Full text of "Contributions to midwifery"

See other formats

Google

This is a digital copy of a book that was preserved for generations on library shelves before it was carefully scanned by Google as part of a project

to make the world's books discoverable online.

It has survived long enough for the copyright to expire and the book to enter the public domain. A public domain book is one that was never subject

to copyright or whose legal copyright term has expired. Whether a book is in the public domain may vary country to country. Public domain books

are our gateways to the past, representing a wealth of history, culture and knowledge that's often difficult to discover.

Marks, notations and other maiginalia present in the original volume will appear in this file - a reminder of this book's long journey from the

publisher to a library and finally to you.

Usage guidelines

Google is proud to partner with libraries to digitize public domain materials and make them widely accessible. Public domain books belong to the
public and we are merely their custodians. Nevertheless, this work is expensive, so in order to keep providing tliis resource, we liave taken steps to
prevent abuse by commercial parties, including placing technical restrictions on automated querying.
We also ask that you:

+ Make non-commercial use of the files We designed Google Book Search for use by individuals, and we request that you use these files for
personal, non-commercial purposes.

+ Refrain fivm automated querying Do not send automated queries of any sort to Google's system: If you are conducting research on machine
translation, optical character recognition or other areas where access to a large amount of text is helpful, please contact us. We encourage the
use of public domain materials for these purposes and may be able to help.

+ Maintain attributionTht GoogXt "watermark" you see on each file is essential for in forming people about this project and helping them find
additional materials through Google Book Search. Please do not remove it.

+ Keep it legal Whatever your use, remember that you are responsible for ensuring that what you are doing is legal. Do not assume that just
because we believe a book is in the public domain for users in the United States, that the work is also in the public domain for users in other
countries. Whether a book is still in copyright varies from country to country, and we can't offer guidance on whether any specific use of
any specific book is allowed. Please do not assume that a book's appearance in Google Book Search means it can be used in any manner
anywhere in the world. Copyright infringement liabili^ can be quite severe.

About Google Book Search

Google's mission is to organize the world's information and to make it universally accessible and useful. Google Book Search helps readers
discover the world's books while helping authors and publishers reach new audiences. You can search through the full text of this book on the web

at |http: //books .google .com/I

REMOTE STORAGE

Please return at ttie circulation desk.
To renew your material call-
(650) 723-6691 ext. 3

Date due in Lane Library;

CONTRIBUTIONS TO MIDWIFERY,

AXD

ismts d Wimm mii CIjHton,

wrru A

REPORT OX THE PKOGRESS OF OBSTETRICS,

• % » •

• • • •

m # • * • "

» •

• * • • *

. • "

AND

UTERINE AND INFANTILE PATHOLOGY IN 1858.

N j; >,

v::v

E. N0EGGEIIATH, M.D., AND A. JACOBI, M.D. X.^y/.^<S,

NEW YORK:
BAILLlfiRE BROTHERS, 440 BROADWAY;

IjONPON :— H. BAnJJKRE, 219 RET.ENT STREErT ;

PARIS :— I. B. BAnUKRE, ET FIIS 19 RUE HAnEFEnilJ: ;

MADRID:— C. BAILLY BAILLIERE, 11 CALLE DEL rRINCIPE;

LEIPZIG :— a IffSTESQiASS k GO.
18|9.

'I 1*

/.' .' I -

*. Qitctfd, ^^conlfM t« AcU>r Cc&greY» |p )liejea{ 1859,

V • .: ••••JL 1

Id tbe Clerk's Office of the District Court of tho United {states, for the Soathem District of

New York.

THOMAS HOULVN', PRINTER,

OOCCFR OF CENTRE AXD WHITE STREETS, N. T.

PKEFACE.

Diseases of women and children have, in the last century, re-
ceived gi-eat attention from physicians, both on this Continent and
in Europe, and so much has been written of late upon this branch
of our science, that an author or student of the present day is at
a loss how to make himself acquainted with all tliat exists on
the subject. This difficulty is increased by the absence of a jour-
nal giving a knowledge of previous works on uterine and in-
fantile pathology. AlUiough we are in possession of very valu-
able retrospects on medicine in general, it must be admitted tliat
their tendency and size are such as to exclude anything like com-
pleteness. While in the books referred to, general pathology of
so-called internal and surgical diseases is treated of at sufficient
lengtli, the chapters on obstetrics, uterine and infantile pathology
are dealt with in a rather off-hand manner. The necessity of a
book, intended to supply this want, will be readily understood by
every one who feels a desire to make himself acquainted with the
progress of science, but more particularly to those of our brethren
who feel called upon to write articles of their own. In preparing
this book, we were more and more impressed with the truth of
this remark. A perusal of our periodicals reveals a frightful
state of ignorance as to what has come before, and thus a vast
amount of labor is wasted by tlie publication of so-called new
facts and theories, which might be more usefully employed, if tlic

IV PREFACE.

books, already there, were more generally known. This was,
hitherto, a very dilDScult task, because we were in want of a book
which should contain the essence of all that is dispersed in hun-
dreds of publications, written in a great variety of languages. In
preparing a work of this kind, we have endeavored, at least, to
give an account of every original article, or monograph, that appeared
to be of any importance; while we have tried also, to men-
tion, at ICtOst, the headings of those of less value, or beyond our reach.
From 1858, we intend to keep up a review of every successive
year, especially with regard to German literature, provided that
it should meet with the approval of tlie profession.

The report is preceded by a number of original articles, which
will, we tliink, repay a perusal.

E. NOEGGERATH, M.D.,

A. Jacobi, M.D.

■

50 Amity Street, N. Y.

PA.RT I.

CONTEIBUTIONS TO MIDWIFEKY,

IXD

Dtsca0C0 of iHomcu anh Cl)il5rm.

CONTENTS.

^^i^m^^f^0^0^^^^^^

Fli«e.
Art. 1.— Three Cases of Induction of Premature Labor, performed in New

York, after Cohen's Method. With Remarks. By £. Noeggerahi,

M.D 9

Art. 2.— Four Cases of Injection of a Caustic Solution into the Cavity of the
Womb, illustrative of the Advantages and Dangers connected with
this Proceeding. By the Same 24

^VTwT. 3.~RemarkB on the Employment of PoFsarics ; with the Description of a

New Instrument By the Same 36

.\jiT. 4.— A Contribution to the Pathogenesis of Uterine Polypi By the Same. 48

.Vrt. 5.— Invagination of the Colon Dcscendens in an Infant ; with Repeated

Hemorrhages in the Colon Transvorsum. By A. Jacobi, M.D. ... 61

Art. C— On the Oxysulphuret of Antimony as an Expectorant in Inflammatory

Diseases of the Infantile Respiratory Organs. By the Same 59

Art. 7.— On the Etiological and Prognostic Importance of the Premature
Closure of the Fontanels and Sutures of the Infantile Cranium. By
the Same 70

ARTICLE I.

T%ree Cases of Induction of Premature Labor performed in J^Tew
York after Cohen^s Method. With Remarks by E. Noeggerath,
M.D.

When I published my first case of induction of premature labor
performed in this city, I said : " The time will come, and is rapidly
drawing near, in this country, that the average number of labors
ending naturally, without operative assistance, will lessen, in a
r^narkable degree. The immense immigration of a far from
wealthy and well-shaped people on the one hand, and the strong
tendency to high city life on the other, must show their influence
upon the coming generations/' Two years have elapsed since the
above was written, and in this short period I have had ample
occasion to see the truth of my former remarks exemplified. I
have to add an account of two other cases in which Dr. Cohen's
method was successfully employed — a method, the full value of
which I desire to demonstrate to the profession. I hope to see
the day that it will supplant the douche, rupture of the membranes
and ergot in America, England, and France, as it is doing in
Germany.

* Cbsho 1. — Mrs. G. M., born in Germany, living now in New
York, presents, in her external appearance, the form of a healthy,
well-shaped female, though she is of a rather short stature, and
exhibits, on a closer examination, the well-known form of knock-
kneed rhachitic lower extremities.

In her first confinement, which took place about fourteen months
igo, she was attended by Dr. G. C. E. Weber. This eminent
practitioner was compelled, to perform the operation of cranio^
omy, in consequence of the malformation of the pelvis. He
advised her then to be delivered artificially, before the full
term, in case of a second pregnancy, not only for her own safety,
but becaose it would afford a chance of her having a living child.
The latter circumstance being of considerable importance, induced
the lady to follow the advice of her physician. Conception again
took place at the end of October, or the beginning of November,

* New York Journal of Medtemtt for July, 1856.

1855, for, at that period, her courses, always regular, ceased. She
expected, therefore, to be confined during the first week of August,

1856, with which statement we could thoroughly agree upon a
first examination made towards the end of May. The superior
margin of the fundus uteri was then found between the umbilicus
and the processus xiphoides, the womb being equally developed
on both sides. The foetal pulsations we could easily observe on
the right side, at a level with the umbilicus, while the feet were
distinctly felt near the left upper portion of the uterus. Corre-
sponding results were obtained by a vaginal exploration. The
pregnacy was decided to have advanced to the end of the eighth
lunar month, with a large-sized living child, having a cranial pre-
sentation.

The pelvis was a model of rhachitic deformity. The promontory
of the sacrum protruding forward and towards the left side of the
pelvic cavity, diminished the antero-posterior diameter to 2J-2|
inches, while the lateral diameter remained unchanged in extent ;
the outlet of the small pelvis was rather enlarged in consequence
of the widely open pubic arch and the flattening of the sacral
curvature. The whole basin presented but a very small degree of
inclination. The general state of health of the patient was satis
factory. On Monday, 2nd June, about 11 o'clock in the morning.
Dr. G. C. E. Weber and myself proceeded to perform the opera-
tion of inducing labor after the method of Schweighauser, Cohen.
The woman was placed upon her back with the nates projecting
somewhat over the edge of the bed, and the feet supported by
two chairs ; an elastic catheter, of the ordinary size, was intro-
duced into the mouth of the uterus, and pushed upwards, with the
intention of bringing the instrument between the anterior wall of
the uterus, and the fcBtal membranes ; — the point of it entered the
womb to the extent of about four inches — then, with a syringe
adjusted to it, we injected about seven ounces of water, heated to
90^ or 100® Fahrenheit. As soon as the fluid touched the internal
surface of the uterus, the woman complained of uneasy feeling in
the abdomen, and we distinctly felt the uterus in a state of rigidi-
ty, which lasted for several minutes. After a time, the finger was
removed from the external opening of the catheter, when a portion
of the water was rejected through the instrument with considera-
ble force. The withdrawal of the tube was followed by another
escape of some water. During the following thirty minutes, the

Qternfl was in an almost continual state of contraction with bat
Tery few and short iiitermiasions of Baccidity. Besides a slight
desree of excitement and little headache, the woman's state of
health, as well as her pulse, proved to bo unchanged. Towards
noon the pains grew stronger, but less in frequency, with longer
intervals.

At about seven o'clock in the night, the pain lessened in a de-
gree that we thought it proper to make another injection. This
was applied in the same way with the exception that we did not
oliange the ordinany position of the patient in her bed, because
the lips of the os uteri were already ao much retracted by the pre-
Tiofi8 pains, that the introduction of the catheter would meet with
BO difficulty at all. Whether the water was injected with a some-
what greater force than at the first time we cannot decide, but it
( all remained in tlio uterus, and the operation was followed by
a sadden enlargement of the womb. Mrs, M., experienced a very
^ distreasing pain in her abdomen ; much more so than she did at
the former injections. It made such an impression upon her sys-
tem that she fell into an almost unconscious state; the pulse sunk
I suddenly, bo as to be scarcely perceptible ; her face instantly
I became purple, and her breathing very much embarrassed. Half
[ an hour later, when she recovered from these symptoms, she was
seized with a violent chill, which lasted for nearly two hours. This
was followed by a feverish condition, general heat, and a pulse of
130 in a minute. This alarming state gradually subsided, and a
renewed succession of strong uterine contractions comraCQced. At
' seven o'clock. A. M., of the following day, we were told that she
endured almost incessant and very severe labor pains during the
last night. At this time wo found that the vaginal cervix had
disappeared completely, tlie os uteri was opened to the size of a
siiier dollar, the well-lilled bag protruded into the vagina with
I every recurring pain. Now we could ascertain, beyond question,
I a vertex presentation. At nine o'clock, A. M., the os uteri dilated
to its full extent, and the membranous cyst broke while it was
protruded almost to tlie external orifice. At that time, the vertex
was just engaged in the entrance of the pelvis. Passing over the
I Tory interesting peculiarities of this cranial partui-ition, it will be
I sufficient to say, that it required a full hour of time to bring the
I bead down through the brim of the small pelvis, notwithstanding
' Uiot-e tremendous paius, which are only witnessed with rhachitio

females. But when the greatest circumference of the cranium had
passed the upper part of the pelvis, then one of these violent pains
was sufficient to drive the head through the whole cavity, and at
once out of the labia externa up to the shoulders. The entire
paturition, from the time of the first injection, was achieved in less
than twenty-four hours.

The child, though born in a weak cofidition, was soon brought
to the most satisfactory state of breathing and crying. After the
placenta was removed^ by the ordinary manipulations, the uterus
proved to be well contracted. The mother's condition was satis-
factory, and has continued favorable.

Oase 2. — ^Mrs. L , of Sixth Avenue, New York, bom of

a German mother, who, although of a very small stature, lived to
the age of sixty in average good health, and died rather suddenly
from a disease of the chest. The only sister of our patient went
through several easy confinements. Mrs. L., had the first men-
strual flux when eighteen years old, and this continued regular up
to the time of her marriage, which occurred in January, 1855.
She soon became endente^ and was taken in labor in February, 1856.
Dr. Michaelis, who attended her on that occasion, recognized a
contraction of the pelvis and a cross presentation of the child, its
head being situated near the left iliac region ; thirty-six hours
after the beginning of labor. Dr. M. turned the child by the feet,
extracted it, and delivered the head by means of a forceps. The
child died during this series of operations. The mother recovered
promptly. On March 7, 1857, Mrs. L. fell in labor with her
second child, and was attended by Dr. S ^1, who tried to de-
liver the child by a forceps operation, but could not succeed,
owing to considerable contraction of the pelvis. Another phy-
sician was called in to assist, and finally a dead child was deliv-
ered by the forceps. Thus the mother's hope of having a living
offspring was twice blighted. During her next pregnancy, she
learned from her acquaintances that she might have a living child
by being delivered at a time prior to the full term, and she was
at once resolved to try her chances. With a view of having pre-
mature confinement induced, she applied to Dr. Krackowizer,
and to no worthier man could she have trusted her own life and
that of her child. This gentleman, to whom I am indebted for
the particulars of the case, invited me to see Mrs. L. in consulta-
tion. We met at the patient's residence, June 26, 1858, and

learned that she was last unwell at the time ot the Jewish New-
Year (September 19, 1857), and that she quickened near the end
of February, 1858. The woman was of dark complexion, and
very short of stature, measuring from head to feet only four feet
six inches, the bones of the entire skeleton being rather short and
massive, more especially the epiphyses. From the strong inclina-
tion of the pelvis, the lower part of the backbone stands out in a
remarkable way, while the lumbar portion of the vertebral column
is apparently curved in a forward direction. The measurement of
the pelvis with Baudelocque's calipers presented the following
data:

Distance of both spinas anter. sup. . . 9| inches.

" " trochanters, . . . .12 "
External Conjogata, . . . . 6^ "
Gonjugata, 3| "

By internal examination the promontorium could be easily de-
tected, it being directed somewhat towards the right side of the
pelvis, thus allowing a larger space for the left pelvic exca-
vation. The OS tincae was directed considerably backwards,
almost touching the os sacrum, both external and internal orifices
permeable to the finger ; laquear vaginae empty, head found float-
ing towards the left iliac region ; lower part of the pelvis and
outlet spacious ; uterus considerably anteverted.

Thus we had to deal with a markedly rhachitic pelvis, and an
antero-posterior diameter of the brim of three inches and odd
lines. This disposition, taken together with the history of her
two previous confinements, induced us to comply with her wish to
have premature labor induced as the only chance of having a
living child. She, therefore, was placed across the bed, the feet
being supported by two chairs. By gently pushing the fundus
uteri backwards, the os tincae was brought more fully in a direc-
tion corresponding with the axis of the pelvis, and an elastic
English catheter, with a metallic mandrin was introduced into the
cavity of the womb, between its anterior wall and the membranes,
as far as ofie and one-half inches, as it was impossible to push it
any further without using considerable force. Through it about
three ounces of warm water were injected and instantly expelled
beneath the instrument. This was repeated with the same result.
We now withdrew the catheter and introduced it again in a
somewhat difierent direction. By this manoeuvre, the catheter

could be introduced considerably further upwards, and tbe full
amount of the injected water was retained. Immediately after
this, the uterus became, hard and rigid, and the patient had to
press downwards as if in labor pains, which lasted for about half
a minute. The patient was now ordered to rise and walk about
the room. No water was discharged. Prom half-past nine, A. M.,
June 8th, when the first injection was made until half-past ten,
A. M., she experienced four well-marked though feeble pains.
From this time up to half-past nine, P. M., regular labor pains,
increasing in strength and rapidity of succession, were observed,
and with almost every one of them a small quantity of water was
discharged. Still their influence upon the os uteri was as yet very
insignificant, being dilated to about the size of a two shilling
piece. Towards midnight the pains grew v^ry strong, and at
about three, A. M., a large quantity of water was discharged with
one forcing pain. Dr. Kj-ackowizer saw the patient at four, A. M.,
and found the right scapula presentiog (in front), head towards
the left side ; foetal pulsations easily perceptible on the left side
of the abdomen below the umbilicus. The patient was placed
under chloroform, when the doctor turned the child by one foot
and extracted it, except the head. The operation of turning was
attended with some difficulties, and could not be performed as
quickly as was desirable. The head itself proved too large to be
extracted in the usual way, and consequently the forceps was
applied, and thus the child was delivered. It proved to be still-
born, and, although every eflfort was made to revive it, life could
not be restored. The mother did perfectly well and was up after
the ninth day.

From the appearance of the child it became evident that the
gestation was more advanced than we supposed, from the account
given by the parents, or from the results of the obstetric examina-
tion ; the peculiar displacement and formation of the uterus hin-
dering a fair estimate.

Full length of the foetus, ... 16 inches.

Lateral diameter of the head . . .3 "

Antcro-posterior, 4 "

Vertical, 4 "

Long diagonal 5J "

Distance of shoulders, .... 5

*' " trochanters, .... 3/ "

Case 3. — I July last I wns called to sec Mrs. N., of Sullivan
Stieet, in consultation with Dr. Shnetter, of tliia city. Here I
found & lady confined to bed for the last three weeks, and unable
to walk more than a few steps, owing to an tedematous awelling
of her almost entire body. Both legs were swollen, and stiff
with Hrrous effusion as high as the abdomen, as also her arms and
face. The urine tested by heat and nitric acid, became instantly
thick, giving a very copious sediment, consisting of albumen.
The microscopical examination conducted previously by Dr.
Shnetter, confirmed the chemical analysis ; numerous fibrinous
casts, as well as epithelial cells from the kidneys, filled with a
fatty detritus, having been detected by this gentleman. We
therefore considered Mrs. N. suffering from far advanced degen-
cratioa of the kidneys and consequent anasarca. Prom her pre-
vious history, it appeared that similar symptoms, although in a
less remarkable degree, had occurred in a former pregnancy, and
she had been taken with eclamptic convulsions at the time of her
last labor. She was now about six months gone, and we most
naturally concluded, that if pregnancy was allowed to proceed
op to the full terra, she would not only be subject to eclampsia,
but it even seemed more than probable, that the disease, advanced
as it was, would gradually undermine her system, or destroy her
by a sudden attack of cedema pulmonura or pericardii. It was,
therefore, resolved to interrupt pregnancy as the only chance of
saving, or rather prolonging l^r life. At five o'clock in the after-
noon, we introduced an elastic catheter between the membranes
and the walls of the uterus, about four inches, and injected five
ounces of tepid water. No reaction took place at first, and it was
not until two hours after the injection was performed, that the
patient was taken in labor. From this time the pains came on
slowly, but steadily, and, during the night, effected a gradual
dilatation of the os. At about nine o'clock, A. M., on the follow-
ing morning, the os was fully dilated. Upon rupture of the mem.
bnmes, the child presented with the back, when Dr. Shnetter
turned and extracted a small immature foetus, which expired after
a few ineffectual efforts at respiration. The mother advanced
very slowly towards recovery, but she finally convalesced, and is
able again to attend to her household duties.

Theiie are the three eases of induction of premature labor per-
formed — after Cohen's method, in the ei tj- of New York. The only

case on record, where this method was made use of in the United
States, is that of Dr. Blatchford, an account of which was read be-
fore the Rensselaer County Medical Society, at the Semi- Annual
meeting, January 7, 1850, and published in the JVeio York Journal of
Medicine, N. S., Vol. IV., No. II., March, 1850. It was per-
formed at the seventh month of gestation, on account of con-
tracted pelvis. We give a condensed extract from Dr. Blatch-
ford's valuable paper.

Mrs. M. has been delivered twice with the perforator, be-
cause the pelvis was so contracted in all its diameters, that
the children could not be removed alive with the forceps.
Therefore, on Wednesday, 5th of December, ten o'clock, A. M.,
being just seven months since she was last unwell, and two
and a half since she quickened, everything being in readiness,
with the assistance of Dr. Robbins, half a pint of " tar water "
was injected into the womb through a large sized male catheter,
moderately curved, and by means of the syringe of a common
self-injecting apparatus. The catheter passed without the least
resistance from two to two and a half inches within the uterus, oc-
casioning not the slightest pain. After remaining about ten
minutes in a recumbent posture, she was permitted to get up,
which she did, and moved about the house as usual, experiencing
no other inconvenience than a constant draining from the vagina,
of a small quantity of a fluid slightly tinged with blood, and
tainted with tar, and a sense of weight, as if, to use her own ex-
pression, " the child had settled down." Nothing unusual oc-
curred until Friday evening, the seventh, when she was suddenly
taken with a chill and rigor, which lasted nearly two hours,
accompanied with severe headache. It was succeeded by slight
fever. Saturday morning she was .very comfortable, with the ex-
ception of the slight draining before mentioned. At eleven
o'clock, however, and after the operation of a carthartic pre-
viously given, she was taken in labor. The pains at first were few
and far between, until about one o'clock, P. M., when they became
quite violent and frequent. At two o'clock the membranes gave
way during a hard pain, and a very large quantity of water was
discharged. The effect of this large evacuation was, to give
almost entire relief from pain. By a little after eight o'clock.
Sabbath morning, her pains again returned, and they soon became
very regular, but it was not until noon that dilatation could be

said to have fairly commenced ; by eight o'clock, the head could
be felt forcing its way through the upper strait. From this time
until about one o'clock the pains were very severe, and yet very
little progress had apparently been made toward the completion
of labor. The patient, hitherto firm, began to manifest signs of
restlessness and impatience, and her spirits evidently began to
flag. Still Dr. Blatchford left the case to nature, and at half-past
two, A. M. (113 houi's from the time the tar water was injected)
she was delivered of a plump an,d vigorous child, loudly vocifer-
ating its own advent. It weighed nearly four pounds ; the
placenta soon followed. The mother recovered without any un-
pleasant symptoms whatsoever, and had the satisfaction of nursing
her own infant.

From an analysis of these four operations performed in the
United States, or rather in the Empire State, the following table
may be drawn :

AUTHOBS.

matchford.

Noeggerath

Nnmber of
Injections.

nme of Labor
after first
Injection.

2
1
1

113 liours.
23 hoars.
19 hoars.
16 hours.

F^te of

Children.

Alive.
AUve.

Dead.

Died soon
afterbirth.

Fate of
Mothers.

Recovery.
Recovery.
Recovery.
Recovery.

Reason for
Operation.

Gontaraoted
pelvis.

Contracted
pelvis.

Morbns
brightii.

BEMARKa

Cranial present-
ation.

Gross OTesenta-
tion. Turmng.

Cross presenta-
tion. Taming.

This limited nmnber of observations is, of coarse, insufficient for
a final discussion with regard to the value of the method, but
added to the statistics already known, they will throw additional
light upon the operation, and tend to determine its ttue position.
The first man who conceived the idea of inducing premature labor
by injection of water into the uterus, was Dr. Tac. Pried.
Schweighauser, of Strassburg. In his excellent work, "Do*
GMren nack der beobachteten JSTaiur" etc., Strassburg and Leip-
zig, 1825 ; he recommends to throw a quantity of warm water
into the womb for that purpose. But, as he never seems to have
practiced it, we must attribute the whole merit to Dr. H. M.
Cohen, of Hamburg, who first introduced this proceeding into
practice. He called the attention of the profession to this method
in a thesis written in the year 1846. Since this time, we have

through the diflferent medical journals, accounts of upwards of
sixty cases in which^ Dr. Cohen's directions were imitated, all of
which are very favorable to the operation. From a perusal of
monographs and periodicals, I have been able to collect sixty-two
cases (Birnbaum, seven ; Cred6, three ; Cohen, seven ; Steitz,
ten ; Naegele, one ; Harting, two ; Kilian, two ; Ritgen, one ;
Germann, nine ; Strauss, one ; Ri^el, six ; Krause, one ; Wag-
eninge, one ; Snoep, two ; Potonnier, two ; Viguier, one ; Stein-
brenner, one ; Scanzoni, one ; Blatchford, one ; Noeggerathf
three). With regard to the time from the first injection and the
termination of labor, the shortest period was noticed by Potonnier,
viz., three hours ; the longest occurring in one of Steitz cases, viz.i
eight days ; two days being the average time. The only instance
where this method failed, was recorded by Scanzoni (Langen-
heinrich). This case is published in " ScanzonVs BeUragen zur
Geburtskunde," Vd. 11. ; Wurzburg, 1855 ; Article IV., Mitthei-
lungen von der geburtshilflichen Klinik in WUrzburg, von Dr.
Langenheinrich ; page 50. But from a careful perusal of this
case, it appears that the method was not subjected to a fair trial,
the catheter being introduced into the womb two inches, where
its further progress was arrested by an unknown obstacle. The
water was rejected instantly, as might have been expected, from
the fact, that the catheter was not introduced high enough. All
authors agree that a considerable portion of the water has to be
retained within the womb, to make sure of efficient labor pains.
The same thing happened in the second of our cases reported, and
if we had not persisted in finding out a* region where the catheter
could be safely introduced as far as four or five inches, we should
certainly have failed. All the mothers recovered, except three,
which, however, died from diseases unconnected with the opera-
tion, viz., two from eclampsia ; one from puerperal fever. The
fjBite of the child we find noted in fifty-eight cases, thirty-six of
which were born alive, and eighteen dead ; the number of deaths
corresponding pretty accurately with the number of cross pres-
entations.

Let us now endeavor to compare these restdts with those of
other methods. It would be a waste of time, to discuss anew the *
value of puncturing the membranes. What accoucheur would
not prefer a method by which the membranes remain intact, thus
avoiding all the trouble, and all the danger, connected with a dry

labor ? And as to ergot ? I think uo nnprejudiced accoQchcur
will now resort to this remedy, with a view of inducing prema-
ture confinement, partly on account of the uncertainty of its opera-
lion (one failure in every fifth case, Krause), and partly on
aeconnt of ila generally admitted iwisouons influence upon the
foetus. This remedy has had its day, and it ought now to be men-
tioned only from r historical point of view. The dilatation of tlie
o9 uteri, by compressed sponge (Klugo's method) has met with
invincible obstacles in many cases. In some instances, a sufficient
dilatation of the os nteri was effected, but no pains followed;
cases of this kind have been reported by Houbeau, 5ffische,
Jacoby, and Barnes, and altogether about eighteen cases arc re-
ported where other means had to be employed, as the action of
the sponge ppovcd to be insufficient. Moreover, the application
of compressed sponge is tedious both to the patient and the
accoucheur. The same may be said of Husch's instrumental dil.
station, and the method of Hamilton and of Riecke. The plug-
ging of the vagina with scraped linen (SchoHer), or with i
animal bladder (Hiiter), or with the colpcurynter (Braun) are,
doubtless, more safe than the methods just mentioned, but alto-
gether not free from inconvemences. The best of these con-
trivances is Dr. Braun'a caoutchouc bladder-plug. Still, some
cases aie reported where it was unable to produce pains. Its
cliief drawback is the irritation of the vagina, and lower sectioa
of tlie uterus, in coosequenco of its application. Thus Professor
Breit, of Tubingen, has published the case of a woman who died
from inflammation of the internal genital organs eflected by the
colpeuryntor. Bat for controlling hsmorrhage, and promoting
labor in cases of placenta prrevia, the bladder-plug will always
renmin the risnedy par excellence. ScanKoni's methods of in-
ilDciDg premature confinement by irritation of the nipples, or by
irritation of the vagina and uterus, with carbonic acid, have met
already with a number of failures counterbalancing entirely the
■moant of success obtained by them. The methods of Drs. Simp-
son, Merrem, Lehmaun, Krause, which are intended to effect
labor, by the introduction of a sound, or a catheter with immedi-
ate removal, or with a view of leaving the instrument in the
uterus, seem to bo simple and efi'ectual remedies for this purpose.
But very few cases are reported in which they failed. Dr.
Branirs' latest proposition {^^ee our report), seems to be invented

for the sake only of making a new invention. He proposes to in-
troduce a gut-string between the membranes and the inner surface
of the uterus, the eflFect of which proceeding is certainly no other
than that obtained by Erause's method. The use of Galvanism
(Radford, Simpson, Mikschik) is often very painful, not certain in
its results, and tedious for the accoucheur, even should he happen
to be in possession of an electro-galvanic apparatus.

