Property of the

Lancaster City and County Medical Society

No.

N-Vt-*

- ,<•/

THE

AMERICAN JOURNAL

or THE

MEDICAL SCIENCES.

EDITED BY

ISAAC HAYS, M.D.,

SURGEON TO WILLS HOSPITAL,

PHYSICIAN TO THE PHILADELPHIA ORPHAN ASYLUM, &C. &C.

NEW SERIES

VOL. IV.

PHILADELPHIA; LEA & B L A N C H A R D

LONDON: WILEY & PUTNAM:

1S42.

69431

Entered according to Act of Congress, in the year 1842, by

LEA & BLANCHARD,

In the office of the Clerk of the District Court for the Eastern District of

Pennsylvania.

T. K. & P. G. COLLINS, PRINTERS.

TO SENDERS AND CORRESPONDENTS.

Communications have been received from Drs. Gibson, Earle, Arnold, Met- tauer, Nott and Henkel.

Dr. Taylor's article vi^as crowded out of the present number.

The following works have been received: —

Traite Pratique sur les Maladies des oiganes Genito-urinaires, par le Docteur Civiale. Deuxieme partie Maladies du col de la vessie et de la prostate; avec cinq planches. Paris, 1841. Troisieme et derniere partie Maladies du corps de la vessie. Paris, 1842. (From the Author.)

The Pharmacopoeia of the United States of America. By Authority of the National Medical Convention, held at Washington, A. D. 1841. (From the Committee of Publication.)

A memoir on the Fossil Reptiles of the Southeast of England. By G. A. Mantell, Esq., LL. D., F. R. S., &c. London, 1841: 4to. (From the Author.)

A Popular Treatise on Vegetable Physiology. Published under the auspices of the Society for the Promotion of Popular Instruction. With numerous cuts. Philadelphia: Lea & Blanchard, 1842. (From the Publishers.)

Twenty-fifth Annual Report of the Asylum for the Relief of Persons Deprived of their Reason. Philadelphia, 1842. (From Dr. Warrington and Dr. Earl.)

Quarterly Summary of the Transactions of the College of Physicians of Phi- ladelphia. February, March and April, 1842.

Fifty-fifth Annual Report of the Regents of the University of the State of New York. Made to the Legislature, March 1, 1842. Albany, 1842. (From the Regents.) ""

The London Dissector, or Guide to Anatomy, for the Use of Students, com- prising a description of the Muscles, Vessels, Nerves, Lymphatics, and Viscera of the human body, as they appear in Dissection; with directions for their De- monstration. From the first American Edition. Revised and corrected by Edw. J. Christy, M. D., Demonstrator of Anatomy in the Univ. of Maryland. Baltimore, 1839.

Lectures on the Diagnosis, Pathology and Treatment of the Diseases of the Chest. By W. VV. Gerhard, M. D., Lecturer on Clinical Medicine to the Univ. of Penn., &c. Philadelphia: Haswell & Barrington, 1842. (From the Publishers.)

An Historical Sketch of the State of American Medicine before the Revolu- tion; being the annual address delivered before the Medical Society of the Slate of New York, Feb. 1, 1842. By John B. Beck, M. D., President of the Soci- ety, &c. &c. &o. Albany, 1842. (From the Author.)

Observations on some of the signs of live and still birth, in their applications to Medical Jurisprudence. By John B. Beck, M. D., Prof, of Mat. Med. and Med. Jurisprudence in College of Phys. and Surg., New York. (From the Author.)

Report of the Trustees of the New York State Lunatic Asylum, with the

4 TO READERS AND CORRESPONDENTS.

documents accompanying the same, pursuant to the act of the Legislature, passed May 26th, 1841. Albany: January, 1842. (From D. Russell, Chairman of Board of Trustees.)

Transactions of the Medical Society of the State of New York, vol. v, pt. ii. (From the Society.)

Introductory Lecture delivered in the Castleton Medical College, March 8, 1842. By James McClintock, M. D., Prof, of Anatomy. Castleton, 1842. (From the Author.)

A Circular Letter to the Physicians of Kentucky. Maysville, 1842.

Address to the Graduates of the Medical Institution of Geneva College. De- livered 25th January, 1842. By C. B. Coventry, M. D., Dean of the Faculty, and Prof, of Obstetrics and Medical Jurisprudence. Utica, 1842. (From the Author.)

Annual Catalogue of the Medical Institute of Louisville, session 1841-42, and the circular for the ensuing session. Louisville, Ky., 1842. (From the Librarian.)

A.n Address to the Graduates of the Medical Department of the Columbian College. By Thomas Miller, M. D., Prof, of Anat. and Physiol., Dean of the Med. Faculty. Delivered March 2, 1842. (From the Author.)

Circular and Catalogue of the Officers, Professors and Students of Willough- by University, at Willoughby, Lake county, Ohio. Session 1841-2. Cleave- land, 1842. (From the Faculty.)

Address introductory to the course of instruction in the Anatomical Rooms of Geneva Medical College, Nov. 2, 1841. By Sumner Rhoades, M. D., Demon- strator of Anatomy. Geneva, 1841. (From the Author.)

Revue Medicale Francaise et etrangere. Par J. B. Cayol. Nov., Dec. 1841. (In exchange.)

Journal de Medecine et de Chirurgie pratiques a I'usage des Medecins prati- ciens. Par Lucas — Championniaire D. M. P. &c. &c. Dec. 1841, Jan. 1842. (In exchange.)

Gazette Medicale de Paris. Oct., Nov., Dec. 1841, Jan. 1842. (In exchange.)

Journal des Connaissances Medico-Chirurgicales. Publie par MM. A. Trousseau, J. Lebaudy, H. Gouraud. Dec. 1841, Jan. 1842. (In exchange.)

Journal des Connaissances Medicales Pratiques et de Pharmacologic, Nov., Dec. 1841. (In exchange.)

Journal de Pharmacie et des Sciences Accessoires. Dec. 1841. (In ex- change.)

Journal de Pharmacie et de Chimie, contenant une Revue de tons les travaux publiees en France et a I'Etranger, sur les Sciences Physiques, Naturelles, Medicales et industrielles ainsi que le Bulletin des Travaux de la Societe de Pharmacie de Paris. Jan. 1842. (In exchange.)

L'Examinateur Medical. Redacteurs en chef MM. Am. Dechambre et Aug. Mercier. Nov., Dec. 1841, Jan. 1842. (In exchange.)

London and Edinburgh Monthly Journal of Medical Science. Edited by John Rose Cormack, M. D. Feb., March, April, May, 1842. (In exchange.)

Dublin Medical Press. Jan., Feb., March, April, May, 1842. (In exchange.)

Provincial Medical and Surgical Journal. Edited by Dr. Hennis Green and Dr. Streeten. Feb., March, April, May, 1842. (In exchange.)

TO READERS AND CORRESPONDENTS. 5

Edinburgh Medical and Surgical Journal. April, 1842. (In exchange.)

Medico-Chirurgical Review. Edited by James Johnson, M. D., and Henry James Johnson, Lect, on Anat. April, 1842. (In exchange.)

British and Foreign Medical Review. Edited by John Forbes, M. D., &c. April, 1842. (In exchange.)

London Medical Gazette. Jan., Feb., March, April, 1842. (In exchange.)

The Select Medical Library and Bulletin of Medical Science. Edited by John Bell, M. D., &c. &c. April, 1842. (In exchange.)

Medical Examiner. April, May and June, 1842. (In exchange.)

The New York Medical Gazette. April, May and June, 1842. (In exchange.)

The Boston Medical and Surgical Journal. April, May and June, 1842. (In exchange.)

The American Journal of Science and the Arts. Conducted by Prof. Silliman and Benj. Silliman, Jr. April, 1842. (In exchange.)

The Western Journal of Medicine and Surgery. Edited by Drs. Drake, Yan- dell and Colescott. March, April, 1842. (In exchange.)

The New York Lancet. Edited by J. A. Houston, M. D. April, May, and June, 1842. (In exchange.)

The Western and Southern Medical Recorder. Edited by J. C. Cross, M. D., Prof, of Inst. Med. and Med. Jur. in Trans. University. April, May 1842. (In exchange.)

The American Journal of Pharmacy. Published by the Philadelphia College of Pharmacy. Edited by Jos. Carson, M. D., and Robert Bridges, M. D. April, 1842. (In exchange.)

The New England Quarterly Journal of Medicine and Surgery. Edited by C. E. Ware, M. D., and Saml. Parkman, M. D. July, 1842. (In exchange.)

The Western Lancet, devoted to Medical and Surgical Science. Edited by Leonidas Moreau Lawson, M. D. May, June, 1842. (In exchange.)

The American Journal and Library of Dental Science. June, 1842. (In exchange.)

A Practical Treatise on Medical Inhalation, with numerous cases demon- strating the curative powers of the local application of various remedies in Bronchitis, Consumption, and other Diseases of the Respiratory Organs; em- bracing the opinions and experience of Rush, Sir Charles Scudamore, Eberle, Mudge, Crichton, Thomas, Corrigan, Ramadge, and others. By Edward Jen- nerCoxe, M.D. Philadelphia: J. Dobson, 1841. (From the Publisher.)

Ornithology: The Natural History of Birds. Third Book of Natural His- tory, prepared for the use of Schools and Colleges. By W. S. W. Ruschen- berger, M. D., Surgeon U. S. N., &c. &c. From the text of Milne Edwards and Achille Compte. Philadelphia: Turner & Fisher, 1842. (From the Pub- lishers.)

Communications intended for publication, and Books for Review, should be sent,/ree of expense^ directed to Isaac Hays, M. D., Editor of the Amer. Journ. of Med. Sci., care of Messrs. Lea & Blanchard, Philadelphia. Parcels directed as above, and sent (carriage paid) under cover, to John Miller, Henrietta Street,

1*

6 TO READERS AND CORRESPONDENTS.

Covent Garden, London, or to Wiley & Putnam, New York, or W. D. Ticknor, Boston, will reach us safely. We particularly request the attention of our foreign correspondents to the above, as we are often subjected to unnecessary expense. Some time since we received from New York, through the post office, a parcel, bearing the seal of the Royal Society of Northern Antiquaries, (Copenhagen,) the postage of which was twenty-six dollars, and of course we were compelled to refuse it. Had it been sent under cover to Messrs. Wiley & Putnam, the expenses would have been but a trifle.

All remittances of money and letters on the business of the Journal, should be addressed exclusively to the publishers, Messrs. Lea & Blanchard.

CONTENTS

AMERICAN JOURNAL

OF THE

MEDICAL SCIENCES.

No. V, NEW SERIES.

JULY, 1842.

ORIGINAL COMMUNICATIONS.

MEMOIRS AND CASES.

ART. PAGE.

I. Experiments on Kiesteine, with observations on its application to the diagnosis of Pregnancy. By Elisha K. Kane, M. D. - - - - 13

II. Case of Complete Anchylosis — in which the Knee-joint was permanent- ly flexed — cured by an operation. By Wm. Gibson, M. D., Professor of Surgery in the University of Pennsylvania. Reported by Thomas L. Walker, M. D., of Albemarle, Virginia, one of the resident Physicians

of the Philadelphia Hospital. [With two wood cuts.] - - - 39

III. Practical observations on those Malformations of the Male Urethra and Penis, termed Hypospadias and Epispadias, with an Anomalous Case. By John P. Mettauer, M. D., of Prince Edward county, Virginia. [With three wood cuts.] 43

IV. Cases of Disease of the Brain and Spinal Marrow. By James M'Naughton, M. D., Professor of Theory and Practice of Medicine in

the Albany Medical College. .- -57

V. Cases of Deformity from Burns, relieved by Operation. By Thos. D. Mutter, M. D., Professor of Surgery in Jefferson Medical College, Philad., &c. [With eight wood cuts,] 66

VI. Case of Gun-shot Wound of the Face, with loss of a great propor- tion of the Tongue, and extensive lesion of the bony structure, success- fully treated; together with an account of interesting nervous phenome- na, resulting from the injury. By J. F. Peebles, M. D., Petersburg, Va. 80

VII. Two Cases of Inversion of the Uterus. By W. L. Sutton, M. D., of Georgetown, Ky. 83

VIII. Case of Extravasation of Blood into the cellular texture, beneath the skin of the Penis. By Edward Jarvis, M. D., Louisville, Kentucky. - 85

MEDICAL EDUCATION AND INSTITUTIONS.

IX. On the condition of the Profession on the eastern coast of South Ame- rica, and the prevalent Diseases of that country. By H. Pleasants, M.

D.5 of West Philadelphia. - 88

REVIEWS.

X. Traite des Nevralgies, au affections douloureuses des nerfs. Par F. L. I. Valleix, Medecin du Bureau Central des Hopitaux, &c. Paris, 1841, 1 vol. 8vo. pp. 719.

A Treatise on Neuralgia. By F. L. I. Valleix, Physician to the " Bureau Central" of the Hospitals, &c. Paris, 1841, pp. 719, 8vo. - - - 95

8 CONTENTS.

XT. The Climate of the United States and its Endemic Influences. Based chiefly on the Records of the Medical Department and Adjutant-Gene- ral's Office, United States Army. By Samuel Forry, M. D. New York, 1842: 8vo. pp. 378. - 110

XII. A System of Midwifery, with numerous wood cuts. By Edward Rigby, M. D., &c., with Notes and additional illustrations. Philadel- phia, Lea^ Blanchard, 1841: 8vo. pp. 491. 123

BIBLIOGRAPHICAL NOTICES.

XTII. Lectures on the Diagnosis, Pathology and Treatment of the Dis- eases of the Chest. By W. W. Gerhard, M. D., Lecturer on Clinical Medicine to the University of Pennsylvania, &c. &c. Philadelphia: ^ Haswell & Barrington, 1842, 8vo. ^135

XIV. 1. Second Annual Report of the Directors of the Marine Insane Hos- pital. December, 1841. Augusta, Me., 1841, pp. 56.

2. Ninth Annual Report of the Trustees of the State Lunatic Hospital, at Worcester, (Mass.) December, 1841. Boston, 1842, pp. 102.

3. State of the New York Hospital and Blooraingdale Asylum, for the year 1841. New York, 1842, pp. 132.

4. Twenty-fifth Annual Report on the State of the " Asylum for the Re- lief of Persons deprived of the use of their Reason." Philadelphia, 1842, pp. 30.

5. Third Annual Report of the Directors and Superintendent of the Ohio Lunatic Asylum, to the Fortieth General Assembly. Columbus, (Ohio,) 1841, pp. 60.

6. Annual Report of the Court of Directors of the Western Lunatic Asylum, to the Legislature of Virginia; with the Report of the Phy- sician, for 1841. Richmond, Va., 1842, pp. 80.

7. Report of the Superintendent of the Eastern Lunatic Asylum, Wil- liamsburg, Virginia, from July 1st, 1841, to December 31st, 1841.

8. Extracts from a Lecture on Insanity; delivered before the Young Men's Association of the city of Utica. February 18th, 1842. By C. B. Coventry, M. D.

9. What shall we do with the Insane of the Western Country? By Edward Jarvis, M. D.

10. Fifth Annual Report of the Trustees of the Vermont Asylum for the Insane. October 25th, 1841.

11. Report of the Trustees of the State Lunatic Asylum, with the docu- ments accompanying the same, to the Legislature of the State of New York, pp. 203. 136

XV. The Pharmacopoeia of the United States of America, by authority of the National Medical Convention held at W^ashington, A. D. 1840: 8vo., Grigg & Elliott, 1842. 143

XVI. On Regimen and Longevity; comprising Materia Alimentaria, Na- tional Dietetic usages, and the influence of Civilization on Health and the Duration of Life. By John Bell, M. D., &c. Philadelphia: Has- well & Johnson, 1842, 12mo. pp. 420. 145

XVII. Guide du medecin practicien ou resume general de pathologie in- terne et de tlierapeutique appliquees.

The Practitioner's Guide; a Practical Compendium of internal Pathology and Therapeutics. By F. L. I. Valleix. Paris, 1841, Nos. 1 and 2. - 147

XVni. Quarterly Summary of the Transactions of the College of Physi- cians of Philadelphia. February, March, April, 1842, 8vo. p. 24. -148

XIX. Transactions of the Medical Society of the State of New York. Vol.

V, Part II. 149

XX. Annual Report of the Surgeon-General of the United States Army. - 150

XXI. On the Physical Alterations of the Blood and Animal fluids in dis- ease. By M. Andral. 151

CONTENTS.

SUMMARY

IMPROVEMENTS AND DISCOVERIES MEDICAL SCIENCES.

IN THE

FOREIGN INTELLIGENCE.

Anatomy and Physiology.

PAGE

1. Abstract of Mr. Goodsir's paper on the Ultimate Secreting- Struc- ture, and on the laws of its Function. - . - - 155

2. Structure of the Human Kidney, and the changes it undergoes in the granular degeneration. By Mr. Goodsir. - - - - 156

3. Arrangement of the eighth pair

of Nerves. By Mr. Spence. - 158

4. Singular case of Monstrosity.

By Dr. Rodenstab. - - - 1581

PAGE

5. Experiments on the Saliva ob- tained from a man labouring under fistula of the right parotid duct near its extremity. By Messrs. Garrod and Marshall. - 158

6. Observations on Parasitical grovi^ths on living animals. By Dr. Busk, Esq. - - - 160

7. Dentition of Children at the Breast. By Professor Trous- seau. ----- 164

Materia Medica and Pharmacy.

8. Styptic effect of Kreasote. By | By M. Meillet. Dr. Burdach of Luckan. - - 166 10. Lime Moxa.

9. Sulpho-Cyanuret of Potassium. I borne.

By Dr.

" 166 Os- - 166

Medical Pathology, Therapeutics, and Practical Medicine.

11. Five cases of Crowing Inspi- ration of Children in the same family. By Jonathan Toogood, Esq. - . . -

12. Case of enlarged Thymus Gland, producing spasm of Glot- tis by compressing the recurrent Nerves. By Thomas Mitchell, M. D., of Dublin. -

13. Identityof Cow-pox and Small- pox. By Dr. Muhry, of Hano- ver. - - _ - -

14. Vaccination in France in 1840. By M. Gauthier de Claubry. -

15. Sciatica cured by Extract of Belladonna. By M. Hiriart. -

16. On the incipient stage of Can- cerous Affections of the Womb. By Dr. W. F. Montgomery.

17. (Edema of the Glottis. By M. Bricheteau. - - .

18. Complete obliteration of the Aorta. By Prof. Roemer, of

- 167

169

I !

169 170

170,

1711 172

Vienna. - - - -

19. Typhoid fever in the Foetus. By Dr. Manzini. - - _

20. Tincture of Catechu in fissure of the Nipple.

21. Cases of unexpected recovery from large Abscesses in the Lungs. By Dr. Graves.

22. Sympathetic Pruritus. By Mr. Walter C. Dendy.

23. Suffocating Catarrh. By Mr. Robinson. - . - .

24. Cough from Spinal Irritation.

25. Hiccup from Spinal Irritation.

26. Asphyxia — the relative import- ance of warmth and cold to the surface. - - - .

27. Extensive Disease of the Pan- creas. By James A. Wilson, M. D.

28. Influence of venereal excesses in the production of Apoplexy.

By Dr. Muynch. - - - 179

173

173

- 173

- 174

Y

- 174

176 176 176

- 176

178

10

CONTENTS.

Surgical Pathology and Therapeutics, and Operative Surgery.

page!

29. Treatment of Strangulated Hernia by Opium. By Drs. Bell, Davis and Cooper. - - 179

30. Iodine Injections in the treat- ment of Serous Cysts. By M. Velpeau. 180

31. Permanent closure of the jaws cured after a lapse of five years by division of the masseter mus- cle. By Prof. Fergusson. - 180

32. Formation of an Artificial Anus for the relief of Intestinal Obstruction. By Mr. T. P. Teale. ^ 181

33. Artificial Anus in lumbar re- gion in an infant. By M. Amussat. _ - . - 181

34. Rupture of the Spine, by a vio- lent muscular effort. By M. Lasalle. - - - - - 181

35. Wound through the Sternum and arch of the Aorta. By Dr. Caspar. 182

36. Treatment of Ulcers between | the Toes. By Dr. Schlesier. - 182

37. Successful amputation in | spreading Gangrene. By A.

T. S. Dodd, Esq. - - - 182

38. Reunion of the Fingers. M. della Fanteria. - . - 184

39. Varicose crural vein. By Dr.

de Castella. - - - - 184

40. Semi-amputation of the Ute- rus. By Dr. Grembler, of Neider Orschel. 184

41. Introduction of Air into the Veins. By Dr. Godemer. - 184

42. Necrosis of the Os Calcis. By

M. Mallespine. - - - 185

PAGE

43. Hypertrophied state of a fold of the Schneiderian membrane mistaken for nasal polypus.

44. Van Gesscher's Bougies.

45. Ventral Hernia. . - -

46. Amputation for diseased bone in Children. By M. Tayignot.

47. Spontaneous Priapism during thirty hours, with retention of Urine. By M. Demeaux.

48. Berard's mode of applying the Vienna caustic for the cure of varicose veins. By M. Berard.

49. Fracture of the neck of the Femur. By Mr. B. Cooper.

50. Dislocation of the Sternum By M. Maissoneuve.

51. Wounds of the Femoral vein in operations for Aneurism. By Mr. Hadwen. -

52. Polypi of the Rectum in Chil- dren. By Prof. Stolz. -

53. Cases of double Hare-lip — period of life most suitable for operating for this deformity. By Mr. Houston. - - -

54. Amputation during Pregnancy. By Mr. Tarleton, of Birming- ham. - _ - - -

55. Solution of Urinary Calculi By M. Pelouse.

56. Cauterization of the neck of the Uterus. By M. Lisfranc. -

57. Vesico-vaginal Fistula. By M. Leroy d'Etiolles.

58. Hernia of the Stomach.

59. Rare form of Internal Strangu- I lation. By Prof. Geoghegan. -

185 185 185

186

186

187

- 187

- 187

- 187

188

- 188

192

- 193

195

195 195

196

Ophthalmology.

