisms, both putrefactive and 
pathogenic, and has found that many assertions hitherto made on this subject, treated 
in the above light, are absolutely untrustworthy and erroneous. According to this 
observer, various species of putrefactive micrococci, bacterium termo, bacillus subtilis, 
various pathogenic microorganisms, as bacillus anthracis, bacillus of swine fever, abso- 
lutely refuse to grow in media to which is added phenyl-proprionic acid, or phenyl- 
acetic acid, to an amount so small as one in 1600; but if the same organisms are exposed 
to these substances in much stronger solutions-1 to 800, 1 in 400, or even one in 200- 
and then transferred to a suitable nourishing material, it is found that they have 
completely retained their vitality : they multiply as if nothing had been done to 
them. 
Dr. Klein has exposed the spores of bacillus anthracis to the above acids, of the 
strength of 1 in 200, for forty-eight hours and longer, and then inoculated guinea pigs 
with them, and found that the animals died of typical anthrax in exactly the same 
way as if they had been inoculated with pure spores of the bacillus anthracis. Koch 
has published a large series of systematic observations made in testing the influence on 
spores of bacillus anthracis of a large number of antiseptics (thymol, arsenite of potas- 
sium, turpentine, clove oil, iodine, hydrochloric acid, permanganate of potassium, 
eucalyptol, camphor, quinine, salicylic acid, benzoic acid and many others), and among 
them he found perchloride of mercury to be the most powerful, since even a solution 
of 1 in 600,000 is capable of impeding, one of 1 in 300,000 of completely checking, the 
germinating power of the spores. 
Klein has shown that to regard these substances, from these observations of Koch, 
in any way as antiseptics for the spores of bacillus anthracis, would be no more justifi- 
able than to consider a weak vinegar as such. Perchloride of mercury, a solution of 1 in 
300,000, is no more capable of interfering with the life and functions of the spores of 
bacillus anthracis than water or salt solution; for the spores maybe steeped in this 
solution for any length of time, and yet, on being transferred to any suitable medium, 
Vol. IV-39 610 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
they grow and multiply rapidly, and when inoculated into rodents they produce fatal 
anthrax with absolute certainty. 
In common with Dr. Blythe, Medical Officer of Health for the Marylebone District, 
in London, Dr. Klein tried the action of a number of substances in common use as 
antiseptics, namely, Calvert's fluid, pure terebene, phenol ten per cent., perchloride of 
mercury one per cent., on the spores of bacillus anthracis, exposing them in compara- 
tively large quantities of the above fluid (the two being well mixed) for twenty-four 
hours, and then inoculating Guinea pigs with them (spores and antiseptics). The ani- 
mals died with symptoms of typical anthrax, the blood teeming with the bacillus 
anthrax. These substances, then, are no more antiseptics, and still less germicides, for 
the spores of the bacillus anthracis than water is. 
In all these inquiries, particularly in those upon pathogenic organisms capable of 
forming spores, the influence of the substances must be judged, not merely by their 
action on the organisms, but also on the spores, as in this very case of the bacillus 
anthracis. The bacilli taken from the blood of an animal dead of anthrax are killed 
after an exposure, of say ten minutes, to a solution of phenyl-propionic acid the strength 
of 1 in 400, or even 1 in 800, whereas the spores of the bacilli (produced in artificial 
cultures) withstand complete exposure to this acid of any strength, and for any length 
of time. Bacteria belong to the vegetable kingdom. Ammonia dissolves the eggs, 
the embryos of all animals, the bodies of all the inferior infusoria, attacks the sperma- 
tozoa, etc., while it leaves absolutely intact all the varieties of cellulose and the repro- 
ductive elements of plants, whether it is used cold or boiling. Concentrated acetic acid 
causes all animal tissnesto become pale, while it is without action on bacteria ; hæmatoxy- 
lon and fuchsin color bacteria deeply. We should, therefore, no longer give to the bac- 
teria the names of microscopic animalculæ, infusoria, microzoa and other names which 
imply animal origin, nature and functions. 
In conclusion, the author expresses the hope that the method of experimental 
research which he has endeavored to illustrate may be employed in the determination 
of the antiseptic and germicidal powers of many substances now employed in the prac- 
tical operations and applications of medical and sanitary science. 
NOTES SUR LE DANGER DES CONSERVES ALIMENTAIRES POUR 
LA SANTÉ PUBLIQUE. 
ON THE DANGER OF CANNED GOODS TO THE PUBLIC HEALTH. 
BEMERKUNGEN ÜBER DIE GEFÄHRLICHKEIT CONSERVIRTER NAHRUNGSMITTEL FÜR 
DIE ÖFFENTLICHE GESUNDHEIT. 
PAR LE DR. LADMIRAULT. 
Louisiana. 
Depuis plusieurs années les journaux de Médecine des Etats Unis rapportent des cas 
d'empoisonnement par l'usage de conserves alimentaires. Une Cour de Justice de New 
York l'année dernière avait à juger une plainte en dommages pour empoisonnement 
d'une famille par des tomates en boîtes, préparées par un fermier. Un jeune homme de 
quatorze ans raconta comment il formait le trans inutile fait aux caverales des boites. 
Il usait de véritable chlorure de zinc qui pénétrait un quantité dans les boîtes souvent 
avec de la soude composée de deux parties de plomb et une d'étain ainsi que les ou- SECTION XV PUBLIC AND INTERNATIONAL HYGIENE. 