Before entering upon a discussion of the position which ought
to be assigned to the douche, we will briefly mention a case in
which this remedy was used without making the least impression
upon the pregnant uterus. The woman to whom we refer was
received into the lying-in hospital of Bonn, endente with her first
child, and at about seven months. She was of small rhachitic
stature, and, although her spinal column was pretty straight, she
measured not more than about four feet ten inches. ' Her pelvis
was, therefore, not spacious and a pretty fair specimen of pel-
vis justo minor, with an antero-posterior diameter of three and
three-quarter inches. Under these circumstances, it was thought ad-
visable not to let her go the filll term, and the douche was select-
ed for exciting labor pains in the thirty-sixth or thirty-seventh
week of pregnancy. We had a large douche ascendante, which
threw a powerful stream of water from a hight of twelve feet.
The basin on thetop of it was filled with hot water (100^ F.), and
I directed the nozzle of the tube as near as possible towards
the OS tincse. In this way the water was allowed to play against
the lower segment of the womb twice a day for fifteen minutes,
and this application continued for a full month. This douche was
applied at least fifty-six times, but in vain ; not the slightest im-
pression could be made upon the uterus, and not the least indica-
tion of uterine contraction could be obtained from beginning to
end. She, therefore, was left alone till her full time, and as she
had an exceedingly small child, and very strong pains, she was
delivered even without the aid of the forceps.

But this is not the only instance of this kind. Dr. ELrause, in
his elaborate treatise on induction of premature labor, notices
thirteen cases in which the douche was insufficient to efiect labor
(Scanzoni, three ; Kowalsky, two ; Michaelis, Grenser, Ziehl, Kil-
ian, Ritgen, Goudoever, Dubois. Levy, each one), and not a few
cases are mentioned where thirty to seventy applications were
required to induce efficient pains (Diesterweg, Germann, Grenser,

Aroetb). We are in pogscBsIoii of accounts of abont ninety^fonx J
cases in which the douche was used {Kiwisch, seven ; Chiari, Gren- j
ser, each six ; Harting, Diesterweg, Levy, each four ; Arncth, I
Busch, Kilian, Gcrmann, Birnbaum, Scanzoni, 8imon Thomas, i
Doboip, Kowalaky, Elliot, each three ; Elein, Stengclmaier,
Trogher, Lanz, Braun, Smith, Simpson, each two ; Betschler, '
Mikschik, Ziehl, Michaelis, Ritgen, Bendlen, Ludwig, Lacy, Sltel* j
cton, Atthil, Sinclair, Goudoever, Aubinais, Bourgeois, A. K. i
Gardner, Xoeggerath, each one). Of this number, fourteen mothers
sickened during the application of the douche — i. e., one was
taken with nausea, two with vomiting, three with hcemorrliage,
one with violent diarrhtea. two with vaginitis, two with metritis,
three with fever ; out of these ninety-three women, in whom the
douche was applied, twelve died in childbed. This ia a number i
uni>aralle1ed in the history of induction of premature labor. From
eighty cases in which ergot was used, ouly three women died ; from
one hundred and thirty-live cases of induction of labor l)y tapping,
eleven died ; from ninety-six cases of intra-utcrine injection, three
died — viz., two from eclampsia, one from puerperal fever. Out of
th^e eleven ea.'!es of death after application of the douche, sii were
owing to metritis. Wo are inclined to believe that some, if not
all, of these metritides were caused by the douche itself. It is
right to suppose that the congestion produced and constantly re-
peated by the act of throwing a full stream of warm water, as often
as thirty or seventy times, in an interval of a few weeks, against
the aterna, will at last become stationary, and pass through the
different stages of an inflammatory proces?. It further appears
from a perusal of the facts stated above, that the douche cannot
be relied upon when applied for the purpose of inducing prema-
ture labor ; it proved insufficient in about every sixtit case, and
had to be exchanged for another method. The uncertainty of
action combined with the unfavorable results to the life of the
mother are objections which cannot be denied. With regard to
the fate of the children, it must be remarked that a considerable
nomber of tliem were born in a cross presentation, altogether a
larger per centage than with the other metliods, a fact easily ex-
plained by the influence of a concussion (with an upward tenden-
cy) of the lower uterine segment and its eontcnis. But as it is
well known that almost all children who are artificially delivered
before the end of the seventh month are still-born, it will be read-

ily understood, that everything that haa a tendency to produce
malpositions does actually increase the per centage of still-births.
These considerations are modified when we examine the history
of those cases, in which the stream of water, thrown from the
douche, was directed so as to enter the os uteri. The manoeuvre
just mentioned has been recommended or executed by Kiwisch
himself, by Ameth of Vienna, by Simon Thomas, by Trogher, by
G. T. Elliot, A. K. Gardner, and many others. A glance at the
results of the operation performed in this manner reveals a re-
markable difference in the effects of the douche when applied in
tiie usual manner. In most instances the result was striking,
pains arising soon after the first application, while a few cases are
recorded where death followed upon its administration. One in-
stance of this kind is reported by Chiari, in which during the applica-
tion of the douche, the patient was taken with convulsions, cyanosis
dyspnoea and died soon afterwards. A similar case is reported by
Dr. Germann (see Monatschriflfur Geburtsk. xii., p. 193), who, after
thirty-seven unsuccessful applications of the douche in the usual
mann^, introduced the mouthpiece of the chlysopompe into the os
uteri one inch, and threw about one or one and a half ounces of
cold water into the cavity of the womb. The patient perceived im-
mediately afterwards a kind of tension and expansion of her abdo-
men. A few hours later, she had a most violent chill, and at once
a series of the most forcible labor pains, of such a character that
Dr. G. became alarmed for the patient's safety. The child was
bom, and twenty-four hours later the woman was a corpse.

It appears that the application of the douche, with the nozzle
inserted into the mouth of the uterus, is a proceeding in many
respects similar to that above described as Cohen's method, only
less certain in its results, and, as it seems, more dangerous. We
think that every reader of this article will conclude with us that
the douche, used in the way first recommended by Kiwisch — t. e.,
without introduction of the mouthpiece into the cavity of the
neck, is a procedure, in the generality of cases, too slow, too un-
certain, and, as it seems, too dangerous for both mother and child,
to be relied upon, and it is now quite common to direct the
stream bf the douche into the uterus. But if labor is promptly
induced in this way, this is mainly due to the water which
entered by chance into the uterine cavity. It is really only by
chance that the water passes between the uterine walls and the

membranes, nnless driven in by strong force ; a proceeding too
dangerOQS, as we have shown above, to be recommenileil. But if
it is our intention to throw a certain quantity of water into the
uterus, why not choose a method which is better adapted to the
parpoae, far more prompt in its effect, more safo to mother and
child, easier for the operator, and less troublesome to the patient?
We, therefore, propose to abandon the douche entirely, except in
certain cases hereafter to be named, and substitute for it the in-
jection of warm water into the cavity of the womb, by means of a
catheter and a common syringe, 1 am sure that every one who
has once tested Dr. Cohen's method, will be struck with the gen-
tlenesB and promptness of its action, and the simplicity of lla
execution. In most instances, only one or two injections were
required, and the average duration of labor from the time of the
first injection was two days ; not one instance is known of its fail-
ure, while the prompt recovery of the mothers in childbed, with
the exception of those few cases where death resolted from eclaTop-
sia, gives us the best gaarantce of the harmlessness of this proced-
ure. Moreover, the apparatus required consists of such simple
means, that every country-practitioner, residing in the Bmnllcst
village, is in possession of them ; they consist of an elastic catheter,
a common enema-syringe, and a few ounces of warm water. The
performance of this simple operation requires only a sufficient
knowledge of the female sexual organs in the state of gestation, its
execution is fully detailed in the history of the cases at the head
of this article, and the only precaution to betaken is, to inject
the water not with violence and force, but gently and slowly.
But we meet, from time to time, with such a disposition of the
internal sexual organs, that the introduction of a catheter is abso-
lutely impossible, whether from a firm closure of the os, or from a
location of the vaginal portion, so tiiat it is out of our reach, in
an upward or backward direction. Under such circumstances,
we have to resort to a preparatory treatment in order to change
the condition of the lower uterine segment, a treatment which in
many cases may prove sufBcient to induce efficient labor pains.

Of all means which may be chosen for this purpose, the douche
is no doubt best adapted to our purpose. In acting principally
upon the lower circumference of the womb, it ia apt to soften the
parts, 'to open somewhat the os, and to bring the vaginal portion
more in the direction of the pelvic axis. We will further remark

that Cohen's method ought not to be resorted to when induction
of labor is required in case of uterine haemorrhage, from whatever
cause it may arise. In such cases, nothing can surpass the caout-
chouc bladder-plug (Braun's colpeurynter), which, introduced
empty and filled with ice water, at once controls the bleeding by
the double action of cold and pressure, and is almost sure to
induce efficient labor-pains by its mere presence in the vagina.

ARTICLE II.

Fowr Cases of Injection of a Caustic Solution into the Cavity of the
Wombf iUustrative of the Advantages and Dangers connected with
this Proceeding. By E. Noeggerath, M.D.

Oase 1. — Intractable Hamorrhage; Injection of Iodine; Cure. —
Mrs B^ , of New York, a well formed woman, of dark com-
plexion, somewhat emaciated and pale, has been suffering from
uterine haemorrhage for the last twelve months. She was mar-
ried six years ago, and had one child, a boy five years old. Two
years ago, her husband died, and left her in charge of an estab-
lishment for prostitutes. She became pregnant, and not wishing
to bear her child to the full term, she applied to an irregular
physician of Brooklyn, with a view of having an abortion per-
formed. This was effected, by means of introducing a pointed
instrument into her womb, and a few days after the operation, the
contents of the uterus were discharged. From this time, she
flowed freely for about two weeks, when the haemorrhage ceased
gradually for about ten or twelve days. It returned regularly
every fourth week, and lasted for about a fortnight. The blood
she lost was dark and clotted, and its discharge was increased
when the patient moved about. Latterly, the haemorrhage was
so violent, that she applied for medical attendance, and notwith-
standing she had tried several skillful physicians, one after
another, not the least impression was made upon the quantity of
blood lost. Finally, I was called in (June, 1858), and found her
suffering very much from repeated loss of blood, and unable to
attend to her business. First, I applied such internal remedies as
I thought proper under the circumstances, recommending at once
absolute rest in the recumbent position. Alum, tannin, 'ergot,
iron, oxyde of silver, were administered in large doses, and

lUthough every ooe of tliese remedies was allowed to have a fair
trial, tlic hiemorrhage was only arrested for a short time. Exter-
nal applicatious were added, cold fomcntatioDS, aBtriDgcnt injec-
tions, but with no better result. In this way, I attended her for
about three months, without making any actual progress towards
a radical cui-e. All that could Ijc a!<ccrtained by an examination
of the parts, was a slight hypertrophy of the whole organ, and the
very easy passage of the uterine probe, as liigh as the fundus.
The latter circumstance, combined with the complete absence of
pain, served to induce mO to try an intra-uterine injection. With
regard to the cause of the bleediog, I was of opinion that there
existed small polypoid growths in the caTity of the womb, as rem-
nanta from an Incompletely detached serolina at the lime of abor-
tion, Of a hypertrophical swelling of the mucous membrane ia
gcneraJ, owing to imperfect iuyolution .iirt9f*_*t(l,aiy. of ,^ioIeiic^ .,
alluded to. In both instances, an intra-uteHne injection Va^ not
only justified, but demanded. An intra-uterine syringe, with
long pipe, made of hard-rubber, and of about Sss capacity, was
filled with tinetura jodi, and the slender mouthpiece inti^oduecd
through a speculnm into the cavity of the womb, until it touched
the fundus uteri. By slowly advancing the piston, I emptied the
contents into the uterus, which were immediately expelled beneath
the syringe, and thrown back iuto the speculum by violent con-
tractions of the womb. This first injection was made at the time'
when the last hemorrhage had nearly subsided, so that I had be-
fore me about twelve days till the next menstrual period. Besides
a sensation of fiillnoss about the bowels, nothing was perceived by
the patient during or after the injection. She immediately after-
wards got up and walked about the house. The reiietion being
so Tery trifling, I asked the patient to call at my office every other
day, to have the injection repeated. This was regularly done,
and after every injection, the patient rode and walked downi from
Twenty-sixth Street to Centre, near Broome Street, without
experiencing the least inconvenience. The iodine was thus em-
ployed four times before the next menses made their appearance,
and when they came on, a complete change in their chafacter
conld be remarked. The blood was fluid instead of clotted, con-
siderably brighter colored than before, and lasting for five days,,
not more copious than is usual in a woman menstruating nor-
mally. "When the period was over, 1 repeated the injection*

twice a week, in order to consolidate the results already ob*
tained. The next period was all that could be desired, and I dis-
charged her as cured. She afterwards left for the country, but
from occasional reports of her condition, I am aware that she has
had no recurrence of haemorrhage.

Case 2. — Uterine Juemorrliage^ of twenty-three years' standing^
cured by a single injection of diluted Uquar fern sesquichloraH. —
Alarming symptoms after the Injection; Slow Recovery. — Mrs.
G d, of East Seventeenth Street, forty-five years of age, of Ger-
man parentage, mensti*uated early in life, and her courses con-
tinued regular up to the year 1835, when she was married, and
nine months later, delivered of a healthy child. The confinement
was as natural as could be desired, so that she was about the
house before nine days had elapsed. Although she did not nurse
lier baljiy, hep couirses. 4id not appear until twelve months after
•delivery, brought on', as it seems, by the use of emmenagogic
remedies, and then lasted for half a year without intermission.
Medical advice was sought, and everything was tried to bring on
:a more natural periodical discharge. But treatment seemed to
l^ave very little influence, the flux ceasing only ten or twelve days,
to return with unchecked violence. This condition lasted for six-
teen or eighteen years, when the menorrhagic attacks began to
iincrease. For the last five or six years, she had very often only
:a few days of intermission, and this space was filled by an even
imore troublesome acrid watery discharge. At the beginning of
1857, new complaints were added, viz., a burning pain in the
•ovarian region, and a sharp pain at the time when she had sexual
intercourse, which act was always followed by a discharge of
l^lood from the genitals. She therefore dragged out a most
miserable existence, being all the time wet with blood or other
•discharges; constantly in pain, weak, nervous, and emaciated,
vrithout the hope of relief, and altogether a burden to herself and
family. Under these circumstances, I was called upon to see her,
:and give my advice. I found a person whose aspect was pitiful
to witness, of an ashy complexion, a mere skeleton, scarcely able
to move, and even fatigued by a short conversation, but resolved
to submit to anything ihsX might effect a change in her condition,
he it at the risk of her life. When I saw her, I was moved with
« strong desire to give her all the relief that might be afforded by
medical science and art, but my hopes with regard to a radical

core were very faint, uot so much from tho rcduceiS state of tba
patient's health, as from the fact that she had been for the last
Jew years attended, without deriving much benefit, by Dr. S., a
physician for whose ability and learning I entertain the highest
•dmiration. A digital examination being necessary, was readily
consented to. The vaginal portion of the nterns rested somewhat
lower than it ought to be under normal circumstances, was con-
Biderably tliickcr, but soft, the os tincse patalous, and covered with
small grannlationg. By the double touch, the entire organ ap-
peared to be enlarged", and of a more spherical form than usual,
painful even upon gentle pressure ; left ovary considerably en-
larged, and very painful. By examining through the rectum, a
pretty large section of the posterior surface of the womb could be
circumscribed, and in this way it was ascertained that a hard,
flat tumor, of considerable ahe, was imbedded in the uterine tissue.
The probe passed easily into the cavity, and could be advanced three
inches and a half, thus giving a hypertrophy of one inch in length.
The results thus obtained, together with the patient's acconnt of
her ailings, induced me to assume that I had to deal with a fibrous
growth in the uterine tissue, or a simple uterine polypus, protrud-
ing into its cavity. In order to make sure of the diagnosis, and
as a preparatory step for treatment, I proceeded to enlarge the
uterine cavity, by means of compressed sponge tents.

First, a sponge of small circumference, one inch and a half long,
was introduced, and loft there for about eight hours ; a time suffi-
cient for its perfect softening and ctpansion. Immediately after
ita removal, a second sponge was introduced sufficiently long,
nearly to touch the fundus ntcri, and left there over night. I was
now enabled to pass my forefinger almost its entire length into
the cavity of the womb, so that I was enabled to examine its
entire inner surface. No polypus could be detected, the mucous
membrane seemed to be not perfectly smooth, perhaps, owing to
the influence of the irregular surface of the sponge, which stuck
very fast to it in every direction, when it was withdrawn. While
thus examining the womb, there was a feeling as if the posterior
wall protruded to a groat extent, and as if a largo hard body was
situated beiiind the thickened lining membrane. This examination
excluded the diagnosis of polypus nteri, verifying that of inter-
etitjftl fibroid tumor. I now proceeded to introduce a glass-
fipeculnm into the vagina, and through it a syringe, which

^L etitjftl
^^M fipeculuE

contained the liquor ferri sesqnichlorati mixed with equal parts of
water, making altogether about half an ounce. The mouthpiece
being advanced up to the fundus uteri, its contents were emptied
into the womb, and almost instantly rejected into the vagina. I
took care not to remove the speculum as long as a drop of the
solution came away from the os uteri. The first symptom was a
burning sensation in the vagina, which was owing to a portion of
the injected fluid, which came in contact with the vagina, when
the speculum was withdrawn. The injection was made at eleven
o'clock, A. M., April 30, 1858. When I saw the patient in the
evening, she seemed to be much prostrated^ always complaining
of the soreness above mentioned, and a dull pain in the lower part
of the stomach, which corresponded with the uterus. I ordered
cooling injections into the vagina, and a few doses of acetate of
morphium. On the following day, her condition was not much
changed ; the sore spot less noticed ; pains in the st(Hnach in-
creased ; sensation of nausea ; continued morphium. Third day ;
so low that she was scarcely able to move or speak ; pain in
the uterine region increased by the slightest touch ; abdomen
slightly swollen ; ordered stimulant drinks, opium with camphor.
In the evening about the same ; complained of headache and gid-
diness ; pulse about 130 ; very feeble ; abdominal pains not re-
markably increased. Fourth day : very much prostrated ; her
family thinks she cannot live much longer ; pulse scarcely per-
ceptible ; skin cold ; constant nausea ; no change in local symp-
toms; ordered brandy and quinine. Sixth day: feels a little
stronger ; pulse somewhat stronger ; treatment continued.
Seventh day : slowly improving ; remarked a few drops of a
watery discharge from the vagina. With returning irritability,
the pain around the uterus is more acutely perceived, and I
therefore had a blister applied above the pubic region, as soon as
I considered her strong enough to bear all the pain and trouble
connected with the dressing a blister. Recovery proceeded very
slowly, and not without one or two alarming relapses, which
tlireatened to carry her off. The discharge above mentioned,
continued for eight weeks, when she had, for the first time, a
small flux of blood which lasted for five days. It ^^ not before
ten weeks from the day the ii\jection was made, that she was
strong enough to leave her bed, and then, only for a few hours at
a time. One month after the first show, she had another dis-

£9

charge of blood which continued six days, but did not make an
unfavorable impression upon the state of her health. At the end
of August, 1858, she was able to leave her house to be removed
to the country, where she gained strength considerably, and in a
comparatively short time. Her menses appeared every fourth
week regularly, diminishing in quantity on every succeeding turn,
so that from October last, she professed to have her courses as reg-
ular, and in that quantity which every healthy woman ought to
have. X

Case 3. — Injection of a Caustic Solution into the Uterus ; Severe

Meiro-peritonitis ; Recovery. — Mrs. K , of Seventh Avenue,

called at my oflBce to be treated for fluor albus, of which she had
complained ever since the birth of her last child, which was now
about two years old. She had been attended by several physi-
cians, who prescribed internal remedies and astringent injections ;
but all to no avail, for as soon as she stopped using the syringe,
the white discharge came on in undiminished quantity. Latterly,
her courses had become very scanty, her strength began to give
away, and she was constantly tormented by a pain in the small of
her back. Upon examination, I found the vagina covered with a
copious, thick, semi-transparent fluid, the uterus in its normal posi-
tion, slightly sensible to the touch, very little hypertrophied,
mouth somewhat open, its surface not quite smooth, both lips cov-
ered with red granulations, and bathed in a muco-purulent
secretion from the cavity of the womb. This was no doubt a fair
specimen of catarrhus uteri, and a caustic application to the dis-
eased sur&ce seemed to be the very thing that was required, as
the only safe means of effecting a permanent cure. I, therefore,
introduced the mouth-piece of an India-rubber syringe with long
pipe, containing a few drops of a solution of one part of nitrate of
silver to four parts of water, into the mouth of the uterus, and
emptied the contents o^f the syringe very slowly into the womb.
Most of the fluid returned immediately, and I am sure that the end
of the syringe entered not further than one inch into the cervical
canal.

When the patient stepped from the lounge she had to sit down
quickly upon a chair, because of a transient sensation of fainting.
This was at three o'clock, P. M., and at about six o'clock I was
called in haste to see her at her residence. I found her very low
and uneasy, vomiting incessantly, and complaining of pain in her

head. I learned that a few minutes after leaving my oflSce she
began to vomit, and continued to vomit to the time of my visit.
There was besides a dull pain both around the left ovarian and
the pubic region, which increased on pressure with my hands ;
still the abdomen was not tensq nor swollen ; pulse feeble, about
one hundred strokes in a minute. I ordered Magendies solution
dissolved in potio Riveri, and linseed poultices to be applied to
the painful spot. She passed a very uncomfortable night, feeling
as if she was always near fainting, and vomiting as soon as she
took the least drink. I found her on the following day very low
and pale, so much that I felt alarmed about her condition, pulse
one hundred and thirty, feeble, pain in the region of the womb
increased. Ordered a large blister and powerful doses of opium
with camphor, small pieces of ice to be taken when she felt
thirsty. Towards evening she was under the influence of the
drug and felt somewhat easier. On the third day, the vomiting
had almost entirely ceased, but she did not dare to lift up her
head, fearful of increasing the sensation of giddiness which she
had experienced from the very first day of her sickness. The '
pain in the lower part of the stomach not increased, pulse falling.
All the while not the least show of a secretion from the vagina
was remarked. On the following days her condition was even
more satisfactory, especially on the sixth day, when a flux of clear,
bright blood had suddenly made its appearance. The blister was
now permitted to dry up, and the patient was ablef to leave her
bed on the tenth day from the time of the caustic application.
After this she could not be induced to continue a course of local
treatment, being impressed with the idea that the first attempt
had come very near killing her.

Case 4. — Application of a Solution o/JSTUrate of Silver to the inner

surface of the Womb ; Death on the sixth day. — Mrs. U , of

Sixth Avenue, a slender woman of light complexion and an irrita-
ble disposition. When I saw her first (September 1856), I was
called to attend her for the " whites " and *' pains in the small of
her back." Of her history I learned briefly that she was married
about seven years ago to a man, who not only neglected her, but
whom she suspected of having intercourse with prostitutes, from
the fact of his having contracted a venereal disease, for which she
could not account in any other way. Upon being questioned,
she admitted tiiat her disease might have been communicated to

her by her busViand. Altiioiigh she was not able to trace the csact
time when Wic liegan to suffer ; she had been ill for one and a half or
two yeara. The discharge of which she coiDplained was at first very
little and thick, becomiDg more profuse, watery, and KomcwUat
offensive of laie. This circumstauce, connected with her growing
daily thinner and weaker, induced her to seek medical advice, and
she readily submitted to a thorough examination. The vulva and
TagJDa were bathed in a serous, greenish, offensive fluid, and con6&-
qaently were red and irritated. Upon examining the uterus with
the Gngcr, it was found that about two-thirds of the vaginal por-
tion were gone, and what little remained, tho seat of an irregular
nlcer&tiou which extended far into tho cavity of the neck. This
part was laid open to view by means of a speculum. The surface
thus exposed was of a dirty, grayish color, with irregular, sharp
cut protuberances, limited by a jagged margin which, towards the
right side, embraced part of the laquear vaginse. A small particle
vas taken away from this diseased spot for microscopical examina-
tion. Il was afterwards found to consist of notiiing but the nat-
nral elements of the cervical portion, areolar tissue, and fibres of
Organic muscles, all of which wore in a state of desintcgration,
Ceprescnting a granulated appearance, as if interspersed with
molecular (fatty) corpuacula.

Diagnosiii : ulcus corrodens portionis vaginalis e causa .syphi-
litica.

Treatment. — We are of opinion that most, if not all, the corro-
sive ulcers of the vaginal portions arc chancres iu a phagedienic
Btste ; we further believe, that the phageda^nic chancre is a
variety of the soft chancre, thus demanding no general anti-syphil-
itic but chiefiy a local treatment. In this instance, at least, there
could be no doubt about the nature of the disease, and never had
mny secondary symptoms occurred. On September IStli. the actual
cautery was applied. An olive-shaped iron was heated white
and brought In contact with the entire surface as far as it was
diseased, and even passed into tlie cavity of the neck for a consid-
erable distance. The pain experienced during the operation was
trifling, and the patient rose from the table, where she was placed,
aad walked to her bed as if nothing had happened. The reliction
which followed was insignificant, the pulse rising not above nine-
ty strokes in the minute ; the discharge diniinisiied in qnantity

id quality, being less ofl'enaivc and of a better color. ThC'

patient was ordered to take a strong decoction of bark and rich
food, under which treatment she seemed to recoyer soole strength.
Ten days after the cauterization she was examined again, and the
affected portion seemed to be in a fair way towards healing ; in-
stead of the ragged, pale surface, I found a fresh looking wound,
partly coyered with red granulations. Still some small spots were
left, exhibiting traces of the old disease. I, therefore, thought it
necessary to continue cauterization, though on a less actiye plan.
Nitrate of siWer seemed to be all that could be desired, and I
dissolved a drachm in an ounce of water to be used for local appli-
cation. The patient, therefore, was again placed on the table, the
speculum again introduced, and a small camel-hair brush soaked
in the solution just mentioned was applied to the ulceration. The
place which had the most unhealthy aspect was that situated in
the centre of the os tine®, and thinking that the corrosion might
have spread far into the neck, I introduced the brush into the
cervical canal as far as I thought proper, but certainly not more
than one inch or one and a half. When the patient was brought
to bed, she remarked that the pain from this application was as
great, if not worse, than that of the first one. Still she did not
seem to have any alarming symptoms about her. When I saw her
on the following day, there was a change in her expression ; her fea-
tures were not as lively as before ; she felt very weak and com-
plained of a pain in the lower part of her stomach. This pain
she had felt coming on gradually ever since the operation, and
upon closer examination it could be ascertained that its seat was
in the womb itself; the discharge had entirely ceased, her skin was
hot but moist, pulse about one hundred and ten in a minute. I
was at a loss to determine the cause of these symptoms, consider-
ing it singular that the milder caustic should produce more serious
symptoms than the stronger one. I ordered her to take the
extract of hyosciamus in an emulsion of castor-oil, and warm poul-
tices to be applied to her stomach. The two days following, she
was much the same, and, therefore, she continued the hyosciamus
and the poultices. On the fourth day she was ratlier worse ;
abdomen very painful and somewhat swollen ; small doses of
opium administered. On the night following, she was very rest-
less, speaking as if in delirium, constantly grasping her stomach.
On the fifth day, I found her fully prostrated, with a clammy
sweat, a small, fluttering pulse, and only half conscious. I gave

■p all hopes of recovery, bnt orciercd large doses of musk, which

iMincd lo revive her, but only for a short time. Towards night

tbe sank rapidly, and died about three o'clock, A. M., of the fol-

'lowing day. \o post mortem examination allowed. Although

antopsy was made in this case, it is clear that the woman died

im metro-peritonitis, induced by application of a caustic solution

lo the inner surface of the womb. After the first application of

le heated iron she was in a fair way of recovery, as well with

to the conBideration of tlie local disease, as to tliat of her

leral system, she had began to walk around the house, and had

[together a brighter look than before, Bnt as soon as the nitrate

r silver was used, she was suddenly and unexpectedly taken ill,

ith symptoms of mctro-poritonilis, from which she ultimately died.

,1 though at first I was not inclined t« attribnte the sudden change

I the health of the patient to the caustic, I was at last forced to

consider this application as the only cause of the inBaramation of

le womb and appendages, and I believe that every unprejudiced

iader will agree in tins explanation of the facts.

From a perusal of the cases reported above, it appears that in

oe of them no reSction whatever followed upon the injection of

le caustic agent ; two exhibited very alarming symptoms, and one

isulted in death. Tlie question whether caustic injections into

omb are connected with dangers or not, seems to be as yet un-

>tt]ed. While some authors reject their use entirely, others seem

> think light of it, and most of them consider it a safe proceed-

ig, provided the uterine cavity had been previously enlarged

rtificially. Thus Dr. West, in his recent work on the Diseases

f Women, remarks : " I say nothing about the use of intra-uterine

ijections in cases of long-standing leucorrhoea, for I have no per-

»DaL experience of their employment, and besides the risk of the

rocrrding hm Ud to their almost universal abandonment." Dr.