60. On certain structures in the Orbit, and an improved method of treating its Diseases. By J. M. Ferrall, Esq. - -

61. Rupture of the Sclerotica by a blow with the Fist. -

62. Symblepharon. By M. Petre- quin, of Lyons. - - -

63. Turpentine in Scrofulous Cor- neitis. By Mr. Obre.

64. Irideremia. By M. France. -

65. Imperfect development of the Eyes with Cataract. By Mr. Walker, of Manchester. -

66. Cases in which, after the fail-

ure of the operation for Cataract

on one eye, the vision of both

eyes was restored, by operating

197 on the cataract on the opposite

side. By M. Serre, Prof, at

- 201 Montpellier. - - - - 206

67. Melanosis of the Eye. By

203 Dr. Byron. - - - - 206

i68. Cysticerus lodged under the

205} Conjunctiva. By Dr. Hoering,

205j of Luisburg. - - - - 211

69. Cataract suddenly formed in

boih Eyes. By Dr. Martin, of

205 Portlaw. 211

CONTENTS.

11

Midwifery.

PAGE

70. Extra-uterine Pregnancy. By

M. Blache. - - - - 211

71. Number of Pulsations of the Foetal Chord. By Mr. Streeter. 212

72. Rupture of the Womb during Gestation — Recovery. By Dr. Richter. 212

73. On the Management of the Placenta. By Mr. Joseph Bell. 212

74. Facts relative to the statistics

of Menstruation. - . - 213

75. Extraordinary Birth. By Dr. Schnackenberg. - - - 213

76. Abstraction of the Uterus after delivery. By Dr. Peracchi. - 214

77. Polypusof the Uterus expelled by the action of Secale Cornu- tum. By M. P. Moyle. - - 214

78. Pregnancy unattended with the usual signs, and in which partu- rition occurred without labour- pains: rupture of the funis which remained untied forty-five mi- nutes. By Thomas Lewis, Esq., Liverpool. . - . . 216

Medical Jurisprudence and Toxicology.

79. Guerard on the consequences of drinking cold liquids when heated.

80. Detection of Arsenic acid by M. Eisner. - - - _

81. On spots in glass resembling those of Marsh, produced by a reducing flame. By Prof. Lou- yet.

82. Do Metallic poisons when mixed with cultivated land, enter into the composition of the vege- tables produced? By MM. Lou- yet and Verver. _ . _

83. Superfo3tation. By Mr. Re- nauldin.

84. Plea of Quick with Child in criminal cases. By Mr. Grif- fiths, of Wexham. - - -

85. Presence of Lead in the solids and fluids. By Dr. Budd.

86. On a new mode of distinguish- ing arsenical spots from antimo- nial spots. By M. Bischoff". -

87. Nicotine. By M. Barral.

88. Ergot. By Mr. Quekett.

89. Suicide from Asphyxia by choking, from the introduction of a firm plug into the fauces. By Dr. Handyside, of Edin- burgh. - - - . -

190. Minute quantity of Opium de-

I structive to the life of a child. 217! By Mr. Everest.

91. Signs of Pregnancy. — Kies- 218 teine. By Mr. Letheby. -

192. New Test for Nitric Acid. -

93. Are medical men liable to punishment if they refuse to

218 make a medico-legal dissection, or a chemical analysis, when called upon by the coroner? By Dr. Cambrelin, of Namur

94. Poisoning with flour contain- 219j inglead. By Dr. Schillbach. - 225

95. On the varieties observed in 2201 the symptoms of poisoning with

I Opium. By David Skae. - 225

96. Advanced stage of the Putre- 220| faction of the Brain, without any

I corresponding appearances in the 221 i rest of the body. By M. Millet. 226 [97. Birth of a living child on the 1 179th day. By Mr. Tait. - 227

221 98. Child born at the end of the

223

223

224

- 224

222

222

222

fifth month, which lived six days. By Dr. John Cochrane, of Edinburgh. - - - 227

99. Recovery from taking two drachms of Arsenic. Mr. Too- good. - - - - - 228

Miscellaneous.

100. Animal Magnetism. By Mr. Longmore. - - - - 228

101. Abstractof a paper on Opium smoking in China. By G. H. Smith, Esq. - - - _ 229

102. The Bavarian Schools of

Medicine suspended. - - 233

103. Desertion of children in France. By MM. Terme and Monfalcon. - - . - 233

104. University College, London. 233

105. Obituary Record. - - 233

12

CONTENTS.

American Intelligence.

PAGE

Expulsion of a mass of hair from the Uterus. By Henry R. Frost, M.D., Charleston, S. C. - 235

Case of expulsion of the Foetus about the sixth month with the membranes entire. By Robert S. Bailey, M. D., Charleston, S. C. 236

Statistics of the Medical Colleges in the United States. - - 237

On the Intermittent Fever of New England. By Samuel Forry, M.D. - - - - - 239

Nathaniel Chapman, M.D. - 240

Observations on some of the signs of live and still-birth, in their applications to Medical Juris- prudence By John B. Beck, M. D. 243

Inversion of the Uterus. By D. Humphreys Storer, M. D. - 247

Operation for Artificial Pupil and subsequent section of the Rec- tus superior. By J. Kearny Rodgers, M. D. - - . 248

PAGE

Rupture of the Uterus from exter- nal injury. By Dr. F. Hyde. - 249 Ligature of the External Iliac

Artery. By Dr. E. Peace. - 250 Excision of a large Tumour upon the Neck. By R. D. Mussey,

M. D. 253

Thymic Enlargement. By Dr.

W. C. Roberts. - - - 254

Blepharoplastic operation for Ec- tropion. By Dr. A. C. Post. - 258 Snake Bites. By Prof. Drake, of

Louisville. - - - - 258 Medical Schools of the West. -259 Assistant Surgeons in the Navy. - 259 Medical Advertising. - - - 259 Medical College of Ohio. - - 259 A Popular Treatise on Vegetable

Physiology. - - - _ 260 Philadelphia College of Pharmacy. 260 University of Maryland. - -260 Willoughby Medical School. - 260 Pennsylvania Hospital. - - 260 Yellow Fever at Key West. - 260 Obituary, 260

THE

AMERICAN JOURNAL

OF THE

MEDICAL SCIENCES

JULY, 1842.

Article L — Experiments on Kiesteine, ivith observations on its ajyplica" Hon to the diagnosis of Pregnancy. By Elisha K. Kane, M. D.*

In 1831, M. Nauche communicated to the Society of Practical Medicine of Paris, some observations on a gelatino-albuminous product found in the urine of pregnant females subsequent to the first month of gestation, and which is separated from the other elements of that fluid by rest alone. To this product he gave the name of Kiesteine.

If the urine, he says, be exposed for a few days in a glass, the kiesteine shows itself at the surface, in the form of specks [points) and oblong fila- ments, which unite in a pellicle or scum of a line in thickness. A portion of this sinks to the bottom of the vessel, and forms there a whitish deposite of a milky appearance; the rest remains on the surface, adheres to the sides of the glass, and is converted into a solid membraniform substance.

The pellicle thus formed, he regards as furnishing a certain test of preg- nancy almost from its commencement, if the woman is in health; and he asserts that he has frequently determined by reference to it the existence of that condition, when it would not otherwise have been suspected. He admits that in diseases in which there is a secretion of pus, in dropsy, in diabetes, and in children having worms, the urine is often covered with an albuminous, fatty, or saline scum, resembling somewhat that observed during pregnancy; but he affirms that after a litde practice, these are dis- tinguishable at a glance.

M. Nauche was followed by M. Eguisier, of the Sainte Genevieve Dis- pensary of Paris, who, in February, 1839, published an article in the Lan- cette Frangaise, in which he described the pellicle as observed by himself.

* This was an inaugural dissertation for the degree of Doctor of Medicine; and is published in pursuance of a recommendation of the Medical Faculty of the University of Pennsylvania.

No. VII.— July, 1842. 2

14 Kane on Kiesteine, . [July

"From the second to the sixth day," he says, "small opaque bodies are seen rising from the bottom to the surface of the liquid; and these aggregat- ing by degrees, form a layer which covers the entire surface: this is the kiesteine. It has sufficient consistency to admit of being lifted up with some care by its edges. It is whitish, opaline and somewhat granulated, and may be well compared to the fatty scum of cool broth." He considers it an invariable attendant of pregnancy, and so well marked in its distinctive characters as to prevent its being readily confounded with others.

M. Eguisier had examined twenty-five cases. Seventeen of these, at periods varying from the fourth to the ninth month of utero-gestation, were under his care for slight indisposition: four had been pregnant from one to four months, and were under treatment for uterine disease: and the four others were affected, respectively, with ascites, sciatica, ulceration of the neck, and a supposed uterine disease, for which repeated cauterizations had been resorted to. In all of these the characteristic indications of kiesteine were present; and in the four last mentioned, the existence of pregnancy was ascertained in the first instance by reference to them alone.

In the following year. Dr. Golding Bird, of Guy's Hospital, published in the reports of that institution his paper " on the existence of certain ele- ments of the milk in the urine of pregnant women," founded upon the observation of " about thirty cases."* He gave succinctly the result of his examinations, touched on the microscopic and chemical characters of the pellicle, and expressed his belief that it is an imperfect caseous matter mixed with crystals of the ammoniacal phosphate of magnesia. Pursuing an idea of Professor Burdach of Konigsburg,! that the elements of the milk exist- ing in the circulation may, during certain conditions, be eliminated, and not finding an outlet by the mammae, be again taken up and excreted by the kidneys, he supposes such elements to enter into the constitution of the kiesteinic pellicle.

A still later writer, M. Becquerel,:j: in his " Semeiotique des Urines," has noticed the observations of M. Nauche, but without admitting the truth of his conclusions. He had, himself, analysed and examined the urine of three pregnant females, and had occasionally inspected that of a ^^ certain number" in different stages of utero-gestation, without discovering traces of the kies- teine.

I believe that I have referred in this brief sketch to all the personal obser- vations which have been published in Europe upon this subject. They have of course attracted the notice of the journalists,§ and some of the

* Guy's Hospital Reports, No. 10, April, 1840.

t Traile de Physiologie, Paris, 1839.

^ Semeiotique des Urines, ch. ix., Paris, 1841.

§ Journal de Chimie Medicale, Fev., 1839, p. 64. London Lancet, No. 417, p. 675. Dublin Journal, vol. VI. Medico-Cliirurgical Review, 1839, p. 228. Am. Journ. of Med, Sci., Feb. 1840, p. 483; Ibid. Aug. 1840, p. 501. Am. Med. Tntelligencer.

1843.] Kane on Kiesteine, 15

more elaborate writers of the profession have alluded to them in their trea- tises.*

Some indeed have assigned to the discovery a much earlier date, referring it to Savonarola, who, as far back as 1486, detailed minutely a series of changes incidental to the urinary excretion from the commencement of utero-gestation to the seventh month. I have been unable to obtain a copy of this venerable author, and cannot, therefore, speak personally with regard to his observations; but I find by reference to Fodere, and others who quote his opinions, that after describing the colour of the fluid, he mentions a *' cloud upon the surface," adverting at the same time to a deposite par- tially suspended resembling carded wool. This description may perhaps identify this superficial cloud with the pellicle of M. Nauche. If so, how- ever, the question of originality will arise between Savonarola, and some of the still more ancient writers of the Moorish and Arabian schools.

The urine, it is well known, in common with all the excrementitial and secreted fluids, was anciently a subject of habitual though vague observa- tion. Yet, if we except the increased redness, noticed by Hippocrates and some others, as pertaining to the latter months of gestation, nothing can in any case be gleaned from the works of ancient writers, by which the phases of the urine may be applied to the determination of pregnancy. Thus, Galen, Magnus of Antioch, and Pliny, allude in a general and obscure manner to the urine and its changes, without referring to the peculiarities it exhibits during pregnancy. But Avicenna and Rhazes are quoted by M. Eguisier, as describing the white cloud, the central deposite, and the minute bodies ascending and descending; not indeed as signs absolutely indicative of pregnancy; yet as generally attending it, — the deposite beimg perhaps the most constant.

It may, however, be conceded, that up to the present time, the existence and character of these appearances have not been the subject of entirely satis- factory investigation. To justify general conclusions, a larger number of cases should be examined, individually and in group, and their progress, changes, and points of difl"erence noted. They should be viewed under diflferent aspects, at regular and frequently recurring intervals. If the indications of a particular case should appear to vary from those of others, repeated obser- vations would become necessary to detect the causes of variance; and the influence of similar causes upon other cases, where they existed, also should then be sought for. And I may be excused for adding, that a candid spirit, not too much biased in favour of theory to admit the existence of observed exceptions, that looks to each clearly ascertained result as an independent element, and rejects nothing that appears true because irreconcilable with what was known before, is not less important to the formation of correct opinions, than the most careful and varied scrutiny of facts.

* Montgomery, Dunglison, Churchill, Rigby, Traill, &.c. &c.

16 Kane on Kiesteine. [July

It is not meant to intimate by this, that the gentlemen who have treated on this subject have been regardless of these precautions, or wanting in the proper spirit of inquiry; but it is apparent that their observations have been rather of isolated cases than of classes, that they have not compared a large number of results, and that they have failed to detect any exceptions to their general conclusions.

M. Eguisier speaks of only twenty-five cases, Dr. Golding Bird of ** about thirty," and M. Becquerel's scrutiny, with immediate reference to this question, embraced only three. So that, as to all those who have fol- lowed M. Nauche in Europe, it may be said with truth, that the aggregate of their observations does not number sixty cases. It should not, therefore, surprise us, if a more extended investigation were to lead to a modification of their conclusions.

In the spring of last year, while one of the resident physicians at the Phi- ladelphia Hospital, I availed myself of the facilities which were liberally afforded me by the managers of that institution, to commence a series of observations on the subject of kiesteine; and I have continued them to the present time. The number of patients in the several wards was such as to make it easy to classify and group the cases, and my position enabled me at all times to scrutinize the circumstances of each, much more fully than could have been done in private practice.

My friends, Drs. McPheeters and Perry, who were residents with me at the time I began, had already made some interesting observations on the subject at the instance of Dr. Dunglison,* which they subsequently published in his Medical Intelligencer; but though their politeness had enabled me to watch the progress of their investigations, I had not adopted their conclu- sions, and was in fact careful to avoid the influence which the known opi- nions of others might have had upon the freedom of my own.

My mode of conducting the experiments was this. The recent urine was placed in open glass cylinders, of diameters varying from an inch and a half to that of a common tumbler, and protected from dust by paper covers. These were arranged in a dry, well ventilated room, where the temperature was uniform and moderate, and were exposed in groups to the equal action of air and light. f I examined them frequently during the day; but as the changes were not rapid, I determined after a little while to note only one set

* I should do much wrong to my feelinors, were I to pass the name of this gentleman without acknowledging the obligations I am under to his unwearying kindness. No one promotes more happily a spirit of inquiry among the younger members of the profession, or is more prompt to render them service.

t These precautions were not unimportant. My attempts in the " Green Room of the Hospital" were unsuccessful, in consequence of the dampness producing fungoid modifi- cations of the scum; and in very cold or very hot weather, the pellicle formed very re- luctantly, or was anticipated by the decomposition of the urine. The room should be sufficiently lighted to admit of minute examination, and the specimen should be kept absolutely at rest during the progress of the inquiry.

1842.] Kane on Kiesteine, 17

of observations in the twenty-four hours. My notes were always made upon the spot. If from any cause, an individual observation or a series was unsatisfactory, or inconclusive; or if it led to a different result from others, I repeated it at once with increased care; and I was always careful to observe the constitution, habits and circumstances generally of each patient.

The examination of the first group of cases satisfied me, that the urine during pregnancy assumes appearances different from those witnessed under other circumstances, and which I was therefore disposed to regard as cha- racteristic of that state. Subsequent inquiries confirmed me in the general accuracy of this opinion, but compelled me at the same time to admit its lia- bility to exception.

The more obvious of these appearances regard the superficial formation described by Dr. Bird, and recently investigated by Drs. McPheeters and Perry; but there are others which point to a series of intestine changes somewhat more obscure, though scarcely less interesting. My observations applied to both; and I regret that the limited time at my command during the studies preliminary to graduation, obliges me to select a single class as the subject of this dissertation. I take, however, that indication which seems to me best fitted for practical usefulness in diagnosis, the pellicular change, and which I suppose to be most properly called the Kiesteine.

The urine, submitted to observation in the way I have described, presents but little change during the first thirty-six hours. The mucous flocculi, if they exist, gradually subside during this period, forming a whitish cloud- like deposite at the bottom and sometimes on the sides of the glass; while more or less alteration occurs in the colour and transparency of the fluid.

The surface remains for a short time entirely unchanged; but in most cases, a greater or less number of shining acicular specks, apparently crys- talline, begins to be seen within the first eighteen or twenty-four hours. These are generally scattered over the surface without regularity; but in some rare cases, they are so disposed as to form a translucent film of uni- form thickness, which afterwards assumes the more defined characters of the pellicle. How far these crystals are essentially connected with the forma- tion of the pellicle, X am not prepared to say. In many cases, I have not succeeded in detecting their presence, even by the microscope; and, indeed, I have failed to discover any unvarying indications whatever of the ap- proaching development of the Kiesteine.

The cloudlike appearance, which is alluded to by Nauche and Eguisier, although possessed of much interest, I have not found to be a uniform premo- nitor of the forming pellicle; I have supposed it to be nothing more than the Enaeorema of the older writers, depending upon the imperfect aggregation of mucous flocculi; for I have seen it repeatedly when there was no pregnancy to account for it, and it was uniformly absent where the fluid presented per- fect transparency.

The time at which the pellicle begins to form varies considerably. I have

2*

18 Kane on Kiesteine. [Jw^y

seen it well marked at the end of thirty-six hours, and have known it make its first appearance as late as the eighth day. At first, it is hardly discern- ible. It is generally seen forming at the centre or on the sides of the glass, presenting a delicate milky or bluish white aspect. It is however in some cases uniformly disposed over the surface from the commencement, and assumes the appearance of a nearly transparent film, which gradually be- comes more distinct. But it has not always the continuous strongly marked character, which some have ascribed to it. I have seen it begin in striated irregular lines, somewhat resembling a spider's web, in rings, circles, trape- ziums, and irregular figures of almost every shape, which gradually became obscured by the full development of the pellicle.

When it has attained this stage, which occurs generally about the fifth day, it presents a continuous scum of an opaline white or creamy appear- ance, with a slight tinge of yellow, which gradually becomes deeper and more decided. The uniformity of this colour, however, is generally broken by granulated spots of a clearer white, giving it a dotted or roughened aspect. The crystals of the forming stage now appear like shining points, and I have sometimes found numerous small brownish specks, sprinkled over the sur- face, not unlike the gratings of nutmeg. It is at this period, that the pel- licle may be compared " to the fatty scum of cooled broth."

In this state it continues for some time, preserving all its characters un- broken. The glass, where the surface meets it, is discoloured by a white opaline ring; and a series of such rings, varying in extent from a line to the fourth of an inch, marks the descent of the surface during the progress of evaporation.

The cheesy odour, mentioned by Dr. Bird as a valuable aid in diagnosis, and as " by no means unfrequent in those specimens in which the pellicle is very thick," I have found in but seven cases. Many pellicles of great thick- ness were entirely without it; and in two of those presenting it, the pellicle was thin and not very well developed. Drs. McPheeters and Perry were unable to detect it in either of the twenty-seven cases examined by them, and I have found it unequivocally developed in at least three cases in which pregnancy did not exist.

The pellicle, if left undisturbed for some days, breaks into cracks, com- mencing generally from the central portions, but not always extending to the edge of the glass. These are again crossed by other fissures, and the pel- licle is more or less broken up. In the mean time, the flakes, which have been forming from the commencement of disintegration, have their edges depressed into the fluid, while at the same time the general thickness of the pellicle is much diminished; and this depression or dip gradually increasing, the depending particle is detached, and sinks slowly to the bottom. Its complete disintegration, however, is but seldom seen; being anticipated by the decomposition of the fluid. The deposite is of course considerably in- creased by the fallen portions of the pellicle, and is found irregularly dis-

1842.] Kane on Kiesteine, 19

posed over the bottom of the vessel; but as I have remarked, most abundant on the side farthest from the light.

I cannot agree with those who consider this deposite as presenting well marked distinctive characters to the eye, and I certainly have not found it uniformly coincident with the approach of the pellicle. It has indeed in many cases been absent at that period; and in others, until augmented by the detached pellicle, I have been unable to distinguish it from the very many deposites found in other urine. How far a chemical investigation may give it value, I am not prepared to say: although its liability to be con- founded with other sediments makes it practically unavailable as a test, it offers a fine field for microscopic and chemical research.