611 
vriers qui usent de cette composition pour souder de préférence à la résine il mettait 
dans l'acide chlorhydrique des fragments de feuilles de zinc jusqu'à ce que toute ébulli- 
tion ait cessé, c'est ce que les ouvriers ferblantiers appellent éteindre l'acide. En pas- 
sant avec mes pinceaux ce liquide sur le fer blanc, il s'échauffe et la soudure qu'ou y 
applique avec le fer à souder adhère promptement, mais la trace de poinçon laisse passer 
ce chlorure et même la soudure. Les substances contenues dans les boîtes en sont telle- 
ment imprégnées qu'elles sont décolorées. Que l'on ouvre une boîte de salmon, mac- 
kerel, canned beef, lunch tongues d'Armour and Plankington, on les trouvera décolo- 
rées et recouvertes souvent d'une couche noire qui n'est autre chose qu'un sulfure 
d'étain de plomb ou de zinc. Dernièrement j'ai vu un empoisonnement par une eau de 
salmon. Une famille en avait soupé. Une demi-heure après le repas, ceqx qui en 
avaient mangé furent pris de coliques, vomissement et diarrhée avec prostration ex- 
trêmes. Ces accidents se calmèrent au bout de trois jours, sauf un des enfants chez 
qui ils persistèrent jusqu'au cinquième jour. 
Je fus alors appelé, ut quelques calmants amenèrent un prompt rétablissement. Les 
personnes de la famille qui n'avaient pas mangé de ce salmon ne furent pas malades. 
Les conserves préparées par ce procédé sont donc dangereuses pour la santé publique. 
Tel n'est pas celui d'Appert qui en est l'inventeur. Il consiste tout simplement à ren- 
fermer la substance à conserver, qu'elle soit cuite ou crue, dans un vase hermétiquement 
fermé, à soumettre le vase et son contenu à la chaleur du bain marie ou mieux de la 
vapeur. La perforation des couvercles, dans le but illusoire de chasser l'air n'est pas 
nécessaire, cause un surcroit de dépenses, perte de temps, et introduit dans ces aliments 
des substances vénéneuses. 
Appert pour contenir ses conserves se servait de vases de verre ce qui lui causait beau- 
coup de traces pour un bouchage hermétique, et toujours un peu de casse des bouteil- 
les. L'industrie lui substitua avec succès des boîtes de fer blanc, et devint universelle. 
Maintenant quel est l'agent conservatif? Telle était la question adressée à l'inven- 
teur par les membres du Comité Consultatif des arts et métiers devant qui il faisait ses 
expériences. Il répondait c'est la chaleur qui détruit les germes de putréfaction, idée par- 
faitement conforme aux découvertes ultérieures des germes des différentes espèces de 
fermentation. La chimie et le microscope en démontrent l'existence. Après ces expé- 
riences d'Appert, et l'épreuve de leurs produits en parfaite conservation, après un 
temps assez long, et les récompenses du Gouvernement Français, il exposa dans un 
pamphlet intitulé le livre de tous les ménages, tout le détail de ses procédés, qui ne 
compromettaient nullement la santé publique. Dans ce livre il indique avec précision 
le temps nécessaire d'exposition à la chaleur du bain marie ou de la vapeur pour la con- 
servation du nombre des substances alimentaires. 
Les boards of health des différents États devraient donc interdire la vaste de tout 
lan qui a été poncturé et resoudé, et publier une instruction sur les simples opérations 
nécessaires pour cette fabrication. 612 
NINTH INTERNATIONAL MEDICAL CONGRESS, 
A NEW METHOD FOR THE CERTAIN DETECTION OF THE 
TRICHINA SPIRALIS IN MEAT. 
UNE MÉTHODE NOUVELLE POUR DÉCOUVRIR LA TRICHINE SPIRALE DANS 
LA VIANDE. 
ÜBER EINE NEUE METHODE ZUR SICHEREN ENTDECKUNG DER TRICHINA SPIRALIS IM 
FLEISCHE. 
JAMES A. CLOSE, M. D., M. B., L. R. C. S., EDIN., ETC., 
Of Summerfield, Ill 
I have the honor of presenting to you, this morning, a new method for detecting the 
trichina spiralis in meat, whether encysted or free. 
As far as my reading and observation extend, the only methods hitherto employed 
have been- 
1. The teasing or tearing of the suspected muscle under a dissecting microscope, or 
2. The method of placing thin pieces of the meat between two glass slides, and 
applying pressure, when, if the worms are encysted, they can be easily seen under a 
low power of the microscope. 
The first of the above-mentioned methods is often excessively tedious, and in case 
the meat contains but few worms, say four or five'-to the cubic inch, a prolonged exami- 
nation by this method might give only negative results. 
The second method gives very good results when the worms are encysted, as, by 
using quite thin pieces of the meat, and applying moderate pressure, the cysts can be 
readily seen. But, if the examination were made within forty to sixty days after the 
animal from which the meat was taken was infected, the worms would not be encysted, 
and the examiner would be compelled to rely upon the detection of a free worm. 
The chief objections that can be urged against the above-mentioned methods are:- 
1. The non-discovery of trichinae in a specimen of meat, by those methods, is not 
proof positive that none exist in it. 
2. Both methods require that the examiner possess at least a moderate amount of 
skill. 
By the method which I propose to demonstrate this morning, it would be perfectly 
feasible to detect the presence of the worms, even if the meat contained but one worm 
to a cubic inch. The examination requires also but a minimum amount of skilled 
labor, as most, if not all, of the work can be performed by an ofiice boy or household 
servant of ordinary intelligence. 
The method is as follows: The meat to be examined is freed, as far as possible, 
from fat, and minced somewhat finely, and, if salted, well washed in ordinary water. 
From one-fourth of a cubic inch to one cubic inch of the finely/minced meat is placed 
in an ordinary four-ounce wide-mouthed vial, and the bottle two-thirds filled with 
water, then from two to five grains of a good quality of pepsine and from five to fifteen 
drops of strong hydrochloric acid are added. The vial is then corked and well shaken 
for a few moments, and set aside in some place where the temperature is about 100° F. 