Kiwiseli (Klinische Vortriege, etc), says the impression following

caustic intra-uterine injections is only momentary and uncon-

lected with disa.strouB symptoms, if tlie fluid injected can easily

low back from the cavity. Dr. Bcanzoni, when speaking of intra-

Vterine injections {I^hrhueh der Krankkeiten der useiblichen Sexuahr-

fpmr), remarks that he had never remarked any disagreeable

CODScquences from caustic injections in those cases where the

cavity of Uie womb and the os uteri were large enough to allow

a free escape of the injected fluid. But from our second case, it

JL.

appears that, although the cavity of the womb had been enlarged
throughout so as to admit the forefinger to pass inside the womb
up to the fundus, the reaction was such that the patient's life was
endangered. The fluid injected in this instance was discharged
instantly beneath the syringe to its full amount ; very little pain
was perceived after the injection, and no violent symptoms follow-
ed after the operation. We must, therefore, exclude the possibili-
ty that a part of the fluid had entered the abdominal cavity,
an accident often quoted as the cause of danger connected with
intra-uterine injections. We are of opinion that the entrance of
a caustic solution into the peritoneal cavity would give rise to
instant acute pain on one well-marked spot, and to a rapid devel-
opment of abdominal meteorism. Nothing of this kind occurred
in any of our cases, and we are inclined to believe that this event
is prevented in all cases of caustic injections by the contraction of
the tubal sphincters excited by the irritating fluid itself.

We have often had occasion to observe that an irritating injec-
tion into the womb is instantly followed by a spasmodic contrac-
tion of its muscular apparatus, driving the fluid out of the os uteri
with considerable force. This peristaltic motion is no doubt com-
municated to the muscular layer of the tubes, and as the tendency
of their action is physiologically directed towards the cavity of
the womb, it is but natural to suppose that every particle of fluid
which by chance might have been thrown into the fallopian tubes
will be immediately rejected into the uterus by the peristaltic
motion proper to them. But even if this theoretical reasoning
should leave the least doubt with regard to the non-propagation
of the fluid through the tubes, we will refer to the fourth case,
the one which resulted in death. In this instance, the caustic
solution was brought in contact with the uterine cavity by means
of a small brush, and was not injected. The quantity of liquid
thus applied could not .be more than one large drop, and the re-
motest point touched by the brush was about one inch and a half
distant from the os tincae. But we have often remarked, that a
strong solution of nitrate of silver is apt to spread considerably
in the neighborhood of the spot touched with the brush. This
accident must have happened in the case just mentioned ; the
fluid proceeded, we suppose, from the cavity of the neck into that
of the womb, through the sphincter internus, which, paralized as
it was by a uterine disease of long standing, offered not the least

W 35

' Tesistance to ita progress, and by following the laws of gravitatioa

it slowly advanced into the uterus, which was slightly retroverted.

Also in the third case only a few dropa were slowly injected iuto

I Uie cavity of the neck, and still this was enough to kindle a metri-

I, accompanied by such a fearful depression of tlio system, that

»very seemed doublful.

The conclusions drawn from these conftidcrations seem to show

t the dangers connected with intra-uterine injections are not so

tach derived from a passage of the fluid into the abdominal cav-

, as from the direct influence of the caustic agent upon the

itself. In those cases where the milder caustics are

^lied, or where the organ has only a limited degree of susccpti-

Uity, the injection is followed by a more or less severe endome-

ritia, which generally terminates by resolution. But under circum-

Jiccs similar to those mentioned in the history of the cases

"orted, the inflammation seems to proceed to the deeper layers,

! areolar, muscular tissue, and lastly to the peritoneal mem-

■anc lining the body of the uterus, thus terminating in the most

istrous form of metro-peritonitis.

Frotn this it would appear that we oiight to abstain entirely

Pom the use of caustic injections into the cavity of the womb.

V>r if it ia true that they are at times followed by dangerous and

ten fatal consequences, they must be considered as means inade-

Mte to the evils which they are intended to relieve. I mean to

my that a complaint which is not endangering in a direct way the

ifferer's life, ought not to bo attacked with a remedy that might

ieibly remove the disease and the patient at once. To this class

if morbid alterations belong hypertrophy, ulceration, abnormal

sretion, and fungoid cxcrcscenses of the uterine mucous mem-

rane. conditions which have been often treated with caustic

iolutions. From this consideration, the treatment of violent

morrhagesis naturally excluded ; with regard to them, we must

|Ct after ttie principle : aux grands manx les grands rem^dcs.

In coming to this conclusion, I am far from advising against

i nse of caustics in general. All I want to impress upon my

Breaders is the necessity of being cautious in their application,

more cauUous I mean than some of our obstetric specialists. There

seems to exist a certain climax in the different remedies thcm-

selves, some of them, although very effectual, are comparatively

innocuons, while others are almost always followed by violent

reaction. Among the former we count the tincture of iodine, and
some of the organic acids, such as tannin and benzoe, among the
latter, the solutions of silver and mercury as well as the stronger
mineral acids. The remedy which most happily combines a high
degree of innocuity and of efficiency is the tincture of iodine. I
have had frequent occasions to inject it into the cavity of the
womb, and as yet I have never remarked the least untoward
symptom from its application. The use of a strong solution of
nitrate of silver is almost always followed by a destruction of
part or the whole of the mucous membrane, an incident which no
doubt is at times required and intended for effectual treatment,
and really in many instances this is perfected without any injury
to the patient's health. It, indeed, seems that a solution which in
one instance is very well born, does produce the most alarming
symptoms in another person. In this the uterus resembles the
urethra of the male, which at times can bear manipulation with
impunity, while again a single cautious application of the catheter
may prove fatal. We should, therefore, ascertain the irritability
of the womb before we attempt to apply one of the stronger caus-
tics to its inner surface. This can be readily done by throwing a
quantity of common water into the uterus, this test to be followed
by a series of weaker and stronger irritating injections. A few
trials of this kind will soon enable us to learn to what degree we
are allowed to saturate the solution. Another advantage of these
graduated injections is the fact of their diminishing the uterine
irritability, thus preparing the womb for the reception of stronger
solutions, in case they should be demanded.

ARTICLE III,

Remarks on the Employment of Pessaries ; with the description of a
Jfew Instrument.^ By E. Nobggebath, M.D.

The more intractable a disease has proved to the treatment, the
greater is the number of so-called infallible remedies proposed for
it. This is true of prolapsus uteri. Every year, almost from the
days of Hippocrates, has enriched the number of uterine instru-

* IhU artide it rqmnied wUh additiom from the yew York Journal of Medicine for

nor

lents for tho cure of falling of the womb, and still tlio mystery
iftems to be undissolved. Tiiia is partially owing to the faut, that
all Qow, no iostrumeut has been constructed tiiat satisfies prac-
Itioners in general, partially to the inToatiag-iaaniii of some of
professional brethren.

There are two classes of physicians, one of which being dis-
gusted with the host of mechanical appliances, now lauded, now
rejected, has almost entirely abandonded the application of pes-
saries ; while the other treats tlie slightest deviation with a
mcdianical support. Though tlie latter do more than the former,
neither of them proceed upon the correct principle.

As to the comparative raluo of the operation for prolapsus, the

lestiou is not yet settled. When wo attempt a final solution of
question, whether the average number of subjects operated
npon are permanently benefited by it or not, we are overwhelmed
daily with the most contradictory reports of its value. More-
over, the greatest number of practitioners are called upon to treat
cases, not in the hospital, but private patients, who claim a right
to dispose of themselves just as tliey choose. And most of them
are alarmed at the very sight of a bistoury.

And still tliero are physicians, some of the highest standing,
who try to avoid the use of a pessary by treating cases of prolap-
sus, on the so-called radical plan, i. e., by removing the original
disease, chronic metritis, hypertrophy of the womb, etc., applying
afterwards astringent injections and suppositories, while the
patients are laid up for two or six moDthei, to be discharged with
an abdomiual supporter I The great objection to this plan is the
fact, lliat it is crowned with success only in an exceedingly small
number of cases, while its employment is perfectly out of the ques-
tion in the large majori^? of cases, because that class of society
among which prolapsus is commonly found, has neither time
nor means to resort to it. It Is tlie working portion of the sex
'liich suffer with tliis complaint, and they want a prompt and
!roedy.

In regard to abdominal supporters (Annan, Hull, n&milton,
Giehrl) I consider them as erccellent adjuvants in the treatment of
prolapsus, but the relief derived from them is far loss than that
offered by a well-adapted pessary.

operation which is always followed by great relief,
amputation of the cervix, in cases where tbe prolapsus

rO]
til

owing to hypertrophy of the lower section of ihe womb. Dr. C.
Mayeb, of Berlin, the well-known obstetrician, has resorted to it
with the fullest satisfaction in a great number of cases.

In recommending the use of pessaries in the treatment of pro-
lapsus uteri, I am far from resorting to it in every-day practice, viz.,
that of diagnosticating prolapsus uteri, and prescribing a pessary
at once. Nay, there are cases which do not justify instrumental
treatment at all, while almost every single case demands a
preparatory treatment before a pessary can be applied. The
necessity of a careful examination, and a full consideration of the
complication present cannot be urged too strongly. The neglect
of this principle is the common source of failure in the treatment
of prolapsus. For the same reason, no physician should prescribe
a pessary on the sole assertion of the patient herself, that she
suffers from falling of the womb. I have frequently met with
patients, who believed themselves to be subject to this complaint,
who, upon examination, were found to have metritis or mal-
positions and flexions of the womb. It is obvious, that a pessary
in this class of cases, would be injurious instead of beneficial.

The patient must be examined as well in an erect as in a hori-
zontal position, as it often happens, that a prolapsus disappears
entirely when the patient is lying on her back. After the pres-
ence of prolapsus has beea ascertained in this way, the patient
must be subjected to a thorough examination, while in a horizontal
position. It is best to begin with the palpation of the abdomen,
in order to get a knowledge of abnormities in the supra-pelvic and
pelvic cavities. Hereafter the prolapsed portions themselves must
be inspected, and the state of the anterior and posterior wall, and
that of the womb itself, have to be taken into consideration.

Moreover, the color and condition of the respective mucous
membranes have to be taken into consideration, as well as the
presence of ulcerations, their different characti&r, their seat in the
cervical canal, near the orifice, or on the walls of .the vagina.
Hereafter the prolapsed portions have to be touched all around
with the fingers, in order to ascertain their condition, and the
possibility of full or partial reduction. In order to get a full view
of the position of the uterus, it is well to introduce one or two
fingers into that portion of the vagina which is inside of the pel-
vis. By examining through the rectum, we may ascertain how
far it is involved in the prolapsus. Hereafter the situation and

* ire of the womb has to be ascertained with the probe, and that of
bladder with the catheter. After this the parts must be
I pushed upwards, in order to examine the gexual organs inside of
ii^ pclvia and the pelvis itself In those cases, where the neck of
tifte uterus is not in sight, it has to be explored with the speculum.
The different forma which a prolapsus may represent, are as
Ibllows : 1. One of the walls of the vagina may prolapse, without

Lfticipation of the womb, viz. :
r (a) Prolapsus of the anterior wall of the vagina.
I (b) Prolapsus of the posterior wall. These cases are generally
»)rdcd under the name of cystocele and rcctocele raginali:!.
2. Prolapsus of one or both vaginal walls, with partial prolap-
6 of the womb.

(a) Prolapsus of the anter-wall of the vagina and partial pro-
uis of the womb.
(6) Prolapsus of the posterior wall of the vagina and partial
vlapsus of the womb.
' (c) Prolapsus of both walls of the vagina and partial prolapsus
f tlio womb.

t The cases of prolapsus of the anterior wall and the utems arc
r often connected with retroversion and flexions of the womb.
Ifce body of the womb is generally turned somewliat backwards,
saing upon the os sacrum and rectum. These cases, therefore,
B very often complicated with very troublesome constipations of
e bowels.
i 3. Prolapsus of both vaginal walls and complete prolapsus of
B womb. This variety is the most commonly met with, because
men affected with the disease very often do not apply for medi-
1 advice until twenty or even forty years have passed since its
nt start.

' 4. Prolapsus of the uterus. This is of very rare occurrence,
inferior portion of the womb, generally hypertroplued in a
sat measure, protrudes between the labia majora as a thin cone,
liich sometimes attains the length of three or four incites. As its
bver end is rounded off, and perforated by the oriBce, it resera-

3 Uio penis of the male.
i In most cases of prolapsus the lining membrane is the seat of
'ficial or deeper ulceration. The ulcerations coincident with
■olapEus must be divided into two different classes, viz., those
liich are the consequences of an idiopathic uterine disease, and

those which are the result of mechanical irritations. This distinc-
tion is important with regard to treatment. The ulcerations from a
mechanical cause are limited by irregular, sharp, callous edges,
and their base is discolored with a brownish hue, yielding a dirty,
thin, often very offensive secretion. The ulcerations from chronic
metritis are of a more inflammatory character, inclined to bleeding,
spreading rapidly on the slightest occasion, and very obstinate to
treatment, unless the metritis has been subdued beforehand.

Other complications very often connected with prolapsus are
reirqflexio, retroversion and antefkxio. Every complete prolapsus
uteri is followed by hypertrophy of the organ, which attains in
most cases the longitudinal axis, while at times the womb is con-
siderably increased in thickness. In the first instances, the probe
may be advanced into its cavity as far as five or seven inchea. Ju
other cases the cervical portion alone or one of the lips only are
hypertrophied.

In consequence of the displacement of the bladder^ always present
in cases prolapsus of the anterir wall of the vagina, the urethra is
often covered with fungous vegetations, which at times attain the
length of half an inch in diameter. Hernia recti and prolapsus ani
are of comparatively rare occurrence, while rupture of the perineum
is not seldom. These and other complications have to be removed,
as far as possible, before the application of a pessary can be
thought of. The treatment of some is very tedious, and demands
a good deal of patience from the attending physician and the
woman herself.

Chronic metritis, hypersemia and painfulness of the prolapsed
parts must be treated with leeches, sacrifications, anodynes, resor-
bents, etc. The ulcerations have to be cured thoroughly before
a permanent retention of the womb can be thought of. It is per-
fectly contradictory to experience, that the reposition of the parts
into the vagina is sufficient for the cure of these ulcerations, an
opinion cherished by some of our very first obstetric physicians.
The only complication which requires no treatment before the
application of a pessary is simple hypertrophy of the womb.

The most efficient remedies for treating these ulcerations are
nitrate of silver, acideum pyrolignosum, scarifications, removal
with the knife of the callous edges, fomentations with lead-water,
slight cathartics.

The ulcerations of the vaginal waUs are of a very intractable

; they ere never benefited by the application of canstics,
•acU as nitrate of silver ; scarifications repeated every third or
feurth day, and the applications of acid— pyrolignosum answer
iuch better. They often require twelve or eighteen months'
treatment before a snEBciently firm scar has been attained. The
idcerations seated in or near the cervical canal must be healed up
(kt least as far as they spread over the lips) before a pessary can
be introduced, while the treatment of the intra-cervical ulcera-
tions may be continued afterwards with the speculum. It must
sever be forgotten, that all ulcerations which are touched by the
jjcssary will increase and make the use of an instrument impossi-
■We. Only in those exceptional cases, where the ulcerations resist
the most rational and persevering treatment, they may be covered
Kith a piece of soft and dry lint, and a pessary introduced after-
wards, and treatment continued intra-vagiuam. In those cases
Wbcro bodily rest can be resorted to, it is of great value for the
euro of ulcerations ; at any rate, in treating these affections, the
.greatest cleanliness must be observed, the parts ranst lie thorougii-
ly sponged after going to stool, and they must be covered always
with a clean piece of dry linen.

The nee of a pessary seems to bo connected with the greatest dif-
ficulty in those patients where prolapsus ia complicated with both
iypertrophy and flexion of tJie womb.

Ia the very first days of its application violent back-ache, a
IKnsation of bearing-down and prolapsus of one of the vaginal
Tails make their appe-arance. When examined, the body of the
retroflected uterus is found very painful, and ulcerations appear
on different places.

In these cases it is & good plan to elevate the retroflected
womb by the uterine sound, thus fixing it towards tho promontory.
Tlien a pessary may be introdaced and aiisolute rest recommended
for some lime, if this is not sufficient, t!ic only means left, is to
introdnce a soft sponge behind the cervical neck, which, in many
does retain the prolapsed womb in its position. The sponge
lias to be removed, cleansed, and reintroduced daily for some
weeks before another application of a pessary may be tried, which
•t first must be applied in connection with the sponge. By a
•trict and indefatigable adherence to these rules, a pessary is
'finally endured without any inconvenience.

After a full consideration and treatment of the diflferent com-

plications, it is of the greatest importance to choose the right
kind of instrument.

The requisites of a good instrument are as follows : 1. Itmu st
retain the womb in or near its natural position. 2. It must
neither irritate the womb nor the vagina. 3. It must not inter-
fere with the patient's moving .round, sitting, or excretion of
urine and fasces. 4. It must be composed of a substance, which
resists the corrosive influence of the secretions from the genitals.
5. It must be constructed so as to be easily introduced, removed
and cleaned by the patient herself. 6. It must be as cheap as
possible.

The diflferent pessaries may be divided into two sections, viz.,
those which support the womb directly, and those which support
it indirectly, by elevating the vagina. Until late years, only the
former class was exclusively applied, as this idea most naturally
suggested itself at first sight. They are divided again into stalked
and unstal/ced. Both are intended to give a direct support to the
fallen uterus. Later researches seem to show that the chief and
most natural support of the uterus was presented by the vagina,
and in this view surgical operations as well as instruments were
invented, and, as it seems, successfully applied for the cure of
prolapsus.

The first man who clearly followed this indication in construct-
ing his pessary, was Prof. Kilian, in 1846, and he called it
elytromochlion — i. «., vaginal supporter.

His instrument consisted of a thin,
steel spring, four inches long, the points
of which ended in wooden buttons, and
the whole of it was covered with a
thin layer of india-rubber. In introduc-
ing the instrument, the ends of it are
approximated to each other as much as
is required for its easy introduction
into the vagina.

In applying it, it must be elevated in the direction of the lateral
diameter of the vagina, while its convex portion is directed
towards the anterior walls of the pelvis. The instrument thus
bent is gently pushed upwards, so that its points take a position
to the right and left side of the uterine neck, as high up as possi-
ble in the laquear vagince. ""

Although the instrument has been abandoned by the profession,
owing to the fact that very few women can bear the pressure
which it necessarily must exert, in order to sustain itself in the
vagina, the elytromochlion of Kilian has been applied in some
cases successfully, thus proving that the theory of its construction
was based upon sound principles.

In 1853, Dr. Zwank, of Hamburg, published the description of
his new hysterophor. It consists of two ovoid thin pieces of metal,
covered with india-rubber, or of wood, connected on one end by
a joint. In the neighborhood of this joint, on the external surface
of the wings, is a metallic pin, on each side two inches long, which
can be screwed together at the lower end.

Fig. 2. r«. 3.

In applying the instrument, the wings are approached as much
as possible (fig. 2), and introduced so that its convex portion is
turned towards the os sacrum, and pushed upwards, as high as
possible, towards the anterior portion of the laquear vaginae, in
front of the neck of the uterus. Afterwards the lower ends of the
metallic handles are compressed, and fastened by the screw
(fig. 3). In this position the instrument is retained by itself.

About the same time, Dr. Schilling, of ^Munich, invented quite
a similar instrument to that of Zwank ; the only difi'erence being,
that the movement of the wings is efi'ected, and can be regulated
by the screw at its lower end. The purpose of both instruments
is, to gently expand the lateral portions, and sustain the superior
wall of the vagina, thus preventing its inversion, and conse-
quently, the falling of the womb.

Dr. Zwank's instrument was received enthusiastically by the

profession in Germany. Such men as C. Mayer, Ghiari, Braun,
Scanzoni, Breslau, etc., thought it of suflficient importance, to pub-
lish their observations in favor of this instrument, and at the
present time it has actually supplanted all of its kind.

What is the reason of this ? Is it because the profession seized
upon the instrument, because it was a new invention ? Is it be-
cause an instrument was wanted? or has it fulfilled what it
claimed to do ?

The question which we propose to consider, is whether this in-
strument has any advantage over others hitherto applied for the
same purpese. It certainly has ; because, 1. It is lighter. 2. It
touches only a comparatively small circumference of the vagina,
and scarcely any portion of the womb ; thus preventing irritation
and ulceration of the vagina, incarceration of the uterus, fluor
albus, uneasy feelings. 3. It can be easily introduced and re-
moved, easily brought to its proper place, easily cleaned by the
patient herself. This is a combination of advantages, sought for
in vain among the host of previously-invented pessaries. On the
other hand, the hysterophors of Zwank and Schilling have some
disadvantages, owing to the substance of which they are com-
posed. The greatest number of them, as now in use, are covered
with a coat of vulcanized india-rubber. The discharges of the
vagina destroy it in a very short time. After this has been done,
the metallic portions begin to rust and decay, thus irritating the
vulva ; the furrows of the screw at the lower end of the instru-
ment begin to crust, or the screw, if turned too firmly, cannot be
untwisted. Some patients have little dexterity, and do not know
how to manage the screw at all. An illustration of these facts 1
am seeing daily, in the case of a lady belonging to the first class
of society. She is the widow of a well-known physician of this
city, and has suffered from prolapsus uteri ever since her first con-
finement, many years ago. The most thorough examination is
unable to detect anything abnormal about her genital organs, ex-
cept prolapsus uteri. She has been under the very best treatment
of general practitioners and uterine specialists. Everything has
been resorted to, to effect a radical cure, and all kinds of pes-
saries employed, but in vain. At length, one of Zwank's pes-
saries was suggested. She has worn it now for a year, and is
perfectly satisfied ; the only drawback being the loss of the india-
rubber coating, and the rusting of the metallic skeleton.

In order to avoid these inconvenienceg, Dr. Eulenburg, of I
Coblenz, modified Dr. Zwank's pessary, and descriljcd his inBtm- f
mcnt in a short thesis, in 1857. It is made entirely of boxwood,
and its wings are a little differently shaped, viz. : they are slightly J
curved downwards at both ends, so that the lower side forma* i
concave surface. In consequence of this shape, the lateral J
branches closely adapt themselves to the inner surface of the I
ramos descendens ossiura pubis ; tlius presenting a kind of hook,
whidi gives a strong hold to the instrument when in the vagina.
Both wings move in the centre part by two joints, thus leaving a
hole in the raidille, throngh which the secretions of the vagina are
allowed to escape. Instead of the screw. Dr. Enlcnburg perfected
the opening and shutting of the wings, by means of an elastic
india-rubber ring, which runs in a channel around the body of tiie I
hysterophor, immediately below t!ie two joints.

By this contrivance, the introduction of the instrument is 1
greatly simplified, and as it shuts on its own account, by the elaa- j
ticity of the india-rubber ring, its application becomes very easy, i
tiins requiring not the least ingenuity upon the patient's part!
(see figs. 4 and 5}. As every particle of metal is avoided (except I
the small pin, running through the joint), and as the boxwood re- 1
sists more than any other substance the corrosive influence of the 1
vaginal dischai-ges, it is lighter, will keep longer, and will cause '
less irritation than the other instruments.

The author Yoond four different sizes, filling to the greatest
nnmber of cases, viz. : for the measure from side to side, 2%",
3", 3j" and 31". and correspondingly the largest autero-postcrior

• 4C

diameter of every wing, 1" 3'", for the two largest sizes, and for
the following, 1" 4'" and 1" 5'".*

The first application of the instrument ought to b6 performed
by the physician himself, who has to choose the size required for
every case. His judgment will be conducted by the sensation of
the patient, after walking to and fro for awhile, and more so by
the way in which the india-rubber ring contracts. If the extra-
vaginal portion is not shut entirely, the instrument is too large, and
has to be removed ; if it shuts too quick, a larger one must be
chosen. The following duties devolve upon the patient herself,
viz., removing and cleaning it at bed-time, and readjusting it
before getting up in the morning. This is performed by seizing
the buttons at the lower end, and while separating them from each
other, as much as possible, the other end of the instrument is
to be gently introduced into the vagina till it cannot go any fur-
ther ; and (when left alone) now it shuts on its own account. The
same way is followed in its extraction. Before its introduc-
tion, it ought to be well oiled. In order to render this pessary
even more harmless, it is advisable to cover its branches with a
kind of glove, made of soft deer-skin, which coat may be moistened
with cod-liver oil before every application.

Of great importance is the breadth and direction of the pubic
arch, because this is the chief guide for the selection of a pessary.
It can be ascertained by introducing the second and third fin-
ger behind the arcus and expand both fingers till each of them
touches one^side of the arcus. The distance of the fingers thus
obtained may guide our judgment in the choice of an instrument.
As a general rule it may be stated, that a comparatively small
instrument ought to be tried first, because it very often happens,
that even the most extensive prolapsus is benefited by small
instruments.

After the instrument has been closed, the patient must be ques-
tioned as to what her sensations are. If the instrument was too
large, a singular kind of smarting is perceived and considerable

• The instrument has been modified in the construction of the joint after my sug-
jgestion, so that the pessary can be easily taken in two lateral pieces, thus allowing
u more thorough cleansing, while even the small metallic pin of Dr. E.'s pessary is
Avoided. Sold by G. Tiemann & Co., No. 63 Chatham Street, New York. Lately
Mr. Russel has modified for Dr. Savage, of London, Mr. Zwank's instrument, in such
« way. that the metallic screw is avoided, and from a sketch of it in the Medical
times and Qazetie^ wo should think that the modification is a very happy one.

tmimsmees expressed. It is a good plan to have the patient walk
around, in order to ascertaia if the prolapsus will be perfectly |
retained by the instrnmcnt, |

Even in cases where the perineum has been ruptured, onr inatrn- j
ment has been used with perfect success ; the only precaution to be
token, ia the choice of a broad pessary. j

On the eecond day arter the application of the instrument, the i
patient must be aeen again by her attending physician, because at
this time generally certain symptoms occur, which originate from
the presence of a foreign body in the vagina, and wliich prove, if
they art very intense, that the instrument is too large.

The symptoms alluded to, are a chilly sensation, heat, headache,
trembling, nausea, want of appetite, obstinate constipation. The
iostrn meat must be removed, and the vagina must be examined
witli the speculum, to see if a portion of it is inflamed or ulcer-
ated, a condition always met with, if the instrument chosen was
too large. After ihe third day is over, chills and heat are very
trifling, and disappear entirely some time afterwards.

If the instrument ia borne after some days with no discomfort
at all, the patient must bo tauglit how to use it, and must repeat
the manoeuvre of adjusting and removing it several times in tlie
presence of the physician.

At the time of the monthly courses, the patient had better have
the instrument removed, provided she can keep quiet. At times
it happens, that a portion of the anterior wall of the vagina falla
beneath the pessary. In this case, a broader instrument must bo
chogen, or a small piece of plugged linen must be placed in the
midet of the instrument, corresponding with the prolapsed portion,
which is easily retained by this contrivance.

In recommending these instruments, and especially the latter
one, to the consideration of tlie profeasion, I am sustained by the
experience of our European brethren, who have used them with
Buch general satisfaction, that scarcely any otlier form is now in
ase. Lately Dr. A, JIayer, of Berlin, has published a paper on
the use of Zwank's pessary, wherein ho reports to have suceess-
fuUy applied it in two hundred and thirty cases. For my own
pari, I avoid the use of pessaries as much as possible. But I have
had under my care a number of cases, in which a pessary was the
only means justifiable. I have tried a great variety of them, and
have now come to tlic c6nc!usion that Zwank's (or Eulenburg's)

hysterophor answers better the requisites of a good pessary than
any other.

I, therefore, ask practitioners to give it a fair trial. I do not
mean to buy a hysterophor, and sell it to the next woman with
prolapsus uteri, but after carefully selecting the case, in which
nothing but a good pessary will give sufficient satisfaction, let the
di£ferent sizes be tested, until the proper instrument is found.

ARTICLE IV.

A CoTUribtUion to the Pathogenesis of Uterine Polypi, By E.

NOEGGBRATH, M.D.

Mrs. Fischer, of New York, apparently a healthy woman, was
delivered on the 12th of July, 1858, of a strong, living child, after
a short and easy labor. She was attended by Dr. Rupprecht, to
whom I am indebted for the history of this case. Soon after the
child was born, the placenta was found lying in the vagina, near
the OS externum, and removed without the least difficulty. The
doctor left in about an hour, but was scarcely at home, when he
was summoned back to the patient in haste, as the woman was
"swimming in blood." On his arrival, the haemorrhage had
already ceased spontaneously, the uterus was found well con-
tracted, and as nothing seemed to indicate any farther appre-
hension, the patient was quieted, and stimulating drinks ordered
to be taken.

During the following days everything proceeded as well as
could be expected, secretion of milk and lochial discharge in the
best condition. At about the ninth day after this, the woman re- ,
marked another show of blood, which, however, did not seem to
be serious enough, to call for actual treatment. A strengthening
diet, combined with the use of tonics, was recommended, and suc-
cessfully so, as the discharge diminished, while the patient was
gaining strength. But this condition did not last very long.
After a lapse of four days, the blood began to flow anew, and in
such quantities, that it occasioned serious apprehensions. Under
these circumstances. Dr. Rupprecht insisted upon a thorough ex-
amination of the parts involved ; on passing his forefinger into
the vagina, he detected a large tumor filling the entire space of
the vagina. This body was of the size of a large hen's egg, per-

fectiy smootb, round, aud somewlmt flatteDod on its upper ex-
tremity, where it was firmly attached to the anterior lip of the
Taginal portion. This attachment was so firm, that by moving
the tumor, from riglit to Jcft, the entire uterus was displaced side-
irays. This esaminatiou, although performed with the greatest
care, produced on alarming increase of the Lajmorrhage, From
these symptoms, and his examination together, Dr. Rupprccht
concluded that she was sufTering from a polypus of the womb,
Thich ought to bo removed as early as possible. He accordingly
prepared to perform the 0|>eration, with the assistance of Dr.
Ifichaelis, who agreed with Dr. R.'s diagnosis. But the patient
insisted upon calling in a third physician. Consequently, Dr.