This description of the appearances and changes of the pellicle, though more detailed than those of Nauche and his followers, still applies only to the better defined examples. In a considerable proportion of cases, some of the phases mentioned are not to be found together; and I have not been able by the most careful observation to discover the causes of variance. This I allude to here, because the absolute and unqualified language, which I have met elsewhere upon the subject, seems to me calculated to mislead the un practised inquirer.

It must not however be inferred that the presence of kiesteine is determi- nable only by vague and undefined characteristics. On the contrary, the tables which are appended to this dissertation, will show that they are as well defined as most pathological phenomena, though like them they some- times require for their discrimination a practised comparative scrutiny.

Tlie table marked A exhibits a condensed record of my observations, more or less frequently repeated, on the urine of eighty-five pregnant females. Of these, as will be seen, sixty-eight gave a well marked pellicle of the sort called kiesteinic, eleven gave the pellicle under a modified form, but with appearances which enabled me to recognize it clearly, and six gave no pellicle whatever. Of these last, one was labouring under mammary abscess and convalescing from typhoid fever, and one was in a condition of extreme anaemia from repeated uterine hemorrhages; but the others, unless they suc- ceeded in practising reiterated deceptions on me, which I can hardly believe, must be regarded as absolute exceptions.

The cases in the table were all of them observed at the hospital, and were of course considerably advanced before being submitted to my inspection. I have since, by the courtesy of my friends in the city, and especially of Dr. N. Benedict, been invited to examine the urine of several patients in cases of very recent yet unascertained pregnancies. My diagnosis has been in every case successful, and I have detected the kiesteine repeatedly before the second period of suspended menstruation. I found it in one of these before the fourth, and in another before the fifth week, computed from the middle of the preceding period. In several others I have determined it be- fore the end of the third month. In one case the kiesteine was not visible

20 Kane on Kiesteine* [July

on the fourth, fifth or seventh week, although perfectly manifest on the tenth.

The urine of unimpregnated females in a state of health rarely undergoes any change which in this respect can be misapprehended. I have examined twenty-eight cases in a perfectly healthy condition, and have sometimes known pellicles form on the urine, as well as on that of males; but the dis- tinctive character of the kiesteine was wanting in every case.

In certain pathological conditions, however, discrimination is somewhat more difficult. The pellicle that is not unfrequently seen on the urine in the last stages of phthisis, in arthritic diseases, and in cases of metastatic ab- scess, vesical catarrh, and uterine tumours, has points of resemblance to the kiesteinic which might readily mislead the unpractised. With reference to this, I have examined a large number of cases in various states of health and disease, and noted the results; but it may not be necessary to give more than a concise summary of them.

In thirty cases of phthisis pulmonalis, the urine of four presented a pelli- cle somewhat like the kiesteine, and one a pellicle bearing a strong resem- blance to it: though, more unequally and irregularly disposed, and thus dis- tinguishable by the eye. Fourteen of the cases were in the latter stages of the affection, and among these were three that presented the pellicle.

In arthritic diseases, eight cases of acute rheumatism and a large number of chronic rarely presented any well-marked pellicle, and never one that could be confounded with the kiesteinic.

Sixteen females between the ages of sixty and one hundred, as well as ten epileptics, presented no change that could give rise to confusion.

Numerous blennorrhagic and leucorrhoeal cases were likewise examined. In the urine of these an increased quantity of mucus was generally present, disposed in flocculi, as M. Becquerel and others have noticed, but this was by no means uniform. In most of them the pellicle was of a cloudy character, much obscured by rapidly induced decomposition. In only two of them did it approach in appearance the kiesteine. But in these the resemblance was close; the most remarkable difference being in the manner of its formation, which was apparently referable to the advance of decompo- sition. The pellicle, moreover, was thickened by depending flocculi of mucus, which gave to its lower surface an irregular fungiform appearance.

The particulars in which the kiesteine differs from other pellicles regard the manner of its formation and departure, even more than its appearance when developed. As I have already mentioned, it generally begins to show itself within a day, or at furthest within two days after the discharge of the fluid, and advances gradually to its complete development. The other pelli- cles, on the contrary, rarely give indications of their approach until the fluid has stood a longer time, or even till decomposition has supervened, and then form with rapidity. I have known them entirely defined within a few hours.

1842.] Kane on Kiesteine. 21

The kiesteinic pellicle, when fully formed, has almost always a much greater degree of tenacity than the others: I have often, for purposes of microscopic examination, lifted large flakes entirely out of the urine; and when it was well defined, this was easily done: with the others it was never practica- ble. It seems also to be independent of putrefaction; it is not obscured for some time by the disorganization of the liquid on which it rests; and the characteristics which I have already described as accompanying its dis- appearance are very seldom simulated.

The appearances which I have observed seem to point directly to the con- clusion, that the formation of the kiesteine is unconnected with the presence of extraneous pus or flocculent mucus. I was aware that these and other animal matters might under certain modifications give rise to a scum upon the surface, the " cremor urinae" of the older writers. This has been no- ticed by M. Becquerel, as especially observable in leucorrhcea; and I have observed it very frequently, not only in that disease, but in cystitis, gonor- rhoea, vaginal and uterine hemorrhages, and immediately after delivery when the lochial discharge was mingled with the urine.

By the kindness of Dr. Stewardson, I have had the opportunity of seeing M. Becquerel's recent and very elaborate work on the " Semeiology of Urines,"* and I have been struck with the discrepancy between his observa- tions and my own in several particulars connected with this inquiry.

After remarking that the urine is modified in its appearances by the con- stitutional changes incident to pregnancy, he says, that it often, especially in the latter period of gestation, grows palish, diminishes in density, containing less solid matter in solution, and partakes of the general anaemic character of the patient; and that it also often remains unchanged after exposure. Without attempting to deny the presence of the matter denominated kiesteine, he is not prepared to admit it, but refers to the " influence of a certain quantity of mucus on decomposition" as capable of producing the appearance which has been mistaken for it.

I cannot avoid referring to the results of some experiments, which appear to me to be at variance with these suggestions. Many of the specimens which I examined had been first submitted to filtration, with a view of sepa- rating any mucus they might contain; yet in every case, the pellicle formed with the same regularity as when this precaution had not been resorted to.

It was formed also on urine which, when treated with acetic acid, pre- sented no coagulation, and which underwent no change when treated while hot with alcohol. And in many cases, where the urine was withdrawn by the catheter, and freed of course from the possibility of vaginal extermix- ture, the formation of the kiesteinic pellicle was uninterrupted. I can scarcely believe, that in such cases it was owing to the presence of the ex- traneous mucus.

* Reviewed in the Number of this Journal for January last.

22 Kane on Kiesteine, [July

The observation, too, that the urine becomes paler in the later stages of pregnancy has not been confirmed by my experience. The urine when deposited embraced a great range of colours; the different shades of yellow with more or less intermixture of red being the most common. The degree of its transparency also varied much. But towards the last month of ges- tation, the urine, with more or less uniformity, as will be seen by the tables, became much darker, assumed a reddish or salmon colour, and often di- minished in transparency. This change has been noticed by the ancient writers; and, although not invariable, seems to me deserving of more atten- tion.

Having convinced myself, that the urine of healthy females undergoes during utero-gestation a change, which is indicated by a pellicle in many respects similar to that described by Nauche, and also that the urine of other states might in some rare cases require for its distinction a careful compar- ative scrutiny; I next sought to determine by observation, whether the kies- teinic pellicle occurred in other conditions.

The well known fact that the elements of the milk have been found in the urine, — the opinion of some physiologists, that, separated from the blood and existing in the mammae, it may during gestation be reabsorbed and ex- creted by the kidneys, — and more immediately, the supposition of Dr. Bird, that the kiesteine was owing to its presence, — naturally led me to examine the urine during the various conditions of lactation.

By resorting to the nursery wards of the hospital, at that time containing a large number of patients, and subsequently by examining all the delivered cases of the obstetrical wards, I was enabled to observe no less than ninety- four cases. These I have grouped in the table marked B.

The results establish the fact, that the kiesteine is by no means peculiar to pregnancy; and they have at the same time an important bearing on cir- cumstances which contribute to the theory of the production of this pellicle.

Of the ninety-four cases of females in a state of lactation, forty-two gave the usual urinary changes without any indication of the kiesteine; eight pre- sented a scum, but modified or imperfectly formed; while forty-four exhi- bited the perfect kiesteinic pellicle, as well developed as in ordinary cases of pregnancy.

The conditions, which appeared to exert an influence over its formation or its absence, may be the subject of a few remarks.

Immediately after delivery, and during the lochial discharge, when the urine owing to its intermixture was more or less reddened, a scum formed of a semi-transparent hornlike appearance, marked by arborescent figures of a sanguineous tinge.

In the interval between the birth of the child and the free establishment and exit of the lacteal secretion, — of twenty-three cases in which I succeeded in preventing lochial admixture, fifteen gave a kiesteinic pellicle.

After the more immediate sequelae of pregnancy and delivery had disap-

1842.] Kane on Kiesteine, 23

peared, when the secretion of the milk was perfectly established, and the mother had begun to suckle freely, it appeared in two cases only.

Of the large number of cases that were examined during lactation, several gave the pellicle well marked, when there was no lacteal disturbance to ex- plain it. In these, however, the breasts were full and even turgid, indicat- ing an exuberant supply or inadequate withdrawal of the secretion.

Of cases in which the flow of the milk was prevented by mechanical or local obstructions, as in mammary abscess, &c., eleven in number, seven gave the kiesteine: of those in which the secretion was interrupted or par- tially suspended by constitutional disturbances, eight in number, it was given by only three: while of ten healthy females, eight at the period of tveaning exhibited it perfectly well defined.

Four of these who had presented the kiesteinic pellicle, while weaning, had their milk afterwards regularly withdrawn by the cupping glass and the mouth. After the lacteal secretion had been in this way freely re-established, the urine was again examined, and no pellicle appeared. Intermitting the use of the cupping glass, and allowing the breasts to become turgid again, the urine of two again presented the pellicle.

These results, while they demonstrate that the kiesteine is not peculiar to iitero-gestation, indicate also its unquestionable connection with the lacteal secretion.*

Its presence during pregnancy, and even after delivery, until the milk is freely withdrawn by the child; its very rare occurrence during uninterrupted lactation; its reappearance when the discharge of milk is prevented, but not when the corresponding secretion is arrested; and finally its return for the time during the process of weaning, and its occasional absence when that process is intermitted; all these, regarding them as the general results of the observations above cited, point to one probable conclusion, — that the kiesteine makes its appearance, whenever the lacteal secretion exists, and its discharge is prevented or considerably impeded. I am confirmed in this judgment by its perfect consistency with the theory suggested by Dr. Gold- ing Bird, in the Guy's Hospital Reports for April 1840.

Having described this pellicle under its various forms and conditions, it may be proper to add a few words on its nature and properties.

Dr. Golding Bird, to whose interesting observations I have before so often alluded, states that " none of the specimens examined by him were coagu- lable by heat, nitric acid, or, with but one or two exceptions, by acetic acid."

In all the cases mentioned in my first tables, the urine w^s submitted to the action of nitric acid; in about forty to that of heat; and in many, it was

* With reference to the remark in the text, I am at this time observing the urine in some cases of uterine tumour, and in other conditions which exercise an influence on the mammary secretion.

24 Kane on Kiesteine. [J"b'

tested with the ferro-cyanuret of potassium, after having been acidulated with acetic acid.

Of those which were exposed to heat, seven presented a coagulum; but re- membering the precautions urged by Dr. Rees* to prevent the earthy phos- phates being mistaken for albumen, 1 submitted the fluid in these cases to other tests, and thus found that of the seven cases apparently albuminous, three were in reality phosphatic. Four only, of course, were to be regarded as containing albumen.

Ammonia gave a deposite of varying density; and acetic acid in several cases caused coagulation.

The urine, tested daily with litmus, was found in almost every instance to be faintly acid, up to the time of disintegration of the crust. At this pe- riod, however, it undergoes the ammoniacal development, and acquires well marked alkaline properties, which probably induce the disintegration.

The pellicle itself, treated with alcohol, became of a fatty saponaceous character; the crystals remaining but little affected. Treated with ammonia, the granular matter was partially dissolved, and the crystals were made more manifest: they were even susceptible of isolation by careful washing and fil- tration. Acetic acid destroyed the crystals, and reduced the accompanying matter to a pultaceous mass, without materially altering its structure.

In the present state of physiological chemistry, but little can be determin- ed with regard to the nature of the kiesteine, and its very doubtful claims to be considered as a new principle. The absence of coagulation by appro- priate agents indicates in a measure that neither caseum nor albumen exists in very perceptible quantities; while the acid reaction up to the moment of disintegration seems opposed to the idea of its being a mere attendant upon increased quantities of pus or mucus.

Still, these with other as yet undetected principles may be constituents of the pellicle itself; and the question, whether any matters developed in it are identical with the caseum of the milk, must be determined by further observations, made perhaps in a more advanced stage of science. For, in- dependently of the possibility of this principle occurring without the inter- vention of the mammary secretion (see Andral, &;c.), Orfila himself has acknowledged his inability to distinguish the caseum from other organic matters;! and M. Dumas has announced a substance in every respect simi- lar to it, as one of the ingredients in the composition of pus.

My remaining observations were microscopic. I employed for them during the earlier stage of my inquiries, a simple Raspail instrument, with a Wollaston eye-glass; but the few results which I feel justified in detailing

* See paper on "Real and supposed pathological conditions of the urine," by G. O. Rees, M. D., Northern Dispensary, London. Guy's Hospital Reports, t Traite de Chimie, &c.

1842.] Kane on Kiesteine. 25

were attained by an excellent Berlin microscope, belonging to Dr. Goddard, and which he with great kindness assisted me in using. I can have no rea- son to doubt the correctness of observations made under the guidance of so practised an observer; but owing to the many sources of fallacy attendant upon microscopic evidence generally, I do not venture to claim for these the same confidence, which is due to my examinations by the unassisted eye.

The pellicle, taken immediately from the urine on a glass plate, carefully introduced, when examined with a magnifying power of one hundred diameters, exhibited, while yet moist, a well defined series of flakes of a somewhat darkish yellow, made up apparently of minute granules. This appearance, which I at first thought to consist of minute globules of mucus or pus, was at once recognised by Dr. Goddard, as closely resembling, if not identical with, the granules of the colostrum. Having with some diffi- culty procured a supply of this fluid, a comparison of the two exhibited still more clearly this interesting resemblance. The granules of the kiesteine were however more flattened than those of the colostrum, a change they might readily have undergone during their passage through the kidneys; but the general aspect of the two was such as to give strong evidence of their identity.*

Connected with these appearances, and sometimes obscuring them, the kiesteine presented under the microscope an irregularly disposed amorphous matter, sometimes arranged in groups of granules that resembled the urate of ammonia,! and sometimes of badly marked globules, allied to those of pus or mucus, and accompanied by laminee resembling epithelia.:}:

Throughout the field of the instrument was seen, in varying numbers and distribution, a series of rectangular rhomboidal prisms, more or less dis- tinctly marked, and strongly refracting light. The triangular prisms were also occasionally distinguished, but not in the " myriads" seen by Dr. Bird; and sometimes other crystalline forms were observed in addition to these. They all belong most probably to some of the earthy phosphates. Not only were the triangular prisms recognised to be those described by Dr. Bird, as belonging to the ammoniacal phosphate of magnesia, but by com- paring them with the microscopic plates of Rayer and Vigla, and Mandl, (Etude Microscopique sur I'Urine,) many others were discovered, coincid- ing with the varied forms of this prominent salt.

On treating the pellicle, collected as for examination, with acetic acid, applying a gentle heat, and then carefully washing the residuum; the crys- tals, as in a similar experiment by Dr. Bird, entirely disappeared, and the graniform masses, somewhat obscured, presented themselves al(>ne.§ By

* This resemblance was very striking upon comparing it with the plates of M. Mandl. t See Mandl, Raspail, and Rayer.

X See plates of Rayer and Vigla, Encyclographie Medicale, Vol. VI. § So completely were they deprived of erystalline matter, that in a similar experiment by Dr. Bird, after illuminating the granular, or — as he defines it— the "opaque mass," with

No. VII.— .July, 1842. 3

26 Kane on Kiesteine. [July

using ammonia, the reverse was the case. The crystals, nearly unaltered, remained unusually distinct; while, by the careful addition of water, the granular and other matter, much softened, was readily washed away, leaving the supposed triple phosphates remaining.

When the pellicle has been for a short time exposed under the micro- scope, the natural salts of the urine are developed by evaporation, present- ing numerous shining crystals of varied forms; among the most prominent of which are the triangular and the obscurely marked hexagonal prisms.

The cubic crystals, which M. Eguisier describes, as present in the true pel- licle after it becomes old, I have never seen. In a few cases of both kies- teinic and other pellicles, a hollow four-sided pyramid was obseived, resem- bling the chloride of sodium, and in one case a regularly formed cube. This was the nearest approach to the appearances mentioned by Eguisier.

In the pellicle not kiesteinic, the peculiar granular arrangement noticed as so strongly resembling the colostrum, was in no case present. Amorphous darkish masses, accompanied by various crystalline forms, were seen only. Where much discoloration existed from sanguineous or lochial intermixture, a strong resemblance was observed to the globule of the blood.

The shining appearance of the kiesteine is evidently not owing to fatty matter, unless under very peculiar modifications. Neither do I think it entirely owing to the numerous crystals of the triple phosphates, observed by Dr. Bird. I apprehend, that the specimens, in which he found them so abun- dant, may have been exposed for soma minutes to evaporation; as I have remarked, that under such circumstances, the proper salts of the urine de- velop themselves rapidly in their crystalline forms. I would rather refer the glossy character of the surface to the presence of animal matters gene- rally in the pellicle, without adducing either its fatty elements or the crystals on its surface as the explanation.

It may be proper that I should close this paper by some remarks on the value of the kiesteine as a diagnostic of pregnancy. I do so with diffidence, for my opinions are not sustained by the judgment of the more experienced observers who have preceded me.

I cannot regard the kiesteine as an unerriyig test of pregnancy. I have already shown that it is present under other conditions of the system; and even where pregnancy exists, I am satisfied that this indication is not always observable.

I am convinced too, that the kiesteine is not always distinguishable from other pellicles which appear on the surface of the urine. At least, I am bound to say, that, in the absence of other indications, I should sometimes have found myself unable to distinguish between them. Not that they are

a beam of polarised light and analysing the ray by means of tourmaline, not a trace of colour was perceptible.

1842.] Kane on Kiesteine. 27

generally liable to be confounded; but between the imperfectly developed pellicle of the one character, and the best simulation of it which is some- times presented by others, the distinction is too slight to be satisfactory or unfailing.

But with the qualifications which these remarks imply, I have no doubt that the pellicle which has been denominated kiesteine is among the best, if indeed it be not the most certain, of the earlier indications of pregnancy. I resorted to it habitually in my diagnosis in the obstetric wards of our hospital, and with constantly increasing confidence.

In one case, I felt myself at liberty to direct the removal of a patient to the working ward, who claimed the privileges of pregnancy in round terras, and presented all the other symptoms of that state in confirmation of her pretensions. She still retains the suspended catamenia, enlarged abdomen, &c., though five months have elapsed since the birth of the infant was pro- mised me as a proof of my mistake. Other cases of attempted imposture, some of them ludicrous enough, which were detected by the same means, I have collected in my table C.

My associates at the hospital have not unfrequently amused themselves by presenting for my inspection, the urinary excretions of all sorts of pa- tients, and in many varieties of combination. I believe they will bear me witness, that my reliance on the kiesteinic test has not misled me.

Indeed, the cases which I have referred to, and which are arranged in series in the accompanying tables, must satisfy an unprejudiced mind, that there is something well worthy of the obstetrician's study in the pellicles presented by the urine during utero-gestation.

The result of my observations may be summed up in the following gene- ral conclusions:

1. That the kiesteine is not peculiar to pregnancy, but may occur when- ever the lacteal elements are secreted without a free discharge at the mammae.

2. That though sometimes obscurely developed and occasionally simu- lated by other pellicles, it is generally distinguishable from all others.

3. That where pregnancy is possible, the exhibition of a clearly defined kiesteinic pellicle, is one of the least equivocal proofs of that condition; and

4. That when this pellicle is not found in the more advanced stages of supposed pregnancy, the probabilities, if the female be otherwise healthy, are as 20 to 1 (81 to 4) that the prognosis is incorrect.