A temperature of 120° F. will effect the solution of the meat much more rapidly, par- 
ticularly if the vial is frequently and thoroughly shaken. 
Of course, it would be more satisfactory to use a water bath and thermometer, but 
these are by no means essential. 
The vial is occasionally shaken until the meat is all dissolved, which will require 
from two to three hours. The meat solution is then poured into a conical champagne 
glass, similar to that used in urinary analysis, and half its bulk of water added. The 
specific gravity of the trichinæ being much higher than that of the diluted meat soln- SECTION XV PUBLIC AND INTERNATIONAL HYGIENE. 
613 
lion, they sink rapidly to the conical point of the precipitating glass and may be easily 
removed by means of a pipette, transferred to a slide and examined. And if the exam- 
iner will take the trouble to make for himself a simple hot stage, costing about ten 
cents, similar to the one which I exhibit to-day, he will have the pleasure of seeing 
the worms alive and moving actively, under a power of from twenty to sixty diameters. 
There is another advantage in the use of the hot stage in making the examination, 
which is, that a person possessing only sufficient knowledge of microscopical technique 
to focus a microscope, must inevitably detect the worms, when seen alive and active, 
as I demonstrate them to you to-day. 
In conclusion, I claim for this method of examination the following advantages, 
viz.:- 
1. The greater part of the work of the examination can be performed by a person 
possessing no knowledge whatever of the use of the microscope. 
2. The certainty with which the examiner can state positively that a given specimen 
of meat does or does not contain trichinae, as it would be quite possible, in examining 
a pound of meat containing but one solitary trichina, to bring that one worm with very 
little labor to a certain, definite, predetermined spot, where it could easily be found. 
3. The ease with which, for scientific purposes, the exact number of trichinæ con- 
tained in a cubic inch of meat can be ascertained. 
[abstract.] 
THE INFLUENCE OF EASY CIRCUMSTANCES ON THE PROLONG- 
ATION OF LIFE. 
L'INFLUENCE DU BIEN ÊTRE DANS LA PROLONGATION DE LA VIE. 
ÜBER DEN EINFLUSS EINER SORGENFREIEN EXISTENZ AUF DIE VERLÄNGERUNG DES 
LEBENS. 
BY C. R. DRYSDALE, M.D., 
Of London, England. 
In the numerous discussions on mortality statistics which have taken place for some 
years past, it has been the custom to speak as if the main points in sanitation were to attend 
to the drainage and water supply of cities and villages and to get rid of the other lædentia 
in the shape of zymotic diseases. To many this is the alpha and omega of sanitary art. 
For my part, I am convinced that there are essential points in the question of longevity 
which require more attention than even these very important topics, for, in my capacity 
as physician to one of the free hospitals of London, greatly attended by the poorer classes, 
I have seen an immense amount of preventable mortality which I could attribute to 
nothing more than bad living, bad shelter, and poor clothing. M. Villermé, of Paris, 
one of the earliest writers on hygienic science, found, in his day, that in France per- 
sons between the ages of 40 and 50 years, when in easy circumstances, had a death 
rate of 8.3 per 1000, against 18.7 per 1000 in a similar group of ages among the poor. 
He found, too, that in Paris, between 1817 and 1836, 1 in 15 of the poor population of 
the twelfth arrondissement died, against 1 in 65 in the rich or second arrondissement. 
In 1887, when I was at the International Hygienic Congress at Paris, I received from 614 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Mr. Edwin Chadwick's hand some statistics about London, collected by himself, which 
showed that there were sub-districts in that city containing houses in good condition 
where the death rate was not over 11.3 per 1000, while there were other sub-districts in 
the same district (slums) where the death rate was as high as 38 per 1000, and even as 
50 per 1000. That distinguished hygienist, in 1843, when the mean death rate of all 
London was 24 per 1000, found that in the parish of Bethnal Green the mean age at 
death among the gentry, professionalists and their families was 44; of the shopkeepers 
and their families, 23; and of the wage classes, laborers and their families, 22. It 
seems, then, to me, that in future we must attempt to discriminate more than has 
hitherto been done in our mortality statistics, and endeavor to give the mortality of the 
various classes according to their annual income. Mr. C. Ansell, Jr., Secretary to the 
National Assurance Company of London, obtained, in the year 1874, statistics of the 
mortality of the children (no less than 48,000) of the well-to-do classes in England and 
Wales. The result of his inquiries showed that 80.5 per 1000 of such children died in the 
first year of life. The death rate of children of similar ages in Liverpool is 188, and in 
the slums of that and other European cities as many as 330, or 400 even, of the children 
born die in the first year of life. Ansell further showed that the mean age at death 
among the richer classes in England and Wales was, in 1874, as high as 55; whereas, Dr. 
B. W. Richardson and Mr. Chadwick, a few years ago, stated that the average age at 
death among the wage-receiving class in Lambeth was 291 years. To make his con- 
clusions more plain, Mr. Ansell calculated that there died in 1873, in England and 
Wales, 386,179 persons under the age of 60; and if these all had had the mortality of 
the well-to-do classes, he estimated that only 226,040 would have died. Thus, in 
one year poverty had killed no less than 142,139 persons in England and Wales alone. 