P met them, and after examination, declared that tho case

3 not one of polypus, bnt inversio uteri. But as neither Dr.
Eupprecht nor Dr. Michaelis coincided in this opinion, it was de-
eded to hava Dr. Krackowizer's opinion. The latter gentleman
began his examination with the forefmger, to which he added the
third finger, in order to circumscribe more easily the entire sur-
&CC of the protruding mass. He found that the lower surface of
both uterine lips was imbedded in the tumor, and he confirmed in
every other respect, the results of Dr. Rupprechts examination, as
given above. In the process of examination. Dr. Krackowizer
directed his fingers ao that they held the vaginal portion be-
tween thera ; and when pressing downwards upon the polypus, he
iftad the sensation as if something yielded, which induced him to
increase the pressure, when suddenly the polypus separated from
hits place of attachment, and was easily extracted from the vagina,
.after which the hemorrhage ceased entirely.

The polypus was removed on the morning of July 25th, and I
Ukd occasion to examine it on the same day at three o'clock, P.M.
»of a spherical form, its longest diameter being about 2J".
tre mass was perfectly smooth, and seemed to be lined
^ _ i proper membrane. The continuity of this membrane was
tokea at the lowest scctio'n of the tumor, and on this portion a
(deft i" long could be observed, which, running from right
partly disclosed a fibrous, bluish-white heterogeneous
Bobelance, which, upon closer examination, proved to be an ob-
literated blood-vessel. The upper aspect of the tumor, instead of
being soiooth tike tho rest, showed an irregular, rugged surface
^^b its middle portion, of about the size of a fifty cent piece. This

place looked very much like a fresh granulating ulcer, and was
undoubtedly the seat of adhesion with the uterus. The entire
mass was solid, and as hard as the normal uterine tissue. Upon
dividing its deeper portions with the knife, it offered the color
and consistency of muscular tissue, now and then interspersed
with lighter tendinous stripes, which ran in every direction.
We were altogether at a loss what to make out of this tumor, and
it was left to the microscope to throw suflficient light upon its
true nature. For when a small section of it was examined, it be-
came evident, that the whole mass consisted chiefly of shriveled
tufts belonging to the chorion. And, consequently, the polypus
before us, was nothing but part of the placenta. We must add,
that the tumor was entirely free from any offensive smell.

From the history of the case, it appeared not only that the
physician removed the afterbirth without the least obstacle, but
that it had already descended into the vagina, when its removal
was attempted. This circumstance, as well as the regularity of
its shape, induces us to believe, that the tumor in question, was a
so-called placenta-succenturiata. The time when this placenta
was detached from the cavity of the womb, must have been imme-
diately (one hour) 'after delivery ; it was preceded by a sudden
and violent haemorrhage, which ceased spontaneously. This symp-
tom is always observed in cases where portions of the placenta
or the membranes are retained in the womb, as every accoucheur
will readily admit. After the mass had left the uterus, no
haemorrhage ensued until the ninth day. This was the time
when relinion with the uterus was completed, and the oozing of
blood, which, set in now, was caused by the same circumstance
that causes the bleeding in cases of genuine uterine polypi.
That this adhesion with the womb was not a mere agglutination,
but an organic union, is proven : 1. By the fresh condition of
the corpus delicti. It is well known that no substance under-
goes putrifaction more readily than the detached placenta,
especially when deposited in the vagina, where it is in free con-
tact with the atmosphere and the vaginal discharges. 2. By
the smoothness of its surface and the rounded shape, an attribute
proper to living organic tissues. 3. By the appearance of the
granulated part on its upper plane, which might be compared
with the raw surface of a tumor just removed by enucleation or
torsion. 4. By the bleeding following upon its being touched
with the finger. . .

We therefore conclude, that this is an instance of migration of
a placenta-succenturiata from the cavity of the womb, and re-
attachment to its vaginal portion, with a tendency to be trans-
formed into a uterine polypus. If the case had not been so
promptly attended as it was by Dr. Rupprecht, if only its chief
symptom, the bleeding, had been treated, as it is done too often
under similar circumstances, the patient would have at the present
day a polypus uteri, which, detached, perhaps, after a lapse of
years, and removed with the knife, would not excite the least
interest, the minute circumstances connected with the history of
the case being lost and forgotten. Although not a few cases are
recorded in our literature of placentas remaining in organic union
with the uterus, we think that the observation just laid before our
readers, is unique in its way, and may perhaps serve to' throw
some light upon the pathogenesis of uterine polypi. *

ARTICLE V.

Invagination of the Colon Descendens in an Infant, with Repeated
Hemorrhages in the Colon Transversum* By A. Jacobi, M.D.

brvAomATiON of the intestines, from a merely anatomical point
of view, is not a rare occurrence. Before and in the moment of
death, the paralysis of the muscular tissue of the intestines pro-
gressing by degrees and sometimes unproportionally, invaginations
of the jejunum and ileum are very frequent ; indeed, so much so,
as to be a very common result of a great many post-mortem exam-
inations. The same alteration is not of the same frequency in
the living, but wherever it occurs, it is generally known to be a
dangerous disease. It occurs, in almost all the cases, in the
jejunum and ileum, the intestina crassa being as it were exempt.
The reason why this is so, is : 1st, the vast development and con-
siderable strength of the muscular fibres of the intestina crassa ;
and 2d, their firm adhesion in the fossa iliaca. Now, in very
young children, neither of these things are found ; in them the
muscular tissue of the colon is not very much developed, nor are
there strong adhesions in the fossa iliaca. Therefore it is only
natural, that there should be, in infants, cases of invagination of

♦ X".

New York Journal of Medicine^ May, 1858.

the intestina crassa, so very unusual in older children or in adults.
Nevertheless, there are not many observations of such cases, and
the literature of the subject is very poor, so much so, that a number
of even the best manuals on diseases of children do not mention it
For this reason the profession is under the greatest obligation to
Rilliet, who collected more than a dozen of well-authenticated
cases, and described the disease in so masterly a manner as only
Billiet and Barthez are able to do. And for the same reason I
think it important to relate the following case of invagination of
the colon descendens, with its peculiar complication with enter-
orrhagia, in order to establish if possible the exact diagnosis of
this dangerous disease by comparison.

Oase. — D. S., a robust and vigorous boy of seven and a half
months, was always lively and- healthy from his birth. The only
trouble, for T^hich now and then medical advice was procured,
were slight broncho-catarrhs ; and the only thing remarkable in
the external appearance of the child (being apparently brisk and
healthy), was an uncommon paleness of the skin. Being exclusively
nourished by breastmilk, he never once suffered from disorders of
digestion, not even at the time when the first two lower incisors
made their appearance. No particular alteration in the state of
his general health was perceived up to the 1st of March, 1857, on
which day, towards evening, the child began to grow restless and
troublesome, crying all night and seeming to be feverish. This
symptom being the only one to be perceived, it was not much
thought of, particularly when the child, towards morning of
March 2d, fell asleep and rested for some hours. About 9 A. M.,
the same day, he had an evacuation of the usual quality, after
which he again slept; three hours later, about noon, he had
another evacuation, with much pressing and straining, no faeces
coming from him, but only some serous fluid mixed with a little
blood, of red color. This symptom causing some alarm, I was sent
for, and found, at 2 o'clock P. M., the following status prasens :
Last normal evacuation at 9 o'clock A. M., first bloody one at 12,
second bloody one at 1 P. M., of just the same quality as the first,
with only a sign of faeces. The child is pale, but not more so than
usually ; looks uneasy, without having a particularly timid or anx-
ious expression; cries aloud, in a fierce and abrupt manner from time
to time, as from colic ; the temperature of the surface in general,
and of the head and extremities in particular, is normal. The

abdomen is soft to the touch ; there is nowhere a swelling to be
felt; no pain effected liy pressing ; percussion yielda the common
Ij-rapanitic sound. Pulse 100, somewhat small, but rhythmical.
The child has not taken any food for the last four or five liours
and haa not vomiled. 3Iy diagnosis, after the foregoing symptoms
and results of examination, being merely syroptomalic, a dose of
calomel was given ; the prognosis being sufBciently favorable.

March 3, 9 o'clock, A. M, — The child is much changed for the
worse J he is paler than ever, cheeks hollow, eyes sunk in tho
orbits ; he looks timid, anxious, restless ; cries often, but in a low-
er and more languid voice, and his extremities move in a much
less Tiolent manner than yesterday. Neverthelcaa, there is no
cliftnge in the general appearance of the patient, akin and circum-
ference of the extremities have not lost their former appearance,
and the embonpoint does not seem to be diminished. Abdomen is
soft to the touch, and without pain, when pressed, neither inflated,
nor sank. Only there is, in tlic left inguinal region, immediately
above the S Romannm, a swelling offering aome resistance to the
linger of a longitudinal form, of about one and a half inches, and
a lateral width of about one inch, which was not discovered there
the preceding day. Nowhere in the colon could another patho-
logical altei-ation be found, particularly not in the ileo-coecal
rc^on. No faicea have been ci^acuatcd since yesterday, but there
have been from twelve to fourteen passages consisting each of a
drachm or two of seroua fluid, some tliree or four of them being
colored with ha^matine ; all of them being accompanied by pain-
ful straining and pressing. The child began last night to throw
up everything he Bwallowed, prettysoon after having taken it, and
coiilinued vomiting, for ten or twelve times, through botli the
aight and the following morning, bringing up nothing but some
mucosand hilc. Always, after the child threw up, or evacuated
his bowels, he seemed more languid, anxious, and nervous, liia
nervouancsa increasing in proportion to his weakness. He doea
not seem to bo very desirous of drinking. His tongue is nioiat,
slightly covered with some white mucus. Pulse 120, very small,
but riiythmical. — Diagnom : Invagination of the lower part of
the colon dcsccndcus. — The treatment consisted in the immediate
and repeated injection of warm water, in order to relieve, if pos-
sible, the obstruction of tho intestine, by pressing the invaginatcd
piece out of the lumen of the bowel. Every effort proved unauc-

cessful. The insufflation of the bowels, for the same purpose, was
resorted to, and continued for a long while, with no better success.
Both the injected water and air returned from the rectum at the
moment the injections were being made ; the intestine filling with
water or being inflated with air exaclly as far up as to the place
where the swelling could be felt in the left inguinal region. Only
once did I believe that a small stream of air passed the invagina-
ted bowel. It has been observed in many cases of invagination,
that some gas escaped through the obstruction. I then left the
child, who was to have a warm bath and some doses of Hydrarg,
mur. and extr. hyosc.

4 o^clock, P. M. — There is no material change. The child looks,
if possible, more anxious, with a particular expression of his
features, sometimes of nervous excitement, sometimes of total de-
pression ; temperature of the head and extremities normal ; thirst
increasing, pulse 130, small, contracted but regular. Patient
vomited frequently since the forenoon, from twelve to fifteen times,
and had about the same number of evacuations, which were even
less bloody than the preceding ones ; almost wholly consisting of
a serous fluid. I think the amount of blood excreted in all the
passages for the last two days, did not exceed one drachm. The
same treatment as before was resorted to, but proved just as un-
successful.

10 o'c/ocAr, P. M. — I saw the patient, in consultation with Dr. H.,
who recommend ol. crot. in large doses, in order to have the ob-
struction removed at all events. Besides, injections of warm water
and air were resorted to again and again, but all our efforts
proved wholly ineffectual in overcoming the obstacle. The patient
was in about thfe same condition he was in the afternoon, only
more depressed in his strength, his motions being slower and
sometimes as it were tired, and his voice sounding duller and
lower than before. The eyes deeply sunk in the orbits ; the
cheeks hollow ; pulse 136, smaller, but always regular. Vomiting
occurred only four or five times since the afternoon ; bowels
evacuated about as many times a serous and mucous fluid, without
blood. Fecal matter appeared in neither of them ; no sign of it was
ever brought up by vomiting ; only once there was a slight tinge of
greenish color in the passage, which I felt at first inclined to con-
sider as produced by the repeated doses of Hydrargyrum.

March 4/A, 9 o^ clock, A, M. — JVb more vomiting has occurred since

kul night, bat the bowels excreted some five or sLs limea the Hsrae se-
rous fluid, which had, this time, the smell of bloodaorura undergoing
dissolution. The child is sinking rapidly (although the body docs
not lose very much), and is anxiously looking around for help ;
the pulse IB becoming smaller and weaker, 140 ; thirst increasing.
The general condition of the patient remained the same during
tlie day, the treatment being, as above described, repeated several
times witliout giving the least relief. JVb more vomiling.

March 5th. — The last day did not bring any particular change
iu the course of the disease. JVo vomiting occurred, nor were
evacuations of the bowels so frequent as on the previous days, nor
was there blood contained in them. Hands, feet, legs, became
cold, pulse 150, 160, small, contracted, at last scarcely to be felt.
No loud crying was any more poaaible, only a whimpering heard
from time to time. AH the while the abdomm was painless, only
very Iiltle tympanitic. The eyes were so much sunk into the or-
bits and the cheeks had become so hollow that it would have been
impossible to recognize the child. During all the periods of the
^ease, the little patient was conscious of himself, and an anxious
observer of what was going on around him : looking around for help
as if knowing that every ono was engaged in trying to relieve him j
sometimes depressed by his rapidly increasing weakness, sometimes
disturbed by a sudden nervous excitement, sometimes troubled by
the often repeated excretion of some drops of serous fluid from the
bowels. Finally, conscious almoi^t to tlie last quarter of an hour,
Ujo patient 6nished his four days' dying shortly before midnight.

Post mortem examination, March &th, 10 o'clock, Jl. M. — Only the
examination of the abdomen was allowed. Rigor mortis. No
unusual number of hypostatic spots on the back of the corpse. *3
grtat difference is perceptible beluxen the general appearance of the
Jace and the other ports of the body ; the face being extremely thin,
the eyes deeply sunk in the orbits, and tlio subcutaneous fat of the
checks gone, the rest of the body pretty nearly retaining its usual
and normal roundness and fullness. The abdomen is not very
mucii inflated with gas ; percussion yields a tympanitic sound ; to
the touch it is equally soft on all parts, only a slight swelling as
described above among the symptoms of the disease, in the left
inguinal region. After tlie integuments were opened, the follow-
ing appearance presented itself: Stomach normal, without con-
tents : the Jejunum and ileum moderately inflated with gas, very

few contents in them. The colon ascendens normal, the ileo-
coecal valve shows nothing particular. The flexion between
colon transversum and descendens not so manifest as it ought to
be, being more a spherical curvature than a right angle. In the
lower part of the colon descendens just above the S Romanum, a
piece of the intestine has dropped, or is introduced into the next
lower one, constituting a simple invagination of the colon, which
was probably prevented by the S Romaimm from growing larger
than it is found to be. As usual in such cases, there is no difficul-
ty in removing the invagination and bringing the several parts
into their normal proportion. On the upper flexion of the in-
testine, where the invagination is beginning, there is a manifest
hyperaemia, on the lower flexion ; inside the invagination, there is
extravasation of blood between the membranes.

The colon transversum shows the following remarkable appear-
ance : In its middle part, hanging down from the upper wall,
there is a purely fbrinous coagulation^ of a diameter of somewhat
more than a third of an inch and two inches long, between the se-
rous and the mtumLS membranes of the intestine, the muscular tissue
being wholly destroyed ; the whole offering the clear signs of an
extravasation having occurred long ago, of which nothing was
left except the fibrine. Next to it there is another fibrinous co-
agtdum of the same size and nature, with the exception, that it
appears, from some pieces of coagulated blood being still attached
to it, and from its not being so hard and dense, somewhat kss old
than the former one. Third, there is a coagulation, not fibrinous,
but really bloody, of fresh appearance, but firm and dense. The
mucous membrane, which had been extended by the two former haem-
orrhages, of which the fibrinous coagulations have remained, has
been broken and lacerated by the third one. The last coagulation
obstructs entirely the lumen of the colon, its walls being extended by
and closely adhering to the fibrinous and bloody contents. It is
evident, that the last extravasation was sufficient to shut the colon
up, after it had become more and more narrow without injury to
its functions, by its former local haemorrhages.
. The results of this post-mortem examination do not fully agree
with those which Rilliet tells us are found in the majority of cases.
In most of them the invagination was of a larger size, because in
another part of the intestine. They mostly occurred in the colon
ascendens, and, there being no hindrance to their further dcvel-

opment, tnlai^d to sucli a size, as to implicate, eometimes, the
vliole colon between the ileo-coecal valve and the S Romanum, in
Soch a manner, that the flexures of the colon had wholly disap-

mred and the ileum seemed aa it were to immerge directly in the

Ktum or the lower end of the culon descejidcns.

* From this the positive statement of F. Rilliet (E. Barthez and
'. Rilliet: Manual of the Diseases of Children, vol. 1, chap, xiii.^

., 1). that in no age whatever can an invagination occur without
fte lower end of the ileum being the guiJe of the invaginated
nndle. is evidently not in conformity with the facta, and is a pre-
Mtnre esaggeration.

* The invaginated portion, in the majorily of Rilliet's cases had a
irk red color, particularly the serous membrane ; the mucous

icmbrane participating in the inflammation and congestion and
fcred with dark blood and mucus. In one case there was only
I limited hypera-mia and extravasation, although fully corrcspond-
mtg with the small extent of the invagination, the enlargement of
Fbich was apparently kept back by the normal iropcdiraent given
f the fltTura Uiaca. It is generally stated, that in many cases
1 invagination of even a considerable extent cannot be felt dur-
t life ; 80 much the more remarkable is the case above described,
I which the anomaly, although small, was discernible by the touch
lOn after its occurrence.

A highly interesting feature in the whole nnmber of facta re-

lalting from the post-mortem examination, and not even thought

r during the life of the patient, is the condition of the colon

Rtngversum. From the fjuality of the coagulations between the

bltestinal membranes, it is impossible to consider them as fresh

rodnctions ; besides, no opening of a bloodvessel could be found,

r which the hemorrhage could have taken place ; weeks must

■'ilAvo elapsed, since, tit different times, fhrinous coagulations were de-

The last hemorrftagc was a fresh one, since it obstructed

Sie whole lumen of the bowel and was able to lead, by itself alone,

to death. It is not the least interesting fact, amongst all the fore-

Ijjoiig once, that the extravasated blood etag^ated so rapidly, as not

D aHaw a drop or even the color of blood to escape' into the hitesfine be-

n ifif place of hemorrha/^e and the inva^nation, not to speak of

mall quantity of blood excreted by the passages, after the in-

^nation had occurred.

As to the symptomatic importance of either the obstruction by

«8

hemorrhage and the occlusion by invagination, there can be no
doubt, in my opinion. I do not hesitate to sav, that the symptoms
of either of these anomalies, during life, must and would have
been tliQ same, if only one of them had occurred ; for the general
effect of either of them, as well on the lumen and function of the
intestine as on the whole system must be equally destructive. Of
some diagnostic importance is the fact, that, although the coagu-
lations in the colon transversum were firm, solid, and as large as I
have described, at all events a great deal larger and more solid
than the invaginated part of the colon descendens, this one was
soon discovered, while the former one could not be found, neither
by repeated palpation nor percussion ; this is a fact, which cor-
responds with Rilliet's remarks on the difficulty of findings some-
times^ even large and solid invaginations in the living subject. The
question arises, which of the two, tlie invagination, or the ob-
struction of the colon by hemorrhage, occurred first. In my
opinion there can be no absolute certainty about the answer ; but
the following remarks may, perhaps, be thought sufficient to eluci-
date the subject. It is a fact, that two local hemorrhages occurred
a long time before the invagination took place, and on the same
spot, where the third and last one was to occur later ; I do not
feel enabled to say, whether there was a local predisposition to
hemorrhage in only one blood vessel, it being too large or too
thin, or abnormal in some other way ; or if there was a general
disposition, in all the internal organs of the child, to hemorrhage,
which resulted, perhaps, from a comparative hyperemia of the
abdominal organs, corresponding with the continual paleness of
the child, while robust and healthy. A further fact is this, that
the invagination occurred below the bloody obstruction of the
intestine, and it is highly probable, that after the hemorrhage oc-
curred, the muscular motion below it would have been, if not
stopped entirely, at least diminished. If, on the contrary, the
invagination had taken place above the hemorrhage, there would
be more probability of the former having been produced by the in-
crease of the anti-peristaltic movement of the intestine. As the
facts are, I am rather disposed to say, that the invagination was the
primary abnormity^ and the cause of the small quantity of bloody
discharge excreted through the anus ; and that the hemorrhage, to
which a predisposition was clearly present and cannot be well de-
nied, ensued as^soon as a strong anti-peristaltic motion of the mus-

£9

Jllar tisane of the intestine set in. Tlierc are, then, two different

luses of death, both almost equally dangerous; both likely, with

I same symptoms in the living subject. Finally, I have no

|oubt, that had no invagination occurred. probably tlie third hem-

rrhagc would have occurred a short time afterwards, and led to

II death, under the same or similar symptoms as the ones re-

|ltcd.

As to tlie pymptoma of the case reported, I have only a few re-

»rk8 to make, ae the symptomatology given by Rilliet is most

mpletc and able. His description fully corresponds with what

I liad occasion to relate. The only facts which, in my case, seem to

B worthy of particular attention are these : that, first, the thirst

f the child, which hag been said to be usually not extraordina-

Ijr, kept increasing in proportion to the duration, and to the ap-

roximation of the fatal end of the disease ; and second, that vom-

jfiDg, DCrcr bringing up fiscal matter, in opposition to what is

llways observed in cases of invagination in adulLt, stopped full

pro days before death, alUiough the post-mortem examination did

IDtgivo tlic least evidence of mortification, or even inflammation.

ARTICLE VI.
mOn the OxysvJpkuret of Antimony ax an Expectorant in Jnflammaiory
Dixcuesof the In faniiU Respiratory Organs* By A. JaCOBI, M.D.

The oxysulphuret of antimony, although mentioned by Basilius

Talentinus in the fifteenth century, was made known for tiie first

in 1654 by Glauber, who prepared it while operating on the

■etallio antimony. Although generally well known from that

mttie, there is scarcely another chemical preparation for which

Itaore different modes of preparation have been recommended, the

dicmical composition of which has been sought in more different

■VayB, and the pharmaceutical and medical reports on which are

various and even contradictory. Now, it not being our

(^lention to write a treatise on the chemical constituents uf the

iXTsuIpliuret of antimony, wc shall rest satisfied with merely laying

nfore our readers what we sincerely believe to be the best method

f preparing this remedy— one wc have largely employed in our

■iOv Tork Journal 4 Mt£txiu for September ISaS.

practice, and the results of which we are about to give to our pro-
fessional brethren.

The sixth edition of the Prussian Pharmacopma (1846) gives
the following prescription for preparing the oxysulphuret of
antimony : 3 pounds of common carbonate of soda are dissolved
in an iron vessel in 15 pounds of water, and are well mixed with
a pound of lime made half fluid by three pounds of water, with 2
pounds of the black sulphuret of antimony, and with 4 ounces of
flowers of sulphur. This mixture is to be boiled for an hour and
a half, the evaporating water being always compensated by filling
up anew. The remainder is again boiled with 6 pounds of water,
filtered and washed out with hot water. The fluid is made to
crystallize. The crystals are washed out with distilled water
which has been mixed with ^ij of potassa, and afterwards dried.
One pound of them is dissolved in 5 pounds of water, the whole
filtered and diluted again with 25 pounds of water. A mixture
of 4^ ounces of 8ulphui*ic acid and 8 pounds of water decanted
after refrigeration is then added. The sediment is filtered, washed
out with common water at first, and with distilled water after-
wards ; is [then pressed out between blotting paper, dried in a
dark place, in a temperature of 77° Fahr.. reduced to powder, and
kept in a dark, well-closed vessel.

We omit the description of any physical and chemical qualities
of this preparation, but give the analysis of Berzelius and H. Rose,
the best analytical authorities. Both of these declare it to consist
of 2 atoms of antimony and 5 atoms of sulphur (Sb^ S*), or of
61.59 equivalents of antimony and 38.41! of sulphur. It has been
called by Liebig the persulphide of antimony.

We have given in full the mode of preparing this drug, which
we make use of in our practice, for obvious reasons. The princi*
pal objection to the oxysulphuret bf antimony has always been that
it was so extremely liable to decomposition as not to be adminis-
tered with any degree of surety. It has been asserted that there
is always oxide of antimony formed in what is presumed to be the
genuine article, and undoubtedly it is very often found. Sulphur
too is formed, even in the shape of sulphuric acid, from decomposi-
tion induced principally by the influence of air and light. As to
the latter influences, and those of a similar kind, it is evident that
it is not the fault of the chemical preparation, if the conditions
necessary to its unaltered state are not given. Nitrate of silver

I BolnUoD, pra^ic acid, and many chemical Bnbatances reqnire
JJhe greatest care in preserviDg them ; nevertheless, no one ever
I Tcntui-ed to object to their administration in medical practice.
l-il ia truQ that great cure has to be taken in preparing our mcdica-
t ttent ; that it requires washing out finally in distilled water instead
l-|pf common water ; that it needs to be dried slowly at a certain
I temperature, end kept under peculiar external conditions ; it is
•ne, besides, that the many other ways of preparing it are unsafe
Rtod give rise to decomposition ; but after all, we see no reason to
> declare a substance to be subject to decomposition, if it can be
f proved that it is easily decomposed only when made by a wrong
Lpocess and kept under unfavorable circumstances.

Another objection to the medical use of the osysulphuret of

alimony has been, that it isBoluble in alkalies, and might undergo

composition in the stomach when the secretions happened to be

K|jbnormally alkaline. It has been asserted that it is decomposed

Vtoo by acids, however slight they be. Now, we are unable to see,

p|f indeed decomposition would easily take place, why a raedica-

r jBent ought not to be given for such a reason. If the secretions

L ^ the stomach are too alkaline, make them less so ; if acid drinks

I irill decompose your medicine, do not administer them. There arc

ft great many other medicines requiring the same and more pre-

KUtions ; it has never been urged as a reason against the medici-

E|ul use of the nitrate of silver, that its tendency to decompose,

■Itlier by the secretions of the stomach or by ingested food, makes

S unfit for internal administration.

Tha truth is, that tlie oxysulphurct of antimony has not been in
general use for a long time ; twenty-five or fifty years ago it waa
Ighly estimated, but the majority of writers at the present day,
»r to scarcely know of its existence. In order to show this,
B will give some literary notices, particularly such as have been
taken from authors on infantile diseases, it being our object to
mmanicate a few observations on the mode of operation of the
reysulphuret in diseases of children, and to recommend it for
[Airtber use. We will premise that we desire our readers to give
tbeir special attention to the dose of this remedy, it being our firm
WnvictioD, after a great number of observations, that the want of
s often complained of in its administration, and the want of
mfidencc in its power, is but the consequence of an entire mistake
B to the amount to be given.

Behrcnds administered one grain every two hours in the second
stage of pneumonia, when expectoration was deficient and strength
was failing, jn combination with camphor and benzoic acid. Jahn
gave one grain three or four times a day, in pulmonary catarrh,
with opium and camphor. Richter gave one grain twice a day,
in acute catarrh of the stomach, with tartrate of potassa, and two
grains twice a day, in chronic arthritis, together with calomel and
aconite. Brera employed a fourth of a grain every three hours,
in painful arthritic affections, with morphine. Lessing gave one
grain and a half three or four times, in chronic pulmonary catarrh.

From these quotations it is evident that it was impossible from
the manner of administering this remedy, in combination with
others frequently of the same class, to decide on its effects ; and
further, that the dose seldom exceeded one grain, and only in ex-
ceptional cases reached as high as six or eight grains in the
course of a day. It is, moreover, to be kept in mind, that such
are the doses administered to adults.

In looking over the literature of diseases of children, we find
as many negative as positive facts ; that is to say, there are as
many writers who do not even mention the name of this article,
as there are who recommend it highly. In the oldest paediatric
literature, even hi Nils Rosen von Rosenstein's work, the oxy-
sulphuret of antimony is not mentioned. Jahn (1803) says, it has
been recommended by some in hooping cough.

Henke gave half a grain twice a day, together with half a grain
of powdered herb of belladonna, in hooping cough. Tourtual
gave a quarter of a grain, with three grains of sulphur, three
times a day, in pseudo-croup, and the second stage of inflamma-
tion of the trachea. Dornbliith used a quarter of a grain every
three hours, in pneumonia of children of one year of age. Wendt
gave the same quantity, in the like disease, four times a day, to
children of from three to four years of age. Hinze gave half a
grain every two hours, with oxide of zinc and musk in hooping
cough. Meikisch, who wrote his " Contributions to the Knowl-
edge of the Infantile Organism" at about the same time (1825),
neither recommends nor mentions it. Wenzel (1829) prescribed
it in pneumonia, to a child of one year of age, a third of a grain
to be taken three times a day ; to a child of two years of age,
either half a grain four times a day, or a quarter of a grain twice
a day, or a sixth of a grain to be taken every hour ; in measles, to

It cbild of two years of age six doses of half a grain each, every
two hours ; to a child, one year old, twelve doses, of an eighth of
k grniD each, to be taken four times n day. Rau (1S32) considers
it to be a powerful expectorant, in a dose of a sixth or a quarter
of a Rrain, in infantile pneumonia, after the higlit of inflammation
'wad fever is over, and where the accuinulation of phlegm in the
%ronchia forbids free breathing. Mcissner (1832) mentions it as
D expectorant, but does not appear to espect mnch of its admin-
istration. After this period, the oxpulphuret of antimony is sel-
dom menlioned, and never so strongly recommended as before.
It is true, that Cruse (1S39) in his work on infantile bronchitis,
fpeaks of it as an expectorant, but he frankly states that he pre-
fers the anisated liquor of hartshorn.