Philadelphia, January 28, 1842,

28

Kane on Kiesteine,

[July

		(A) — Table of Cases during Utero- Gestation.
	Names.	■u		Condition of Mammae.	Appearance when received.	Remarks.	Result.
1			UbI
1	M. Biddee,	24	H	Milk exuding	Salmon yellow,	Surface gave a filmy pel-	Kiest.
				upon pressure.	turbid, flocculent,	licle in 16 hours, preceded	on 3d
				Mammae much	and with no depo-	by crystals. No well	day.
				distended.	sits	marked cloud or deposite.
2	S. Gilbert,	20	88	Milk in mammae Deep reddish yel- fromthe seventh low. Turbid, and	Crystalline dots. A firm cream-coloured pellicle	K. on 4th day.
				month.	with some deposi- tion.	on 4th day, covered with nutmeg like specks.
3	M. Hill,	32	7.	No milk.	Transparent, with a deep tinge of red. No mucous flocculi.	The shining specks pre- ceding the formation of the pellicle which occurred on the 2nd day. No cloud.	K. on 2d day.
4	E. Williams,	25	8.	Milk from this	Turbid honey yel-	Surface covered with striae	K. on 3d
				time.	low, with little or no deposite.	of a deep yellow, a firm pellicle filling up the in- terstices. Odour cheesy.	day- cheesy.
	(( u	((	9.	(( ((	Dirty red,with some deposition.	Sides of glass coated by deposition. Distinct pel- licle on fourth day.	K. on 4th day.
5	S. Dunken,	17	9.	Milk exuding by	Pale glaring white	Pellicle in circles, greasy	K. on
				pressure.	flocculi.	in appearance, and not well defined until the 5th day. Little pellicular change until 4th day; it then gave	5th day."
6	A. Lippincott,	36	8.12	No milk.	Salmon yellow,	K. on
					much deposite.	7th day.
						a perfect pellicle about
						the 7th.
7	A. Banks,	37	8.20	Milk by cupping	Salmon colour with	A good type of the pelli-	K. on 3d
				glass.	deposition.	cular appearance. Not perfect until the 4th day.	day.
8	H. Walker,	24	7.	Milk a few days	Turbid, flocculent,	A well marked opaline	K. on 3d
				previous.	and with a copious deposite.	cloud, above which the pellicle, much modified, appeared.	modified
9	M. Yacely,	24	8.13	No milk, but ve-	Turbid salmon co-	Stood for 12 days without	^1 1 K.
				ry turgid.	lour, but very scan-	any pellicular change.
					ty.
	(( ((	u	6.	No milk.	Lighter, and nearly	Stood until putrefaction
					transparent.	took place without any pellicular manifestations.	^\
10	M. Gallagher,	39	During	No milk.	Reddish yellow.	Pellicle not continuous.	K. on 3d
			labour.		with much floccu- 1-ent deposition.	and wanting the tenacious character of the kiesteine.	modified
11	M. Delano,	20	8.11	Milk from the	Straw yellow,	Decided pellicle on the	K. on 2d
				6th month.	bright and transpa- rent. Muddy reddish yel-	2nd day.	day.
12	E. Buckley,	40	Day of	Milk by pressure	An irregular striated pel-	Excep.
			deliv.		low, and no depo- site.	licle; no crystals, and not such as to warrant me in pronouncing it kiesteine. Regularly formed pellicle	tion. No K.
13	M. Yorkley,	20	8.	Milk.	Pale yellow, nearly	K. on 3d
					transparent.	— thin and pale; odour cheesy. Spider like lines and cir-	cheesy.
14	S. Miller,	20	7.6	Milk in breast at	Reddish yellow,	K. on 2d
				the 7th month—	nearly transparent.	cles, yet a well defined	day.
				none at present.		pellicle. Pellicle characteristic.
15	C. Ryter,	17	9th	None.	Bright straw yellow	K. on 3d
					- no deposite.		day.
16	B. M'Gurth,	21	9th	Small and flac-	Yellow tinged with	Pellicle not over the en-	K on 1st
				cid mammae.	red, and very tur- bid.	tire surface; decomposi- tion rapidly set in.	day mo- dified.
17	A. Weaver,	21	7.	Copious exuda	Turbid red, with a	An obscured pellicle on	Doubtful
				tion of milk.	deposite coatine; sides of glass.	2nd day; not well defined.	K. on 2d day.
	(( ((	a	8.	(( ((	Not so much depo- sition.	A characteristic pellicle on the 3d day.	K. on 3d day.
18	R. Dawson,	22	Day of	No milk.	Muddy red, with	The urine was of a dark	K. on 5th
			deliv.		much deposite.	brown at the surface: on the 2d day this disappear- ed, and on the 4th a well marked pellicle appear'd.	day.
19	C. Scoby,	24	during	Milk at the 7th	Bright ruby, red	Pellicle very thin and	NoK.
			labour.	month.	tinge with much transparency.	filmy, the crystals very numerous.

1842.]

Kane on Kiesteine.

29

Table (A) continued.

	Names.	B'm	geof ignancy months i days.	Condition of Mammee.	Appearance when received.	Remarks.	Result.
6			l£.ai
C. Scoby,	24	4.20	No milk.	Lighter and not so	Pellicle, although not ve-	K. on 4th
					transparent.	ry well marked^still kies- teinic	modified
20	H. Benal,	24	During	None.	Pale whitish yel-	Surface covered with a	K. on 1st
			labour.		low, translucent.	cloudy pellicle from 36 day hours after deposite; odour cheesy, cheesy. Labouring under much fe- K. on 4th
	U IC	((	7.	(( a	Very turbid, and
					tinged with red.	brile disturbance : pelli- day, cle, though not well mark- ed, is still present: not cheesy.
21	E. Hull,	20	^	No milk.	Straw yellow- transparent.	Mouldy dots on surface; K. on 4th pellicle forming around day
						them. Very damp wea- ther.	cheesy.
	u «	((	7th	u a	Bright straw yel- low, with a few floc- culi.	Pellicle advancing regu- larly from 2nd day.	K. on 4th day cheesy.
22	M. Robinson,	19	9.	No milk.	Purulent or mucoid very turbid yellow.	Gave no acid reaction K on' 3d with the litmus. Pellicle day. very flat.
23	M. Robinson, white vene- real ward.	a	6th	a a	Light straw yellow; transparent.	Gave a well marked de- K. on4lh cided pellicle, preceded day. by crystals, and covered with brown nutmeg dots.
24	C. Clarke,	30	5th	Milk by pressure from one mamma	Bright red; nearly transparent.	Gradual and characteris- K. on 3d tic. day.
25	A. M'Hugh,	26	7.	Milk in breasts since 5th month.	Pale light translu- cent yellow.	Kiest. well marked, but! K. on 2d not in a uniform stratum, day.
26	M. Curio w,	22	8.	Milk since 7th month.	Turbid red.	The pellicle forming with K. on 2d great regularity; moulding day. on 3d day, owing to damp.
27	M. Rider,		6,	No milk at pre-	Turbid red: many	Decomposition after sian-' t^jl ding8days. Extreme an- Ji INo semia. Alkaline reaction. kS (K. Same result. |S-j
				sent.	flocculi.
	u u	a		a u	Not so turbid.
28	A. Clarke,		8.	Milk by pressure	Deep salmon colour —some deposition.	Stood for 3 days without'K.on8th any change: it then exhi-;day.
						biied the crystals and a
						gradual characteristic pel-
						licle, well formed by 8th
						day.
29	M. Ackland,		7.	Milk at present	Straw yellow ting'd	Stood for some time with-	K. on 4th
					with red.	out change. A pellicle on 'day. 4th day. 1
30	E. Johnson,		6.	No milk.	Yellow honied, translucent.	A modified irregular pel- K on 3d licle. modified
31	J. Garrigan,		5.	No milk.	Salmon colour, tur- bid, and with depo-	A singular tenacious scum K. on 3d two lines in thickness and modified
					sitions.	of a deep blue colour.
32	S. Dashur,	30	During	Milk from last	Deep red, translu-	A well developed pelli-	K. on 4th
	women's out		labour.	pregnancy, 18	cent.	cle.	day.
	wards.			months previous.
33	L. Hauwick,	25	6.25	Milk one week	Straw yellow —	Decomposed rapidly— a	K on 2d
				afterquickening.	transparent.	very copious deposite and day. tolerably marked pellicle were observed.
34	M. Stratton,	30	9.	No enlargement and no milk.	Straw yellow, with flaky masses.	No very evident crystals. K. on 5th day.
35	M. A. Bowers,	23	7.14	Milk at and du- ring last month.	Red, with lateri- tious deposite.	No pellicle whatsoever K. on 3d until 3d day. jday.
36	M. B. Mark.	18	7.19	Milk from her 8th month.	Reddish yellow— no deposition.	The cloud like appear- .K. on 4th ance preceded the charac- day. teristic pellicle.
37	E. Wilkinson, or Atkinson,	41	9.	No milk.	Purulent yellow, with copious depo- site.	Litmus gave no acid reac- Excep- tionr fefrocyanuret oiT^o-tion. tassium and heat gave No K. coagulation.
38	M. Stevens,	34	8.20	Milk by pressure	White glaring and pale.	A very thin buthighly cha-l K. on 1st racteristic pellicle, with day cheesy odour. j cheesy.
39	M. Sailers,	29	9.	Milk by pressure	Reddish yellow.	A thick pellicle, not pre- K. on 4th ceded by crystals. day.

30

Kane on Kiesteine,

[July

Table (A) continued*

	Names.	i^	age of egnancy months id days.	Condition of Mammae.	Appearance when received.	Remarks.	Result.
40		^^	cc^as
M. Hero,	15	6.16	Distended and	Reddish yellow,	Presented for the two first	K. on 3d
				exuding milk.	translucent with flocculi.	days the acicular crystal- line specks; on the third day the pellicle, and on the fifth well marked nut- meg like spots.	day.
	(( ((	15	9.	(( ((	More turbid; colour very nearly the same.	Crystals, creamy pellicle, &c. at their greatest deve- lopment on 5th day.	K. on 2d day.
41	A. M'Cully,	22	7.14	Large and exud-	Pale straw colour,	Surface marbled on 2nd	K. on 6th
				ing the mi!k.	rather dim, yet transparent.	day; crystals also evident; pellicle on 3d: by 6th day well marked.	day.
42	S. Palmer,	19	6.	No milk.	Dim, transparent.	A horn like or waxen pel-	K. on 4th
					honied yellow.	licle, crystalline _pom^s day mo- |
						interspersed.	dified.
	u a	((	During	Abundantsupply	Red, highly colour	Urine highly coloured-	NoK.
			labour.	of milk.	ed, with lateritious deposite.	presented a horny pellicle with white striae intersect- ing it. Minute crystals on the 1st
43	B. Devine,	20	5.27	Milk.	Salmon colour.	K.on4ih
						day; surface studded on day.
						2d; cloudy appearance on
						3d; pellicle on 4lh. Uniform scum; crystals K on 3d
44	M. M'Guire,	23	8.	No milk.	Bright straw yel-
					low, clear.	not very evident, day.
	(( K		2 days	Very tense, but Garnet colour, with	Athickconsistentpellicle|K. on 2d
			previous	no exudation of a few flocculi.	formed on 2nd day, slight- day.
				milk.		ly tinged with red, one line in thickness.
45	E. Hastley,	36 4mos.	Distended.	Translucent, red, with some deposi- tion. Clear cider yellow;	A characteristic ^creamy' pellicle.	K. on 4th day.
46	A. Hutchins,	19 4mos.	Mammary ab-	A cloud on the 2nd day.	K. on 3d
				scess, with fistu- some deposite.	preceded by crystals, and day. |
				lous orifices.		followed by a pellicle with brown dots.
47	A. Graves,	25 6mos.	Distended.	Brownish ochre	Does not redden litmus pa-'Excep-
					yellow, with much	per: decomposition com-Hion.
					deposite.	mencedon2ndday: gives No K.
						no pellicle.
48	H. Thompson,	20 6mos.	Tumid, but no Slight muddy yel	Presented no pellicle	1
				milk.	low; quantity 20 oz.	whatever: found on inqui- ry that it was voided in the afternoon.	,K. on f 3d day
	(( ((	a	9.	(( (I	Straw yellow, mud- dy.	Presented a well marked pellicle on the 3d day Little change until 4th	J
49	J. M'Cartney,	39	8.10	Turgid, but ex-	Greenish or citrine	K on 5th
				uding milk.	yellow.	da,y: pellicle perfect on	day.
	(C t(	11		(( «	Clear cider yellow.	Pellicle apparent on 2nd K. on 2d day: at its maximum on day
						7lh: odour cheesy.	cheesy.
50	S. Fisher. .	24	7.20	Milk.	Clear cider yellow, trans.	Milky, opaline or white pellicle on 3d day. iPellicle on 3d day; odour	K on 3d day.
51	A. Lenam,	40	8.20	No milk, but Xight reddish, cider	K. on 3d
				tense.	yellow, flocculent.	cheesy, but very slightly so. Pellicle on 3d day, soon	day.
52	M. Gilbert,	24	6.25	No milk.	Reddish yellow and	K. on 3d
					no deposite.	obscured by decomposi- tion. Well marked on 2nd day	day.
	u <e	((		(( ((	Deep red, with floc-	K on2d
					culi.	with crystals, specks and	day.
	_					fat like appearance.
53	M. M'Mename	20	7.21	Left mamma ex-jLight cider yellow.	Peculiar pellicle arranged	II No 1 fK.
				udes milk: ab-		in striae and in circles—
				scess in right.		not the kiesteine.
	« u	«			Rather dusky.	Same result.	^J
54	C. Smith,	23	7.	Milk.	Bright straw yel- low.	Pellicle regularly formed on 2nd day; cheesy on 5th.	K. on 2d cheesy.
65	M. Moody,	23	8.16	Milk since her	Reddish yellow.	A well marked pellicle	K. on 3d
				3d month.	somewhat brown.	studded with crystals.	day
	(( «			(( ((	Same with flocculi.	Voided a few hours before delivery: decomposed ra- pidly but the pellicle well marked.	K.on2d day. ,

1842.]

Kane on Kiesteine.

31

Table (A) continued.

	Names.	S m	Stage of Pregnancy in months and days.	Condition of Mammee.	Appearance when received.	Remark.	Result,
i		tl
56	M. Schuyler,	29	Day of	Week before de-	Honey yellow, ra-	Decomposition about the	Modi.
			delivery	livery had milk in mammae.	ther turbid.	3d day: pellicle ramiform and not regularly disposed	fiedK.
	(( «			(( u	Same, rather more transparent.	No pellicle until 4th day, and then very feebly de veloped.	K. on 4th day.
57	H. Charles,	30	9.	Milk since 7th	Reddish yellow,	Pellicle formed regularly	K. on 2d
				month.	some deposite.	from 2nd day.	day.
m	M. Parker,	20	8 days	No milk, but	Transparent, gar-	Pellicle in circles incrust-	K. on 3d
			previous	much distended.	net colour.	ing sides of glass.	day mo- dified.
			.0 deliv.
59	M. Milnor,	30	7.28	Milk upon pres-	Clear straw yellow;	Milky, dotted and charac-	K.on4lh
				sure.	no deposite.	teristic pellicle— cheesy.	day.
GO	M. Collins,	20	6.	U ((	Abundant lateri- tious deposite.	Striated, glazed, unsatis- factory pellicle.	K. on 5th modified
61	E. Connor,	20	7.10	Milk in mammae	Palish water yel-	Minute doited pellicle,	K. on 3d
				from 3d month.	low; muddy.	kiesteinic but very thin.	day.
62	A. Petsai,	30	6	No milk.	Deep red, with floc- culi.	Characteristic.	K. on 5th day.
63	A. Mason,		7.	No milk.	Light reddish.	The brownish nutmeg specks.	K. on 3d day.
64	H. Conway,		61	No milk.	Transparent bright ruby red.	Regularly formed; stood 14 days without disinte- grating _ In circles, havmg a corru-	K. on 2d day.
65	E. Hutten,		5.	Milk exuded in	Transparent red, as	K. on 3d
				3d month.	above.	gated aspect.	day.
66	H. Anderson,	18	7.	No milk.	Flocculent red.	Not uniformly disposed.	K on 3d modified
	« ((	u	7|	Milk.	(( u	A well marked pellicle on 3d day.	K. on 3d day.
67	E. Jeansire,	20	6|	Milk a week pre-	Bright straw yel-	Opalescent regularly	K. on 3d
				viously.	low.	formed pellicle. A well defined cloudy de-	day.
68	M. Miller,*	32	3 trials of	Trifling altera-	Flocculent red.	NoK.
			2 weeks,	tions.		posite, but no kiesteinic
			7 weeks,			pellicle.
			& 3 mos
69	Mrs. C. G-m,	35	Full 21	Full and turgid.	Cider yellow; very flocculent Straw yellow.	Gave a well marked K.	K.
70	Miss Baker,	21	10th	No changes in	Accompanied by the	K. on 3d
			week.	conformation.		brownish specks.	day.
71	E. Black,	161	6 weeks.	Enlarged slight-	Bright honey yel-	A well formed kiesteinic	K. on 2d
				ly ; no marked	low.	pellicle on 2nd day. •	day.
				characteristics.
72	M. Alexander,	36	8 mos.	Milk by syringe.	Flocculent.	A well marked pellicle preceded by the crystals and sediment.	K. on 3d day.
73	M. A. Cornell,	22	7 mos.	Milk.	((	Kiesteine with great te- nacity on 4th day.	K. on 4th day.
74	M. M'Canny,	19	6 mos.	Turgid and with milk.	Turbid straw colour	Well marked kiesteine— alkaline with litmus.	K. on 2d day.
75	S. Sharp,	25	5.	No milk.	Very viscid.	But a well marked pel- licle.	K. on 2d day.
76	M. Richardson,	21	8.	No milk.	Obscured dark red.	Bronchitis, urine alkaline and no pellicle	NoK.
	« C(	"	((	Milk.	Lighter colour and	Gave a modified pellicle.	Mod. K.
77	A. Thompson,	30	9.	Milk.	transparent. Ruby red	Well marked pellicle.	K.on3d.
78	S. Spangler,	26	8.	Turgid and exud- ing milk.	Flocculent.	Firm consistent pellicle.	K. on 3d day.
79	S. Carey,	23	5.	Milk.	Honey yellow.	Well marked kiesteine.	K. on 4th
80	M.A.Andrews,	22	7.	Milk.	Turbid.	K. on 3d; no deposition evident to the eye.	K. on 3d day.
81	S. Ford,	28	9.	No milk.	Highly coloured- ruby tinge.	K. on 5th.	K. on 5th day.
82	M. A. O'Neill,	25	7.	Turgid with m'k.	Flocculent.	Well marked pellicle with cheesy odour.	K. on 4th cheesy.
83	J. Scantlen,	22	7.	Milk.	Muddy straw colour	Somewhat striated, yet a characteristic scum.	K. on 1st day.
84	E. Dougherty,	27	a	Milk.	Reddish do.	Consistent pellicle.	K.on2d.
85	M. Thompson,	32	3.	Milk.	Clear straw colour.	Modified by striae.	Mod. K.

* Found after these results were in type not to be pregnant.

32

Kane on Kiesteine.

[July

(B) — Cases during Lactation,

1	Names.	Age.	Time after Delivery.	Condition of Mammae	Remarks.	Result.
S. Miller, 1	20	2 months.	Freely withdrawn.	No pellicle.	NoK.
2 C. Ryter,	17	2 weeks.	u u	li u	No K.
3 B. M'Gurth,	21	6 weeks.	(( u	i( «	No K.
4 A. Weaver,	21	8 hours.	Rather turgid, but ex-	Before establishment of the	No K.
				uding milk.	lacteal secretion on the ap- plication of the child to the breast.
5,R. Dawson,	22	2 weeks.	Freely suckling.	No pellicle whatsoever.	No K.
<( (f	"	3 months.	u u	No change.	No K.
e'c. Scoby,	24 1 week. |	H 11	No change	No K.
7|H. Benel,	24	72 hours.	Milk not yet with- drawn.	Immediately afterbirth gave a red horn like pellicle.	No K.
8 E. Hull,	20	4 days.	Freely suckling.	No change.	NoK.
9 M. Robinson,	19	Iday.	Large, tumid, and but little milk.	One day after birth of a still- born child rather sanguine-	K. on 4th day.
10 C. Clarke,	30	2 months.	Withdrawn freely.	ous. No change by pellicle.	No K.
11	A. M'Hugh,	26	1 month.	It u	(( u u	No K.
12	M. Curlew,	22	3 weeks.	(( u	(( (( u	No K.
13	M. Ryder,		1 month.	(( u	(( (( li	No K.
14	A. Clarke,		1 or 2 months	Mammae large and secretion scanty.	Secretion much disturbed from a gastro-enteritic at- tack. No pellicle resembling K.	No K.
15	M. Aiklyn,		4 months.	Freely withdrawn.	No K.
16	E. Johnson,		6 months.	(( K	" "	No K.
17	J. Garrigan,		3 weeks.	Much inflamed and swollen.	Inflammationof the papillae —gave a well defined pelli- cle on 4th.	K. on 3d day.
18	S. Dashur,		18 months.	No exit to milk.	While weaning on 3d day.	NoK.
19	L. Hawick,		3 months.	Freely emptied.	Milk plentiful and regular- ly withdrawn.	NoK.
20	M. A. Straton,		2 months.	Painful, and no milk visible.	Severe bronchitis; secretion much impeded.	K. on 3d day cheesy.
21	M. Bowers,		4 weeks.	Milk freely withdr'n.	No change.	NoK.
22	M. Mark,		2 months.		Pellicle on 4th day.	K.
23	E. Wilson,		il u	IC « «	No pellicular change.	NoK.
24	M. Stevens,		3 months.	No milk.	Gastritis; no pellicle.	NoK.
25	M. Salters,		4 months.	(( (( a	No pellicle.	NoK.
26	M. Hero,	15	3 days.	Large and distended; no exudation.	4 days after birth gave a red horny pellicle.	NoK.
	(( a	((	(( «	Milk scanty and bad- ly withdrawn.	A febrile attack (gastritic) gave a modified pellicle. Free discharge, &c.	K. modified.
	u a	((	a 11	Freely emptied.	No K.
27	A. M'Cully,	22	3 hours.	Large, and no exuda- tion.	Carefully withdrawn before secretion was well establ'd.	K. on 4th day.
	<( ((	((	3 months.	a ((	" " but no K.	NoK.
28	S. Palmer,	19	4 days.	Large, and badly emptied.	During lochia a horny scum.	NoK.
	u a		3 months.	Freely emptied.	Freely nursing.	Cheesy K.
29	B. Devine,	20	3 weeks.	Turgid, full, and no exudation.	Had not had her breasts well emptied for 48 hours	K. on 4th day.
30	P. Bunting,		4 weeks.	Red, indurated, and no egress to secretion.	Much distension, and com- mencing mammary abscess.	K. on 3d day.
31	M. Biddee,	24	6 hours.	Natural, and exuding milk.	6 hours after delivery yield- ed a true pellicle.	K.
32	S. Gilbert,	20 i4 weeks.	Freely emptied.	No pellicle.	NoK.
33	M. Hull,	32 j3 weeks.	a u	a i<	No K.
34	E.Williams,	25 i Not known.	u «	(( ((	No K
35	M. Shrook,	22	13 m. wean-	Large, full and pain- ful.	Weaning her child 3d day.	K. on 3d day.
36	Mrs.C.C.C.		ing. Weaning.	" « 2d day.	K. on 4th day.
37	C. Saxon,	28	8 hours.	Bieast turgid.	Immediately after birth gave a red horn like pellicle.
	a u		Weaning.	Natural, not very full.	While weaning 3d day.	No K.
38	H. Black,	22	3 months	Milk tolerably well ! Tumefaction and inflamma-	Modified K .
				withdrawn.	ti on of mammae. A partial scum was presented.
39	S. Compes,	19	8 hours.	Turgid.	Interval between com- mencement of free secretion and delivery.	No K.
	" "	((	3 weeks.	Scanty milk.	Acute colitis with its accom- panying fever. Breasts freely discharged.	NoK.
	u «	((	4 months.	Freely withdrawn.	NoK.
40	M. O'Neil,	25	3 months.	u u	11 U li	No K.
41	M. Spillrine,	20	2 months.	(( a	11 11 a	No K.
43.	M M'Closky,	23	i6 months.	ii ((	11 li (1	NoK.