About the time- when Ansell's tables were published, in the healthy colony of New 
Zealand, where food was so cheap that a leg of mutton there sold for a shilling in 
Christchurch, the condition of the people was so completely free from indigence that, 
although there was a birth rate of over 41 per 1000 annually, there was a death rate of 
only 12} per 1000. With a similar death rate for England and Wales, 230,000 lives 
would have been saved in 1873. According to Dr. Thouvenin, in the Annales d'Hy- 
giene, the mortality of several so-called unhealthy occupations was only another word 
for poverty. With the exception of cotton beating, dividing and carding of silk 
cocoons, white lead and grinding, there were scarcely any trades necessarily dangerous 
to life. Tubercular diseases, he found, caused 65 per 1000 of all the deaths among the 
rich, and 250 per 1000 among the poor. The late Dr. Edward Smith's statistics at the 
Brampton Hospital explained this; for he found that the parents of the consumptives 
attending that hospital had, on an average, produced no less than 7.5 children. My 
own hospital experience among the poor women in the East End of London fully cor- 
roborated this, for I had found that the average number of children produced by such 
married women was 7.2 each. Evidently, such enormous families cause the greatest 
misery to the unfortunate children as well as to their reckless parents, for the child- 
ren were, in many cases, chronically starved, and died of bronchitis and rickets, in 
infancy, in consequence. If the mortality of the parishes of London inhabited by the 
wealthy, such as Kensington, with 186,684 inhabitants; St. George, Hanover Square, 
with 88,176; Hampstead, with 53,178; and St. James, Westminster, with 28,176, were 
examined, it would be found that, taken together, these four rich parishes had a birth 
rate of 21.8 per 1000 and a death rate of 16 per 1000; while four East End parishes of 
nearly similar population, viz., Shoreditch, with 125,508; Bethnal Green, with 129,895; 
Whitechapel, with 68,345; and St. George-in-the-East, with 46,403 inhabitants, had a 
birth rate in 1886 of 38.3 per 1000 and a death rate of 24.4 per 1000. Thus, it would 
appear that equal populations of the poor of London produced about twice as many 
children as the rich of the West End, and had a death rate which was to that of the SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
615 
West End parishes as 3 is to 2. Such facts are not comprehensible, unless it be admitted 
that poverty is the main cause of high death rates; and it is gratifying to find that this 
fact is beginning to be perceived by the distinguished Registrar of Dublin, Ireland. Dr. 
Grimshaw has observed, in company with Sir Charles Cameron, of Dublin, that a main 
fact in the high death-rate of the city of Dublin proper, which is about 28 per 1000 
annually, is the deplorable poverty of a large proportion of the population of that city, 
caused by the crowding into the city from the country of very poor people, many of 
them in the decline of life, lured by the existence of a host of hospitals for the sick 
and infirm; for Dublin contains three-fourths of all the hospital accommodations in all 
Ireland. In a paper read before the British Medical Association, in August, 1887, Dr. 
Grimshaw made the first accurate attempt to give the mortality of the various classes 
in Dublin, and by dividing the population (346,693) of Dublin registration district into 
five classes : 1. Professional and independent; 2. Middle class; 3. Artisans and petty 
shopkeepers; 4. General service class; 5. Inmates of workhouses, he shows that in 
1886 the death rate of the independent and professional class was only 13.4 against 
33.7 in the fourth and fifth classes of "general service." The number of children in 
each class, as given by Dr. Grimshaw, under five years of age was, in class 1, 7 per 
cent. ; in class 2, 10 per cent. ; in class 3, 12 per cent. ; and classes 4 and 5, 15 per cent., 
which gives, as in other cases, twice as many children born among the poor as among 
the rich. 
I have already referred to the high death-rates of the twelfth or poor arrondissement 
of Paris (Gobelins) as compared with that of the Champs Elysées. The Annuaire Sta- 
tistique de la Ville de Paris, of 1881, has explained this when it shows that, in the 
Parish of the Gobelins, in every 10,000 inhabitants there are 957 children under the 
age of five against 397 in the Champs Elysées. In the Gobelins there is one pauper in 
every nine inhabitants. 
M. de Haussonville (Per. d. deux mondes') says that in Paris, if statistics were 
available of the families of the rich and poor, it would be found that the number of 
children to a family among the latter would be thrice what it is among the former. 
It is, therefore, axiomatic that in European cities, wherever birth rates are high, pov- 
erty and early death must abound. In 1877, when I was Vice-President of one of the 
Sections of the International Hygienic Congress, I found, by collecting statistics, that 
the average family of the medical men in Paris was 1.74 children each; whereas, on 
returning to London, I found that the poorer classes in the East End produced 7.2 
children on an average each family. The greatest economist of our century, Mr. J. S. 
Mill, said that ' ' little advance can be expected in morality until the producing of large 
families is regarded in the same light as drunkenness or any other physical excess;" 
and all enlightened hygienic inquirers must surely agree with this when they read the 
statistics above cited. But if they do agree with Mr. J. S. Mill, in company with 
myself, what shall we say to the conduct of the Royal College of Physicians of 
Edinburgh, who, in March, 1887, sent a notice to Dr. H. A. Allbut, of Leeds, England, 
to show cause why he should not be deprived of his license, on account of the publica- 
tion of a pamphlet in which he explained to the public and the poor how such misery 
as that caused by large families could be innocently avoided. Such conduct fills my 
mind with horror and amazement, and the decision of that college betrays an ignorance 
of economical science unpardonable in a learned society. It is true that the Fellows of 
the Council of that college have apparently abandoned their hasty and ill-j udged perse- 
cution of Dr. Allbutt, but they have as yet tendered him and the medical profession 
no apology for their action. A humane profession like the medical, I hold, should ever 
be in the van in striving to alleviate the miseries of the poor, and should act as a bul- 
wark against the bigotry and narrow-mindedness of an ignorant public. 616 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
MEMORANDA ON CHOLERA. 
NOTES SUR LE CHOLERA. 
MEMORANDA ÜBER DIE CHOLERA. 
BY THOMAS J. TURNER, A.M., M.D., PH.D., 
Medical Director U. S. N. 
The latest suggested modes for the treatment of cholera, as gleaned from the most 
recent articles in the journals, can be grouped under two classes. 