Fuchs, in his monograph on infantile bronchitis (1849), merely
anentions its name, but as early as 1837, Seifcrt did not think
^yropcr to name it among his medicinal agenttt, in his monograph
4n tbc broncho-pneuraouia of new-born infants and nurslings.
Koreovcr, there is perhaps no manual on infantile diseases, of the
Iftst twenty years or more, which takes the least notice of it,
ifrliereby sufficient proof is given, that tlic recommendations of
3 of the earlier writers were not confirmed by the experience
'«f their successors. In the manuals of the following authors:
Tallcix, Barrier, Underwood, Colcy, Evanson and Maunsell,
filewart, Eberlc, Legendro, Dewecs, Hennig. Meigs, Condie,
iGfaurchill, Bcdnar, West, Rilliet and Barthcz, Bouehut, and Tan'
Kr, not the slightest mention is made of the effect of the oxysulph-
irct of antimony as an expectorant.

In tJie works of some of the latest writers we Cud similar re-
marks. Aulon, in bis collection of prescriptions, employs in
^eamonia of children of from eight to twelve yeai-s of age, a
qnarter or one-half of a grain. Joseph Schnoller, in his " Materia
Hcdica, applied to the Diseases of the lufantile Age" (1857),
while eayiug, that it is administered in long continued catarrh,
bronchial blennorrhoea, in croup, when the more dangerous symp-
toms are disappearing, in hooping cough, as a diaphoretic and
apcctorant, speaks of doses of an eighth or a quarter of a grain
I, to be taken three or four times a day. The pharmaceutical
ritera of the present day offer similar remarks; Schroff. of
^ienna. speaks of several daily doses of from a quarter of a grain
6 a grain each ; Schucbardt, of Gottingen, has from a quarter of

a grain to two grains, and allows even five grains in exceptional
cases. Oesterlen, of Heidelberg, whose doses are believed in
Germany to be generally very high, speaks of doses of from one
to four grains, to be given several times a day. Sobernheim recom-
mends a quarter or one-half of a grain, sometimes even one or
two grains, to be administered two or four times a day. All these
doses are considered to be normal doses for adults. While, then,
authors on pharmaceutics and therapeutics deem it their duty to
register anything that has been said on any pharmaceutical object,
pathologists of the present day, especially such of the last year,
as Wunderlich, Leubuscher, Niemeyer, either entirely overlook
this antimonial remedy, or have very little indeed to say in its
favor. Finally, from "Thomson's Conspectus of the British
Pharmacopoeias," seventeenth edition, 1852, we copy the follow-
ing notes on the oxysulphuret of antimony : " Operation : emetic,
diaphoretic, cathartic, according to the extent of the dose ; alter-
ative, used now only for forming Plummer's pill. Use : for
chronic rheumatism and obstinate eruptions. Seldom ordered.
Dose : gr. i. to iv, twice or thrice a day, in a pill." The " Dispen-
satory of the United States," eleventh edition, p. 929, pronounces
the very same opinion : " The precipitated sulphuret of antimony
is alterative, diaphoretic, and emetic. It is, however, an uncer-
tain medicine, as well from the want of uniformity in its composi-
tion, as from its liability to vary in its action with the state of the
stomach. It is seldom given alone, but generally in combination
with calomel and guaiacum, in the form of Plummer*s pill, as an
alterative in secondary syphilis and cutaneous eruptions, or con-
joined with henbane or hemlock in chronic rheumatism. During
its use the patient should abstain from acidulous drinks. Its dose
as an alterative, is from one to two grains twice a day, in the form
of a pill ; as an emetic, from five grains to a scruple."

From the facts thus selected from the authors of more than
the last half century, it becomes evident that there is a great
variety of opinions as to the operation of the oxysulphuret of an-
timony. While believed to be, at a certain period, a highly valu-
able remedy in diflFerent morbid conditions of the organism, or
inflammations of the respiratory organs, scrofula, rheumatism, arth-
ritis, blennorrhoea, diseases of the lymphatic glands, of the skin,
and of the pulmonary nerves, it has been again considered to be
80 valueless as not to attract the least attention from the medical

»•

writers of the last twenty years. We believe the reason may be
found in the fact we insisted upon above, that the majority of
preparations have been uncertain, because of their being badly
made ; and in the further fact, that medical practitioners followed
more the theoretical impression of the caution required by anti-
monial medicaments in general, than their own careful observa-
tions on the mode and strength of the operation of the precipitated
oxysulphuret.

Thus, what we are going to prove next is, that the doses given
have been incompetent and insufficient for any considerable result :
and that what is put down as the highest dose to be administered^
is scarcely proper to begin with even in the slightest aflFections.

It is well understood by our readers, that the larger doses of
one grain, etc., as above mentioned, are to be taken as the quanti-
ty allowed for adults. If these doses were to be reduced to the
proportion necessary for infantile diseases, we shall, after having
r^)orted our practice and the results of our doses, appear more
justified in saying that the difference of opinion and the want of
confidence is entirely due to the insufficiency of the doses admin-
istered.

Before making some general remarks on the indications, we an-
nex the subjoined list of cases taken from the journal of the chil-
dren's department of "the Gorman Dispensary of the City of Now
York,'' which, for the use of our readers, has the number on the
journal, the sex and age of the patient, the diagnosis, and the do-
ses of the oxysulphuret of antimony ; all the cases occurring in the
first eight months of 1858. We shall add some observations taken
from our private practice :

DiMMe.

Doee of oxpraulph. of

GoabiiMd vUk

Vr.

Ho.

Pneumonia, left, inf.

t >^ gr. every 2 bonrs.

4 days.
12 «^

" " rap.

I gr. 4 tinMM a day.

158

" bUat. Bup.

I gr. every 2 hours.

216

Hooping ooarii, cat.

Xgr.A time* a day.

265

H (t

IH gr-

EKtr. beUad. K P.

281

({ II

it II

290

II II

I )^ gr. every 2 hours,
i gr. 4 tiroen a day.

M (f

aoo

" pnenmo'a.

J gr.

811

Pneanumia, left, inf.
af^er meaxles.

IH gr.

Snlpb. ehia. X f*>

813

Hooping ciiagh, eat.

I gr.

EKtr. beUad. M fr.

826

I^eumonia.

?K gr.

Sulpb. ebin. )i gr.

855

" left, Bop.

i gr. «

870

Bronch, eat.

I gr.

807

11 ti

}i gr. every 2 houm.

4 days.

410

Hooping eoogb, eat.

! gr. 3 timt^ a day.

Eztr. beOad. K gr.

457

Hronch. cat

' H gr. every 2 hours

2 «

486

Hooping eough, eat.

I gr. 4 tiroes a day.

12 ««

Extr. bellad.l.6fr.

541

Broncb. and ga«tr. cat.

I gr. every 8 hours.

2 "

Sulpb. ebin. yi gr.

610

Brooeh. cat, eropbys.

■! W gr. 3 times a day.

6 "

628

Hooping oougb, cat

«Kgr.

8 "

Extr. beUad. }igr.

601

It 11 It

I gr. 4 tiroes a day.

6 "

Xgr.

700

Broncb. cat

I gr. every 2 hours.

12 «

826

I gr. 4 times a day.

061

Hooping cougb, cat. '
I'neumonia, Tefl, inf.

}i gr.

Extr. beUad. 1-6 gr.

1000

I gr. every 3 hours.

1134

Pneumonia, left, sup.
Ditto, Hooping cougb.

I gr. every 2 hours.

4 "

1144

I gr.

2 "
2 «
8 "

•

gr.
3 gr. 4 times a day.

Extr. beUad. J^gr.

1160

Rronebopneumonla.

2 gr. every 2 hours.

6 ««

1168

Pneumonia, b. cougb.

2 gr.

4 «*

1172

" right, middle.

3 gr.

6 "

1176

Hoop, oougb, br. cat.

1 gr. 3 times a day.

Kxtr. belUd. 1^6 gr.

1261

I^eu- right, nup., tub.

^K gr. every 2 hours.

4 "

Sulpb. chin, )i gr.

1870

Pneumonia, left

I gr. "

1373

Pneumonia, right, inf.

•2 gr.

Of this number two patients died ; one of pneumonia combined
with measles, the other of quite recent pneumonia of the inferior
lobe of the left lung, for which she had not been under treatment,
after her hooping cough subsided. All the others recovered.

Tlie general result of the dispensary was also obtained in our
private practice. We remember a great number of patients of a
year and under, who took a grain of the oxysulphuret of antimony
every two hours, oven every hour, without vomiting more than once
or twice, some without vomiting at all. The same occurred with
children of two or three years of age, who took doses of two grains,
four, and even si.x or eight times a day, without showing any oth-
er result than the desired one. We recollect the case of a boy of
two years four months of age, in the basement of No. 158 Leonard
street, who while suffering from a severe double pleuro-pncumonia,
after having for a while taken somewhat smaller doses, took for

fcur days, either a dose of two and a lialf grains erery hour, or of
five grains every two liours ; lie did not vomit more than once,
and that easily, in twcnty-rour hours, and did not show more than
& trace of the doaes in tlio passages, of wliich he had one daily,
before the end of the second day. The pathological alteration of
the lungs and pleura was such, that the prognosis was unfavorable
from the beginning ; but the purpose of the administration of largo
doses of the remedy was readily accomplished as tiie patient, in
tensequence of his easy and copious expectoration, avoided the
death of suffocation.

A boy of six months of age has been under our earo for the last
ireck, who has taken, every other hour, a dose of a grain and a
half, while in the second stage of pneumonia of the loft lung. It
ll true that the infant vomited after the first four doses, but he did
liot feci the worse for it ; only on the third day of his taking the
lemedy it would be found in the passages, which were not particu-
Ivly changed from their general norma! appearance. When, in-
deed, children arc vomiting after the first, or one of the first, doses
of tlie medicament, we do not see any harm in it ; the bronchial
Kcretions cannot bo removed in a quicker and generally safer man-
.aer.

We omit giving further special reports on individual cases ; tho
liscascs wc refer to are so common as to be the daily anxiety of
^ery practitioner ; and ovory one will he capable of proving tho
Accuracy of our observations, and the truth of our remarks very
|»eedily. After the favorable results above reported, by means of
irge doses of the oxysulphurct of antimony, we trust the profos-
bn will resort to larger doses, and thus again introduce into thoir
rnctice a long- forgotten remedy.

But it cannot be too strenuously urged, that the indications for
IBic use of this medicine in inflammatory diseases of tho infantile
itttspiratory organs, ought not to bo overlooked. Whoever con-
tends against the fever of the first onset of pneumonia with the
'Qxysnlphuret, will feci sadly disappointed as to the final result.

Whoever treats' acute bronchitis in the same manner, will soon
become aware of his mistake. Its operation is only to liquefy
the secretion of the mucous membranes of the respiratory organs.

We think it may bo well compared to the preparations of mer-
cury ; in tho same manner as those effect the liquefaction of plas-
tic exudations and alter the plastic quality of the blood, the osy-

sulphuret of antimony effects the liquefaction of the secretions of
the mucous membranes of the respiratory organs. How this is
done it is impossible to determine. At all events some eflfect on
the respiratory nerves is also produced, and possibly much of the
result is the consequence of their altered functions. How far, be-
sides, the mucous membranes of other systems are subject to the
operation of the medicine, our experience does not fully enable
us to say.

It has been used, and is used by us, in inflammations of the larynx,
trachea, bronchi, bronchia, and lungs. After the inflammatory
fever is removed, and the disease has reached its highest develop-
ment, it ought to be given alone, or in combination with other
agents, in full doses. Not before this stage of the disease can this
effect be obtained. We have generally been fortunate enough to
see a speedy recovery follow its administration. We need no
add. that it renders the best services in common bronchial catarrh*

where full and speedy expectoration is wanted. Such were the
indications for the use of the oxysulphuret of antimony at the time
of its cautious administration, long before it appeared to be almost
entirely forgotten, particularly in the United States and Great
Britain. But the want of knowledge as to its proper use, seems
to have impaired the success due to it when used right.

There is but one writer, Neumann (1840), who went as far as to
prescribe to adult patients, doses of six or seven grains without
producing vomiting, and to confess that he did not see an objec-
tion to giving, if necessary, a dose of twenty grains. To this re-
mark, and to the fact, that this remedy has been recommended, and
administered by us also, in a few large doses daily, in pulmonary
emphysema, and, finally, to a remark in Rilliet and Barthez's
Manual (vol. iii. chest, chap. viii. art. ix.) on the use of from five-
sixths of a grain to thirteen grains, in some cases, of the mineral
kermes, another, but not so safe a preparation of antimony, we
owe the first idea of introducing into our practice the oxysulphuret
in large doses. We had abandoned it years ago, tired and disap-
pointed with the entire want of success in the use of the small
doses taught by the manuals on materia medica.

We are aware of the objection to large doses of this remedy»
that it cannot but sometimes produce excessive vomiting. Such
a case might occur, but could easily be remedied by diminishing

■tte dose; there is no remedy against which iudividual idioayn-
l|jrasies will not prove rebellious, although given in small doses,
W- Generally, vomiting will not provo of any importance ; at least
pre have been taught so hy experience. Furthermore, it is to be
t&ept in mind that there are influences which raay be avoided by
HMfeful management ; it is well known, for instance, that nausea-
niog remedies, although in small quantities may operate as emetics ;
nhis, a little tartar emetic will, when dissolved in a large quantity
Hf water, prove to operate as an emetic and purgative. On this
Erinctple the oxysulphm-ct of antimony, too, could have a nausea-
KtiBg effect, when brought into further contact with the whole sur-
Kbcc of the mucous membrane of the stomach ; it is even possible,
Kb onr opinion, to produce diarrhcea by diluting the remedy by co-
Bilious drinking of sugar-water, or similar things. AH this will
Have to be avpidcd.

■ We are less afraid of diarrhcea being produced by spontaneous
■Aemical decomposition, especially by formation of the oxide of
Ei&timony, for acids and alkalies can be avoided, and kept from
nOEoing into contact with the oxysulphuret, and diet may always
Kb regulated according to circumstances. Further, wc scarcely
KWollect a case where diarrhcea of any importance followed
■fee administration of our medicament ; at all events, there was
Hknte, the cause of which we could look for in the antimony.
Hliird, onr preparation, when found in the evacuations of the
Hbwels, is not decomposed.

■'As to the fact, that the oxysnlphnrct of antimony is found in
Bbe passages a day or two, or three, after commencing its admin-
■Mration, we have had the objection made to our largo doses, that
^Bey are worthless because of their leaving the organism without
HkEercising any influence. Now we have often experienced the fact,
B^tno difference can be found as to the time {usually the second
By third day) when the medicament is visible in the ffeces, whether
Wtk has been given in large or small doses. Besides, we do not
Bnov exactly what the mode of its o]>eration is ; perhaps it is not
^Beessary at all to have it entirely dissolved and taken into the
^Bltem in order to see its full power developed ; and besides, we
Kmw very well that other remedies appear in the fasces very soon
Rfier their having been swallowed, and, like the iron in its several
fi)rm3 and combinations, lose nothing of their mcdifinal effect.

The last objection to the oxysulphuret of antimony has been,
that it belongs to the class of nauseating remedies, and will, un-
doubtedly, when taken any length of time, affect the appetite of
the patients, and thereby injure their strength. Now, we desire
our readers to remember what the indications are which require
its administration. An inflammatory fever has just been removed
by an antiphlogistic treatment ; the assimilating functions are al-
most entirely gone ; there is still a fever, and the necessity, at the
same time, of furthering the secretion of the mucous membrane and
removing exudation. This is the period for the employment of
this drug. The appetite cannot be affected by the medicament,
for there is none ; if there was, in spite of fever and inflammation,
it would be better to impair it, in order to keep the digestive funo-
tions as inactive as possible. At a later period of the disease, or
where danger arises from anasmia, it is certainly necessary to think
of the stimulation of appetite, digestion, and assimilation. Then
the oxysulphuret of antimony may be combined with iron, with
quinine, with rhubarb, or nux vomica, etc., each of which has its
own indication. One remedy cannot answer all indications.

We have a single additional remark to make. Our therapeu-
tical observations have generally taught us, that wherever a rem-
edy is really and fully indicated, it is tolerated in large doses.
Thus, we have the firm conviction that the large doses of the
oxysulphuret of antimony, recommended above, will surely be adop-
ted in general practice, as has been the case with the tartar emetic
since the times of Peschier and Basori, and with the opium since
the ingenious and important discoveries of Clark.

ARTICLE VII.

On the^ Etiological and Prognostic Importance of the PremaJturt
Closure of the Fontanek and Sutures of the Infantile Cranium.
By A. Jacobi, M.D.

The development of the various organs of the infantile body
generally proceeds in an equable measure. Only the skull, with
its contents, seems sometimes to form an exception to this rule.
Compared with the whole body, the infantile head is large ; its
blood-vessels are in due proportion to its size, and before the
closure of the sutures, the blood-vessels of the brain and of its

I jBembrancs, finding less resistance from outside pressure, are
1 npaneiMc in a higher degree tlian are tliose in other parts of the
rbody. In consequence, then, of increased upward motion of the
Ijllood, wo find that in cliildrcu the development of the skull, jawa,
T-«nd teeth, and the frequency of inflammatory and exndatory
[■ diseaf^es of the brain and its membranes, go hand in hand ; they
! ire rourdinate effects of the same cause. The bones of tlic infan-
tile body develop themselves with (he same equabilily as ita other
Protracted teething, retardation of the closure of the
fcftntanels, retardation of walking, usually consist, and arc not at
rtll favorable symptoms, being but too frequently the first signs of
[.ncbitis. Nor is prematurity of teething, of closure of the fontan-
I sis, and of walking, very rare. One fact, however, muat not bo
overlooked here, vIe., that the head and upper extremities, in
tiieir normal state, contain more lime, proportionately, than the
[ pelvis and lower extremities. This fact is well understood, and
\ explains the pathological alterations as well in the lower cxtrerai-
w "ties as in the cranium, morbid tendencies going to develop mollifica-
1 tion in the former, sclerosis in the latter. Indeed, all the cases
I af genuine sclerosis of the cranium, that have been reported in
I fiteratnre, seem to have commenced in early life.

Other exceptions to the rule, in which the skull i.i developed in
[iroportion to the other bones, are frequently found, the causes of
tvhich can hardly be defined. Doth parental constitution and ma-
^4emal blood arc, no doubt, of some influence. This is. however.
K*ot without restriction, as robust children arc frequently born of
I weak mothers, and wee versa ; hut it has been shown by Spiindli,*
I tiiat large maternal skulls have a great inSuoncc on the develop-
I nent of that of the infant.

Climatical and typical peculiarities seem also to account for
I loroe of the dilTerences in the formation of the cranium. Thus,
I Edwardst asserts that in the West Indies the coronal juncture is
I broad, and remains open for a longer period than in cold coun-
I tries. Aa to the custom of the natives, of pressing downwards
I Ifae OB fronlis and os occipitis, lie thinks it might be explained by
1 the instinctive endeavor to effect an earlier closure of the fon ta-

il arlificUlla du trSnt. Piiri», ISSS, p. 23.—

nels and the cranial junctures in general. Schoepf Merei* thinks
himself justified in assuming that the large fontanel closes latar
at Manchester, England, than at Pesth, in Hungary. Many simi-
lar facts are brought to light by comparative observations. Thus,
we are ii|formed by Mauthner^t that the skulls of Slavonian chil-
dren are more compact, disproportionate, and clumsy, larger in
every dimension, and more subject to hyperostosis, than those of
Hungarians. And Gratiolet observed, that the cranial sutures
close later in the white race ths^n in the black one, and that the
coronal suture, being the first to ossify in negroes, is the last
to do 80 in Caucasians.

It is to be considered a law, that the incisors cut, before the
closure of the large fontanel takes place, this being followed only
by the ability of walking. In the average, the first incisors make
their appearance at the age of six or seven months, the large fon-
tanel is closed at twelve, walking ensues at thirteen months.
By closure of the large fontanel, however, I do not mean its en-
tire ossification, as this is consummated only with the third year.
Some weeks after birth, the large fontanel has a size of a square
inch, or nearly so ; somewhat less in small and weak children,
somewhat more in large and robust ones. From a merely patho-
logical point of view, we take the closure of the fontanel to be
complete, when the fibrous bridge between the osseous margins
gives way no longer to the pressing finger, and no pulse can be
felt through it. The fontanel is seldom closed before the first in-
cisors have broken through ; walking is rarely possible before the
closure of the fontanel. Sometimes, however, I have seen children
walk without a single tooth in their mouth. Merei relates the
case of a child who walked at fifteen, had his first incisors at six-
teen, and whose large fontanel had the size of about one-half of a
square inch at nineteen months of age. Nevertheless, the child
was lively, sensitive, not rickety — ^which seems fully to prove, that
irregularities in the development of tlie osseous system may occur,
sometimes, without any morbid symptoms.

The best evidence of a normal development is the regular ap^

* A. Schoepf Merki : On the Disordert of Infantile Deodopment, and RickeU^ Preceded
hy Obaervations on the Nature^ Pectdiar Influence and Modifying Agendea <^ Thnperamentt,
London, 1855, p. 116.

t Entwichdunffianomalieen am KinderkhadeL, Oederreiehitehe ZeiUehrifl fiir KinderheH-
hmde, Nov., 1856, p. 52.

pearance of the teeth. Eichmann* reports four hundred observa-
tions on dentition, from which he draws the following conclusions ,
The first inferior incisors break through between the 28th and
32d week ; the first superior ones, between the 36th and 40th ;
the first anterior molar teeth, between the 48th and 54th week ;
the canine teeth, between the 16th and l^th; the first posterior
molar teeth, between the 22d and 24th month. At 27 or 30
months there are 20 teeth formed ; about this time, or shortly
after, the large fontanel has finished its entire and permanent os-
sification.

Sometimes, however, and indiscriminately so with robust or
feeble children, the first incisors cut in the fourth or fifth month.
Merei reports the case of a child which had his first incisor at
three months of age, and had fourteen teeth when eleven months
old. In newborn children teeth are not frequently found. We
arc toldt that Louis XIV., Richard III., and Mirabeau, were born
with teeth ; one case is reported by Churchill ; in another case:
Whitehead, J in order to facilitate suckling, removed from the
inferior jaw of a newborn child two teeth, which were reproduced
simultaneously with the appearance of the canine teeth. One case
is leported by Fleming, one by Denman, nineteen by Haller. Nor
are remarkable cases of unusually protracted dentition more fre-
quent. Among Eichmann's 400 cases, there are a few, in which
the first tooth cut at the twenty-second month ; in a case reported
by Churchill^ it cut in the seventh year ; and Mef ei knew a child
whose large fontanel closed at four years of age, but whose mouth
was still toothless at six.§ We have observed, in the " German
Dispensary of the City of New York," a child of thirty-four
months, without a single tooth, and whose fontanel did not even >
begin to close. The record of the children's department of the,
Dispensary contains another similar case of a child two years old. .
There are, moreover, irregularities sometimes, defying accurate •
explanation, but worthy of notice. There is, in the written records -
of the meetings of the Society of German Physicians (Feb. 27th, .
1857), the case of a man of 63 years, whose large fontanel waa
open ; also a case of a girl of 14 years, of feeble constitution, with .
well developed mental faculties, and a large head. Her father has

■ ■ — ^■■[■■■■■l» » M^^ ■.....■■I ■ ■ ■ ■ ■■ ■ — » — — — -— — -^ ■ -I ■ ■ ■ . ■ ■■ „ ■■ .■■^» "-^

* ScuMiDT-S Jahrhucher der in-und axuldnduchen gesammtcn Median, 1853, No. 12.

t Fleetwood Churchill. M.D. : Diseases of Infants and Children, Second Am. Ed.^
p: 417. t Mebbi, p. 118. § L. C, p. 119.

been syphilitic sometime during his life. Frederick C. Stahl re-
lates the case of a man of 50 years of age, and Eulenberg and
Marfels* report the same anomaly to have occurred in a cretin of
20 years^of age.

The following results of Eichmann's seem to be worthy of a
particular consideration : Of twenty healthy and robust children,
the fontanel was closed in ten at from eleven to thirteen months ;
in five at thirteen ; in two at fourteen ; in two at ten ; in one at
fifteen. In fourteen of them, the first teeth cut at from six to eight
months ; in four at from eight to nine ; in two before the sixth
month. Consequently there is, in healthy children, an interval
of from four to seven months between the cutting of the first in-
cisors and the closure of the large fontanel.

Of eight feeble or sickly, but not rickety children, the large
fontanel was closed in six at from eleven to thirteen ; in two at
from thirteen to fourteen months of age. In seven of them the
first incisors cut from four to seven months before the closure of
the fontanel ; in one the cutting of the first tooth, which took
place at thirteen months, was directly succeeded by the closure of
the fontanel.

Of eight rickety children, the fontanel in three was closed in
the thirteenth month ; symptoms of rachitis developed themselves
immediately afterwards. The incisive teeth came at the regular
time ; the other ones too late. In three the closure of the fon-
tanel took place between the sixteenth and nineteenth month, the
first tooth having cut at twelve months, and being followed by
the rest in rapid succession. In one the large fontanel was open
at nineteen months ; the first teeth cut at the regular time, but at
eighteen months there were only eight of them formed. In one,
rickety also before the eleventh month, the fontanel was not
closed, and the mouth toothless, at the age of twenty-five months.

A. Schopf Merei and J. Whitehead have published, in their
first report on the Children's Hospital of Manchester, England,!
their observations on the closure of the large fontanel, made in
children from five months to three years of age. They state at
once, that children of one and one-half, two, or three years, in
whom the large fontanel was found open, showed a very unfavor-

* Hennann Ealenberg and Ferdinand Marfels, Zor pathologischen Anatomic des
CretinismaB. Wetslar, 1857.

t Jintnud for KmderkrankheUmt 1857. March and April.

able general development; they being very late in teething,
feeble as to their locomotory organfi, and exhibiting anomalies in
the size and shape of cranium and thorax, and symptoms of uni-
versal rachitis. Some children who had been walking from
their eleventh, twelfth, or thirteenth month, and had some sixteen
teeth, had their fontanel open when eighteen months old ; in,
others the reverse took place, the fontanel being closed before the
appearance of the very first tooth. Among the whole number of
well developed children, observed by our authors, the fontanel was

At the age of 6-7 months closed in 3, open in the rest.

II
11
li
II
II
II
II
II
II

15-18

»l

each,

except 2.

After the eighteenth month the fontanel was not found open in
any well developed child.

Among viciously developed children the fontonel was

At the age of 7 months, closed in 1, open in the rest.

"11 " 1 "

" 12 " 3 " 14

13 " 1 " 12

<c 14 II 5 II 11

15 " 4 " 12

"16-36 " 13 " 14

In a very small number of children, who exhibited a general
state of very bad development and general rachitis, the fontanel
was even found open in the third or fourth year of age.

From these facts the conclusion may be safely drawn, that the
large fontanel is closed, in well developed children, at or before
thirteen months of age, and that it is open at the same period of
life, or later, in a large majority of badly developed children. It
must not be supposed, however, that the diminution of the size of
the fontanel takes place gradually. Schopf Merei and White-
head prove by a large number of observations on healthy and

well developed children, that the fontanel is largest at from five
to seven months, the size being from one to two inches from one
margin to the other ; Liharzik* arrives at a similar result, and
Elssessert considers the age of nine months as the period at which
the large fontanel ceases growing, and commences its rapid ossifi-
cation.

The completion of the cranial sutures is often delayed in spite
of a normal condition of the brain. Sometimes the ossification in
newborn children is deficient ; in such cases it may have started
from the usual points, but the bones are thin, their periphery
fibrous, or there are fibrous gaps in the osseous structure. Both
the circumference of the skull, and the general development of the
children, may be entirely normal in such a state of the osseous
structure of the cranium. Sometimes, however, abnormities are
found, as, for instance, hydrocephalus. In some cases, the fault
has been attributed to constitutional diseases of the parents, to
pathologico-anatomical peculiarities of the maternal pelvis. Ab-
normal sutures also may be found, the ossa frontis, occipitis,
temporum, parietalia, remaining each divided as in the foetal state.
Or there are the so-called ossa Wormiana, results of normal ossi-'
fication, but proceeding from an unusual abundance of starting
points, in groups of sometimes such a remarkable number, that
Meckel met with and counted two hundred of them in one in-
dit4dual.