1842.]

Kane on Kiesteine.

33

Table (B) continued.

43	Names.	Age	Time after Delivery.	Condition of Mammae	Remarks.	Result.
E.Wilkinson,	41	Weaning.	Tense and full.	2d day of weaning period.	K. on 3d day.
44	E.Pugh,		2 months.	One mamma tumid, and no exit to milk.	Injured by teeth of child.	K. on 2d day.
45	M. Martha,	22	4 days.	Natural.	Free exit and well secreted; presented no pellicle.	NoK.
46	M. Reilly,	20	48 hours.	Mammae distended.	Withdrawn by catheter 48 hours after delivery.	K. on 2d day.
47	M. M'Carty,	39	3 weeks.	Freely withdrawn.	No change.	No K.
48	S. Duncan,	17	3 months.	U ii	a ii	No K.
49	A. Lippincott,	36	3 weeks.	Breast rather turgid.	Bronchitis with angina; much lacteal secretion, but exit impeded.	K. on 3d day.
50	A. Banks,	37	1 month.	a li a	No pellicular chanee.	No K.
51	H. Walker,	24	8 hours.	Large, protrudiifg and no milk.	Secretion not re-establ ished; voided with care yet no K.	No K.
52	M. Yaseley,	24	48 hours.	(( a a	48 hours after— milk not yet withdrawn.	K. on 3d day.
53	M. Gallagher,	39	3 days.	Milk freely secreted and withd'n by child.	No Kiesteine.	No K.
54	M. Delano,	20	5 days.	a a ■' a	(( ((	No K.
55	E. Buckly,	40	7 days.	a a a	(( a	No K.
56	M. Yorkley,	20	10 days.	a a a	li a	No K.
57	M. M'Guire,	23	48 hours.	Large, tumid and painful.	Tested 36 hours after death of child— gave a well mark- ed pellicle.	K. on 4th day cheesy.
	(( a	<(	1 week.	Same; less distended.	1 week after delivery breast much distended; child still- born.	NoK.
58	E. Hastley,	36	3 weeks.	Entire suspension of the lacteal secretion.	Inflammation of mammary glands and entire suspen- sion of secretion.	K. on 3d day.
59	Mrs. Ann Hatch- ings,	19	4 days.	7 fistulous sinus.	Peritonitis and mammary abscess.	K. on 2d day.
	«( "^ ' »		1 month.	Induration and one or two closed.	Large abscesses with 7' si- nous orifices ; secretion much impeded.	K. on 2d day.
	(( ((	(I	3 months.	Partially restored.	Same condition; secretion restored. Immediately after delivery mammary inflammation &	NoK.
60	A. Graves,	25	24 hours.	Commencing ulcera-	NoK.
				tion and no exit of
				milk.	induration.
	it K	«	Weaning.	a li	While weaning.	No K.
61	H. Thompson,	26	2 weeks.	Freely secreting and well withdrawn.	Gave a well defined kiestei- nic pellicle, rather reddish.	K. on 4th day.
62	J. M'Cartney,	39	4 weeks.	Flaccid and not se- creting.	General anaemia; secretion much retarded.	No K.
63	S. Fisher,	24	1 month.	Freely emptied.	No pellicle.	No K.
64	A. Lenam,	40	Not known.	Distended.	After death of child.	K.
65	M. Gilbert,	24	10 hours.	"	Between establishment of the secretion and birth.	No K.
	(( ii	(C	3 months.	N"atural.	Free exit, &c.	No K.
66	M. M'Mename,	20	4 hours.	Not exuding.	Immediately after birth carefully withdrawn.	K. on 2d day.
67	C. Smith,	23	2 months.	Natural	Gave no pellicle.
68	M. Moody,		2d month.	Tumid, large, and suspended secretion.	Commencing mammary ab- scess; gave a well defined K.	K.
	11 IC		3d month.	Natural.	Free exit.	No K.
69	M. Schuyler,	29'	36 hours.	Natural.	Dropped her child while on the urinal— 36 hours after. Natural, &c. No pellicle.	No K.
70	H. Charles,	30	10 days.	Freely exuding and withdrawn.	No change until 3d day, when a well marked pelli- cle appeared.	K. on 4th day.
71	M. Parker,	20	5 months.	Freely withdrawn.	No change.	No K.
72	M. Milnor,	30	2 months.	a a	" " indicative of ki- esteine.	No K.
73	M. Collins,	20	1 month.	ii a	No kiesteinic change.	No K.
74	E. Connor,	20	10 days.	(( a	Lochia continue; a reddish pellicle' was presented. Presented no change	No K.
	(I (I	((	2 months.	li a	NoK.
75	A Petsan,	30	20 days.	Large, tumid, and not secreting.	Inflammation and tumefac- No K. tion of mammae. 1
76	A. Mason,	22	1 month.	Suspended secretion.	Peritoneal inflammation. !No K.
77	H. Conway,	19	15 days.	Some exudation of Mammary abscess: gave a K. on 3d day. |
				milk. well defined kiesteinic pel- licle. Breasts freely empt'd.j No kiesteinic change.
78	E. Hutton,	20	1 week.	NoK.

34

Kane on Kiesteine,

[July

Table (B) continued.

79	Names.	Age.	Time after Delivery.	Condition of Mammae-	Remarks.	Result.
H. Anderson,	19	5 days.	Breasts tumid, large	Child lived 2 days: a well K. on 5th day.
				and tense.	defined pellicle 5 days afteri birth. 1 During interval of birth and No K.
m	E. Jeansire,	20	10 hours.	Not exuding.
					free exit.
	a (I		1 month.	Well withdrawn.	Fully and freely discharged No K.
R1	J. Mills,	24	4 hours.	Large, yet exud. m'k.	During interval no milk. No K.
			Weaning.	^u u	While v/eaning. ;No K.
R2	H. Minor,	36 hours.	Tense and no milk.	By catheter, during interval. K.
83	C. Baker,	20 10 hours.	Tense, yet exuding.	During interval between ap-'No K.
					plication of child and birth.
84	H Willomeine,	22	Weaning.	Full and turgid.	While weaning gave a mo- dified pellicle.	K. on 3d day modified.
85	C. Van Arsdale,	22 2 years.	Varying. *	Restored by glass: no kies- teine while weaning.	No K. and K.
86	C. Cunningham,	27 : 18 months.	«	While weaning restored by cupping glass.	K. on 1st day.
87	Wilhermeine,	22 After death lof child.	((	Secretion restored: gave no liiestine.	NoK.
	(( ((	IS months.	Full and turgid.	Gave a well marked K.	K. on 3d day.
88	S. Ford,	28 3 days.	Full and turgid.	Puerperal peritonitis.	NoK.
89	J. Scantlin,	22 36 hours.	Flaccid.	ii li	NoK.
90	E. Andrews,	18 4 days after d'th of child.	Large and distended.	Pellicle well marked.	K. on 2d day.
91	S. Sharpe,	25 4 days after delivery.	Large.	No marked pellicle.	NoK.
92	E. Dougherty,	27 10 days.	Flaccid.	Puerperal peritonitis.	NoK.
93	J. Wilson,	25 2 months.	Freely suckling.	No pellicle.	No K.
94	Mrs. Dickenson,	20 3 months.	Freely withdrawn.	No scum nor deposits. No K. ]

Summary of Besults in Table B.

Condition of Patient.	Number Examined.	Result.
Obstructions^ mechanical and otherwise, to the free exit of the secretion, Suspension and obstructions from constitutional disturbances, Interval between birth and the free exit of the milk, During vs^eaning, in various conditions of the lacteal function. Lactation suddenly interrupted by death of child, - During unimpeded and natural lactation, ... Total number during lactation in various conditions,	11 8 13 10 4 48	7 gave the K. 3 gave the K. 6 gave the K. 8 g-ave the K. 3 gave the K. 5 gave the K.
94	32

(C) — Exainples of Cases tested hy the Kiesteinic Indication.

1. Helen Anderson, sstat. 18, woman's venereal ward, was under treatment for commencing secondary symptoms, attended with a recent gonorrhcea. Her habits were extremely irregular, and her intercourse had been for the last eighteen months promiscuous. The menses had during this period been much ir>terrupted, and for the last twelve months were entirely suspended.

Her abdomen attracting attention from its increased size, the urine was submit- ted to examination, and presented a well-marked pellicle; a second trial gave the same result; some time after, she was removed to the obstetrical ward, and here delivered of a premature infant.

2. Mrs. Mary Welsh, aetat. 37, May 25th, 1841, white obstetrical wards, had been for tv^'o years an inmate of the women's out-wards. On the 23d of July she married for the second time, having had by her former husband five healthy chil- dren. Some months after her marriage, her menstrual function was somewhat deranged; but for two months immediately preceding, and for three after, its regu- larity was uninterrupted. Since the 27th of October her catamenia have entirely

1842.] Kane on Kiesteine. 85

ceased, the cessation being- unaccompanied by the ordinary indications of a "change of life." Her sensations resembled those of previous pregnancies; and on the following March, five months after, she distinctly felt the motion of the child.

Wishing, in the course of my observations, to procure some urine from preg- nant females well advanced, I sent for ten specimens of which there could be no doubt, and included this woman on my list. I was surprised to find that her urine presented no kiesteine^ and submitted it in consequence to another trial; and this giving the same result, I noted the case as an exception, and so mentioned it to Dr. Dunglison and to others.

While in her eighth month, however, I made a third examination, which pre- senting also no pellicle, led to a close investigation of her case, and finally to her dismissal from the ward on my own responsibility.

That there were many evidences of pregnancy, and that the absence of the peculiar pellicle had much influence on her discharge, will be seen from the sub- joined examination made in the eighth month.

Mammse. — Large and protruding; much developed; nipple prominent; the disc somewhat tumefied, and the general condition rather firm than flaccid. By pres- sure, a yellowish, milky fluid exuded from the breast, and the papillae were quite mammelated from the enlargement of the follicles. Mdomen.— Tumid, and much protruding, the rugae of previous pregnancies having disappeared by the tension; the navel, although not prominent, was not depressed. On percussion, generally flat, but tympanitic around the umbilical region. Uterus examined per vaginam, rigid, rather patulous about the mouth; vagina very rugose and contracted, dry and badly lubricated. By auscultation and the stethoscope, I made out no foetal pulsa- tion, although opinions were divided as to its existence; a souffle was distinctly heard, but I did not feel myself competent to decide as to its character. By bal- lottement, no result.

After carefully considering the above case, I discharged her, much against her own wishes and those of her fellow patients, to the female working wards, where she remains at the date of this paper without a change of symptoms.

3. Isabella Smith, aetat. 25, entered the white obstetrical wards on the 20th of April, 1841, professing to be in the eighth month, and presenting so many indica- tions of well advanced pregnancy that no deception was suspected. A series of epileptic paroxysms, which prevented the usual more rigid examination, caused her temporary removal to the women's lunatic asylum, where, on the morning after her admission, I procured a specimen of her urine. The absence of a pelli- cle on two trials, made at the instance of Dr. Dunglison, satisfied me that she was an impostor; and on the 28th, during a well simulated paroxysm of epilepsy, her dress gave way, and disclosed an abundant mass of hair padding ingeniously arranged over the abdomen.

4. Black obstetrical wards. This woman came into

the ward in the sixth month, as she supposed, with arrestation of the menses, tumid abdomen, enlarged mammae, &c.

At the time of procuring the first specimen of her urine, I was assured by the nurse and herself that they felt the motion of the child. No indications of the kiesteine were present, however, and a second trial giving the same result, she was dismissed from the ward.

36 Kane on Kiesteine. [Ju^y

5. Mary Patterson, setat. 30, in the women's venereal ward, supposed herself pregnant, and had so many of the signs as to render her case an undecided one. Her urine gave no pellicle, and in the result this test was found correct.

6. I have at this moment before me a letter from Dr. T. Lindsey Walker, of Va., one of my colleagues at the Philadelphia Hospital, to whose intelligent inte- rest I am much indebted, in which he states, that of seven specimens of urine, presented under fictitious names, and at a distance of two miles from the place where they were voided, 1 successfully indicated the only four, which were those of pregnant females.

7. >S'. C , aetat. 22. Her urine was presented to me by a medical friend, re- questing an opinion. The evidences of pregnancy were well marked, and to many conclusive. Repeated trials of her urine in no instance gave the kiesteine, and sub- sequent examination confirmed the accuracy of its evidence: she was not pregnant.

8. Maria Hero, aetat. 15. This young woman, at the very commencement of my experiments, refused to give me her urine; and when at last I succeeded in pro- curing a specimen, it yielded no pellicle. I made a second trial, and this gave the same result. Embarrassed by this apparent contradiction of the other indications in her case, I determined to make a third trial, and obtained a perfectly marked kiesteinic pellicle. I learned on subsequent inquiry, that she had, on the two first occasions, borrowed urine from her neighbour.

This was only one of very many cases of attempted imposture detected in the course of my examinations.

9. Miss , setat. 23. Applied to Dr. N. Benedict, of this city, for a

course of treatment for suppressed menstruation. Her previous character had been undoubted. He had felt an interest in the inquiries which I was conducting, and sent me a specimen of her urine for examination.

It presented on the third day the kiesteinic pellicle so well marked as to leave no doubt in my mind as to the proper diagnosis of her case. Having reported to him accordingly, he declined administering emmenagogues, and in the result she reluctantly confessed herself in the second month of pregnancy. She is now awaiting delivery.

With another case, of the many which I have had the pleasure of determining for the same gentleman, I will now conclude.

10. Mrs. M M , aetat. 32. Since her marriage, which occurred five

years ago, has been the mother of three children, the interval between them being of nearly uniform duration. At the expected period, experiencing well understood symptoms, she supposed herself again pregnant. Her urine, tested in the third, fifth, and seventh weeks, presented no pellicle. Her symptoms were now aug- mented by a host of sensible signs; and finally a fourth trial, made after averred quickening, giving no kiesteine, led me to consider her case as an exception, and to note it as such in my tables.

Since that date, however, I am enabled to add her name to my confirmatory list; a subsequent examination making it perfectly evident that her condition is owing to other causes.

P. S. — April 20, 1842. Since this dissertation was submitted to the Medical Faculty of the University of Pennsylvania, two papers on this sub-

1842.] Kane on Kiesteine. 37

ject have appeared; one by Mr. Letheby, in the London Medical Gazette of Dec. 24, 1841, and an elaborate paper by Dr. Stark, in the Edinburgh Medical and Surgical Journal, for January of the present year.

The facts observed by Mr. Letheby accord generally with my own. He found "unquestionable evidence of kiesteine in forty-eight out of fifty cases between the second and ninth month of utero-gestation," and was unable, like myself, to " account for its absence in the two exceptions." In seven- teen non-pregnant women he found no indication of its presence; but detected it in, the urine of ten suckling women, immediately after delivery, and onwards to periods between the second and sixth months, when it disappeared. The few microscopic results which he gives coincide also with my own.

Dr. Stark's paper is devoted to the signs of pregnancy, and among the rest to the state of the urine. He refers succinctly to his own observations relative to the kiesteinic pellicle, which he supposes to be derived from the suspended sediment; and he asserts that there exists a relative proportion be- tween these and the earthy salts which enter into the composition of the urine. His paper derives its principal interest from his researches into the character of the sediment.

In the natural sediment of the urine of pregnancy, he was unable to detect the presence either of albumen or caseum by acids, alkalis, or al- cohol, with the aid of heat; but when he added a certain quantity of milk to the urine, both these principles were discovered readily by the aid of acids, the other tests producing no effect: when milk was added in smaller quan- tities, however, it was undis cover able by any reagent. Being unable to refer the sediment to any of the known deposites of the urine, though his investigations had immediate reference to its distinctive characters, he em- ployed ether to effect a separation of the animalized matter which he thought it might contain, and he supposes that he succeeded by this means in detecting a substance entirely different from any heretofore known.

Failing to determine its constitution by chemical agents, he resorted to the microscope. He here found that this sedimentitious matter, whether ex- amined while yet held in solution by the recent urine, or when it had assumed the form of a deposit, or when it had been disengaged by ether, was com- posed of distinct transparent or " pellucid" globules, which when in their sedimentary condition bore a striking resemblance to the caseum globule of recent milk, but which when pellucid bore an equally strong resemblance to the serous or albuminous globule.

Dr. Stark now reduced the question to very narrow bounds, by inquiring as to the identity of this sedimentary matter with albumen, caseum, fibrine, and gelatine. He thinks that its minute structure and chemical properties sufficiently distinguish it from the two first; — from albumen, because it dis- solves instead of coagulating upon the application of heat; from caseum, be- cause it is soluble in nitric and sulphuric acids, which exert on this principle a very contrary action. From fibrine, it has necessarily a still greater dif- No. VII.— July, 1842. 4

38 Kane on Kiesteine. [July

ference. There remains gelatine; and compared with this, the distinction was less striking. The globules of both under the microscope, were simi- larly formed: both were soluble in the acids and alkalies, arid by the aid of heat. The only distinctive particular seems to have been the action of tannin, which as is well known precipitates gelatine from its solution in water. Some of the natural sediments, dissolved in boiling water, and cooled to a blood heat, were treated with a decoction of galls: a flocculent precipitate was at once produced; but instead of gelatinizing upon cooling — it ivas deposited; and instead of becoming more solid and more easily separable, upon reboil- ing, it again underwent solution.

Upon these grounds he attains the conclusion, which I give without com- ment, " that tbis substance is a matter sui generis <, an elementary substance or principle, forming in some measure a connecting link between the albu- minous and gelatinous elementary principles." This substance he proposes to designate by the name of *' Gravidine,^^

It is unnecessary to say, that this discovery of a new organic principle, if confirmed by future investigation, will be a matter of great interest. I must confess, however, that the distinctive characteristics of the new substance do not seem to me very decidedly marked in the results announced by Dr. Stark; and such is the complex, and often deceptive nature of the investigations of physiological chemistry, that we have a right to wait for renewed experi- ments before admitting too implicitly the certainty of those he has described.

Dr. Stark considers that his experiments entirely subvert an opinion which has met with some favour regarding the theory of these appearances. Ever since the publication of Nauche's paper, the supposed presence of ca- seum in the urine of pregnancy has countenanced the idea entertained by Bird and others, already referred to, that the elements of the milk (not as Dr. Stark infers, the milk itself,) might probably exist in the urine: — as, however, the matter is neither milk nor caseum, a theory based upon their presence must necessarily fall. The conclusion may be a correct one so far as the chemical analysis is concerned; and yet the connection between the kiesteine pellicle and the mammary secretion may be adequately proved by other evidence. If even the Gravidine be regarded as a new organic prin- ciple, its properties are not so peculiar, nor its analogies with caseum so remote, as necessarily to imply the operation of different causes in the form- ation of the two.

I have already mentioned my conviction, founded on personal observations, that the unmodified caseum is not found in the urine; but the presence of the colostral appearances under the microscope, and the numerous pheno- mena which I have described as attending the presence of the Kiesteine leave me no room to doubt its intimate connection with the condition of lactation.