1. Those based upon the indications furnished by the symptomatic phenomena in 
the various stages of that disease, and 
2. Those based upon and addressed to the present received aetiology of the disease. 
Those of the first class are as follows :- 
Chapman-" Cholera curable"-considers all medication as useless or worse. Dur- 
ing the height of the disease absorption is checked and medicines accumulate to work 
with injurious effect later. His treatment is entirely on the neuro-dynamic theory. 
In the cold stage, by the use of cold to the spine, the central vasomotor mechan- 
isms are depressed, the capillaries dilate and warmth is restored. In the reactionary 
fever, hot applications to the spine stimulate the vasomotor centres and the capillaries 
are contracted. 
Jessop quotes Hall's hypodermatic chloral treatment. The theory of this treatment 
is that the vasomotor spasm of the arterioles is relieved and the superficial capillaries 
are filled. 
Bouveret speaks highly of the intravenous injection of artificial serum. The fluid 
acts by filling the vessels, thinning the blood and by distention, stimulating the heart. 
500-1000 cc. of the fluid at 39° C. is used at a time and repeated if necessary. 
The treatment did not appear to result successfully, though there was always tem- 
porary, in some cases extraordinary, improvement. 
Bouveret has abandoned the use of opium entirely. Dr. Cuneo agrees with Bouveret 
in this respect. In the early stages of the diarrhoea Bouveret uses the following for- 
mula :- 
R. Sirop de menthe 25 cc. 
Elixir de gai ns 15 cc. 
Ricini ol 8 cc. 
Calcii phosphas 1 grm. 
Aqua 100 cc. ( 
He finds the calcium phosphate more effective than any other astringent. The 
above formula stops the diarrhoea promptly, though vomiting may continue and require 
treatment of itself. For the hepatic pains belladonna and mercury treatment are used 
locally, or ol. tiglii over the liver. The cramps are relieved by frictions with camphor- 
ated oil. Medication may be continued by the lower bowel, after the small intestine 
ceases to absorb anything. He explains the injurious effect of opium and the good 
effect of atropia in the following manner. The serous effusion is caused by spasm of 
the villi of the intestine, which squeezes out the fluid constituents of the blood ; this 
spasm is relieved by atropia but increased by opium (?). 
RESUMÉ OF BOUVERET'S TREATMENT. 
1. In the prodromic stage, mild laxatives and, if necessary, emetics. 
2. In the first stage, after diarrhoea has begun, laxatives continued and antacids. 
No alcohol is used, since it causes erethism and increases spasm. SECTION XV-PUBLIC AND INTERNATIONAL HYGIENE. 
617 
3. In further advanced stage continue laxatives. Apply heat externally with tonic 
lavements and keep patient still. 
4. When the internal temperature is great, cold affusions and cold compresses to the 
abdomen. 
5. No food, no excitants. Water should be carefully permitted-by spoonful-in 
spite of thirst. 
Bouvier, of the French Navy, has used intravenous injections of saline fluids exten- 
sively and claims excellent results. 
The indications for the injections are dry, wrinkled skin, cold extremities, imper- 
ceptible pulse and other evidences of collapse. After the injections, the heart resumes 
its beating with satisfactory results and force, temperature rises to normal or nearly so, 
and the intellect returns. The injections are entirely harmless ; no bad results have 
ever been seen in his cases, beyond two insignificant superficial abscesses at the point of 
injection, although he has injected 2000 cc. at one time and 4800 cc. in the course of two 
hours. With this method of treatment, Rouvier claims to have saved 33 per cent, of 
cases considered hopeless by other physicians.* 
Kuzman believes that opium is useful but should be carefully used. 
C. Macdowell. For intravenous injection. An artificial serum made in the propor- 
tion of one to two grains of salt to one oz. of distilled water, and injected at a tempera- 
ture of 39° C. (Koch), an aspirator needle, rubber tube and a syringe or funnel, are all 
that are necessary. The procedure is so simple that any hospital attendant can do it. 
The veins at the bend of the elbow are the most convenient. 
Peritoneoclysis. For peritoneal injections a blunt tube with the eye on the side, like 
a catheter, or a small catheter should be used. The tube or catheter is inserted through 
an opening made with a knife in the linea aspera. 
Hypodermoclysis. The fluid may also be injected into the cellular tissue of the 
arms, legs or abdomen, producing an artificial anasarca, which is readily absorbed. Not 
more than .2 of the body weight should be injected at one time, and the rate of intra- 
venous injection should not exceed five to nine cc. per second, for fear of embarrassing 
the heart. 
Vesicoclysis. This was practiced, as well as the two former methods, by Dr. Richard- 
son in 1854, but with less satisfactory results than the other methods, from slowness of 
absorption. 
Warm nutrient fluids may be injected into the peritoneum without serious risk, e.g., 
defibrinated blood, solution of egg-albumin or milk. In France intra-peritoneal injec- 
tions of defibrinated blood were made by Dubar and Remey, in a number of cases, and 
in only one did fatal peritonitis ensue. In this case the injection was made too rapidly. 
Koch maintains that the bacillus dies in a short time, and if the patient can be tided 
over the period of collapse by warm injections, simple, medicated or nutrient, as de- 
scribed above, the patient will rally and tend to recover. He also found that the 
"comma bacillus" was antagonized and killed out by the "bacterium of putrefaction." 
Hence germicides that kill the latter may be worse than useless. Unless germicides 
are very powerful they only check the development of the cholera germ for a time. 