It is, however, the premature solidity of the cranial bones,
which we consider as our special subject in these pages. Some-
times it is inborn, and the result of inflammations suffered during
foetal life ; in such cases an osseous elevation is sometimes felt
along the sutures. Otto records, in his report J on the specimens
of the Anatomical Institute of Breslau, the cranium of a newly-
born child, with very small eyes, face and orbits were extremely
small, the frontal bones firmly joined, formed a prominent edge.
Dr. Haase§ met, in a newly-born child, with a piece of bone,
entirely filling and covering the large fontanel. Trista || deliv-

• F^ani Liharzik, das OeseU dei menxkHchm Wach^ums und der unfer dtr Norm
turitckgMiebene Bnulkorb alt die ersU und wichtigde Vrsache der RhachitiSf SeropkuloH
und Tuberculote, Wien, 1858.

t C. L, JEUouseTj der Weiehe Hinterkopf. Stuttgart und TUbiugen. 1843.

J 1830. § Gemei/uame deutsclu Zeitschrift fiir GthurUkunde. iv. 3.

g Bud und Quper KriUtehet Bq>ertorium fiir die gesammte EsUkunde, xxviii. p. 121.

P'wed a woman of a feeble and lean child, whoge head showed the
I eiact form of a sugar-loaf, the eyes wore oblique from upwarda
I and outwards to downwards and inwards, the nose was flat, and
I liad only one aperture ; this malformation being accompanied
I with haro-lip, Gssurc of the palate, and imperforate anus. lu the
L liospital of Sliitomip, Russia, a ease of inborn idiotism* has been

jobserved, in which the cranium was four and one-half inches in

mgth, and three and three-fourth inches in breadth, and was ia

KiBFeral places two thirds of an inch thick. Dr. Shnetter, of New

I'ork City, has scon three cases of congenital complete osaification
■ of the eatures and fontanels ; the heads being hard and well
Innnded. The delivery was diflScuIt in all of those cases, and the
[ jnfante did not reach the cud of their firstyear. Another case haa
I been reported by AUen.t All the sutures were ossified, the cra-
I Biuin was like that of an adult, dense and solid, and had to be

perforated before it could be born.
The size and symmetry of the skull depond upon both the ad-
[ Tancemeut and seat of the ossification of the sutures, and the
I tdjustmcnt of those parts which are not ossified. For the growth
I of tlio flat cranial boncd which commences from the sutural Bub-
I stance, ceases mostly after the ossification is consummated. Gib-
I aOQ and Soemmering were the first to understand the importance
\ of the substance of the sutures, considering it to be the matrix of
f tlie growth of cranial bones ; but HyrtI was the first to show that
[ pathological forms of the cranium might depend on the premature
[■ closure of single sutures. Fr. C. StahlJ considers the ossification
I of the sutures to be rather the final end of the whole gradual con-
I figaration of the cranium and cerebrum. Ludwig Fiek § thinks
L proper to deny positively any inlluence of the cranium on the cer-
|fibrum.

Wo have stated, that the growth of the flat cranial bonea moat-
mj ceases after ossification of the sutures is consummated. This

is on undoubted fact, but is nevertheless not without limitation.

• On (*( ilaU 0/ nalianal htallh and tht rffdinty of lie eivil ho^niaU in tie empire, in the

fft leaS. SI. PvtL'rsburgb. I806. p. 271.

I lf*Ki Orleant Medical A'eici and Hngiilai OaieOe, March, 1857.

§ LaAeig FtckiKmt Vtdenvtkungnt fi

e Vnwhen der Knofh<i\fon

•

For it is an old remark of KoIIiker's, that after the ossification
of the frontal suture in children, the frontal bone always increases
in size, particularly between the tubera. And Buschke* ar-
rived, from very exact and numerous measurements, at this result,
that the cranium is increasing in size up to the sixtieth year, a
period when the sutures are perfectly closed. The cause of this
general result is found in the fact, that the osseous substance is
reabsorbed from the interior, but reproduced from the exterior
periosteum. Nevertheless, it may be stated as a rule, that gener-
ally after the ossification of the sutures and fontanels is complete,
the brain cannot increase its volume except by forcing asunder the
sutures, or by reabsorption of the inside of the cranium.

The variety of forms of the cranium produced by the earlier or
later, partial or total synostosis of all or some of the-sutures, is
very large. For discerning these various forms, R. Virchowt has
successfully adopted a terminology, similar to the one used by
Betzius, for discriminating the varieties of races by their skulls,
which we reproduce, although being well aware of partial objec-
tions made to it.^

1. Macrocephali, large heads ; general circumference of the head too large. H7-
drocephali, watepheads.

2. Microcephali, small heads ; general circumference of the head too small. Nan-
nocephali, dwarfheads.

3. Dolichocephali, longheads.

a. Simple dolichocephali ; synoetods of the sag^tal suture.

b, Leptocephali, narrow heads ; lateral Exostosis of the frontal and pariet-

al bones.
e, Sphenocephali, cuneat«d heads ; synostosis of the parietal bones, with
elevation of the region of the large fontanel.

d, Glinocephall, saddleheads ; synostosis of the parietal and sphenoid bones.

4. Brachycephali, shortheads.

a. Simple brachycephali, bigheads ; synostosis of the parietal bones with

the occipital bone.

b, Plagiocephali, oblique heads ; synostosis of the frontal with one parietal
bone. Where a considerable adjustment ti^es place : Platycephali, flatheads.

e. Ozycephali, pointed heads, sugarloaf heads ; synostosis of the lambdoid
and squamous sutures.

* Ema Hutehke, Schadd, Him und Seek des Meruchen und dor Tkiere, naeh Alter j Ge-
khkcht und Race, Jena^ 1854.

t Verhandiungm der pkyticaliick-mediemischen GesdUehqfl zu Wurdurg, 1851, Tol. il.
280.— 1852, vol. ili. 247.— 1856, Tol. rii. 199.— R. Ynicuow : OesammeUe Abhandlun^
swr vnttenaeiu/Uiehen Medkin, Frankfurt, 1856, p. 891.

X J, ChritL OusUw Lueae, ntr ArehUedur det MenaehemehaddSf rubd geomdriachen Orir
ginakeUhmmgen von Schaddn normcder und abnonner Form. DranJ^urt, 1857.

We have found that ossificatioa of the sutures leads not only
BCtry of tlie cranium, but to the gradual cessation of the
^ of the cranial bones. The cerebral functions depend to a,
t extent upon the size and symmetry of the cranitmi ; in cases
r considerable diminution and asymmetry, we are almost certain
p) find that not only the intellectual faculties, but also those of
locomotion and sensibility are injured. _ Convulsioos, deafness
ud dumbness, failing of the sexual instinct are known to be frc-
pient consequences of an early and extensive synostosis of the
ntares. Where it is limited to one side or locality, an adjuat-
■aent is possible in the direction of the yielding, uuossified
such cases the cerebral functions may be nearly or
vboUy normal. Other less favorable cases look like the one of
oetGosclerosis cranii, not long ago reported by Schutzenbcrger.*
Hie disease lasted about four years, before the continually increas-
ig compression of the hard, compact, and eburneated cranium,
Ipiccecded in effecting the death of the patient, who had endured
•11 his life frequently repeated faintings, a long series of epileptic
^d tetanic attacks, abnormal irritability, mental weakness, and,
it last, idiocy.

With the only exception of the macrocephalic — hydrocephalic
w-form of the cranium, there is none which has been studied with
^^.D much eagerness and success, as the microcephalic one, particu-
ttrly in its relation to the diminution of mental faculties. Bail-
Itrgert saw, in a village of southern Switzerland, three mieroce-
^atic idiots whom their mother reported to have been born with
flicir skulls perfectly closed and solid. Two other children of
Icrs, who were well developed, both bodily and mentally, had
Hieir large fontanel open for a long while after birth. Similar
bets he learned from another woman, who was mother of one
microcephalic idiot, and of some other children of normal develop-
jtaent. Furthermore, he describes the cranium, in his possession,
of au idiotical child, 4 years old. Its dimensions are very small
Indeed, Uio largest circumference not being thirty-five centimeters.
|The coronal suture had disappeared entirely ; no less so an osseous
jpromiueuce. Only the lambdoid suture was slightly discernible.
Similar cases have been observed by others. VroUk.^ of Am-

' Arriioa, pininla, ISfle. No. 8.

t (iaitttt dn l^paauz, ISJifi. No. 91— £u//. del'Amd. XJTI. p. 9M. 9!ii. 1S56.

i Va-hmdiiinyai dir K. Akad. der WerUiuchapm, I. Ded. Aiiuterdam, 1S54. ScJwaik'i

sterdam, knew atn idiotical boy of 7 years, whose cranial sutures
had entirely disappeared.

The skull was asymmetrical, the face appearing as it were to be
bent from the left to the right side, the occipital portion from the
right to the left. On the left side the fossa cerebelli was larger,
the cavity of the hemisphere of the cerebrum smaller ; the bones
were also thicker on the left side of the cranium, than on the
right. The frontal bone was flat, the frontal tubera very little
prominent ; the parietal bones high but short ; on the left parietal
bone, and on some other parts local rarefication of osseous sub-
stance ; the occipital bone oblique and flat. There were no
digitated impressions on the inside of the cranium, all the sutures
almost completely closed. With the exception only of the mas-
toid foramina, the apertures of the emissaria Santorini were very
narrow, but the carotid canal was wide. The ethmoid bone was
narrow, no juncture visible between the anterior and middle
clinoid processes. The oval, anterior condyloid, and auditory for-
amina were very large, the round one small. Upper jaw, nasal
and jugular bones were remarkably developed. The hemispheres
of the cerebrum were so much shortened, as to leave the cerebel-
lum partly uncovered ; gyri few and incomplete, sulci flat, olfactory
nerves thin. In the cerebrum the right hemisphere, in the cerebel-
lum the left one, was largest. Pons Varolii was narrow, the ob-
longated spine disproportionately thick. The lateral ventricles
were expanded by serum to such a degree as to leave between the
ventricle and the coronal suture, only a thin transparent pellicle
of what was formerly normal cerebral substance. Corpus striatum
and thalanlus were abnormally flat.

Cruveilhier reports the case of a child 18 months old, without
any discernible sutures. There was, besides, instead of the nor-
mal external occipital protuberance and the semicircular line, a
transverse, very sharp osseous prominence. The vertical diame-
ter of the cranium was as short as one inch. There had never
been even a vestige of intellectual faculties.

After all, premature cranial ossification, although there may be
many other causes of idiocy, is deserving of every consideration.

The normal human brain diflFers from the animal not only in its
relative volume, but also in its growth. Besides, the fontanel of
the human cranium is not found in animals, with the exception
only of a few varieties of apes, who have, for a short time after

birth, small and rapidly ossifying fontanels. Therefore Baillar-
ger, taking into consideration both the growth of the brain, and
the premature ossification of the cranial sutures, thinks himself jus-
tified in comparing microcephalic idiots to animals. Gratiolet
did not even stop here, but asserted, in the meeting on August
25th, 1856, of the Paris ^'Jlcademie des Sciences/^ that there is a
direct relation between the earlier or later ossification of the
sutures, in the different races and typeyof mankind, and the hight
of their intellectual faculties. He states, as we have mentioned
above, that the cranial sutures close later in Caucasians than in
Negroes, and particularly, that the coronal suture ossifies early in
Negroes, late in Caucasians. For this reason a proportionally late
ossification of the coronal suture seems to be favorable to intellect-
ual development. The high forehead also, of the Caucasian, and
the low one of the Negro race are evidently depending on this
physiological fact, although it may be stated that the synostosis of
the sutures is not the only cause of cranial difference in the races,
the various characters of the crania, as they are found in different
races, being partially formed before synostosis of the sutures is
complete.*

A frequent result of cranial premature synostosis appears to be
deafness and dumbness (two such cases have been reported by Vir-
chow) and cretinism.

» Eulenberg and Marfels made a post-mortem examination in a
case of cretinism. The cranium and brain were asymmetrical,
gyri of the left side broader, straighter, more simply formed.
Even more difference was shown in the chiasma, which was one-
twelfth of an inch broader on the right side ; nerv. opt. and corp.
striat. more developed on the right side ; the cortical substance
remarkably thin in proportion to the medullary substance. The
right side of the cerebellum was softer and smaller than the left.
There was a far-spread hyperaemia around the sphcno-basilar
synostosis which was present in this case ; and which, for this
reason, is considered by the reporters as the result of an inflam-
matory process, the origin of which is to be traced back to foetal
Ufe.

Even more frequently than the above-mentioned abnormities has

— j^ __ — ^ — . — , — . _

* R Buschke, iiber cranio-sclerosit totalis rhaehitica und verdiekU Sehadd iiberhauplf rubU
nenai Bsobacklungm jener KrahkheiL Jena, 1858.

epilepsy been observed to be a frequent consequence of preco-
cioasness of cranial synostosis. In a great number of epileptics
the form of the cranium is -anomalous; thus Bieken already no'
ticed, in a man suffering from epilepsy, a lower situation, larger
size, and malformation of all the parts of the right half of the head.*
In proportionally few cases it is too large, hydrocephalic ; in most
of them it is too small, and.spherical or pointed. The most import-
ant characteristic, however, is asymmetry, the head appearing, as
it were, compressed from a lateral, anterior or posterior direction.
Among forty-three epileptics, recorded by Miiller, of Pforzheim,t
the heads of thirty-nine were asymmetrical ; in the majority of
them there was, besides, hyperostosis of the cranium. The older
a case of epilepsy, especially if it dates from the first years of lifci
the more the cranium will be dense and eburneated. Epilepsy
originating at this early age, is considered to be the most critical
and incurable, leads often to, or is complicated with idiocy, and
shortens the duration of life.J We have been informed by Dr.
Schilling, of this city, of the case of a girl eight years old, who
has been suffering for some years past from epilepsy, which, led by
anamnestical facts, he does not hesitate to trace back to premature
synostosis of the cranial junctures ; we have ourselves been attend-
ing for four or five months a girl of fifteen years, whose menses
were regular and pretty copious, who has been suffering since her
second year, once, twice, or three times every day of her life from^
epileptic fits, which we can, by every possible evidence, attribute
to the same cause.

Epilepsy is rare in new-bom children — frequent after the first
dentition. Hyperostosis of the cranium, particularly in cases
dating from early childhood, seems also to prove, that too rapid
and abundant ossification of the cranial bones, before the brain
has obtained a sufficient growth, and the compression of the brain
produced thereby, are among the causes of epilepsy. Every case
of this kind is illustrated by Travers,§ who reports the case of an
epileptic boy suffering from compression of the brain, which was

• V, Oraefe^i und v. WdUher^$ Arehiv fur ChirwrgU und AugmhaUcunde. XYIL 2.
t R. YiRCHOW : EaniShuck der tpeddUn Patholo^ und Then^m, yoL It. L 268.
X RosiBERO : Lehrbueh dor NervenkrankheUm, p. 697.

§ B. Trivers : A further Enquiry concerning QmtlUutional Jrrilatwn and Vu Pathology
nf the Nervout Syttemj p. 285.

li l>y a pai'ticic of tiie fractured cranium. Tlicrc was no
olLcr fil, after the fractured boue had been removed.

According to Cliazeauvieilh * of sixty-six cases of epilepsy,
eighteen occurred in the first lustrum, eleven in the second, eleven
in the tliird, ten in the fourth, five in the fifth, four in the sisth,
one in the seventh, two in the eighth, one in tlie ninth, two in the
tenth, one in the twelfth : that is to say, more than twenty-seven
per cent, occnr under the first five years, and probably oven be-
tween the second and fifth year of life. This ia just the period of
infan^le dovelopment, in which irregular ossification may begin
to prove dangerous. For, as Romberg emphatically asserta, the
orgftsm of the brain, inclosed as it is in unyielding osseous walls,
cannot but favor the transmission of remote irritations to the cor-
pora quadrigcmina and the oblongatcd spine, and thereby pro-
duce irregular reflected motions. On this principle, convulsions
are the habitual conscquoncee of cerebral hypertrophy, which is
frequently combined, too, with hypertrophy of the cranium.
Every symptom in all the objects of the foregoing exposition
1 be explained, as it were, by a relative hypertrophy of the
; that ia to say, by a disproportion between the closed and
irrow akull and Iho inclosed and growing brain. Such, how-
Wcr, is the similarity between the symptoms of some of tlie most
■Afferent cerebral diseases, that a distinct diagnosis of the patho-
igi co-anatomical alterations is not always easy, sometimes very
^difficult. La^nneCpi- in referring to Jadelot's remarks on the dis-
Iproporlion between skull and brain, has already acknowledged,
^fbat he sometimes made serious mistakes in the diagnosis of
^drocephalus internus. He confesses tliat in a number of cases
1 met with no water at all, but only with a remarkable llatten-
t of tlio gyri, which seems fully to prove that the brain was
ised, by its volume being too large and its growth too ac-
be ; and next, with an extraordinary firmness and elasticity of
Bie cerebral substance. Next to Ltennec, in 1824, Ilufeland com-
■innicated to the profession his observations on cerebral hyper-
pophy, which he, too, declared to have been often confounded
ritb hydrocephalus internus. It was he who established a new

* Dt I'&pilaHii nraidlrtt dam 3D Ri
15, p. 73,

1 Joamal 4t UidKini. Ctrrurgit tt Fkannaeie. 1806, Tol. x!„
■""" ■ " tr tmnr ihuloire dt Vhj^ptrtrefhu du wn-eaH,

V AUtaaUon JUenlak. Ardi. Girtlr.,
SmuilidieaU,

fact met with in every such case, viz., the cerebral hernia ; that is
to say, he showed, that in every post-mortem examination in these
cases, the compressed, elastic brain springs forth through the
incisions made into the membranes. He is, however, always
speaking of an abnormally large brain vnthin a normal skull, of real
cerebral hypertrophy ; and identical with his cases, are those re-
ported by Scoutetten, Meriadec, Lsennec, Burnet, Papavoine,
Cathcart Lees, and Barthez and Rilliet.

Some years ago, we had occasion to observe three unmistakable
cases, the reverse of those treated of above — that is, cases of an
originally normal brain in an abnorm^ cranium, this having re-
mained too narrow in consequence of premature synostosis of the fon-
tanel and sutures. This narrowness, however, was the only
anomaly ; for the process of ossification would not have been
irregular at all, if it had ended some months later ; there was no
constitutional disease of any kind, not even a sign of hyperostosis,
or of preceding inflammation. The three patients, who came
under my observation in August, 1851, in the fall of 1855, and in
August, 1856, were children — two ten, and one eleven months of
age ; the first one a male, the other two females. All of them
were well developed, had been robust and apparently always healthy.
The third one was said to have, in the last months preceding her
death, from time to time, cried vehemently and suddenly, without
any manifest cause. In neither of these cases was it possible to
perceive weakness of intellect, apathy, somnolence, and feebleness
of the extremities, all of which symptoms Cathcart Lees considers
as indispensable signs of genuine hypertrophy of the brain. In
the first casCj it was stated that the child lost his habitual bright-
ness and liveliness about a fortnight before the symptoms became
severe ; in the other cases, this failing could be observed but a
day or two before symptoms of depression of the brain were
visible. The children grew sleepy, almost soporous, the pupils
enlarged ; vomiting soon followed. From time to time, they ex-
hibited, especially the third patient, light intermediate signs of
irritation. " Contractions of the extrernities came next, and, in
short, all the graver signs of depression of the brain. The sopor-
ousness increased so as to become complete unconsciousness, every
sensual function being totally paralyzed ; and, at last, death
ensued with clonic convulsions.

The picture we have given of this disease is the almost exact

likeness of the last stage of the inflammatory and exudatory diseases
of the brain and its membranes in general. Its distinct diagnosis is,
therefore, sometimes impossible, and always diflScult. Tlie pres-
ent state alone of a patient, who lies prostrate, with all the symp-
toms of depressed brain, will not enable a medical man to get a
clue to what has preceded. Sometimes he will obtain anamnes-
tical facts, the best of which is, at all events, the knowledge of the
condition of the large fontanel and cranial junctures. In this man-
ner, we were enabled to make an exact diagnosis in the cases of our
last two patients. We found that in the children, ten and eleven
months old, the large fontanel was entirely closed, and no pulse
could be felt through it. In the last case, the parents, without
any suggestive questions of ours, and only induced to do so by our
examination of the fontanel, told us, that tlie fontanel of another
child of theirs, who had died two years before, at the same age,
and under the same symptoms, was also closed long before death.

In the first and third cases we were allowed to make a post-mor-
tem examination. The result was alike in both of them. There
was nowhere a pathological alteration to be found, except the abnor-
mal solidity of the cranium and the following state : The cavity of
the cranium was completely and compactly filled up by the brain ;
the membranes were pale. JVo signs of inflammation or only hy-
peramia. The sinus narrow ; gyri flattened ; the substance of the
brain dense, dastic, difficult to cut ; of an apparently considerable
specific weight. The gray substance was whitish ; fluid in the
ventricles not remarkable in quantity. There was no disproportion
between the different parts of the brain, a symptom, which never
fails in genuine cases of cerebral hypertrophy ; this being but an
increase of the white substance, while the grey one remains un-
altered, and aflFecting neither the middle part of the brain nor the
cerebellum, while the pressure of the unyielding cranium, when
no adjustment has taken place, will sometimes, but not always,
operate in every direction, and aflFect every part of the brain,
which may be sound in every other respect.

The abnormal state of the cranium and the brain which we treat
of, is almost overlooked by i\\h best authors on diseases of chil-
dren, Rilliet and Barthez. There is only a short notice in their
book relating to premature closure of the cranium as being a cause
of induration of the brain, and they seem to be so little aware of
the intrinsic diflFerence between induration of the brain and its

hypertrophy, that they treat of both of them in the same short
chapter (the fifth of their first volume). So does Churchill, 1. c. p.
178. Even Porster * one of the most excellent authors on path-
ological anatomy, scarcely mentions our subject, so that in treat-
ing of " induration of the brain," he says : " Increased consistency
of the whole brain, or total sclerosis, is a normal occurrence in
old age, and of the same frequency, but less importance, in intoxi-
cation by lead, in typhus, cholera, puerperal peritonitis, scarlatina.
Only in intoxication by lead, where induration is combined with
atrophy, it reaches such a hight as to affect seriously the cere-
bral functions. In other cases, the increased consistency of the
cerebral substance is of some interest only when found in post-
mortem examinations, and is usually produced by copious exuda-
tions, leaving the brain deprived of its parenchymatous serum.
High degrees of total sclerosis are met with only in atrophy of
the brain.

Cases of sclerosis of the brain are met with, sometimes, in re-
ports on post-mortem examinations ; cases, too, of premature
closure of the cranial junctures have been communicated to the
profession, but in very few of them has an attempt been made to
elucidate the evident relation between these two anomalies.

P. Webert reports a case of sclerosis of a part of the cerebrum,
which we are hardly entitled to consider as belonging to the class
of cases forming the subject of our treatise. The author is not
aware of the importance of the early or late closure of the cranial
junctures, but thinks it a remarkable fact, that sometimes small,
puny children, with small heads, exhibit cranial bones reaching a
high degree of osseous development, while in other cases, in large,
strongly built children the cranial bones were thin and easily cut
with a pair of scissors. Thus, in the report of a post-mortem ex-
amination of a child, who died at the age of seven months, after
having suffered from convulsions for half a year, he entirely omits
to state the condition of the fontanel or cranial sutures. The case
was that of sclerosis of the right hemisphere, which felt to the
knife like cartilage; particularly its gray substance was dense
and hard even where the white substance showed the average soft-

* A. F0R8TBR, Hatndbuch derfHdholoffiKhm Anatomie, ii. p. 427.

t F. VfESBR.BeUra^ZurlPathoU^gitehm AnatomU der Neugebomm, Kidj 1851, i. p. SI.
46.

B of a normal cerebrnra. Nor was the structure of the parietal
bones like that naually found where premature ossification of the
tutures has taken place ; the bones showing rather a soft hyper-
lemic thickening than a solid hyperostotic condition.

Of more value for our purpose is the case of " sclerosis cerebri "
reported by Stiebel, Jun.* It is the case of a'girl, paralyzed in her
left side after a severe attack of convulsions occurring in her third
year. About that time the general health of the child does not
BCcm to have been influenced by the disease, which made progress
during the next half-year to such an extent, that the left half of
the Iwdy being paralyzed, the right was affected with clonical
BpasiDS, and psychical action considerably diminished. At the
Bamc time contractures were observed on the side affected with
q)a9m3 ; hut notwithstanding all this, the bodily development, the
embonpoint, had not been affected. No sooner tlian a year after-
irard?, the child was emaciated, the other sjTnptoms remaining
the same throughout the whole time, until the child died at the
ago of more than five years. The post-mortem examination of the
cranium and cerebrum gave the following results: The skull
was very thick, from ouo-sixth to one-third of an inch, like that
of adults ; the dura mattor Ihickoned to at least as much as twice
ha normal size, firmly adhering to the skull, and, on the right side,
■ to UiC brain. The bloodvessels of the arachnoid membrane were
I much injected with blood, and there was a jelly-like exudation all
[ over the surface of the cerebrum. The left hemisphere was of nor-
mal consistency and pretty well filled with blood; its gray and
white substances were very distinctly separated from each other.
The left ventricle contained a large amount of scrum, foramen
Uonroi was dilated. The right ventricle was' somewhat enlarged ;
its walls were normal. The right cerebrum, with the exception
of the anterior lobe, and the inner part of the middle lobe, was nn-
sllered in its shape, but of a dense, hard, and nearly cartilagin-
ous consistency ; it was of a whitish yellow color and could be
cut into very thin, blueish, transparent slices. The microscopical
examination exhibited a proportionately small number of cerebral
ganglia, very few varicose cerebral fibres, but a large number of
amorphous masses interspersed with some fat globules. In the
gray substance the capillary system was developed to an unusual
extent.

• Jaantai/iir KiiultrkraHkhalm,lS&T,Jan.ivid Feb., p. 70.

I
J

W. Hughes Willshire* reports the case of a sickly, puny
scrofulous girl, of a year and five months, who was said to have
fallen sometime ago and hurt her head. The fontanels were closed,
the eyes squinting, and the tarsal margins somewhat inflamed.
The child could not lift her head, the dorsal muscles appeared to
be somewhat opisthotonic, and the upper part of the body was
drawn backwards. Such was the state from the 17th of January
to the 27th of February,, when the child fell sick with variola ;
convulsions, stupor, and pulmonary oedema soon ensued, and a
speedy death followed. The post-mortem examination gave the
following results : Cranium was completely ossified, dura mater
firmly adhering to the bones, the gyri were narrow, pressed into
each other, sulci partly obliterated. The meningeal bloodvessels
were overfull of blood, on some spots there was some ^ilky exu-
dation along the course of the vessels. Brain was solid to the
touch ; it was hard and heavy after being taken from the skull ;
when incised, it appeared condensed, compressed ; most so the
white substance. Most solid were the thalami optici, much less
so the cerebellum. In the ventricles there was some serum, and a
little exudation on the basis.

One very good observation was published, some time ago, by
Prof. Mauthner, of Vienna.t

Case. — Mary F., 3A years old, is said to have suflfered, 1 J years
ago, from convulsions caused by a fall on the occiput. She has
been sickly ever since. When taken to the hospital, she exhibited
the following state and symptoms : The child is emaciated, feeble ;
hair of a light brown color, cranium remarkably small and hard,
particularly so in the occipital region ; the cownteriance has a suf-
fering expression ; lips and tongue are red. The child sucks her
thumb continually. The abdomen is concave ; the lower extremi-
ties are drawn to the abdomen ; pulse thin and mnch accelerated ;
sleep restless. Evacuations dry, rare.

Treatment. — ^Four leeches on the mastoid region. Carb. Magn.
to facilitate defecation.

Two days later, June 11th. — The child moans frequently ; sleeps
very little. No evacuation. Sulpb. magn. 3i., aq. §iii.

The following day one evacuation. Constipation again to the

* Jxmdcn Lancet^ Oct., 1853.

t Oesferreichische ZaUchrift fur KinderheSkundtj Sept., 1857, p. 661, tclerosis cerebri ez
microcephalia.

iBtB^fM^afiip' 5ss, was required to open the bowels. No
change in the other symptoms, only the emaciation and feebleness
of the patient are increasing. Three convulsive attacks, of only

r three minutes each, occurred dnring the night.
* Jaly 2(1.— Tlie child continues to moan and whine, Handa
ranotic ; abdomen hard, Eomewhat inflated ; skin dry. One con-
plHvc attack in the morning. Sucks her thumb. Constipation
F the bowels. Carb. magn. gr. x,, aq. SiJ.
I July 5lh. — Tlic child is very low ; lias fallen o£F considorably.
f July 14lh. — Since yesterday ten thin, greenish-yellow pasaagos,
Ixed wilh mucuB. Hands cold. Bee. salep Jii., pulv. r. ip. gr.
, eyr. simpl. 3ii'
k July 18th. — Collapse increasing. Itiarrhcea but little better.

* . Dov.

[' The child grew worse from day to day, emaciation going ok in

^id progression ; appetite lost ; eyes hollow ; face and extromi-

B cyanotic ; temperature of the skin low ; passages not so nu-

trous, bnt thin and mucus. After some days of constant sopor,

B patient died on the 25th of July.

L Post-morlem examination. — The corpse is very much emaciated ;

idomcn discolored, greenish, concave ; the extremities are flexi-

The cranium is of unusual compactness and smallness. The

ht^uinenta being removed, the distance from the root of the nose

ll tlie external occipital protuberance is twenty-two centimetres,

n one car to tlic other 23^. The circumference of the cranium

■ forty-two conlimotres. Wliile the cranium is getting opened, a

flit deal of serum is escaping. The. membrane is thick, adheres

]/ to the cranium, and can only with some difficulty be removed.