1842.] G\hson^s Case of Anchylosis of the Knee-joint, 39

Art. II. — Case of complete Anchylosis — in lohich the Knee-joint iv as per- manently flexed — cured by an operation. By Wm. Gibson, M. D., Professor of Surgery in the University of Pennsylvania. Reported by Thomas L. Walker, M. D., of Albemarle, Virginia, one of the resident Physicians of the Philadelphia Hospital. [With two wood cuts!]

The frequency with which Anchylosis succeeds to wounds, and inflam- mation otherwise established in articulations, will, it is hoped, render a report of the continued success of an operation, devised and first executed by Dr. J. Rhea Barton, for the relief of this misfortune, interesting to the public. I would not be understood as having reference to the less serious variety — that in which the rigidity is confined to the soft parts, in which partial mobility of the joint is still maintained, and to accomplish the cure of which, such simple treatment as the gentle use of the limb, combined with the application of suitable embrocations, is in most cases alone indicated. I allude exclusively to that condition, in which the parts, particularly apper- taining to the structure of joints, are disorganized, — in which there is a firm osseous adhesion between the ends of the bones, and in which, since the bones are so consolidated as to form one continuous shaft, there is perfect immobility of the joint, with a loss of all of its functions as such.

It remained for the inventive genius of Dr. Barton, to prove to the pro- fession, the fallacy of the opinion, that this was an irreparable termination, and that it should be regarded rather as a fortunate result, than an evil amenable to surgical skill. In the number of the North American Medi- cal and Surgical Journal, for April, 1827,* he reported his first operation, and the circumstances suggesting the experiment. It was performed on the person of a sailor, whose hip-joint was perfectly anchylosed, and the limb so situated, as to overlap the unaffected one. In this case, there was the twofold indication of correcting the malposition of the limb, and of forming a new joint. Accordingly, the thigh-bone was divided (with a saw) through the great trochanter, and a part of its neck. This being done, the limb was readily straightened, and bony union having been prevented by daily move- ment of the limb, ligamentous attachments were formed, and an artificial joint resulted. After the lapse of sixty days, the patient stood erect upon his feet, with both heels alike touching the floor, and in a short time, possessed per- fect use of the new joint.

The complete success of this operation, encouraged its originator to ex- tend its application; believing it equally adapted to the relief of anchylosis of other joints, as that of the knee, shoulder, elbow, great toe, and fingers. It was not till ten years had passed, however, that an opportunity presented

* See also Philad, Journ. of Med. and Phys. Sci., Vol. XIV, p. 177 and 416.

40

Gibson's Case of Anchylosis of the Knee-joint,

[July

itself for the experiment. An intelligent physician, — who had for many years, from injury upon the knee, endured the inconvenience of anchylosis of that joint, and great deviation of the limb from its proper direction, — ap- plied to Dr. Barton for relief. In this case, an operation was performed for the purpose of straightening the limb. The case was reported in detail in the No. of the American Journal of the Medical Sciences for Feb. 1838, p. 332. It will now only be alluded to, so far as it may be explained, by the details of a recent operation, successfully performed by Professor Gibson. The cases are almost identical, and a description applicable to the one, is equally true of the other.

Last fall, during the attendance of Dr. Gibson as surgeon to the Philadel- phia Hospital, James Johnson, coloured, setat 17, was admitted. He, two years previously, whilst cutting with an axe, inflicted upon his right knee a wound, of which nothing more is known than that he recovered with a loss of the joint, and with the leg flexed backwards toward the thigh. In

this situation he entered the Hos- pital, the leg being so flexed as to form an angle much less than a right angle with the thigh. (See accompanying figure.) He came in determined to submit to an operation, and expressed great anxiety that it should be per- formed. A careful examination satisfied Dr. Gibson, that the parts belonging to the joint were all destroyed: — ligaments, carti- lages, and the synovial mem- branes; and that it was a case of complete anchylosis. As in the patient last operated upon by Dr. Barton, he (Dr. G.) did not think that circumstances justified his attempting the double indication of forming a false joint and extending the limb too. His only aim, therefore, was to correct its malposition. Accordingly, everything seeming to favour the operation, both as to the will and robust health of the patient, and the entire concurrence of other surgeons consulted by Dr. Gibson, it was deter- mined on.

Nov. 17th, 1841.— The patient having been for several days restricted in his diet, was brought forward, prepared for the operation. Before a full attendance of medical students, and many eminent physicians, the proposed operation was explained by Dr. Gibson; after which, he proceeded as fol- lows:— Two incisions were made, as in the operation of Dr. Barton; the first extending from the outer to the inner side of the limb, and passing im-

1842.] Gih&ou^s Case of Anchylosis of the Knee-joint, 41

mediately above the patella; the second commencing on the outer side, two and a half inches above the first, and meeting it at an acute angle on the inner side. These incisions penetrated to the bone, engaging the integu- ments, the tendon of the extensor muscles, and some of their fibres. The soft parts included between the incisions being dissected off and turned back, the bone was exposed to view. A portion of the femur, of a wedge shape, was then removed with the saw, having a base upwards of two inches and a half anteriorly, and reaching to within a few lines of the posterior surface of the bone. The operation was then concluded by inclining the leg back- wards, which caused that portion of the bone's diameter, undivided by the saw, readily to yield, and the solution of continuity to be made complete. This method of accomplishing the separation of the bone, was regarded as an important step in the operation, inasmuch as it guarded the popliteal artery against wounds from the saw; and the dovetailed edges of the opposed sur- faces were influential in fixing the extremities of the bones, until the asperities of these surfaces were removed by absorption, or by the formation of new matter. No blood-vessels were divided requiring the ligature or com- pression. The operation was completed in a few minutes, and the flap being returned to its place, and secured by the interrupted suture, light dressings were applied. The patient, lying upon his back, was put to bed, with the limb supported upon a double inclined plane, having an angle cor- respondent to that of the knee, before the operation. As great care was necessary to provide against pressure upon the popliteal vessels, the limb reposed on two bran bags, which were fastened to the edges of the plane, so fashioned, that its angularity could be varied, without being removed from beneath the leg, as its extension might require. The vacancy between the bags was carefully supplied with cotton. Very slight hemorrhage followed, which, proceeding from the division of one of the articular arteries, stopped spontaneously in a short time; and except for a slight oozing, which con- tinued for two days, there was no sign of hemorrhage afterwards.

In the evening, the patient suflTered very little pain; complaining only of a slight uneasiness in the inguinal region, which was attributed to the position of the limb; was indisposed to sleep, consequently took fifty drops of laudanum.

I8//1. — Passed a comfortable night; was without pain, and felt perfectly easy; oozing from knee very inconsiderable; rigidity of muscles diminished, and leg less contracted.

19^^. — Slept all night without pain. Pulse full, strong, and regular (about 72 in the minute). Leg had, by force of gravitation, extended itself a good deal.

20/^. — Enjoyed undisturbed sleep throughout the night without any laudanum; complains of slight pain opposite the lesion of the bone; no fever; appetite good; bowels opened naturally. The dressings removed for the

42 Gibson's Case of Anchylosis of the Knee-joint, [July

first time, and the leg allowed to extend itself. Measurement proved the height of the angle to be diminished by three-quarters of an inch. Simple dressings applied again.

21 5/. — Continued to do well. No fever or pain; towards evening, slight uneasiness endured, from the stretching of the tendons. Extension of leg increased by full another inch.

23(/. — Limb was approaching the extended condition fast. No fever. In consequence of slight pain experienced, patient was allowed forty drops of laudanum.

24^A. — Bowels were again opened. Passed a restless night, from pain in the foot, caused by the heel's accidentally coming in contact with the splint. Suppuration commenced. Laudanum repeated.

25/A. — Entirely free from pain. Bowels again opened. No fever. The extension of the leg required the splint to be let out. The extension pro- gressed so rapidly, that a pad was applied to the sole of the foot, by which resistance was opposed to the direction of the elongation of the leg.

26/^. — Wound discharged freely. Pulse a little accelerated. Towards evening the knee stripped, and newly dressed. Sutures all free.

Dec. 5th. — Between the 26th of Nov. and the 5th of Dec, nothing transpired worthy of being mentioned. The patient continued uniformly to improve, the limb to extend itself, and his general health such as to require no interference on the part of the surgeon. On the 5th, the straightening of the limb was sufficient to justify the removal of the splint, for which a simple box was substituted. This was carefully lined with carded cotton, no part of the leg or foot being suffered to rest upon the wood. The comparative length of the two limbs was taken, measuring from anterior superior process of the ilium downwards. As far as an accurate measurement was obtained we were induced to give the sound limb an excess of an inch and a half.

lith. — Since the date of the preceding note, the patient's condition was very favourable. No unpleasant symptom appeared. The wound continued to heal. Suppuration was so abundant as to require two dressings daily. Had no pain. Slept naturally. Appetite was good, and digestive functions perfect. In consequence of the too rapid growth of granulations, red pre- cipitate ointment was applied to the wound of integuments, and sponge tent introduced into the upper incision, to favour the escape of pus. Tumefac- tion of the knee commenced. Pulse somewhat excited.

IQth. — Wound improved regularly after the application of the ointment. Tumefaction of knee increased. No pain endured. The secretion of pus was so copious, that an opening was made near the head of the fibula, — which situation being more depending, matter to the amount of eight ounces flowed out. Symptoms of debility now began to manifest themselves. Pulse was quickened, 112. Appetite continued good, and bowels naturally soluble.

1842.]

Mettauer on Hypospadias and Epispadias.

43

23c?. — Progressive improvement. Except the irritation symptomatic of the free suppuration, nothing was observed. The pulse was regularly excited, though the patient always expressed himself, as being perfectly comfortable. Tumefaction of knee diminished.

Jan, 5th, 1842. — From the 23d of Dec. to this time, suppuration con- tinued free. The orifice made with the lancet, enlarged itself by ulceration. Pulse remained quick, but general appearance improved. In consequence of a sinus seeming to run up the thigh, a seton was introduced through the opening opposite the lesion of the bone, and brought out two inches above.

I2th.' — The tape withdrawn. The discharge diminished. The bones were found to be firmly united. Patient was allowed to sit up with the leg supported at a right angle with his body.

26th. — Patient was able to walk with the assistance of crutches. Wound not entirely healed.

Feb. Ibth. — Wound every where closed. Could bear the weight of his body with difficulty. The leg shortened nearly an inch. Walked without the enclosure, assisted by crutches. General health perfect.

May 1st. — For the last two months the patient has walked about continually with- out the use of a crutch or a stick; and lat- terly has been twice to town and back on foot, — having walked three or four miles without the slightest inconvenience. The accompanying figure shows the present appearance of the knee. The knee at this time is only half an inch shorter than the other.

Art. IIL — Practical observations on those Malformations of the Male Urethra and Penis, termed Hypospadias and Epispadias, with an Jino- malous Case. By John P. Mettauer, M. D,, of Prince Edward County, Virginia.

The great importance of malformations of the male genital organs, and the impression that a void exists to some extent relative to their surgical treatment, have induced us to draw up an abstract of our experience in the treatment of these mortifying and disgusting imperfections.

44 Mettauer on Hypospadias and Epispadias. [July

The malformations to which we shall direct attention are those preter- natural openings, or fissures, on the under and upper surfaces of the penis, termed Hypospadias and Epispadias; the former epithet being given when the openings are on the under surface of the penis, and the latter when they are on the superior surface of that organ.

The former is much the more frequent form of these imperfections. These openings occur in the median line, and in almost every point between the meatus and neck of the bladder, though they most frequently occur near the anterior extremity of the penis; and they are liable to every possible variety of form and shape. They are sometimes round and exceedingly small, and transmit the urine with great difficulty. Occasionally they close up and prevent the escape of urine altogether. More frequently, however, they are large and vary in form from an oval to a fissure, or slit. When of an oval form, their margins are generally labiated and more or less thin. When they appear under the form of a fissure, they may extend nearly or quite the whole length of the penis, presenting the opening very much as if the urethra had been artificially slit open. If confined to the glans only, these fissures impart a most singular appearance to the organ, resembling in some degree the head of a fish laid open on its under side. Occasionally, the last named malformation is complicated with a permanent flexure of the penis at its cervix.

In many cases, the urethra is entirely deficient from the preternatural orifice quite to the extremity of the penis. Now and then the organ is greatly shortened, or preternaturally lengthened and thickened, with a cor- responding dilatation of the urethra into a pouch, as complications of the infirmity. And, finally, epispadias occasionally is to be met with as a complication of hypospadias, and then the urine as it passes from the blad- der, flows from both surfaces of the organ at the same time forming two distinct streams. When this complication displays the glans open its whole length, an appearance not very unlike a turtle's head is presented. Oc- casionally, though rarely, the cleft in this complication occupies the whole of the penis, from the extremity of the glans to the arch of the pubes.

Epispadias is of rare occurrence, but when met with presents appearances of the openings very similar to those already described under the head of hypospadias.

In both forms of the malformation, the urethra may terminate without an external opening for the escape of urine; and in early infancy, such a modification of it occasionally occurs, as the cause of those distressing ex- amples of infantile retention of urine, from which such terrible consequences have been known to follow at that tender period of life. Every form and variety of these imperfections, is distinguished by a greater or less deficiency of the prepuce; and sometimes, too, it is either entirely absent, or preter- naturally superabundant.

1 842.] Mettauer on Hypospadias and Epispadias, 45

These malformations are almost always congenital, and must, when this is the case, be referred to arrest of development. Occasionally they have been produced by accidents, and by artificial means. Abscesses along the rapheal line, have resulted in a species of hypospadias, when the openings formed by art, or spontaneously for the evacuation of matter, have remained unhealed. Laceration of the urethra has, likewise, produced something of the same kind, when it has occurred along the rapheal line, and has been followed by sloughing of the parts.

The operation of puncturing the bladder in retention of urine, has also produced a form of this malformation, especially when the urethra instead of the bladder has been penetrated. These examples, however, should be regarded rather as fistulous openings from accidental causes, than instances of hypospadias. The case of the unfortunate shepherd cited by M. Riche- rand in his physiology, is the only one known to us produced by design; and is remarkable for the great extent of the fissure, — which it is stated ex- tended from the extremity of the glans nearly or quite to the arch of the pubes; and, for the complete separation of the corpora cavernosa on both surfaces of the penis, so as to impart to it the appearance of two distinct organs. In this case the corpora cavernosas were gradually separated by the shepherd's own hand, aided at different times by the use of certain instru- ments, to increase the irritation which became necessary to elicit emission; and each corpus cavernosum possessed the erectile power.

Every variety of these malformations exposes their subjects to more or less inconvenience in urinating; and sometimes individuals suffer great pain and anxiety, especially when the orifices are small, or when they become obstructed, or close up, as will occasionally be the case. The parts conti- guous to such openings are liable to excoriate, and to become exceedingly tender and irritable, so as to occasion much distress during urination. But, generally, they become most annoying on account of the mortifying defor- mity they produce, and from the impediments they too frequently oppose to sexual intercourse, and more especially to matrimony. Occasionally, too, the mental depression which always accompanies these imperfections, se- riously impairs the corporeal health; and in some instances it has resulted in epilepsy;* and a wasting melancholy, and even in confirmed mental de- rangement. Sometimes the local irritation connected with these malforma- tions, seriously impairs the constitutional health, by first inducing seminal weakness, or losses; and thereby producing indigestion; irregular bowels; loss of appetite; fever; debility; emaciation; disturbed rest; an endless variety of nervous symptoms; and, extreme susceptibility to colds, or to be morbidly impressed by vicissitudes of atmospheric temperature.

* A case of the kind passed under our care, was of many years standing, and yielded, finally, after the employment of a great variety of remedies, to the crusta genu equina, a most valuable therapeutic agent in such affections.

46 Mettauer on Hypospadias and Epispadias, U^^V

Treatment. — Many, nay we believe all, of these malformations may be corrected, or greatly relieved by proper treatment, although they have in nu- merous instances been regarded as irremediable. Hypospadias of the more simple form, or when the opening is situated only a short distance from the extremity of the glans, and the urethra between those points is either defi- cient, or if present too contracted to allow urine to pass, requires an exceed- ingly simple and easy treatment. Introducing a small trocar about the size of the natural passage from the opening, along the tract usually pursued by the urethra, quite through the extremity of the glans, will eflectually open the passage. Care should be taken, however, during the operation, that the instrument shall not cut through the thin rapheal wall, especially in the glans; and to prevent such an accident, the cutting edges of the trocar should be directed to the sides of the penis, and along the angle between the cor- pora cavernosa. Firmly supporting the penis by grasping it with the left hand, and flexing it at the same time at the 'opening, so as to enable the operator to enter the trocar accurately from the termination of the urethra, little difficulty will be experienced in giving a proper direction to, and in passing the instrument out through the extremity of the glans. As soon as the passage is opened, a gum elastic tube of proper size and length should be introduced quite through it, and at least eight or ten lines beyond it into the urethra. The tube should fill the newly formed passage completely, and must be cut off at its entering extremity, and rounded off so as to enter "without wounding the parts: it must also be headed at its outward extremity with sealing wax. By filling the passage completely its introduction will arrest the hemorrhage at once; and there will be less danger of the displace- ment of a tube fitting the passage tighUy. Where fairly introduced, the tube may be securely confined, by connecting its head to a kind of hood which firmly embraces the penis, with threads, or very narrow tapes. Thus ad- justed it serves to give passage to the urine during urination, and to maintain the newly formed urethra well dilated, and of proper size, until it inflames and suppurates sufficiently to prevent urinal infiltration into the surrounding tex- tures. Generally the tube should remain in the passage two or three days, or until free suppuration is established. After this it may be dispensed with, and a short bougie of proper size introduced in its stead, for half an hour at a time, three or four times daily, until the passage ceases to matter; it should then be introduced once or twice daily for several months, or, until the pas- sage is firmly established. Occasionally, a catheter carried freely into the bladder may be employed instead of the short tube, for the purpose of dilat- ing the newly formed passage; and when there is reason to believe that the corpora cavernosa, or the corpus spongiosum are wounded, it should inva- riably be preferred; it answers admirably for restraining hemorrhage, and preventing accidental infiltrations of urine into the surrounding textures. When the catheter is employed, it should be secured in the passage as

1842.] Mettauer on Hypospadias and Epispadias. 47

already advised with respect to the short tube; and must be guarded with a stopper, to prevent involuntary discharges of urine from the bladder.

If the parts inflame much, as will sometimes be the case, they should be freely bathed with cold water; cold elm-tea; cool saturnine lotions; or, warm fomentations may be used, if found more agreeable. Occasionally, cataplasms will be required to allay the irritation; and they should invariably consist of bland mucilaginous or farinaceous substances. The bowels should be opened freely from time to time. Rest will be highly beneficial, not only in ena- bling the surgeon to maintain the proper adjustment of the dilating means, but, also, in guarding against, and in correcting the traumatic inflammation. Patients, generally, should be confined in bed, and undressed, for at least five or six days after the operation, and even longer, if there is much in- flammation and an antiphlogistic diet directed.

The fistulous openings may be touched with nitras argenti and the slough scraped off" with a knife, before the passage is restored, or afterwards.* We have adopted both methods, but think it best to employ the former, as the surgeon is then enabled to accomplish an immediate cure. The denudation must be efl;*ectually performed, and may be done by scraping ofl" the dark eschar with a small scalpel. The surfaces thus denuded readily unite as a fresh cut; or by granulations which amalgamating efl'ectually close the ori- fice. Sometimes it will be necessary to apply the caustic repeatedly before the cure is effected. And occasionally it will be required to approximate the margins of the opening, either with adhesive plasters, or a bandage, to ena- ble us to effect its obliteration. These openings should never be denuded by excising their margins, as too great a loss of substance would then be the consequence. In all the examples of this form of hypospadias, the plan of treatment which we have briefly described, will be found to answer per- fectly. The same principles of treatment should guide us in cases in which the opening is low down on the penis, or in the perineum; in these last how- ever a longer trocar will be required to form the passage, as well as longer tubes or bougies to maintain it dilated. The catheters for this purpose should be long enough to enter the bladder; and they must fill the passage tightly for the double purpose of rendering it free, and to put an immediate stop to the traumatic bleeding which is sometimes very profuse. After free suppuration is established — which will be the case in three or four days, and sometimes earlier — the tube may be removed. It should never be left out oi the passage, however, long at a time for several days; and must inva-

* This mode of denudation is peculiar to us, and has been almost daily in use in our practice for twelve years. It will be found very convenient in deep and inaccessible locations where cutting^ instruments cannot be effectually employed: and is as effectual as the mode by excision, if not more so. Union may be effected through it either by the first or second intention.

48 Mettauer on Hypospadias and Epispadias. [J"ly

riably be replaced before urination, to prevent the painful scalding which would certainly follow, as well as to guard against the possibihty of infil- tration of urine.

The directions already given in relation to the mode of retaining the tube securely in the bladder and passage, and for guarding against involuntary discharges of urine with a stopper, must govern in the cases now under ex- amination. After a week from the operation, patients may be allowed to urinate without the use of the tube; and for the purposes of dilating the pas- sage after this period, either tubes or bougies may be employed: these in- struments must be used once or twice daily, for months after the operation.