Those of the second class are as follows :- 
Accepting the statements of Koch and others, that the cause of cholera is to be found 
in the "comma bacillus," the therapeusis founded on this resolves itself into the use of 
germicides to destroy the spirillum, and in addition agents to neutralize the products 
manufactured by this organism. For these purposes minute doses of the bichloride of 
* It has been found by other observers, in eases of hemorrhage, that fluid will be taken up 
from the subcutaneous areolar tissue of the abdomen almost as rapidly as it can be injected into 
the veins. This fact might be applied in cholera when intravenous injection was objectionable. 618 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
mercury, and other articles of the materia medica of antiseptic character, have been 
successfully used, and to neutralize the products, the mineral acids, more especially 
sulphuric acid. 
Treatment based, as this is, upon the aetiology of the disease is rational in character, 
extending as it does to the destruction of the cause, antecedent to its effects, as mani- 
fested in the phenomena of cholera and addressed during the presence of such, to the 
like indication. To the empirical treatment, such as is grouped in the first class, must 
be added the suggested use of pilocarpin, as affecting the functions of the skin, and 
founded upon the physiological antagonism of the skin and the intestinal mucous sur- 
face. 
It is in the management of the premonitory diarrhoea that successful results are to 
be attained. 
Chauveau considers the experiments of Ferran, in the preventive inoculation for 
cholera, worthy of serious consideration and further study. 
Godoy found that out of the body, the vapor of sulphuric ether was quickly fatal to 
the cholera bacillus, and applied this fact to the treatment of the disease. The ether 
vapor was injected into the rectum and its effects arrested short of anæsthesia. The 
final results were not particularly striking, although the conditions of the patient 
improved and the bad symptoms abated after the injections. 
Cantani claims to have reduced the mortality one-half, in severe cases, by means of 
injections of tannic acid with opium into the rectum, forcing the fluid past the ileo- 
cæcal valve, and even into the stomach. He used the following formula: 1500 to 2000 
cc. of sterilized water, 3 to 20 grammes of tannic acid and 30 drops of tincture of 
opium. This was injected from two to six times daily. Its efficacy is thought to be 
due to the germicidal properties of the tannic acid. 
In the premonitory diarrhoea and to promote reaction, the following formula has 
met with universal approval in England and India, and is directed by authority to be 
kept in store in the army, and with troops on the march :- 
B. 01. anisi, 
01. cajuput., 
Ol. juniperââ 
Ether fjjss. 
Liq. acid. Haller* fxss. 
Tinct. cinnamom 
The dose of this mixture is ten drops every quarter of an hour in a tablespoonful of 
water. 
* The liq. acid. Haller consists of one part of concentrated sulphuric acid to three parts of 
rectified spirit, and the tincture of cinnamon is made by dissolving one fluid-drachm of the oil of 
cinnamon in two fluid ounces of stronger alcohol. INDEX TO VOLUME IV. 
Address by Pres, of Sec. XIII (Dr. W. H. 
Daly), 2. 
XIV (Dr. A. R. 
Robinson), 156. 
XV (Dr. Joseph 
Jones), 294. 
Air passages, effect of tobacco on, 101. 
galvano-cautery in diseases of, 60. 
recurrent hemorrhage of, 45. 
Allen, Dr. C. Slover, 113,133. 
Alopecia, areata, pathology and treatment of, 
241. 
Antiseptics, actual value of, 608. 
Bailhache, Surgeon P. H., 488, 494. 
Beirut, Syria, dengue in, 466. 
Bell, Dr. A. N., 475, 529, 565, 581. 
Benham, Dr. S. N., 48, 58, 70. 
Bermann, Dr. I., 5, 66. 
Browne, Dr. Walton, 6. 
Dr. Lennox, 2, 6, 13,19, 30, 44, 46, 80, 
88, 103, 105, 132. 
Byrd, Dr. D. E. 434. 
Canned goods, danger of, to public health, 610, 
Carbolic acid as an antiseptic and germicide, 
607. 
Carter, Dr., 168. 
Casselberry, Dr. W. E., 14, 29, 42, 44, 72, 81, 99. 
Catarrh, nasal, resorcin in, 56. 
Cholera infantum, influence of climate in pro- 
duction of, 534. 
memoranda on, 616. 
Chorea laryngis, 82. 
Climate, influence of in production of cholera 
infantum, 534. 
Close, Dr. James A., 612. 
Coghill, Dr. J. S., 26, 30. 
Cohen, Dr. J. Solis, 2, 14, 27, 43, 46. 
Comedo, double, study of, 230. 
Cook, Dr. Wm. C., 587. 
Coomes, Dr. M. F., 6, 18, 28, 80, 100,101, 103. 
Cough, nervous, and its treatment, 133. 
Crudeli, Dr. C. T., 530. 
Curtis, Dr. H. H., 48. 
Dr. Lester, 29. 
Cutter, Dr. E., 67, 88, 105. 
Cystic goitre, new treatment of, 114. 
Daly, Dr. W. H., 1, 2, 70, 153. 
Davies, Dr. G., 192. 
Davis, Dr. N. S., 593. 
Dr. R. C., 456, 593. 
Day, Dr. Richard H., 425, 435. 
De Amicis, Dr. Tomasso, 275. 
Dengue in Beirut, Syria, epidemiological notes 
on, 466. 
Dennison, Dr. C., 99. 
Dermatology and syphilography (Sec. XIV), 
officers, list of, 155. 
Desvernine, Dr. C. N., 115. 
Diphtheria, sulphuret of lime in, 151. 
Disinfectant, steam as a, 565. 
Drysdale, Dr. C. R., 613. 
Eaton, Dr. F. B., 60. 
Eczema, seborrhoeic, 215. 
Education, place of sanitary science in, 443. 
Egypt, modern, hygiene in, 436. 
Elephantiasis arabum in children, 271. 
Endemic and epidemic diseases, causes and 
prevention of, 495. 
Epiglottis, action of, in swallowing, 111. 