^fontaneb have disappeared entirely, the sutures are found to liavc

Kn ossijitd long ago. The left hemisphere is of very small size ;

t gyri are hard, of a dirty yellow color, showing signs of atrophy.

Btwccn the layers of the pia mater are four ounces of a thin dark

■nm, mixed with blood. The pia mater of the riglit hemisphere

i slightly injected with blood. The civebral substance is pretty

The right lateral ventricle is not dilated. All tlie jimws

iriginating in the brain are of a considerable toughness, as well as

be flattened gyri ; pons and cerebellum are normal ; mediUta ob-

ptgala very hard; some fibrine cougulated in the longitudinal

The cranium is as thick as one centimetre about tiie squa-

mous part of the temporal bone. Its longitudinal diameter is 15
centimetres; the transversal llj.

A very interesting and instructive case, wliich has been our for-
tune to meet with, is the following :

George Z., of Forsyth street, eleven montlis old, a robust child,

was not known to have ever been sick. He became restless and
feverish on the first of November, 1857, with augmented tempera-
ture of the head and slight vomiting. His parents, believing him
to suflfer from " dyspepsia," administered an emetic. On the fol-
lowing day he spontaneously vomited twice, the general state re-
maining as above-mentioned. Bowels open and water passed freely.
We were requested to see the patient at seven o'clock, P. M.

Present state, — Slight clonic convulsions of the muscles of the
face and superior extremities ; forty breathings in a minute, pretty
regular ; pulse contracted, 140 ; pupils somewhat dilated, react on
the influence of sudden light, but are floating for a while after-
ward and dilate again ; conjunctiva scleroticse slightly injected
with blood ; occiput abnormally warm ; hands and feet of normal
temperature. The child in general was well developed, the head
somewhat large ; six teeth cut some months ago ; the gum is
swollen. The sutures and the large fontanel perfectly closed, and
have been so, as far as I could learn from the very intelligent re-
latives, for at least three months.

Diagnosis. — Cerebral sclerosis from mechanical compression of
the brain, caused by premature closure of the cranial junctures,
increased by cerebral hyperemia consequent on dentition.

Prognosis. — Probably fatal ; the patient may recover from this
attack, but only to die by a future one, or at best will become
idiotic.

Treatment. — Calom., jalap, aa. gr. j., to be taken every hour ;
head to be kept under ice.

The convulsive attack lasted for three hours, the muscles of the
inferior extremities becoming also aflfccted ; there was only one
short intermission after copious vomiting. Patient vomited once
more at eleven o'clock, P. M. At midnight, fifty -two breathings
in a minute, somewhat irregular ; pulse as before, 172. Tempera-
ture of the occiput even higher than before ; conjunctiva sclero-
ticae more injected. The child no longer fully unconscious.

Nov. 3d, 8 J o'clock, A. M. — Pulse contracted, somewhat irregu-

lar, 144 ; fifty breathings, interrupted by sighing. The child is
prostrate, spiritless, with an expression of pain about the corru-
gatores of the eyebrows. The right eye more injected than the left
one ; no more convulsions ; bowels have been open three times ;
water has been passed several times. Patient vomited once, not
long after midnight ; has taken the breast four times, and is con-
stantly looking around for water.

Four o'clock, P. M. — Took the breast and drank several times ;
vomited four times ; left hand is constantly kept on the parietal
bone ; pulse as before, 144 ; respiration sometimes sighing, thirty-
eight ; eyes hollow, considerably injected with blood ; occiput ab-
normally warm ; feet cool, hands cold.

Treatment the same. Hot poultices of mustard and linseed on
feet and legs.

Ten o'clock, P. M. — ^Vomited twice, each time after drinking ;
took the breast several times ; had no convulsions, but shook his
limbs under the bed-clothes, from time to time, as if from impa-
tience. Respiration, as above, 35 ; pulse, 130, somewhat irregu-
lar ; body warm all over, with the exception of the nose, which
was cool. Feels every slight touch ; scream's abruptly and vio-
lently when his eyes are forced open. During sleep, the eyelids
half opened ; pupils small. After being awakened from his heavy
sleep, his pupils are a little dilated ; contract by the action of
light, but afterwards float, and dilate again.

Treatment. — Calom. gr. j., extr. hyoso. gr. ^ every hour. Ice
continued.

Nov. 4th, half-past eight o'clock, A. M. — ^Pulse and respiration
as yesterday : 144, 54. No change at all, with the exception of
the patient's vomiting no longer ; he is alternately either awake
or unconscious, or in a kind of heavy sleep ; had two evacuations
of the bowels, passed water freely. Feet cool.

Six o'clock, P. M. — No change ; no convulsions ; no vomiting.

Nitri. Sod. 5ij. extr. hyosc. gr. iiss. inf. digit, (egr. xij.) Siij. a
tcaspoonful to be taken every two hours. Ungt. hydrarg. for ex-
ternal use.

The flexions and extensions of the right superior extremity kept
on and increased, the child grew more restless, threw his head from
one side to the other, respired more frequently and irregularly.
Nevertheless, about one o'clock, A. M., he took the breast, but

only for a minute. The increased irritation was soon followed by
unconciousness and sopor, which lasted for about an hour. WiUi
the usual symptoms, oedematous rhonchi, etc., death ensued at half-
past two o'clock, A. M., November 6.

Post-mortem examination^ four o'clock, P. M., thirteen and a half
hours after death. Front side of the corpse pale, back side red
and brown, by hypostasis ; conjunctiva sclerotic® not injected
with blood. Galea aponeurotica pale throughout, except on the
occiput, where it was suffused with blood, more so than could be
explained by hypostasis alone. All the integuments being re-
moved, about fifteen white and uniLsuaUy dense insular spots, of a
diameter of from a twelfth to three-quarters of an inch, become
visible on the frontal and parietal bones. Cranium not abnor-
mally thick, occipital bone even rather thin ; besides, it is hyper-
semic, and shows on its inside dif^tated impressions of such an ex-
tent as are met with only in adults. The insular spots, being the
places of increased local ossification^ are just as manifest inside as
outside. Of the frontal suture there is no sign. Between the
frontal and the parietal bones, there is no interval, the large fon-
tanel having totally disappeared. Where the large fontanel ought
to be, the coronal and sagittal sutui*e3 are not wholly ossified, but
they cannot be disjointed by any means. Ossification is perfect
everywhere else.

The dura mater cannot he torn from the cranium; the mem-
brane is of such a thickness and adheres so firmly to the cranium,
that it has to be separated from the bone by means of the scalpel.
The sinuses are full of blood ; so are all the blood-vessels of the
pia-mater, particularly on the cerebellum ; nowhere extravasated
blood or any pathologico-anatomical alteration, such as tubercles,
exudations, etc.

The hrain large, heavy, solid, proportionally developed in its
several parts ; gyri numerous and solid, some of them evidently
flat, particularly so on the superior surface of the hemispheres.
The gray substance is less hard than the white, but nevertheless is
tough and elastic. This is found to be throughout the condition
of the cerebral substance. When it is laid open by long incisions,
no blood is seen, except on pressure. Ventricles narrow, contain
no serum. Pons Varolii and medulla oblongata are most solid and
dense ; they are diflScult to cut. The cerebral substance, after

having been outside the cranium and handled and turned for at
least an hour, remains pretty hard and solid.

Although the diagnosis, in the foregoing case, was clear and
fully proved to be correct by the post-mortem examination, there
are some interesting facts apparently contradictory. . After the
first attack of convulsions, no other occurred for three days, al-
most up to the hour of death ; constipation and anuria, so com.
mon in cerebral diseases, were also absent.

Between our last case and the one of Prof. Mauthner, there is
one important similarity. The thickness and firm adhesion of the
dura mater along the sutures and in the region of the large fonta-
nel, in both cases, seem to prove, that a chronic congestive or in-
flammaiary process was both the cause of the pathological altera-
tion of the membrane itself, and of the abnormal deposition of
phosphates and carbonates in the flat cranial bones. No such
alteration of the membrane was found in our former post-mortem
examinations, at least to no remarkable degree. This difference is
strikingly confirmed by the condition of the bloodvessels. In
some cases, they were JUkd toith blood, in other ones the menibranes
were pak and bloodless.

In looking over the series of cases and observations referred to,
another highly interesting fact will strike us. We have reported
the case of a child whose brother died at the same age, with the
same sjrmptoms, the fontanel being closed and the sutures perfect;
Baillarger, too, reports the cases of three microcephalic idiots in
one family. Nothing of the kind however, occurred in our last
case ; the boy had sisters — the oldest one nine, the youngest one
three years old — the heads of all of whom are well developed, and
even large. The youngest girl is reported to have been remark-
able for the pulsations of the arteries being Xor a long period visi-
ble through the integuments of the large fontanel. Therefore, i|i
tome cases of premature closure of the fontanel and the cranial junc-
tures^ an hereditary or family influence seems to be absent^ while in
other ones it cannot be denied.

We were so fortunate as to assist Dr. J. Kammercr at the post-
mortem examination of a man, thirty-six years old, who died from
sclerosis cerebri. The facts resulting from this examination, Dr.
Kammerer, who attended the deceased for some years, kindly
allowed us to publish. We feel bound to do so, because this case is
most apt to illustrate the subject of this essay, and because, as one

of our best authorities on diseases of the brain, Prof. Leubuscher,
asserts cases of genuine sclerosis cerebri are exceedingly rare ; so
much so, that the two cases diagnosed, dissected, and published by
Prof. Frerichs,* of Breslau, and the twelve other cases of sclero-
sis of the brain or spine, they being cases only of partial, even
merely local sclerosis, collected by Dr. Valentiner,t are the
largest number known. It may be stated, that only in one of the
12 cases which occurred in a man of 53 years of age, the cranial
bones were found to be hypertrophied, and the meninges hyperse-
mic and somewhat infiltrated. In this single case both halves
were equally aflfected-f The short, but complete history of the
case, communicated to us by Dr. Kammerer, is as follows :

Case. — Deceased, a tailor, is said to have been always healthy.
Only two years ago his countenance began to show a cachectic
color ; in the epigastric region, a frequent soreness was complained
of, which used to be complicated with or followed by vomiting,
and the patient grew morose, taciturn, peevish. About the same
time, or shortly after, a creeping pain was felt, sometimes in the
hands and fingers, sometimes in the feet and toes. Which changed
very often, and used to alternate, as to its scat, and thereby in-
duced the patient to consider it as rheumatic. His physician,
however, was soon led to attribute these symptoms in the peri-
pheric nerves to a cerebral origin, especially when slight and oc-
casional signs of paresis b«came visible. Four or five months ago,
the patient had an attack of syncope, total loss of the mental, sen-
sory, and motory functions coming on suddenly. After this at-
tack, he was sick for about five or six weeks, the main symptoms
being a small and feverish pulse, and all the cerebral symptoms of
typhoid fever, but no typhous alterations at all in the abdominal
organs, and no trace of critical secretions. Ho never felt well
afterwards ; nearly every week an attack of sudden syncope oc-
curred, similar to the one mentioned above, after which the patient
used to feel as usual. But the paretic symptoms in the extremities
increased, the interval between the attacks grew shorter, and they
were preceded by a violent headache, especially in the occiput.
In the last weeks preceding death the attacks occurred almost
daily, even sometimes every day, and they were preceded by the

^Baeser^t Archiv. x. 334. f Deutsche Klinik, 1856, No. 14, 15, 16.
XBirtch^ ein FaU van tderosis cerebri. Prager VieridjdhrKhrtfl^ 1855. iii. 124.

most intolerable headache, which forced the patient to the most
heartrending outcries, arid was mitigated by nothing except a
close and hard pressure on all sides of the head at once ; they
were followed by copious sweats. In the last week of life, the pa-
tient was scarcely able to lie down ; if he did he was sure to feel
worse ; and he walked about his room all night. There were
fipom eight to twelve attacks every day, of the same kind, as de-
scribed above, the sweat being followed by a vehement shaking
and chilliness. In one of these attacks the patient died.

Post-mortem Examination, Dec. 9th, seventeen hours after death.
Galea aponcurotica pale, bloodless ; cranium dense, particularly
so the frontal and parietal bones. Both of them are very con-
cave, extending very far, the one forwards, the other backwards.
The region of the large fontanel, where the coronal and sagittal
sutures meet, depressed ; the sutures are visible only at this meet-
ing point ; everywhere else they have entirely disappeared. The
form of the cranium narrow and long (dolichocephalus, Virchow),
diploe very much developed, impressiones digitattB very deep and
large, particularly so on the inside of the os frontis and the lower
part of the os occipitis. The cranial impressions of the sinus, sul-
ci venosi, uncommonly deep. Foramina emisaria are not found
at all. The margins of the impressiones digitatae, the juga cere-
bralia, uncommonly sharp-pointed, particularly so on the basis
cranii. Sella turcica of an extraordinary size, and with sharp
margins. The whole inside of the cranium and the dura mater
bloodless ; less so the arachnoidea, without being, however, hy-
persemic. The brain stiff, tough, hard ; gyri hard, extremely flat
all over the cerebral sm-face ; the inner and upper edge of both
hemispheres very sharp, their inner surface 'very flat and hard.
The g^ay and white substances contain very little blood. The
white substance looks discolored, showng a dirty grayish tint.
Thin slices cut from the hemispheres are tough, may be suspended
by one end without breaking or even lengthening ; the commis-
sures prove hard and tough. The lateral ventricles very narrow,
without any serum ; the third and fourth ventricles normal but
narrow. The brain throughout of the same density and tough-
ness as its surface ; pons Varolii and medulla oblongata even
more so. No disproportion, as to size, between the gray and
white substances.

This is, undoubtedly, an evident and very instructive case of
sclerosis cerebri. The history of the deceased's cranium and cere-
brum, as may be concluded from the results of this post-mortem
examination, is briefly this : The abnormal state of the cranium
has been the first false step in the general development, the large
fontanel and the cranial junctures closing too early. This is
proved to be a fact by the depression of the upper frontal and
parietal region, by the adjustment which has evidently taken place '
in the frontal and occipital directions, and by the dolichocephalic
shape of the cranium. From this time, that is from the third or
fourth quarter of the first year of life, dates the disproportion be-
tween skull and brain. It is probable that deceased, when a
child, was so fortunate as to escape diflScult dentition, and severe
symptoms of irritation produced thereby ; if he had not been so,
there is a great probability that he would have died in early
childhood. Deceased is said to have been intelligent when at-
tending school. This is not uncommon in cases where the above-
mentioned disproportion advances slowly, and has not been com-
plicated with irritative symptoms. As long as life continued there
was a constant antagonism between cranium and cerebrum. It is
not improbable also, that in the last years of life renewed deposi-
tions of calcareous matter have taken place, more so, probably, on
the basis, than on any other part of the cranium. The frequent
attacks to which the patient was subjected, exhausted, at length,
the power of resistance, which is limited as well in the nervous,
as in every other system of the organism.

Real hypertrophy of the cerebral'substance is out of the question.
We have remarked above, that cerebral hypertrophy afl'ects but
the white substance, not the gray, and the large hemispheres only,
not the cerebellum, and cannot but produce a disproportion be-
tween the two. No such disproportion exists in our case. Be-
sides, the shape of the cranium and the other facts alluded to are
against such an assumption.

After the foregoing expositions, it appears that the prognosis of
the kind of cerebral sclerosis described is highly unfavorable

According to the present symptoms in each case, whether a dis-
tinct and perfect diagnosis be made or not, either a stimulant or
an antiphlogistic treatment will seem to be indicated. The for-
mer will aggravate the condition of the patient in every case, which
is combined with congestion of the brain or its membranes, while

aticAlly it should be adopted only wliere tlie main Fymptoms'
B Ittose of perfect depression. The debilitating course oE treat-
lent may be able, at ouec with the diminution of the dimensions
r the body in general, to remove, for a while, the disproportion
itwecn the brain and the craniniD. Taken theoretically, all this
ikrigkt and promising of success. But we cannot continue to do-
litatc without killing the patient by exhaustion or by menin-
I exudation, which bo very frequently is the result of general
1 continued inanition.
kTioalty, wo wiah to state etnpliatically that wo do not mean to
wrt that every child whose fontanel is ossified prematurely, must
1 will fall sick and perish with cei-ebral symptoms at an early
For tlifi premature ossification of tlie fontanel and sutures
1 not of itself absolutely and always produce congestion of the
raia or its membranes, which often becomes the occasional and
Kt canse of death. But what I assert and wish to be understood
BBay is this, that every child, whose fontaacl and cranial Junc-
a have been prematurely closed, and who falls sick with aymp-
ns of cerebral irritation or depression, is predestined to certain
We do not know if such has been the opinion of Condie*
) has only a few remarks on our subject, stating that " when
le growth of the cranium ceases, while that of the brain continues,
e morbid phenomena reaulting from the compression of the brain,
Wch invariably results, may certainly be, to a great extent, abat-
, the comfort of the patient increased, and life prolonged by a
loper hygienic course of treatment — but all hopes of cfi'ecting a

t be abandoned."
■Id giving, therefore, the preceding exposition, we have been
ell aware of our unability to advance, in the least, therapeutics ;
ronly desire was to call tho attention of the medical practi-
loer to a subject of tho highest etiological, diagnostic, and prog-
tBtic interest,

[ Hitherto, we have taken into consideration only such cases as
bve exhibited the fullest extent of their morbid disposition, in
mscquence of their complete morbid development. Oue case,
iowevcr, of any disease, never appears exactly like the other, tho
Kuliarities of each individual being as marked in disease as in
ulth. Thus, in ono case, fontanels and sutures may be equally

• P. D. CosDiB : A rraitaal Treatkt on Ute Ditemi 'if ChiUrcn- Fourth ed,, 18S4,

and firmly closed, the cranium equally hard in all its parts, the
brain under equal pressure in all directions ; in another case, the
sutures will appear ossified or ossifying, but the large fontanel
will be found open, perhaps pulsating ; nevertheless the pressure
on the cerebral substance will be of nearly equal sererity, because
the fontanel alone offers the compressed brain no opportunity to
escape the surrounding wall.

It is but proper that a number of cases should be observed, in
which the process of ossification has not run its full course and
secondary sclerosis of the cerebral substance has not been fully
developed. We are not always gratified, naturally, with the ob-
servations of genuine interesting cases, for death often occurs
from a trivial and apparently uninteresting cause. A child will
sometimes exhibit for months the symptoms of the approaching
full development of the morbid cranial condition, without our
being able, while relieving it for a short time, to cure its dis-
ease. Such children are usually well-developed, both mentally
and bodily, they are fleshy and lively, but sometimes for a
short period appear puffed in the face, and their eyes are too
brilliant. Their heads are generally warm to the touch, some-
times hot, particularly so the occiput ; it feels harder and
heavier than it normally does, and is moved to and fro on the
pillow, while the child is in a supine position ; there is always
a relief visible, after the child has been raised, and held in an
upright position, and some cold application made to the head.
The child is restless sometimes for weeks or months, without
any visible cause, particularly at night ; congestion of the head
will sometimes manifest itself as a general flushing of the face,
sometimes in single red spots of half an inch or an inch in
diameter, dispersed on face and forehead, and disappearing as
quickly as they spring up, and showing themselves again unex"
pectedly, for a few minutes. In a boy of five months, who has
been under our care for some time, this symptom is remark-
ably developed, the child showing these red marks, especial-
ly nights, together with Other symptoms of congestion of the
brain, restlessness, high temperature of the head, and sometimes
drowsiness. The very best symptom, and of the greatest value
for differential diagnosis, is found on the examination of the
outside of the cranium. Besides the points alluded to above»
the sutures will be found to have fully or nearly disappeared, the

Ibntftncl diminished in size, and tlic cranium in a state of hyper-
nnic sensibility and warmth ; Iiypcricmia of the cranium appearing
B well in company with hyperostotic development, as witli racliit-
ICftl mollification of tbc cranium (craniotabeii).

Wbercvcr this general state is found, wo must have the greatest
^>p^cbeusions of the future safety of our patient. The mal-
developmcnt will be found as irapossible to stop or improve, as to
^ncc tlio amount of phosphate of lime, to furthor its excretion,
i enlarge the calibre of the cerebral and cranial veinH, to dimJn-
S^ the size of the arteries, to remove, in short, all the possible
^oses of too rapid ossification. Leeches, cold, calomel, mustard,
ind a good many other remedies, anlipblogietica, resolvents, re-
frigerants, antiplastics, derivatives, sbould bo resorted to cau-
^osly, rationally, repeatedly. They are followed by good
tCsults. But the majorUy of such chiidren will die. Only such
ibUdrcn may be saved as will escape for the fli-st years of life the
JDinmon diseases of infancy and childhood, inflammation?, ex-
IBtlicms, fevers. And of such children, again, the majority will
consist of microcephali, blockheads, idiots, epileptics.

Every febrile disease in childhood tends to produce nervous
^ptoms. llypersBmia of the brain and its membranes, and con-
mlstons, being well known to follow many instances of local ii>
mmatory diseases in other organs. Wherever, then, cranial
Hid cerebral troubles have been greatest before, they may be ex-
pected to be fostered and increased by every febrile attack or dis-
iBsc invading the organism. In cases of a slight commencement
if cranial Gasification, where the single bones of the cranium are
bot too firmly attached to each other, febrile attacks may be less
[gnrious, althoagh every one, while bringing about congestion,
*ill bring new materials to the completion of the unfortunate
sscoua hyper-development. Wherever the ossification of the
■atnrc and fontanels is in an advanced stage of development, one
nnglc attack of fever, or of any inflammatory disease, even for a
day, may produce congestion to the brain and its membranes, in a
Bofficient degree to cause death Viy hyperaemia and pressure.
We were called to 239 Broome Street, on February 17th, 1858,
see a boy fonr and one-half months old, who was said to have
I a slight cough for some days, and had grown worse the last
Bight. SlafM prascns at fonr, P. M. : child not very robust, but
well-developed ; head appears to be somewhat small in proportion

100

to the body. The main symptom is a considerable dyspnoea,
respir. 58, pulse 130, nostrils move up and down, thorax but
slightly, breathing seeming to be painful. Sensorium clear, head
hot, face pale, on the forehead some small red spots going and
coming from time to time. No pulse can be felt through the
large fontanel, all the sutures are ossified. Auscultation yields
bronchial rhonchi, equally over the whole thorax, percussion gives
no result. The bronchitis present would of itself give no bad
prognosis, but the peculiar configuration of the head, the prema-
ture ossification of the sutures and fontanels, made the prognosis
very unfavorable. The parents were told from the beginning,
that the case was likely to end unsuccessfully.

18th, Nine, P. M. — Resp. 48, pulse 140, Dyspnoea not so great
as yesterday. Bronchial sounds as above ; percussion dull
over the lower lobe of left lung. Sensorium not free. The
child somnolent from time to time, sighing ; the face pale,
pupils react but slowly, and will float a little after having
been suddenly exposed to light. Temperature of the head little
higher than normal. Slight contractions in the thumb and fingers
of both hands, elbow a little bent, angles of the mouth sometimes
undergo slight involuntary motions.

Six, P. M. — Resp. 40, difficult, loud, pulse 154. (Edematous
rhonchi in the bronchia. Hands and feet cold, nose cool, head
hot, but pale. Eyes slowly rolling, pupils a little dilated, react
very slowly, and very little to the light; contractures^of the
hands stronger than before ; toes also contracted by the flexors.
The child is not conscious, apparently moribund.

The child had an attack of clonic convulsions in all the four
extremities, lasting about five minutes, about eleven, P. M. After-
wards the permanent contractions returned, the unconsciousness
increased, coma set in, pulmonary oedema increasing. Another
attack of convulsions occurred at four, A. M., on the 19th, and
death five minutes afterwards.

Post-mortem examination not permitted.

S. F. of 100 Mott Street, a girl of nineteen months, well devel-
oped, who had never been troubled by any kind of disease, even
the fifteen teeth having cut without any difficulty, was seized
with intermittent fever, having been exposed to malarial influence,
on the 18th of April, 1858. The attack did not appear to be a very

101

! one, but tlio child did not recorcr iicr clieerfulnesa for the
vtiole day nor tbe following night; on tho nest day another
■Attack occurred, Bcvcror than tho lirst, and with more dangerous
consequence?. Tlie child remained cither restless or drowsy,
iKarcely opening the eyes^ tiie checks fluslicd, licad burning. After
<he third attack of fever, on tho twentieth, we were called to aee
i^the patient, who appeared to be in a critical !<ituation. Tiie child
.■was drowsy, when roused, fell quickly again into wliat might Lave
.been taken to have been a sound sleep, sighed often, bad a palo
Aoe, a hot head, conti-acted pupils. The cranium was bard and
>■ lilense to the tooch, no suture could be felt, no fontanel distinguish-
'«d from tbe surrounding bones. The size of the liead, which
■was round, waa not abnornml. Lungs not affected, heart hoalthy,
JJTer not abnormal, Epleon a little increased in size. Being aware
©f the iihportanoc of the osseous structure of the cranium, after
.^Ting seen the cases referred to above, we considered the main
J^ptoms to bo coDgcatioR of tlic brain and its membranes induced
hf the intermittent fever. Tims tbe indications following there-
I from were, the suppression of tiie malarial disease, that is to say,
the prevention of another febrile attack ; and the removal of the
aecondary congestion. A large dose of sulph. chin, was given tho
other morning before the usual time of the attack, and no pai-ticu-
lar symptoms referable to malarial influence seemed to rise. The
aecond indication was fulBlIed by applying two leeches to the fore-
•itwad, by constantly applying cold and administering calomel.

The history of the disease is very short indeed. Leeches and
.eold did not appear to be emploj-ed without success, for tho heat
of the head diminislicd. But the drowsiness, interrupted by rest-
leaaness, of the child became no less. The pupils remained con-
tracted, tho face pale ; hands and. feet began to grow cold during
tbe night of the 20tb. .Slight twitchings of tlie angles of tho
mouth, and slight contraction of the fingers of both Lands were
first observed in the early hours of the twenty-Crst. When aroused,
■-fte child took a spoonful of water, which was swallowed slowly
and with difficulty. In the morning of the same day a dose of
quinine was administered, to avoid a new chock from tho attack
of intermittent fever that was expected ; no symptoms of fever
'Vould be observed. But meanwhile the whole aspect of tho case
iraa Bomewhat changed. An attack of clonic convulsions about
9 A. M., of the muscles of the forehead, face, neck, of the upper

102

and lower extremities, in short of all the voluntary muscles of the
whole body seemed to exhaust the child rapidly and leave her in a
worse state than before. Although the convulsions lasted for only
ten minutes, they left the head hot and face red for more than an
hour ; after which time the face grew deadly pale and the pupils
began slowly to dilate. The contraction of the hands grew
stronger, even the elbows were inflected. Contraction of the toes
were visible and did not cease before death ensued. Hands and feet
were cold, the drowsiness became sopor, the sopor coma. Swal-
lowing was no longer possible, the senses were deprived of any
action. Another slight, but general attack of clonic convul-
sions took place at 5 P.M., symptoms of pulmonary oedema set in
and rapidly increased, and half an hour later the child died.

The post-mortem examination was made on the following morn-
ing, only the head being permitted to be inspected.

Galea aponeurotica thick and pale, cranium in its greater part
of a livid color. All the cranial junctures firmly joined, the fonta-
nel no longer covered by a fibrous membrane, but of osseous struc-
ture. The anterior part of the cranium had a thickness of from
an eighth to one-sixth of an inch, the posterior of from one-twelfth
to one-eighth. The surface of the brain was full of blood, the
meninges copiously injected. No extravasation nor exudation was
found between the membranes. The gyri of the hemispheres of the
cerebrum were flattened and approximated, the gray sttbstance was
thin, the white substance of a somewhat yellow tinge without
bloody points when incised and even compressed. White substance
hard and tough ; thin slices cut from it might be suspended with-
out breaking. Ventricles and foramen Monroi narrow, and con-
tained no serum. Cerebellum was softer but scarcely more filled
with blood, except the meninges which were also injected with
blood. Pons and medulla oblongata were of no uncommon den-
sity.

A boy living in No. 203 Stanton St., the fifth child of a family
with scrofulous taint, but without any decided and severe local dis-
ease, showed early the conformation of the head often referred to.
The fontanel was felt not to be ossified at all, but the fibrous cov-
ering was thick, allowed of no pulsation to be felt through it, and
the sutures were firmly and solidly closed. The child next in age
to this one, and sixteen months older, showed the reverse of era-

103

nial development, tlie head being large in size, and tiie autnrea
and fontaDCls open np to an advanced age, as is common])' found
in rbacliitic children. Our patient, up to nine months of age, had
never been sick except from slight intestinal and bronchial ca-
tarrtis. When nine months of age he showed symptoms of intes-
tinal catEurh, in a severe form, which was not cared for ; as he
bad no medical attendance. Bronchitis supervened after a week
■lid lasted for six days, during which period the child had medi-
cal care and recovered, but was much exliausted. During all this
time his mental faculties did not seem to be much affected. The
bronchial symptoms had scarcely disappeared, and couvalcscence
was apparently established, when tlie child again showed symp-
toms of a severe gaslro-inteatinal catarrh, vomiting and diarrhoea
Boddenly arising again and eshaustiug the little patient complete-
One single (it of general clonic convulsions closed the scene
on the last day of July. The post-mortem examination gave some
tcry instructive results, the principal ones of which are given in
tlie following ; The cranium was of the peculiar conformation
which forma the subject of our exposition ; it was fully devel-
oped, round, symmetrical, but hard and solid, the sutures were os-
tiGed, the large fontanel firmly covered although not fully ossified.
The tliickness of the bones a little greater than normal. The
brain did not fully fill the cranial cavity, the meninges were
much injected with blood, and a copious serous exudation was
found, in equal proportions, to be contained in the araclinoidean sac.
The brain itself nowhere soft ; the gray substance was of no un-
ion density, but a little thinner than usual. The white eub-
fttAQce was of normal color, but of abnormal consistency, the
EobBtance proving hard, dense, and tough, both when touched in a
, and when cut in slices. Lateral ventricles were narrow
and contained hardly a drachm of serous fluid. No particular ab-
normity was found about the cerebellum.