The closure of the orifices in these examples of hypospadias will require a plan somewhat different from that already considered. Being generally of large size, and situated in a part of the organ abounding in loose textures, their margins may be readily and rapidly denuded by excision; and this mode we have uniformly adopted, unless there should be a deficiency of substance. The margins may be pared off with a keen delicate knife; and this operation should be effectually done. As soon as accomplished, the denuded surfaces must be accurately brought together and confined in close contact, either with adhesive plasters or the uniting bandage; or, by the introduction of one or more points of the interrupted suture; and these steps should always immediately succeed the introduction of the tube after the formation of the new passage, for the reasons already urged. In some cases, however, the nitras argenti may be depended on exclusively, or be employed as an auxiliary where the surfaces denuded by incision fail to close up the openings completely. The actual cautery we have never used in these malformations, nor are we inclined to recommend so terrific a mea- sure, especially when children are the subjects to be treated. When the malformation is distinguished by an open cleft or fissure, from the termina- tion of the urethra, quite to the extremity of the glans, or nearly so, modi- fications by no means uncommon, the margins must be carefully denuded with a knife; or, by touching them with nitras argenti, and then carefully scraping off the eschars until they are perfectly denuded. The passage corresponding with the tract of the urethra must then be filled with a tube or catheter of proper size, and the denuded margins be brought together so as to embrace it, and at the same time to be in exact and close contact throughout their whole extent. In this condition they are to be retained, and securely fixed with court-plaster applied in successive narrow strips around the organ the whole extent of the fissure. Thus adjusted, the whole must be confined by a narrow soft bandage applied so as to act upon every part of the organ requiring support, and some distance below, the more effectually to prevent displacement. In the application of the bandage no more force should be employed than is sufficient to support the under dress- ing, and to maintain the apposition of the denuded margins perfect. If ap-

!842.] Mettauer on Hypospadias and Epispadias. 49

plied very tightly, great distress and excoriation, or even sloughing may follow.

The tube must now be carefully connected with the bandage by threads or narrow tapes, and guarded with a stopper. In most of these cases, too, the tube should extend quite into the bladder; as by that arrangement it would be less liable to accidental displacement, and more effectually at the same time prevent the escape of urine along the urethra. It must be kept in until free suppuration is established, which will generally be in from three to four days. Generally, the tube should not be removed sooner than the fourth day; and if no inconvenience attend, it may be allowed to remain in until the fifth or even the seventh day after the operation. When removed the tube should be drawn out very gently and gradually, so as not to disturb the lips of the recently united parts.

After the tube is withdrawn, the meatus may be gently washed with tepid or cold water, should the parts require it. The tube may be replaced after a few moments, and kept in for one day more. If union of the lips takes place early, the bandage may be removed for the first time on the third or fourth day; but generally it will be most safe to suffer it to continue on until after the removal of the tube the first time. The plasters, if they adhere, should not be disturbed during the whole treatment. If they loosen, new ones must be put on. The plasters and bandages must be continued until firm union takes place, and reapplied daily if necessary. As soon as there is good reason to believe that pretty firm union has taken place, the tube may be dispensed with in some measure; but it should be introduced once or twice daily, as long as matter escapes from the meatus, for a few mo- ments at a time, to prevent any narrowing of the passage.

This form of hypospadias fortunately does not often present the fissure of very great extent; and being confined almost exclusively to the glans, cer- vix, and a small part of the penis beyond it, comparatively little diflficulty will be experienced in its treatment in a large majority of cases; and the plan which has been premised will generally be found to meet every indication. When it involves the penis behind the glans to any considerable extent, the interrupted suture should be employed to close the fissure after its margins have been well denuded by excision of their epithelium. The points of the suture must invariably be inserted fully three lines from the margins, if not more, and in sufficient number, and near enough together to approximate them, and to close the fissure perfecdy. Over the sutures narrow strips of court-plaster should be placed in succession, and nearly to encircle the penis; the whole to be supported by a narrow, soft bandage. In this form of the imperfection, a long tube or catheter should always be employed as the means of maintaining the passage; and should be introduced quite into the bladder before the sutures are applied; over which, as it is placed along the passage, the margins of the fissure can be readily brought in contact, and - coaptated. The after treatment must be governed by the directions already No. VII.— July, 1842. 5

50 Mettauer on Hypospadias and Epispadias, [July

given. It may be remarked, however, that the adhesive plasters should be allowed to remain on as long as they adhere; and when to be removed, they must be carefully moistened with a soft wet sponge saturated with warm water, applied to them for a few moments, and then taken off with delicate forceps, loosening the extremities first so as to peel them alternately from each extremity to the line of union. This material, it may be remarked here, is the very best for all delicate operations requiring adhesive plasters; and our commendation of it is based upon ample experience during the last twenty-five years in numerous and satisfactory trials.

The treatment of epispadias should be directed by the preceptis which have been presented in regard to the several modifications of hypospadias. Generally, it will be much easier to manage the former than the latter mal- formations, even if they consist of a mere opening or fissure, by reason of the greater width of their margins, which afl?brds more surface for a ready and firm union of them. Complete cures can generally be effected in these malformations in two or three weeks.

When the malformation is compounded of both hypospadias and epispa- dias, as in the case of the shepherd already referred to, and that adverted to by Mr. Liston, it will be necessary to denude the opposing surfaces their whole extent, either, by paring off" their epithelium with a scalpel; or, by first cau- terizing them with nitras argenti, and then scraping oft' the dark eschar. A tube of proper size may now be interposed between them extending fairly into the bladder, and placed along the fissure, so as to form a passage in the angle between the two corpora cavernosas on their under surfaces where they are approximated. The two columns are now to be placed in exact contact throughout their v^'hole extent. Thus arranged, they must be confined with a sufficient number of points of the interrupted suture introduced first, along the dorsal fissure, and then aloug the under surface of the organ, to maintain a perfect juxtaposition of the denuded surfaces: here the sutures should not include much, if any of the elastic ligament, but extend only a sufficient depth into the skin, to enable them to confine the parts firmly. Over the sutures narrow strips of court-plaster should be applied in succession, and long enough to encircle the organ completely; and the whole to be supported by a soft narrow bandage. Great care will be required in the coaptation of the parts, so as to enable them to unite perfectly, and to give to the penis a natural form, especially about the glans. It will also be necessary to be particular, in placing the tube properly along the tract in which the urethra is to be formed. Simply compressing the sides of the organ with the fingers until the tube presents fairly on the under surface of the penis, will enable the surgeon to give it the proper position; and this should be done after the bandage is applied.

The tube employed in this operation must be headed with sealing wax, and should never project more than five or six lines beyond the extremity of the glans. It should also be guarded with a stopper, and securely fixed in

1842.] Mettauer on Hypospadias and epispadias. 51

the passage by making it perforate the cul de sac of a hood which firmly em- braces the anterior portion of the penis. Thus adjusted, the dressings must remain four or five entire days. If the traumatic inflammation becomes vio- lent, cold water should be freely applied, either by using compresses or soft sponges saturated with cold or iced water to the dressings. Generally, this expedient will not be required, as the inflammation is not disposed to become excessive. The urine should, during the whole treatment, be drawn off after short intervals, to prevent as far as possible the danger of violent expulsive efTorts of the bladder forcing any portion of that fluid around the tube, and into the line of expected union of the corpora cavernosa. In all other respects the after treatment is to be conducted pretty much as advised in the preceding modifications already described; and the cure will be ac- complished in two or three weeks.

Should these malformations be complicated with an unsightly and incon- venierit curvature at the cervix, or any other portion of the penis, the con- tracted part must be divided by subcutaneous incisions in succession, until the organ is liberated. The contracted structures can be easily distinguished, and readily divided. They are generally situated in the subcutaneous cel- lular texture, which from some cause has lost its soft and yielding qualities, and, as in cases of burns, refuses to elongate with the development of the contiguous textures, and in that way may produce the curvatures in question. Occasionally, however, the deformity depends on a preternatural shortening of the elastic Ligament. In either case the deformity may be readily cor- rected by division of the contracted textures, taking care, however, to em- ploy an exceedingly delicate instrument in the operation. After the con- traction is removed the organ may be kept perfectly straight, either by using a short tube introduced, as already suggested, below the division, until the parts heal; or, by employing at the same time delicate splints on the four surfaces of the penis, confined by a bandage as already advised. When the eontraetion is slight the tube properly confined with a soft bandage will efl^ee- tually relieve the deformity. In bad cases, it will always be most advisable to employ the tube and splints conjointly. In a few days the parts heal |9€rfectly.

Malformations, when complicated with extensive dilatations and elonga- tions of the urethra and penis, and the organ in those parts incapable of an -erectile movement, present most unsighdy as well as unfortunate deformi- ties. Such modifications, unless corrected, completely preclude all sexual ^itercour^e, as the organ by reason of its permanent flaccidity and nonerectile condition must be utterly incapable of penetrating into the vagina, even should that passage be free from all obstruction at its orifice. An exceed- ingly interesting case of this kind having recently passed under our care and been managed successfully we shall give a detailed account of its history, and treatment, as likely to fyrnish the best commeijtary upon such forms of hypospadias.

52 Mettauer on Hypospadias and Epispadias, U^^f

Mr. , aetat about 19 years, of moderate statUre, good general health,

though suffering much from depression of mind, and exceedingly gloomy from the pain- ful consciousness of his mortifying deformity^ was placed under our care early last autumn^ This penis (see fig. 1) was greatly elongated, measuring fully eight inches from the scrotum to the extremity of the glans in the nonerect- ed state. The anterior three-fifths (e, d, c) une- qually dilated in its lateral dimensions, with a ^1 \^ remarkable expansion of the corresponding portion of the urethra, and perfectly flaccid, and nonerectile: the transverse diameter of this portion of the organ when largest was fifteen ^^ iines^^, from which part it tapered to the

glans, as well as to the pubic portion. The urethra of this part of the organ was capable of containing fully tv/o ounces of fluid; and the cavity was bounded anteriorly by the concave glans; posteriorly by the rough granular surface of the pubic two-fifths, or stump of the organ; and laterally by walls formed of the urethra greatly dilated, the elastic ligament and integuments* The pubic portion which we have denominated the stump {e,f, g) constituted about two-fifths of the penis, was well formed, capable of erectile move- ment, and terminated abruptly, so as to form the pubic extremity of the cavity already described, with the orifice of the urethra projecting from its surface so as to form a kind of os tincae looking into that cavity. Low down in the perinseum, about ten lines anterior to the verge of the anus, and in the rapheal line, there existed an extremely elliptical orifice about four Ihies in extent, and bounded on its margins by a kind of labiated reduplication of the integuments, resembling in some degree the labia pudendi of females, through which the greater part of the urine escaped. The urethra about eight lines in extent anterior to this orifice was nearly impervious, and transmitted only a few drops of urine during urination. On the central part of the expanded portion of the urethra, which we have termed the pouch, and in the rapheal line, an opening existed at the time we examined into the case, which had been formed artificially, but had become completely fistulous, of an oval form, and four lines in length, through which a few drops of uiine would occasionally appear. From the meatus, a mueo-purulent discharge frequently escaped, especially when the urine was forced to take that direction by par- tially closing the perinseal opening with the end of the finger.

With the deformity Ave have attempted to describe, strong sexual desires were associated. The testes were perfectly formed and of large size. Our examination induced to an encouraging opinion as to the practicability of correcting the deformity; so far, at least, as to place the organ in a condition favourable for sexual intercourse; and such unexpected good tidings to the

1842.] Mettauer on Hypospadias and Epispadias. 53

young' man, borne down by melancholy and unhappy afflictions, caused a lively expression of joy and happiness; and he at once formed the philoso- phic determination to submit to any operation we might think proper to undertake for his relief. In a few days the following plan was adopted; and, as the sequel will show, it resulted in the perfect correction of the mal- formation.

The patient being placed in a strong light resting upon a bed of conve- nient height, and on his back, our first aim was to transplant the glans upon the erectile stump. To accomplish this, we laid open the pouch its whole extent by making an incision along the rapheal pj„ 2.

line. We next removed a bell from the interior of the cavity seven lines in width entirely around the base of the glans, and quite to that organ, so as to leave that part of the wall of the pouch to consist ^^^, only of common integuments and cellular mem- brane. A like belt was removed from the inferior portion of the pouch, quite down to the circum- ference of the face of the erectile stump. We then carefully denuded the face of the stump in every part of it. After the blood had been effectually spunged away from the new surfaces, the glans was placed with great care upon the face of the stump, taking care that the denuded margin at its base should correspond accurately with the circumference of the opposing denuded surface of the stump. A short bougie was then passed into the meatus, and carried along the urethra of the stump, nearly to the contracted portion of it, with the design of enabling us to retain the glans more easily and perfectly in its proper position. Thus arranged the glans was firmly connected to the erec- tile stump by eight points of the glover's suture, applied in succession through the glans and stump at the fraenum; then on the middle of the dor- sum and at the base of the glans through these portions of the integuments immediately contiguous to the glans and stump; next on each side through the opposing tegumentary duplications of those parts; and in succession until the whole series was completed. Care was taken, however, in the introduction of the sutures through the tegumentary laminae, that ample space between them was allowed for the free passage of blood to the glans. When the sutures were tightened tliey fixed the glans most perfectly and securely on the erectile stump, and imparted to the organ thus modified, an improved appearance highly gratifying.

The glans thus transferred to and situated upon the erectile stump, neces- sarily shortened the penis, and required that the tegumentary intermedium which had been left, should be inflected upon itself so as to form a loop-like body on the dorsal and lateral portions of the organ immediately behind the base of the glans. (Fig. 2, b, a, c— /, d, e, the orifice opening into the cavity of the intermedium.) This loop-like body was unavoidable, inasmuch as the

5*

54 Mettauer on Bypospaclias and Epispadias. [July

glans could not possibly have been supplied with a sufficiency of blood for its nutrition and support, had the intermedittm been cut away at once. It was large and exceedingly inconvenient as it now existed, and would have interfered with the dressing whieh we designed using at this stage of the operation. To remedy these inconveniences in son>e degree, we removed about one half of the band of which it was formed, talking care not to dis- turb the sutures during the operation; and as the section was effected with scissors little pain was produced by its excision. We found it necessary tO' take up several arteiies, and one of large size after this little operation, so profuse and annoying was the flow of blood from them. After carefully spunging away the blood we covered the margins of the loop-like body with dry lint, then put on a few very narrow strips of adhesive plaster, and over them a narrow, soft bandage, applied in such a manner by circular, oblique, and reverse turns, as to embrace and support the parts with tolerable firm- ness. We next fixed the bougie in the urethra by eonne"cting threads be- tween its extremity and the bandage.

In this condition the parts were permitted to remain until the third day after the operation. To moderate the inflammation cokl water was applied freely after the parts began to swell, and continued until free suppuration was established in all the incisions. Little inflammation followed the ope- ration, and by the third day free suppuration was established throughout alt of the ununited cut and denuded parts. The constitutional fever, too, was very slight.

On the third day the dressing was removed, and the parts about the con- nection of the glans and stump appeared to have united perfectly. After carefully washing the wounds they were redressed as in the first instance, only the bougie was omitted. In this manner the dressings were renewed daily until the eighth day, when three of the sutures were cut away from the under part of the penis. After this a very light dressing was employed;, and the remaining sutures wei-e removed daily until all were taken away. The union, as soon as it was deemed safe to examine the parts carefully,, which was on the twelfth day after the operation, was found perfect and firm. The margins of the intermedium did not heal over until the twentieth day; and fully three months ela{)sed from the date of this operation, before all inflammatory tenderness of the parts involved, subsided.

During this long period, the unsightly fold of integuments left for the sup- port of the glans, occasioned not a little annoyance to the patient, as its bulk and peculiar form continually admonished him that the organ was yet imperfect, and reminded him, too, that another operation yet awaited him before the cure could be effected, which he now greatly dreaded. Three months from the date of the first operation a second was performed for the removal of the fold of integuments, already so often referred to. This was accomplished by first rapidly excising the parts with a strong pair of scis- sors nearly down to the depth of their union > and then cautiously dissecting

1842.] Meiiaue![ on Hypospadias and Epispadias. 55

away the remaining portions, taking care to leave no more integuments than sufficient to render the organ comely. The latter step of this operation was executed with less ease than might have been imagined, as it required great care, and was accomplished amidst torrents of blood pouring from four or five pretty large arteries, two of which required the ligature. As soon as the superfluous textures were dissected away the margins of the skin were carefully approximated, and confined by eight interrupted sutures. Over these, adhesive plasters applied around the penis were next used, and the whole supported by a narrow, soft bandage, put on just firmly enough to impart the necessary support to the under dressing. On the fourth day the wound was examined and redressed; and in two weeks the sutures were cut away, and the parts found to be firmly united and well. After this the only dressing used to the cicatrix (Fig. 3, a, b) was a strip of soft old linen spread with simple cerate, long enough to encircle the organ, and confined by a light bandage merely to prevent the abrasion of its delicate cuticle.

The penis now presented a very natural appearance, and was fully two inches in length during the non-erected state, measuring from the scrotum* The glans, too, which had lost its sensibility from the moment the intermediate skin between it and the stump was divided, had in some slight degree at this period recovered its feeling, and it manifested a decided erectile blush, and some expansion from friction; or, from compression of the root of the organ: during venereal excitation, these changes were also to be perceived in it. In the erected state, the penis measured nearly four inches and a half in length, and presented in all respects a most natural appearance; and,, doubtless, will be found perfectly useful, after the contracted portion of the urethra shall have been restored to its proper condition, and the perinaeal opening closed.

It was judged advisable to defer the operations for restoring the urethra to its pervious and proper condition, as well as for closing the preternatural opening in the perina^um permanently, until the parts previously operated upon should entirely recover from all inflammatory tenderness, and become firm and healthy. In accordance with this view several months elapsed after the removal of the tegumentary intermedium, before we attempted the operations designed to open the contracted portion of the urethra, and to close the opening of the perinaeum permanently. The case at length being favourable for the execution of this operation, first exposing the part to a strong light, we commenced by placing a probe curved near its extremity,. in the perinaeal opening, with the point firmly pressed in the direction of the glans into the cul de sac at the termination of the inferior urethra, which was then passed into the hands of an assistant to be held steadily. The penis was next elevated so as to form nearly a light angle with the abdominal

56 Mettauer on Hypospadias and Epispadias. [July

wall, and firmly held with the left hand embracing it low down, with the middle finger placed along, and supporting the rapheal line corresponding with the passage to be opened. In this situation a h)ng trocar was intro- duced at the meatus, and carried quite down through the anterior, or supe- rior urethra to its cul de sac, with the concavity to the symphisis, and the lancet retracted within the canula, held and directed with the right hand. The blunt extremity of the canula w as now pressed firmly into the bottom of the cul de sac; and after giving it the proper direction, the lancet was pro- jected from its concealment about five lines and immediately retracted within the canula. The canula was now pressed onward so as to fill the part incised quite to the bottom, and in this situation the lancet was again pro- jected as already described. In this manner the operation was repeated until the extremity of the canula entered the inferior portion of the urethra announced by the displacement of the probe from its cul de sac. The trocar was then withdrawn, the lancet having been previously retracted within its canula, and the entire passage from the meatus to the bladder immediately filled with a gum elastic tube of proper size. Care was taken not to carry the tube more than the depth of its proximal aperture into the bladder, so that the urine might be completely decanted from its cavity.

We next touched every part of the opening of the perinseum, from its ex- ternal margins quite down to the tube, with a delicate stick of nitras argenti, so as to cauterize effectually; and after the eschars were carefully scraped off with a small, delicate scalpel so as to expose a new denuded surface, the opening was closed with two points of the interrupted suture, inserted from within outwardly down to the tube, and fully eight lines from the margins. Thus inserted, the threads when tightened and tied, closed the opening com- pletely. A compress was now placed upon the sutures supported by a T bandage applied with moderate firmness. Finally, the tube was guarded with a stopper, and confined as already advised, to prevent its displacement from the urethra. We directed that the bladder should be evacuated every second or third hour, to guard as far as possible against the passage of urine around the tube; an accident which might occur in the event of a large accu- mulation of water in the bladder taking place.

In this situation the case was suffered to remain five days, durino- which time we found it necessary to administer two mild cathartics, and to confine the patient in bed, and to a very abstemious diet. At this period the tube was carefully removed, and the parts found to be in a most favourable condi- tion for a speedy and perfect cure. The urethra suppurated freely, but not too much so; and the margins of the perinaeal opening seemed firmly united. The sutures were not cut away, as they seemed yet firm. A fresh tube was introduced without the wire, guarded and secured as the first, and was kept in the passage three days more. After this the tube was only introduced during urination, to prevent, if possible, any stress from the flow of water along the urethra upon the newly closed permseal opening. On the twelfth

1842.] M'Naughton on Diseases of the Brain and Spinal Marrow. 57

day the sutures were cut away and the margins of the opening found to be firmly and perfectly united.

We advised tlie patient to introduce a tube or bougie .through the newly formed passage, at least once a day for a year, and after that period to em- ploy it occasionally to prevent its contraction.

The urethra was now free from all tenderness, and transmitted the urine from the bladder in a bold and full stream.

Thus modified, there is litde doubt but the penis will prove useful for all purposes; and compensate the young man for the pain and suffering he endured from the different operations performed for his relief.

Prince Edward C. H., Va., April 21, 1842.