Epistaxis, 4. 
Fibromata, nasal, 72. 
Formento, Dr. Felix, 487, 488, 532. 
Fort Jackson, on Savannah river, table of dis- 
eases at, 525. 
Foster, Dr. John F., 6. 
Fox, Dr. R. K., 533. 
Freire, Dr. D., 475, 487, 488. 
Galvano-cautery in diseases of upper air pas- 
sages, 60. 
Gaston, Dr. J. MeF., 488. 
Germicidal and antiseptic powers of certain 
mineral and vegetable substances, 593. 
Goitre, cystic, new treatment of, 114. 
Gottheil, Dr., 169, 185, 229. 
Grant-Bey, Dr. J. A. S., 433, 436, 471, 581. 
Great Britain, growth of preventive medicine 
in, 472. 
Hay-fever, causes and treatment of, 7, 11. 
Hazlewood, Dr. A., 457. 
Health, effect of overflow of Mississippi river 
and rice culture upon, 425. 
public, danger to, from canned goods, 
610. 
Hebert, Dr. Thomas, 541, 547, 582. 
Hemorrhage of air passages, 45. 
Hirsuties, studies in, 180. 
Hobbs, Dr. A. G., 31. 
Hygiene, domestic, 297. 
germicidal and antiseptic powers of 
certain substances in, 593. 
619 620 
INDEX TO VOLUME IV. 
Hygiene in modern Egypt, 436. 
international, 320. 
necessity of teaching in schools, 587. 
public and international (Dr. Jos. 
Jones), 293, 294. 
public and international (Dr. U. R. 
Milner), 458. 
public and national, 302. 
resolution relative to, 592. 
Hypodermic injection in treatment of syphilis, 
225. 
Impetigo herpetiformis, 193. 
Infectious diseases, metropolitan defenses 
against, 491. 
Ingals, Dr. Fletcher, 4, 6, 13, 27, 33, 42, 44, 
81, 105, 113, 115, 153. 
Injection, hypodermic, in treatment of syphilis, 
225. 
Inoculation with attenuated culture of yellow- 
fever microbe, 475. 
Inspection, sanitary, of passenger coaches, 548. 
Intubation in tracheotomy, 89. 
of larynx, 121. 
Jones, Dr. Camalt, 111. 
Dr. Joseph (President Sec. XV), 293, 
294, 435, 475, 487, 495, 532, 540, 581, 
593. 
Juler, Dr. Henry C., 168. 
Keller, Dr. Jas. M., 169. 
Klingensmith, Dr. I. P., 11. 
Klotz, Dr. H. G., 172, 173, 205, 229. 
Knaggs, Dr. Valentine, 186, 204, 269. 
Knight, Dr. Wm., 168. 
Koser, Dr. S. S., 15. 
Laborde, Dr. F. de Winthuysen, 151. 
Ladmirault, Dr., 610. 
Laryngeal chorea, 82. 
phthisis, clinical report on treatment 
of, 38. 
Laryngitis rheumatic, 33. 
Laryngology, Sec. XIII, officers, list of, 1. 
Laryngoscopical work in Mexico, 58. 
Larynx, and throat, tuberculosis of, 19. 
intubation of, 121. 
papillomata of 42. 
primary erysipelas of, 67. 
table of diseases of, 41, 42. 
tuberculous, specific and rheumatic 
diseases, diagnostic differentiation 
of, 38. 
Lathrop, Dr. M. C., 169. 
Lee, Dr. Benjamin, 592. 
Leighton, Dr. A. W., 443. 
LeMonnier, Dr., 423, 424. 
Life, easy circumstances in prolongation of, 613. 
Lime sulphuret in diphtheria, 151. 
Lindsley, Dr. J. B., 424. 
Lupus erythematosus, 198. 
of hands, 206. 
tables of, 210, 211. 
MacGeagh, Dr. T. E. F., 28. 
Malaria, nature and prophylaxis of, 530. 
Malarial fever, chemical and microscopical char- 
acters and changes in blood of, 
495, 
differentiation from enteric, 541. 
history and treatment of, in 
Texas, 541. 
jurisprudence and diagnosis of, 
495. 
relation of soil drainage to, 582. 
Martin, Dr. J. A., 586. 
Mason, Dr. Geo. W., 15. 
Massei, Prof. F., 67. 
Maxwell, Dr. Geo. T., 423, 434, 457, 534, 540. 
McGuire, Dr. Hunter, 192. 
McKenzie, Dr. John N., 14, 29. 
Dr. Morell, 2. 
McLaughlin, Dr. James W., 469. 
Meat, detection of trichina spiralis in, 612. 
Medicine, preventive, growth of, in Great Brit- 
ain, 472. 
Melanosis of skin, unique case of, 269. 
Mercuric chloride, comparison with carbolic 
acid, 607. 
Mercury, hypodermic injection of, in syphilis, 
225. 
Mexico, laryngoscopical work in, 58. 
Microbe of yellow fever, inoculation with, 475. 
Milner, Dr. N. R., 458, 533. 
Mineral and vegetable substances, germicidal 
and antiseptic powers of, 593. 
Mississippi river, overflows of, effect on public 
health, 425. 
Moncorvo, Dr., 271. 
Moura, Dr. F., 143. 
Muscles of organ of voice, 143. 
Mycosis fungoides, existence of parasites in, 275. 
Nasal fibromata, 72. 
tables of, 78, 79. 
stenosis, 48. 
Nash, Dr. A., 586. 
Neoplasms, benign, supraepiglottic, 114. 
Nervous phenomena in exposure of spinal cord, 
etc., 31. 
New Orleans, La., mortality tables of, 306, 310. 
O'Dwyer, Dr. Joseph, 121, 132. 