Art. IV. — Cases of Disease of the Brain and Spinal Marroiv. By James M'Naughton, M. D., Professor of Theory and Practice of Medicine in the Albany Medical College.

No diseases have of late years engaged the attention of the medical pro- fession more than those of the brain and spinal marrow. Much yet remains to be done before the obscurity in which these diseases are involved is removed. The following cases are deemed of sufficient interest to deserve to be put on record, as examples of some of the most formidable of their class.

Case I. Mr. F. F. was a professional gentleman of high character and respectability, who had enjoyed good health until the autumn of 1837. During the cholera in 1832 he was a good deal indisposed, whether from the epidemic influence, or merely from the anxiety which most people felt during that gloomy period, it would be difficult to determine. He then got into the habit of taking medicine to ward off an attack of the disease; but, unfortunately, he continued to tamper with medicines after the cessation of the epidemic, to the injury of his digestive organs.

About the beginning of October, 1837, while engaged in some perplexing business, which required his occasional absence from town, he returned home, labouring under what appeared to be a common cold, namely, chilli- ness, headache, some oppression of breathing, cough, white tongue, and derangement of the digestive organs. In the course of a few days, he be- came so much worse that I was called in. I found his pulse under 50 in a minute, skin cool, tongue much loaded with a whitish, slimy mucus; coun-

58 M'Naughton on Diseases of the Brain and Spinal Marroiu. [July

tenance loaded and heavy; the right eye suffused and cloudy. He also com- plained of headache, and was slightly delirious. Regarding the case as one of congestive fever, I attempted to draw blood from the arm; but the circu- lation was so languid that very little was discharged. The patient lay in a drowsy, torpid state, but when roused could give rational answers to ques- tions. Sinapisms to the extremities and abdomen, friction over the integu- ments, and an epispastic to the neck, were directed, with a view of causing a freer determination of blood to the surface, and of relieving the internal organs from oppression. These answering the purpose but imperfectly, it was thought that an emetic, by unloading the stomach, and by its influence on the abdominal and other secretions, would answer a good purpose. A full dose of ipecacuanha, in combination with five grains of sulphate of zinc, was directed to be administered, if reaction was not soon re-established.

In less than an hour I was sent for in great haste. I was informed that my patient was vomiting blood very profusely. Upon reaching the house, I ascertained that half a chamber-potful of black looking stuff had been thrown off the stomach. By candlelight I could not well determine the true character of what was brought up; but it did not seem to be blood, but a vitiated biliary secretion. Such proved to be the case when I ex- amined it by daylight. The emetic had not been exhibited, consequently the vomitmg was spontaneous. The stupor and oppression were relieved by the vomiting, which was, therefore, for a while promoted by drinking warm water. Afterwards the bowels were opened by a purgative enema; and when the stomach became sufficiently settled to retain medicine, a full dose of calomel was given, and followed in a few hours by a suflacient dose of cas- tor oil, to procure several free evacuations. These for several days conti- nued to have the same general character with the discharges from the sto- mach, dark and pitchy. In the course of a week, however, the evacuations, by the use of gentle purgatives, acquired a natural appearance, the tongue became clean, and the patient gradually recovered his health, without any occurrence worthy of record. During the early part of the attack, there was a retention of urine, so that the catheter had to be used for more than a week, to prevent injurious accumulation in the bladder.

During the winter of 1837-38, he enjoyed a tolerably good share of health, and attended to his professional duties. In March 1838, business required his going to New York. The weather, as often happens in that inclement month, was cold and wet, and he suffered from exposure, both on the voyage down the river, and during his stay in the city. He returned to Albany, complaining of headache, pains about the chest and shoulders, cough, and general indisposition. On the 1st of April he had a second attack of vomiting of black matter, like that of the preceding year, attended by symptoms so exactly similar, that it would be useless to repeat them. The same general plan of treatment was pursued as on the former occasion, ^^(J with sirflil3r result?, ej^cept th^t his recovery was much slower, The

1842.] M'Naughton on Diseases of the Brain and Spinal Marrow. 59

stupor, low delirium, slow, languid pulse, attended with dark discharges from the bowels and retention of urine, continued for more than a week. All the symptoms, however, gradually yielded, and I anticipated as happy a termination as on the first attack. In about three weeks the patient was able to sit up and get dressed; his tongue became tolerably clean; his appe- tite orood; his mind clear and cheerful. There seemed no reason to doubt of his entire recovery.

His strength, however, did not return so fast as might be expected from his good appetite, and the quantity of food he took with apparent relish. His pulse continued slower and softer than natural, and the temperature of his skin remained low. His walk was peculiarly unsteady and tottering, but he made little complaint of uneasiness in the head, and not much even of dizziness. When his arms were in a dependent position, the hands felt cold and clammy, and the blood seemed stagnant in the capillaries, giving the skin a dark purplish hue, leaving a white streak when the finger was drawn along the skin, not unlike that produced in the blue stage of the Asi- atic cholera. In this general condition he remained for two or three weeks, rather losing than gaining in muscular strength. One day when I called to see him, I found him sitting in an arm chair, his forearm and hands hanging over the arms of the chair. I asked him to raise his hand that I might examine his pulse; when I ascertained, to my surprise, that he had not the power to do so. On my former visits, he was either in bed, or had his arms supported, so that I did not, from his general appearance and symp- toms, suspect that there was any tendency to palsy, although his wife had repeatedly told me that her husband was every day becoming weaker instead of stronger. I did not give heed to this warning, believing it to be nothing more than the impatience not unfrequently observed among the friends of the sick. The warning, however, was well-timed; for, upon closer inquiry, I found out that my patient had in point of fact lost, to a considerable degree, the power of voluntary motion of both the upper and lower extremi- ties, attended with some perversion of sensation, but no actual pain. Ex- cepting that the patient was more irascible than usual, there was no marked disturbance of the mental faculties, no headache, and no pain or tenderness on pressure along the spine.

I therefore considered the palsy the effect of the long continued conges- tion of blood in the vessels of the brain and spinal marrow, connected, per- haps, with more or less serous effusion within the cranium. I expected that it would gradually yield under proper treatment, as the injured organs recovered their wonted condition.

As the history of the case indicated at least severe functional disturb- ance of the liver and associated organs, a mild mercurial course seemed to be indicated. The patient was accordingly put upon a course of blue pills, laxatives, vegetable tonics, and nutritive diet, for the improvement of the general health, while cupping on the nape of the neck and along the spine,

60 M'Naughtoii on Diseases of the Brain and Spinal Marrow, [July

followed by blisters, issues, &c., were had recourse to for the purpose of acting more immediately on the nervous centres. Under this treatment he gradually improved, so as to be able to walk about the room, with the aid of a cane, or the arm of an assistant. While in this condition, some officious friend put into his hand a pamphlet, showing the almost miraculous effects of electricity in cases like his. Nothing would satisfy his friends but a trial of that potent agent. It was tried, contrary to my advice, for about a week, when, seeing that it was doing harm, I remonstrated against its further employment, and it was discontinued.

After this, it was thought best to take him into the country during the hot weather of July and August. After spending a few weeks in the coun- try, he returned to town, rather injured than benefited by the excursion. He had suffered several times from imprudent exposure to currents of damp air during his absence.

In October he made a journey to Boston, and returned by way of New York. This excursion, like the visit to the country, proved of no benefit to him. My duties at the College of Physicians and Surgeons of the Western District, required my absence from Albany, from the 1st Nov. 1838 to the 20th of January, during which time my patient had several ill turns of a comatose character, bordering on apoplexy. On my return, I resumed charge of the case, directed attention to the state of the digestive organs, had recourse to cuppings and blisters along the spine, an issue in the nape of the neck, and stimulating frictions to the limbs and trunk of the body.

Under this treatment he again improved, began to acquire the use of his limbs, could walk the room with a little assistance, and in good weather was able to ride out. We again began to hope for a favourable result; but this encouraging state of things did not last long. About the beginning of May, 1839, he began to complain of what he regarded as rheumatic pains in the joints. The pains were at first confined to the neck, elbows, knees and groins. The pains came on in paroxysms, attended with spasmodic contractions of the limbs. At first the contractions ceased with the parox- ysm of pain, but by degrees the contractions became permanent — subject, however, to occasional aggravation. Any attempt to extend the limbs forci- bly, caused immediate spasmodic contraction with excruciating pain. Both the upper and lower extremities became permanently contracted; but the lower to a greater degree than the upper, and attended with more pain. He could use his fingers, to a certain extent, during the whole course of the disease, but had little power over the larger joints. The knees were drawn up towards the abdomen, and the legs bent upon the thighs, so that the heel rested firmly upon the soft parts covering the tuber ischii. Any attempt to extend the limb caused pain, and was immediately followed by a forcible retraction of it to its former position.

The surface of the body during the early stages of the contractions of

1842.] M^Naughton on Diseases of the Brain and Spinal Marrow. 61

the limbs was morbidly sensitive to the touch; so much so that the mere approach of a person to the patient frequently caused him to cry out from fear of being hurt. He appeared to suffer excruciating agony whenever it became necessary to move him.

The case remained for several months very much in this state, in spite of every effort made for his i-elief, with very little amendment, except a gradual diminution of pain. I need not enumerate all the means employed. They were those generally used in cases of Myelitis, with the addition occasionally of other means to obviate derangements occurring in the func- tions of other organs in so protracted a disease.

After the regular faculty had in a measure given up all hope of a cure, a German empiric tried, for several months, the effects of warm baths, and various external and internal applications, but without any permanent ad- vantage.

The patient became gradually emaciated; cough and bronchitis came on, attended with fever of the hectic type. Towards the close of December, 1840, the fever became more severe, mild delirium set in, and on the even- ing of the 28th of January, 1841, the aifficted sufferer breathed his last in the 41st year of his age.

In the whole course of a long and extensive practice, I have not seen a case in all respects so lamentable, or so well calculated to excite the sym- pathy of every feeling heart. The patient, a gentleman of fine talents, in the prime of life, in the highest position in society, and surrounded by every thing that could make life desirable, was cut off for several weary years from all his enjoyments, and at last for several months, stretched as it were on the rack, a helpless, hopeless sufferer. If death be ever welcome, it must truly be in such a case. During the greater part of this severe and protracted illness, the digestive organs performed their functions tolerably well, and the mental operations, with occasional exceptions of no long duration, were not seriously impaired. During the last year of the patient's life he had complete amaurosis of the right eye. The condition of this eye before the state of amaurosis came on, corresponded with the several exa- cerbations of the disease, being uniformly inflamed and turbid whenever there existed any considerable febrile disturbance of the system, and subsid- ing with the febrile symptoms.

Having requested permission to have the body examined, leave was granted.

Post mortem appearances of the brain and spinal canal.

At 11 o'clock A. M., Jan. 21st, 1842, proceeded to examine the body in the presence of Professors Hun and Armsby of the Albany Medical College, my brother Dr. I. M'Naughton, and several medical students and friends of the deceased.

The roof of the cranium was removed in the usual manner by the saw.

Dura mater. The dura mater was more firmly adherent to the cranium No. VII.— July, 1842. 6

62 M'Naughton on Diseases of the Brain and Spinal Marrow. [July

than is usual in adults. The os frontis was thickened, particularly on its inner table, from a little above the superciliary ridge to the coronal suture. Numerous spiculae of bone on the inner table, some of which penetrated between the fibres of the dura mater. On the left side of the mesial line a portion of dura mater of the size of a finger-nail absorbed, corresponding to the situation of a bony prominence on the inner table of the skull. No other morbid appearance on dura mater.

Arachnoid. Arachnoid opaque over the hemispheres, presenting nume- rous pale granulations for some distance on each side of longitudinal sinus. Copious effusion of serum between arachnoid and pia mater, filling the fur- rows between the convolutions. Pia mater. No unusual vascularity, or turgescence of capillaries. No morbid appearance of note.

Hemispheres. General appearance healthy; consistency firm; convolu- tions uncommonly deep. In the fore part of the right hemisphere above the anterior eornu of the lateral ventricle was observed what seemed to be the vestige of a small cavity. No morbid appearances seen in the interior of other parts of the brain or cerebellum.

Under surface of the brain and cerebellum. Pia mater and arachnoid of the same appearance as on the upper surface, excepting that there were no granular bodies on the arachnoid. The same kind of clear serum between the membranes and in the intervals between the convolutions.

Optic nerve of the right side from the eye to the optic commissure smaller, rounder and firmer than that of the left; no perceptible difference in the optic tracts behind the commissure. The optic thalamus of the left side on its outer and back part softer than that of the right. Tuber annulare firmer than usual; corpora pyramidalia and olivaria very prominent and firm; me- dulla oblongata very firm.

Spinal marrow. From the foramen magnum to the first or second dorsal vertebra all the membranes of the spinal marrow firmly united, and much thickened; dura mater united to the posterior common ligament of the spine throughout the cervical region. The marrow in the same region very soft; on its back part semifluid. From the second dorsal vertebra to the lower end of the spinal canal the sheath of the spinal marrow was distended with a very clear serum. The lower end of the spinal marrow firmer than usual, and together with the cauda equina of a beautiful roseate hue, but without distinct vessels. No appearance of flakes of coagulable lymph on the mem- branes of the brain or marrow, or in the serum — nothing that indicated recent acute inflammation.

From the permission granted we did not feel at liberty to examine the thoracic and abdominal viscera.

The contraction of the lower extremities was so excessive that we were obliged to divide the hamstrings to get the body into the coffin.

Case II. Mr. B., a medical student, some time in the month of November

1842.] M'Naughton on Diseases of the Brain and Spinal Marroio. 63

last, when returning from the college to his lodgings, fell in the street and hurt himself. He complained particularly of the "jar" his head had re- ceived; but I could not learn from himself that his head had actually struck the ground, although his companions were of the opinion, from what he had told them at the time, that it had. From that time he complained of not feeling right about the head; was observed to be rather dull and low-spirited at times, so that he was teased about being homesick. He continued, how- ever, to attend lectures with tolerable regularity until the middle of Febru- ary. At that time he went to the neighbouring city of Schenectady to attend a funeral. The weather was cold and disagreeable, and he thought that he caught cold while standing in the street before the procession began to move. On the morning of the 17lh of February he returned to Albany, complaining of not feeling well. At 12 o'clock A. M, of the 18th, he was seized with a severe chill, like the cold stage of an intermittent, which was followed by a paroxysm of high fever and much headache. His room com- panion, a medical student, gave him an emetic, and followed it in the morn- ing by a cathartic. By these means the fever was relieved, so that he acknowledged himself much better next day. On the morning of the 19th, at the same hour with the preceding attack, he had a second chill followed by fever. His room mate inferred from the recurrence of the chill at the same hour that the disease was a quotidian intermittent, and therefore thought the case one in which bleeding in the cold stage would be proper. He accordingly bled him during the chill, but did not take much blood away. On the 20th he had another slight chill, but it did not come on until 7 o'clock in the morning. At this time the young man's friend became uneasy about him, and I was requested to visit him. I called in the fore- noon. When I saw him his pulse was full but not hard, and not over 90 in a minute; tongue white; skin warm and moist; countenance full and flushed; but the flush variable. The breathing was rather slow, and the speech rather more slow and deliberate than usual with him; the voice hoarse, with a tendency to cough. He complained of headache, but it was not severe. He could not sit up in bed on account of a sense of weakness or faintness which he experienced when he made the attempt. He did not appear to suffer much from the admission of light into his room, nor from the ordinary noises in the street, but the conjunctiva of the eyes was some- what red. The young man had a fair complexion, and a skin of feminine delicacy and softness.

Each paroxysm of fever was distinctly marked by the three stages of an ordinary intermittent — cold, hot, and sweating. At the time of my visit there was no delirium, and I could not learn that there had been any worth speaking of. The symptom.s did not seem to indicate the necessity of any very active treatment. I merely directed that the bowels should be kept open, and that antimonials should be given while the skin continued hot and

64 M'Naughton on Diseases of the Brain and Spinal Marrow, [July

dry, and gave suitable instructions in relation to diet, and the general naa- nagement of the case.

From this time to the 27th he continued to improve; had no return of chills; his hoarseness and cough left him; his tongue became clean and his appetite returned. "When I saw him on the 27tli he was sitting up, looking pale and v/eak, but was eating his dinner apparently with a good appetite. He made no more complaint of his head than is usual with persons reco- vering from an acute disease. I considered him convalescent, 'and hoped that in a short time he would be able to return home to his friends in the country.

I heard no more of him until the afternoon of the 2d of March, when I was sent for in great haste. I was so situated at the time that I could not visit him, but directed that if there was any thing urgent in the case another physician should be called in. Dr. Peter Van Beuren, living within a few doors from him, was called in. I was not able to see the patient until the morning of the .3d of March. The family in which he boarded informed me that he had been apparently getting better from the time I last visited him; that he came down stairs from the third story where his room was into the second, and spent some time there. On the 2d of March he came down into the first or lower story, in which the family lived, and took din- ner with them. After dinner he complained of headache, and about four P. M., had a violent epileptic fit, during which he bit his tongue severely. Dr. Van Beuren bled him freely, applied cold to the head, and used other suita- ble means to guard against undue determination of blood to the head. The fits returned three or four times in the course of the evening and night; When I saw him next day his face was flushed, and the expression of his countenance changed; his pulse full and strong, but not frequent. His speech was slow, and his mental operations evidently sluggish. The fits did not return after the first night.

The attending physician treated the case with judgment and energy; by further bleedings, both general and topical, by cold applications to the head, blisters to the neck and forehead, purgatives, &;c., but with no advantage to the patient. He continued gradually to sink — the breathing becoming more slow, the mind more torpid, and the pulse irregular until he died, without a struggle, at five o'clock on the morning of the 10th of March.

Post mortem examination. — Twelve hours after death, having with some difficulty obtained permission to examine the body, before its removal into the country, where the family of the deceased resided, I proceeded to the examination, assisted by my colleague. Professor Hun, Dr. Van Beuren, and several medical students. Dr. Hun made minutes of the dissection at the time. The upper part of the cranium was removed in the usual way. The membranes of the brain were then examined over the hemispheres, and the brain and cerebellum then removed from their situation, having first divided the medulla oblongata as low down as possible.

1842.] M'Nanghton on Diseases of the Brain and Spinal Marrow. 65

Dura mater slightly injected.

Arachnoid smooth, shining, and remarkably dry in its whole extent.

Pia mater, no unusual turgescence or vascularity. No serum between the membranes.

Left hemisphere. — Two abscesses three-fourths of an inch in diameter, about an inch below the surface, at the upper and fore part of the hemi- sphere, above the lateral ventricle, near the mesial line. Each abscess was surrounded by an indurated cyst, with softening of the medullary substance around, particularly above the abscesses. Another abscess larger than the above-mentioned, situated below the lateral ventricle in the middle lobe, extending to its surface, with absorption or disorganization of the pia mater and arachnoid membranes, of half an inch in diameter. The dura mater at the corresponding point was sound. There was extensive softening of the brain all around this abscess.

Right hemisphere. — An abscess similar to those on the left side and nearly opposite to them, but situated on a level with the corpus callosum, and involving Solly's commissure. This abscess had a process extending towards the lateral ventricle, but did not penetrate into it. Both the cortical and medullary substances were greatly softened to a considerable distance around this abscess. The corpus callosum, too, in the vicinity of the ab- scess, was uncommonly soft. Another abscess beneath the hippocampi extending into the middle lobe. Two abscesses at the base of the posterior lobe, with general softening of the entire lobe.

The lateral ventricles were firmer and more contracted than usual, and had hardly any serum in them. The choroid plexus and velum interpositmn exhibited no unusual turgescence, or evidence of previous excitement. The brain in general softer than natural both in its white and its grey matter. Corpora striata, optic thalami, pons varolii, crura cerebri et cerebelli, and cerebellum itself apparently sound. The pus in the abscesses was well formed, had a slightly greenish tint, and exhaled an offensive odour. Each of the abscesses was surrounded by an indurated cyst, and the brain around the cysts was so soft that the cysts could be removed entire by the forceps. There was none of the vascularity or capillary turgescence, which usually indicate recent acute inflammation around the abscesses.

In this case the pain in the head had never been very severe, and there was not much delirium at any stage. Even in the last there was little more than torpor of the mental faculties. At my last visit, the night before he died, he answered all my questions distinctly and rationally.

The article has already extended further than will, perhaps, be agreeable to readers of the Journal. I therefore forbear to make any further remarks on the above cases, at least for the present. I have endeavoured to give a faithful account of the cases, and leave it to others to decide how far the morbid appearances corresponded in kind and degree with the symptoms of the disease as given in the foregoing histories^

66

Mutter's Cases of Deformity from Burns,

[July

Art. V. — Cases of Deformity from Burns^ relieved by Operation. By Tiios. D. Mutter, M« D., Professor of Surgery in Jefferson Medical College, Philad., &c.

In the month of January, 1841, I was requested to attend Miss A, T. of Chesterfield township, New Jersey, who h'c twenty -three years had endured much mental as well as physical inconvenience from the effects of a burn ■which occurred when she was five years old, and involved the face, throat, and upper part of the thorax in front. The following extract from her his- tory of the case, will explain the nature of the accident, as well as 'the treat- ment to which she had been subjected before I saw her: — " I received a burn when five years old by my clothes taking fire. My grandmother being a great doetress nursed me, until prevented by indisposition; and as they wished me