Ohmann-Dumesnil, Dr. A. H., 206, 230, 240. 
Paine, Dr. J. F. Y., 470. 
Papillomata, laryngeal, treatment of, 42. 
Parasite in mycosis fungoides, 275. 
Parasitic diseases of skin, treatment of, 189. 
Parker, Dr. Rogers, 169. 
Passenger coaches, chemical examination of 
water in, 555. 
sanitary inspection of, 548. 
table of carbon dioxide in 
air of, 555. 
Phonation, relation to cantation, 105. 
Porter, Dr. Wm., 44, 45, 105, 153. 
Quarantine, 323. 
Rankin, Dr. D. N., 16, 153. 
Ravogli, Dr. Augustus, 185,192, 204, 205, 269. 
Rectal alimentation in diseases of skin, 170. 
Redard, Dr. M. P., 581. INDEX TO VOLUME IV. 
621 
Reed, Dr. R. II., 528, 540, 548. 
Resolution on publication of papers, 105. 
relative to teaching hygiene in 
schools, 592. 
Resorcin in nasal catarrh, 56. 
Reynolds, Dr. H. J., 185, 189, 192, 268. 
Rheumatic laryngitis, 33. 
Rhinology, history of, 16. 
Rice culture, effect on public health, 425. 
Richardson, Dr. B. W., 472, 475. 
Ridge, Dr. Jas. M., 15. 
Robinson, Dr. A. R., 155, 156, 169, 205, 241, 
269, 292. 
Roe, Dr. John 0., 82, 88. 
Rohé, Dr. Geo. II., 180, 186, 192. 
Rosenbach, Dr. Ottoinar, 133. 
Sanitary science, place of, in education, 443. 
Savannah, Ga., mortality tables of, 305. 
Schenck, Dr. W. L., 423, 457, 586. 
Schools, necessity of teaching hygiene in, 587. 
resolution relative to teaching hygiene 
in, 592. 
Scott, Dr. W. J., 565. 
Seaton, Dr. Edward, 491. 
Section XIII (Laryngology), officers, list of, 1. 
XIV (Dermatology and Syphilography) 
officers, list of, 155. 
XV (Public and International Hy- 
giene), officers, list of, 293. 
Semelder, Dr. F., 58. 
Shoemaker, Dr. Jno. V., 170, 173. 
Shurley, Dr. E. L., 38, 42. 
Skin diseases, rectal alimentation in, 170. 
local treatment of, 186. 
melanosis of, 269. 
ulcers of, in syphilis, 173. 
Snare and écraseur, 133. 
Soil drainage and other methods in relation to 
malarial fever, 582. 
Spinal cord, exposure of, from syphilitic ulcera- 
tion of upper pharynx, nervous phenomena 
in, 31. 
Steam as a disinfectant, 565. 
Stenosis, nasal, 48. 
Stern, Dr. Max J., 89, 101. 
Stockton, Dr. Frank 0., 15, 29, 38, 46, 70, 81, 
103, 111, 113, 115. 
Stucky, Dr. Jos. A., 14, 37, 38, 57. 
Syphilis, treatment of, by injection of mercury, 
225. 
ulcers of skin in, 173. 
Table of carbon dioxide in air of passenger 
coaches, 555. 
cases of nasal fibromata, 78, 79. 
Table of chemical examination of water in 
passenger coaches, 555. 
disease, Fort Jackson, on Savannah 
river, 525. 
Tables of lupus erythematosus, 210, 211. 
mortality (New Orleans), 306, 310. 
(Savannah, Ga.), 305. 
yellow fever, 386, 387, 422. 
vaccination in variola, 163-168. 
symptoms of tuberculous, syphilitic and 
rheumatic diseases of larynx, 41, 42. 
Taylor, Dr. B. D., 533, 540, 541. 
Dr. M. K., 487, 532, 533. 
Temperature chart, 562-564. 
Texas, malarial fever, history and treatment of, 
in, 541. 
Thin, Dr. Geo., 184, 191, 204, 241, 267. 
Thomas, Dr. Richard H., 7, 15, 60, 67. 
Thorner, Dr. Max, 28, 88. 
Thrasher, Dr. A. B., 56, 113. 
Tobacco, effect of, on air passages, 101. ' 
Toeplitz, Dr. Max, 67, 70. 
Trichina spiralis, detection of, in meat, 612. 
Tuberculosis, throat and larynx, pathology and 
treatment of, 19. 
Turner, Thomas J., Med. Director, U. S. Navy, 
616. 
Ulcers of skin in syphilis, 173. 
Unna, Dr. P. G., 172, 179, 184, 189, 198, 204, 
215, 240, 266, 292. 
Vaccination in incubation, period of variola, 
160. 
Vaughn, Prof. V. C., 540. 
Vocal bands, tension of, 115. 
Von Klein, Dr. R. H., 15. 
Walker, Dr. D. R., 532. 
Watraszewski, Dr. X., 225, 230. 
Waxham, Dr. Frank E., 100. 
Welch, Dr. Wm. M., 160, 169. 
Wortabet, Dr. John, 466. 
Wyman, Surgeon Walter, M. H. S., 475. 
Yates, Dr. James, 456. 
Yeamans, Dr. C. C., 169, 192. 
Yellow fever, germ of, 475. 
microbe of, inoculation with, 475. 
tables of mortality in, 386, 387, 
422. 
Zeisler, Dr. Josef, 179, 193, 205, 225, 229, 268. TRANSACTIONS 
OF THE 
International Medical Congress. 
NINTH SESSION. 
EDITED FOR THE EXECUTIVE COMMITTEE 
• BY 
JOHN B. HAMILTON, M. D., 
Secretary-general. 
VOLUME IV. 
WASHINGTON, D.C., U.S.A. 
1887.