This last case affords a particular interest, from the fact that
the compressiou of the brain produced by the early ossification of
the craninm had no direct consequences, and produced no direct
cerebral symptoms. The intestinal catarrh beginning the series of
diseases which terminated fatally, appears to have, togetlicr with
ilhe general bulk of the whole body, gradually diminished the size
of the brain. Thus when bronchitis and fever set in, with the
congestion of the meninges consequent thereon, the brain was sub-

104

jected to such pressure from the cranium as to be unable to allow
of any dilatation of the blood-vessels. Up to this* time, then, no
exudation of the arachnoideal sac had taken place. But when a
sudden attack of cholera infantum exhausted the child, and rapid
diminution of the body and brain ensued, the general inanition and
the existing disproportion between the skull and the suddenly di-
minished volume of the brain resulted in the copious exudation of
the^rachnoideal sac. Nevertheless this pathological process had
no influence in changing the former condition of the brain. T^e
pressure of the cranium on the brain had previously produced the
hardness and toughness alluded to, which was still found after a
part of the cerebral substance had been resorbed in the course of
several exhausting diseases. Thus this case does not strictly be-
long to that class of morbid symptoms directly produced by the
disproportion betwen the cranium and the compressed brain, for
there have been neither symptoms of compression nor death from
this cause ; but even this case tends to show the continued and per-
sistent effect on the cerebral mass which is produced by the early
closed cranium ; the consistence of the cerebral substance being
unaltered even after the pressure was removed.

The other cases are those in which the acute disease was only
indirectly fatal, the slowly developed but unchangeable dispropor-
tion between cranium and cerebrum giving rise to those severe
symptoms which produced death. But without the acute disease
supervening, the children would either have enjoyed comparative
health for months or even years, until death had occurred from
some other cause, or they would have survived to take the chances
of their general growth and development, liable to the pressure
on the sclerotic cerebrum, by the early ossified, hyperostotic cra-
nium. This however seems to be certain, that in the first case a
slight pneumonia, in the second a few attacks of intermittent fever
would not have been sufficient to produce the fatal symptoms
which resulted in death, without the presence of just such path-
ological anomalies as we have here described ; and further, that
the fatal prognosis pronounced from the beginning, was justified,
we do not say by the final result, but by the prominent pathologi-
cal facts resulting from the examination during life.

We desire, then, to remind our readers of the former conclusion,
that children whose fontanels and sutures are prematurely ossi-
fied, and who manifest symptoms of cerebral irritation or depres-

105

sion, arc destined to an early death ; and further, from the argu-
ments superadded we would deduce the following inference, that
in all cases of children, whose cranial junctures are prematurely
ossified, any acute or febrile disease invading the system, slight
though the acute affection may be, offers a most unfavorable
prognosis. At all events we feel justified in drawing the conclu-
sion, that henceforth manv cases of infantile diseases which
tenninate unexpectedly and unfavorably, will be at least explica-
ble to the medical mind, and further that, to give more exactness
to diagnosis, and more certainty to prognosis, the condition of the
cranial fontanels and junctures in general will be deemed worthy
of die closest attention and examination.

PA.RT II.

REPORT ON THE PROGRESS OF OBSTETRICS,

AND

UTERINE AND INFANTILE PATHOLOGY, IN 1858.

CONTENTS.

^»i#^^^^^»*^^»^>^>^>^>^^

A.— REPORT ON OBSTETRICS AND UTERINE PATHOLOGY.

L— Manuals and Reports 113

IL — Anatomy and Physiology of the Uterus and Ovaries 125

in.— Physiology and Pathology of Pregnancy, Labor, and Puerperal State. . 143

IV.— Pathology of the Ovaries 167

V^— Pathology and Therapeutics of Uterine Disease.

1. General Diagnosis and Pathology 174

2. Retarded Development, Malfoimations, and Displacements 185

3. Uterine and Peri-Uterine Hemorrhages 197

4. Tumors and Structural Diseases 205

VI.— Pathology of Bladder, Vagina, and External Genitals 216

Vn.— Physiology and Pathology of the Breasts. . . .' 229

Vm.— The Pelvis 232

IS. — General Diseases of Women during Pregnancy, Labor, and Childbed. . . 235

X^ Appendages of the Foetus, Extra-Uterine and Multiple Pregnancy 275

XL— Remedies 283

XIL— Obstetrical Operations 291

B.— REPORT ON INFANTILE PATHOLOGY.

I.— Manuals, General Pathology, Dietetics, Statistics, etc 303

n.— Dyscrasic and Toxa'mic Diseases 324

m.— Organs of Digestion 342

IV. — Organs of Circulation 364

v.— Organs of Respiration 372

VI.— Organs of the Nervous System 401

VII.— Skin and Sensory Organs 424

Vin. — Organs of the Genito-Urinary System 444

IX — Motory Organs 452

INDEX

JOURNALS REFERRED TO IN THE REPORT.

• • •

1. Gazette, the American Medical.

2. Joumo], the American, of the ^[cdical Sciences.

3. Joarnal, Atlanta Medical and Surgical.

4. Journal, the Boston Medical and Surgical. *

5. Joomal, Buffalo Medical.

6. Jounml, the Charleston Medical and Review.

7. Journal, the Nashville of Medicine and Surgery.

8. Journal, the Xew Orleans Medical and Surgical.

9. Journal, the Medical of North Carolina.

10. Journal, the Oglethorpe Medical and Surreal.

11. Journal, the Pacific Medical and Surgical.

12. Journal, the Savannah of Medicine.

13. Journal, the Southern of Me<lical and Surgical Sciences.

14. Journal, the Virginia Medical.

15. Monthly, the American.

16. News. S'ew Orlciins Medical and Hospital Gazette.

17. Obser>'er, the Cincinnati Meilical.
IH, Keconler, Memphis Medical.

19. Reconkr, the Nashville Monthly.

20. lieporter, the Elaine Medical and Surgical.

21. Review, the North American Medico-Chirurgical.

22. Transactions of the American Medical Association.

23. Archives of Medicine.

24. British Meilical Journal.

25. Chronicle, the Medical, and Montreal Monthly Journal.

26. Gazette, the Dublin Hospital.

27. Journal, the Dublin Quarterly of Medical Sciences.

28. Journal, the (ilasgow Medical.

29. Journal, Edinburgh Medical.

30. Journal, the Liverpool Me«lico-Chinirgical.

31. Journal, the Midland QuartiTly of the Medical Sciences.

32. Lancet, the Journal of British and Foreign Medicine. (American Editioc.)

33. Reports of Guy's Hospital.

34. Rci>orts, Ophtalmic llospital.

35. Betum, Quarterly of Registrar-(jeneral.

36. Review, the British and Foreign Medico-Chinirgical.

37. Times, the Medical, and Gazette.

38. Transactions of the Royal Mwlico-Chirurgical Society.

39. Transactions of the Pathological Society of London.

40. Archiv fiir Physiologische I feilkunde.

41. Archiv fur Patholog. Anatomic und Physiologic und fur Klinischc Medicin

42. Beitrage zur Geburtskunde und (iyuaekologie.

43. Centralzeitung, Allgemeine Medicinische.

44. Correspoudenz-Blatt, Wiirtemberger Medicinisches.

45. lutelligenz-Blatt, Aerztl. Organ fiir Bayern's staatl. und ofTentliche Ileilkundo

46. Jahrbiicher der Gesammten In- und Auslandischen Medicin.

47. Jahrbuch fiir Kinderheilkunde und Physische Erziehuug.
4x. Jahrbiicher, Konigsberger Mcnlicinische.

49. Journal fiir Kinderkrankheiteu.

50. Klinik, Deutsche.

51. Literaturblatt, Aerztliches.

VI INDEX OF JOUBKALS REFERRED TO IK THE REPORT. .

52. Mcmorabilien aus dcr Praxis.

53. Monatsblatt fur Medicinische Statistik and ofTeDtliche Gesundheitspflege.

54. Monatshefte, Medicinisch-Chirurgische.

55. Monatsschrift fi'ir GcburtakuDde und Fraucnkrankheitcn.

56. MoDatsschrift, Schweizerischc, fur Praktische Mcdicin.

57. Organ fiir die Gcsammte Hcilkunde.

58. Sitzaugsberichtc der Mathcmatisch-Pbysicalischen Klasse der K. K. Aka-

demic der Wiaaenscbaflen zn Wien.

59. UntersnchuDgen zar Xaturlchre des Mcnscben und dcr Thiere.

60. Verhandlungen der Pbysikalisch-^kledicinischen Gesellschaft zu Wflrzburg.

61. Vierteljahrschrift fiir uerichtlicbe und Oeflfentlicbe Medicin.

62. Vierteljahrschrift dcr Prakt. Ileilkunde der Medicin. Fakaltat zu Prag.

63. Wochenschrift, Wiener Medicinische.

64. Zeitschrift, Oesterreichische, fur Praktische Ileilkunde.

65. Zeitschrift fur Klinische Medicin.

66. Zeitschrift der K. K. Gesellschaft der Aerzte zu Wien.

67. Zeitschrift fiir Wund&rzte und Geburtshelfer.

68. Zeitschrift, Unparische, fiir Natur- und Ileilkunde.

69. Zeitschrift fiir Wissenschaftliche Zoologic.

70. Zeitschrift, A. Ilenke's, fiir Staatsarzneikunde.

71. Zeitung, Allgemeine Wiener Medicinische.

72. Zeitung, Medicinische Kussland's.

73. Zeitung, Medicinische, vom Yerein fiir Heilkunde in Preussen.

74. L'Abeille Medicale.

75. Annalcs de la Flandrc Occidentale.

76. Annales Medico-Psychologiques.

77. Annales d'Oculistique.

78. Archives G enemies dc Medccine.

79. Bulletin de I'Academie Imperiale de Medccine.

80. Bulletin des Traveaux de la Societe Imperiale de Marseilles.

81. Bulletin de Therancutique.

82. Comptes llendus des seances de TAcademic des Sciences.

83. Echo medical Suisse.

84. Gazette hebdomadaire de Medccine et de Chirurgie.

85. Gazette des Ilopitaux.

86. Grazette medicale de Lyon.

87. Gazette medicale de Paris. «p

88. GkLzette medicale de Strasbourg.

89. Journal de medccine Beige.

90. Journal de medccine de Bordeaux.

91. Journal de medecinc de Bruxelles.

92. Journal de medecinc dc I'oulouse.

93. Jounial de la Physiolo^e de Thomme et des animaux.

94. Memoiree de I'Academie Beige.

95. Memoires de la Societe de Chirurgie dc Paris.

96. Memoires de TAcademie imperiale de Medccine de Paris.

97. Moniteur, le, des HOpitaux.

98. Prcsse medicale Beige.

99. Revue medical, Fran9ai3C et etrang.

100. Revue the therapeutic medico-chirurgicale.

101. L'Union, medicjilc de Paris.

102. L'Union, medicale de la Gironde.

103. Gaccta medica de Lima.

104. Bulletino delle scienze medico-fisiche di Bologna.

105. Gazetta Medica, dei Stati Sardi.

106. Gazetta Medica di Lombardia.

107. II Filiatre Sebezio.

108. Siglo, el, Medico.

109. Bibliothek for L&ger.

I— MANUALS AND REPOKTS.

, THe Prineipli'ii and Practice of (^'ileiria, including the Tra^mcrU of
"' ': Injlamnati'm of the Uterus, conddertd as a Frtquent Cause

^ ^ Abor:ion. Uy Henry Miller, U.D., Professor of Obstetric Medi-

I,; cintf in Ihc Medical Deparlmctit of the University of Louiavillc, Ky.

t With U lustrations on n-ood ; pp. 624. Philadelphia : Blanchard &
Lea. 1858.

8. A Manual of ObsMria : Theoretical and Practical. By W. Tyler
Smith, M.D. 12mo., pp. 628. London. 1858.

8. TraUi theitriqve el pratique de Part dei accouchements, comprenant ThU-
ttairt de» tuUadies'qm peuvent se maniftsler pendant la gTossesise el It
travail. Vindication du soins a downer a fenfavt, depuit la naisxaiice
jiuyu' d Cepoque du sewage. Par P. Cazeaux. Gme. edit. 8vo, Paris,

1858.

t%torelia>l and Practical Treatise on Midwifery, etc. By P.

ICazeaux, M.D. 6lh edit. Paris, 1858.

1 LtArbueA der Gebarlthulfe. Von Dr. Otto Spiepelbcrg. Hit 80 in
feiD den Text gedruckten UolzBchntlteii. pp. 376. Lahr, Schaiicn-

fimg &Co., 1856.

\.Xiiuuil of Obstelrics. By Otto Spicgulbcrg, M.D. "Willi 80 wood-
iota, etc, Lahr, Scliauenbiirg & Co., 1958.
t Iiekrbueh dcr Oeburishul/e fur ITchammen. Von Dr. F, C. Naegele.

I lOte Atxfl. pp, 550. Heidelberg, J. C. B. Mohr. 1858.

V J Manual of Obatetria for Midwifes. By F. C. Naegele, M.D., 10th

ledit. Heidelberg, etc.

\ JBUments of Practical Sridfcifery, or Companion of the Lying4n

WRoom. By Charles Waller, M.D., Obstetric Physician to, and Lect-
urer on Midwifery at St. Thomas's Hospital. Fourth edit, with
plates. 12mo., pp. 193. London, 1853.

T, Traitt prattqat des mcdadia da organes sejeuds delafanm, par M.
Scanzoni, Professcur d' accouchements ct de gynaecolngic & I'uni-

»TGT«it^ de WuTzbourg ; trailnit de rAllcmand et annotd sous lee
grenx dc I'autenr par Ics docteurs Dor et Socin. Paris, 1858.
• A Pradieal IVeatise on the Diseases af the Femalt Sexual Organs, By
Scanzoni, etc, — Translated from the German by Drs. Dor and
Socin. Paris, 1858.
6. Iioeons cliniquet sur les maladies de tuients et de tei annexes. Par le
Dr. F. A. Aran, Medicin do I'Lopital St. Antoine, Professeur agregS
de la Faculty de Medicine do Paris. Paris, Labd. 2 vol. 8vo.
1858 (not complete).

- Clinical Lectures on the Diseases of tie Vlerus, etc By F. A. Aran,
, JI.D.etc.

I Lectures on the Diseases of Women. Part IT. IXseasts of the Ovaries,
By Charles West, M.D., etc. London: John Chtirchill. 1858.

114

10. Practical Midwifery, comprising an Account of 18,478
which occurred in the Dublin Lymg4n HospUal. By E. B. Sinclair,
A.B., T.C.D., and George Johnston, M.D. London, 1858.

11. Vtrhandlwngen der QtsdUhaft fur Gehtirtahulfe in Berlin, 10. Heft.
Mit 2 Taf. Abbildungen. gr. 8. pp. 204. Berlin, A. Hirschwald.

— Transactums of iht Berlin OMetric Society. 10th Vol. With 8
plates, etc.

18. Bericht uber die ThatigkeU und Verhandlwngen der Oeadlsckafi fkr
GehurlsWfe zu Leipzig, erstattet von E. P. Meissner. — In Monat-
schrift fUr GeburtshUlfe. Juni, 1858.

— Transactions of the Leipsic Obstetrical Society, etc. By E. P. Meiss-
ner. — In Monatschrift f. Geburtsh. June, 1858.

13. Drei und vierngster Jakresbericht der Oebaranstalt derJOnifiL SSuhti'
schen medic<Mrurg, Academie zu Dresden. — In Monatschrift fUr Ge-
bnrtshUlfe. XII. t. T>ec. 1858.

— Forty4kird Annual Report of the Lying-in Hospital of the Baml M^
diooHMrurg, Academy at Dresden. By Grenser, M.D. — In Monat-
schrift fUr Geburtsh. XII. 6. Dec. 1858.

14. Bericht uber die VorfdUe in der geburtshulfUchen and gynaekologisdun
KUnik und PoHkHmA zu Jena, wdhrend der Jakre 185 5, 1856, 1867.
Yon Ed. Martin. — ^In Monatschrift f. Geburtsh. XII. 8. Sept
1858.

— Beport of the Obstetrical and Oynaekdog. Clinic of Jena, for 1855,

1856, 1857. By Dr. Ed. Martin, M.D.— In Monatschrift f. Geb. XIL
8. Sept. 1851.*

15. Jahresbericht von der gelnirtshulflichen KUnik pir HAammtn im
Witn, fur das Jakr 1857. Yon Dr. Habit.— In Zeitschrift der Ge-
sellshaft der Aerzte zu Wien. No. 21, 22, 28. 1858.

— Annual Beport of the Obstetric Oliwic for lEdwifes tn Vienna, for

1857. By Habit, M.D. — In Zeitscrift d. Gesellsch. d. Aerzte zu
Wien. Yol. 21, 22, 28. 1858.

16. Bericht uber die Leistungen der water der Leitung des Hofratk und
Prof. Dr. V. Scamoni stehenden gdmrtshulfichen Klimk zu Wurz-
burg, vom 1. Nov: 1858 bis 81. Octob. 1856. Yon Dr. J. B. Schmidt
— ^Ib Scanzoni's Beitr&ge z. Geburtsk. Bd. 8. 1858.

— Report of the Obstetrical Clinic of Prof. Sea/nzoni at Wurzburg,
from Nov. 1, 1858 to Octob. 81, 1856. By J. B. Schmidt^ M.D.—
Scanzoni's Beitrftge z. Geburtsk. YoL 8. 1858.

17. Report of the Committee of Obstetrics of the Ohio State Medical So-
dety. By J. G. F. Holston, M.D. — In Transactions of the Ohio
State Med. Soc. 1858.

18. Beport on Uterine Diseases. By R. McMeens, M.D. — In Trans-
actions of the Ohio State Med. Soc. 1858.

19. A' Beport on Diseases of the Cervix Uteri. — Read before the Medical
Society of the State of Greorgia. With additional notes by Joseph
A. Eve, M.D., Prof of Obstetrics and Diseases of Women and
Children in the Medic College of (Georgia.

118

Tab^rucche ZutammnsUUting der Ereignisse in dtr gfimrtukvif-
HcAen Klinik ju Wv,rzbu.Tg wahrend der 6 John vom 1. Novbr. 1850
6m 31. (M. 1856. Von Dr. Gregor Schmitt— Scanzooi's Beitriige.
B.3.

- Tahviary Iteview of Births Obitrved in the Obsttlricai Clinic of FUrz-
burg during tht fix Yeart from Noe. 1, 1850 (o Odob. 31, 1856. By
1. Sclimitt, M.D.

lie past year has been nnusuallj fruitful in mannale and hand-
les, an accamtilation of science which is certainly not required in
r time. We are already in posecsBJon of bo many excellent bvoka
of this kind, that there will be no need in this direction for the nest
decennium. On the other hand, their value is undeniable for the
student of obstetrical acJence, inasmuch ae he is thus enabled to

Incur to the teachings of his master in case of need, having at once
occasion to make himself acquainted with the most recent stale of
■eience.

Db. Millkh's work is essentially utilitarian in its aim, fairly repre-

arnttng the present state of obstetric science in this country. Dr.

Miller dwells more particularly on a subject which of late has much

occupied the attention of the profession, viz., the influence of inflani-

mation and ulceration of the cervix uteri upon the course and pheno-

a of pregnancy. His views upon this subject appear to be iden-

with those which were promnlgated in France and England

mc fonrfeen years ago. He says that the most prolific cause of

Mrtion consists in a diseased state of the gcstative organ, cither in

lole or in part ; that when a portion only is affected, it is the cer-

I rattier than the body ; and that as to the particular disease itself,

t is inflammation of the uterine mucous membrane, which may

■rade also the parenchyma of the organ. In support of this opinion

t, however, merely alleges that in his experience he lias had many

tortonities of verifying the frequent existence of inflammation,

h ulceration of the cervix uteri, during pregnancy, and of satisfy-

j himself that it is not an uncommon cause of abortion. To sup-

DTt bis view on this subject ho points to analogous phenomena m

r departments of the system. Oastro-enterilis, for example, he

I, quickens and perverts the peristaltic motion of the alimentary

lal, and leads to the precipitate ejection of its contents, not permit-

X tbe food to remain a sufficient length of time to be digested. Tn

B case the food may be said to be prematurely expelled, just as

e ovum is liable to be, when the organ it inhabits is inflamed.

With regard to the important chapter of puerperal hemorrhage,

" . Miller protests strongly against artificial delivery in cases of

tcenta prmvia, referring to tlie want of success which has attended

, as indicated by the statistical data collected by Drs. Simpson,

rask, and otliers. As a substitute for turning, he proposes a modi-

xtian of a method of Puzos, which consists in originating expulsive

mtraction of the uterus by tlie tumpon or plug, and then puncturing

e membranes, relying on the tampon to control the flooding until

e liquor amnii is evacuated. Dr. Miller assorts to have employed

's method with uniform success so far as tlic mother is concerned.

116

Dr. SMrm writes in a peculiarly attractive style, and in conyeying
his information he does it in his own words, instead of compiling
quotations from other writers, whereby his influence orer the mind
of the student is generally increased. The physiological and theo-
retical portions of the book are exceedingly good. Altogether, the
book is well fitted for leading students to become good and scientific
practitioners. In page 62, quite a new suggestion is offered as to
the nature of menstruation. Dr. S. believes that at each menstmal
period the mucous membrane of the uterus is, in great part, or
entirely, broken up, and its delms discharged, and that a new mem-
brane is formed as a preparation for the reception of a fecundated
ovum. This idea is reasonably supported by many well stated facts.

The chapters on physiology and mechanism of labor are very
goodj and convey a correct idea of the process.

In regard to the time when the placenta ought to be removed, we
think that ten minutes is too short a time as a general rule. It is
better to wait for a few efficient contractions of the womb, and let
the woman enjoy some rest from the last and hardest stage of labor.
The chapters on the management and retention of placenta require a
larger share than is allowed to them by the author, because here the
student finds his first puzzles when entering upon his practical
career. The advices for management of the puerperal state are very
reasonable, especially in regard to the diet, allowmg noorishing food
as soon as the secretions are fairly reestablished.

Deficiency of the lochia from reieniion means to say, we suppose,
from retention of hlood-coagiUa in the womb ; at least the treatment re-
commended admits no ot^er explanation. The chapter on convulsions
is very good in every respect And we only can repeat, that the
book is highly recommendable for students as well as practitioners.

Cazeaux's work is distinguished by extraordinary elaboration,
redundancy of detail, and great freedom of style. With regard to
ulcerations met with on the cervix uteri during pregnancy, and their
influence upon the production of abortion and puerperal disease,
he thinks that their importance had been greatly exaggerated,
especially of those occurring in the latter half of gestation, most of
which he regards as the normal condition, as a consequence of the
progress of gestation. He is convinced of their non-injnrions char-
acter, and therefore regards all treatment employed against these
ulcerations, even when fungoid, as much more hurtful than osefoL
Dr. Grisolle's views on the reciprocal influence of pregnancy and
parturition upon the progress of phthisis are endorsed by Dr. Gazeaux.
Contrary to the general belief, they tend to show that neither preg-
nancy nor delivery afiects sensibly the progress of phthisis, nor does
the latter sensibly disturb the course of the former. The relations of
albuminuria to puerperal convulsions have been very carefully inves-
tigated by M. Cazeaux. He insists very strongly upon its import-
ance in ihe etiology of the disease, but regards it rather as its.
predisposing than exciting cause. He is strongly opposed to the
employment of ansBSthetic inhalations in the treatment of this dis-
ease. With regard to the induction of premature labor, our author
lays it down as a rule, that it should not be undertaken boGnre the

117

<^nd nf the fipvcnth month of pregnancy, and that the flmaUeflt p^rio
diameter BhouM not he lose than two inchce and three quarters. Of
all tho mpthoda employed for this pnrposc, he almost exclusively
rrciiiBmcndB tho use of Kiwiech's uterine douche. The operation for
tl*c production of abortion is, in the opinion of our author, perfectly
jastiliabU! in certain cases, such as extreme contractions of the pel-
vis, voluminous tumors of the excavation, extreme dropsy of the
amnion, irredeemable displacements of the womb, and hnmorhages
which have resisted the employincnt of the moxt rational means for
tbeir suppression. With reg^ard to the Cue><ariau operation, M.
Cazeaux believes that the child ought to be sacrificed whonuver the
delivery can be effected by embryotomy, liejocting the use of
■iia^tfa^tics in normal labor, Dr. Oazeaui proposes their adminiatr^-
tiou in the following cases : I. For calming the extreme agitation
and Diental excitement which labor often produces in very nervous
women, i. In those cases in which labor appears to bo suspended
or much retarded by the pain occasioned by previous disease, or
nch as may supervene during labor, as cramps, colic, vomiting,
compression of the sciatic nerve, etc. 8. In cases of irregular or
portinl contraction. 4. Spasmodic contraction, or rigidity of tho
ocTvix uteri, b. Cases of eclampsia, restricted to those which ap-
pear to be manifestly due to tho local irritation of an organ, whose
Btreme sensibility had excited the reflex-action of the spinal nerves.
t Obfltetricul operations, which are productive of much pain, or
eessitate quiescence on the part of the patient — such as turning,
mphyaeotomy, or the Cesarean.
K Db. SnEOELBERo's manual of obstetrics, although a part of a medi-
1 Cycloptedin, mny be considered as a work of itself, as it com-
isea the entire field of obstetric science. One of its greatest
IdTantagca is its practical tendency, aside from theoretical and
^liaticitl speculation, while all the scientific researches of our
are dnly recorded as far as they liave regard to tlie physiology
Bl>regnancy and parturition. The first pages are occupied with the
*1BCription of tho abdomen and pelvis. When speaking of the differ^
It diameters of the pelvis, our anthor mentions the so-called normal
^mgata (tl. II Meyer), which is represented by a line, the posterior
. irminna of which is located in the third lumbar vertebra, while its
Ittori or extremity reaches the Btiperioredgeof the symphysis pubis,
iltwe^n the two tubercula pubis. After this follows a description
■f the external parts ; of the breasts ; tho obstetrical examination ;
'e physiology of pregnancy and of the puerperal state. On page
1, 11. Spiegeiberg mentions the development of sebaceous glands
FDund the nipple as a sign of pregnancy, and ascribes to Dr.
migomery tho honor of having first called attention to this circnm-
moe. This is not quite correct. It was Prof. Roederer, of Gtil-
wen, who first (1753) mentioned the coincidence of pregnancy
tn enlargement of the glands, situated in the areola of the nipple,
e cause of tlic position of the foetus in otero with its head down-
Iftrda, ifl attributed to the gravity of the lotter, aided by the confor-
fetion and reflex actions of the uterus itself. Therefore, cross-
mentations are very often met with in an abnormal state of the

118

uterus, and with deformed children. For the same reason, prema*
ture and dead children rarely present with tiie head, becanse their
specific weight is altered under these circumstances. The chapter
on diagnosis of pregnancy opens with a consideration of the circnila-
tory, cardiac, and umbilical sounds. The first tff these is owing to
the alteration of the circulation of blood in the uterine walla, in some
cases to compression of the large pelvic vessels, and to a dilatation of
the epigastric artery. Therefore it cannot be considered as a certain
sign of pregnancy. The umbilical souffle takes its origin in tibe
arteries of the cord, whenever the navelnstring is exposed to pres-
sure. The cause of the first labor pains is put down as a conse-
quence of an altered circulation of tiie uterus, leaving it undecided
whether a state of anaemia or of hypersemia is formed, although it is
more likely that the latter condition acts as an exciting cause to
labor, produced by the catamenial afflux of blood to ovaries and
uterus. In the chapter on physiology and dietetics of childbed, onr
author mentions the fact that still-born children may be resuscitated
even after a lapse of a couple of hours. The pathology of gestation
comprises, 1. Those afiections which may be considered as an
increased or altered physiological condition of the pregnant stata
2. Those accidental diseases which are unconnected wim gestation.
With regard to the treatment of placenta preavia, the vaginal plug
is warmly and justly recommended. The predisposing dement in
the development of ureomia, one of the many causes of eclampsia, is
the peculiar condition of the blood of pregnant women. As it is con-
stituted very much like that of chlorotic persons, it has a tendency
to the formation of oedema, to transudations, to the passage of
albumen and fibrin through the kidneys, and to excite the nervous
system of pregnant women. The performance of the accouchement
forc^ is surrounded with the most serious dangers, and its execution
must, therefore, be restricted to those cases where the life of the
mother is actually tiireatened by a long continuation of eclamptic
attacks. The use of chloroform is invaluable, inasmuch as its ^pli>
cation retards the evil influence of the convulsions upon the system,
thus giving time to the accoucheur to apply whatever remedies he
thinks proper to choose for promoting delivery. In the chapter on
uterine h»morrhages, the prolapsus placent» is duly mentioned.
The diagnosis of this accident meets with no difficulties, when tiie
afterbirth protrudes from the os uteri, while it is more difficult to
recognize the true nature of the case, when only a small section of
the placenta has come down near the edge of the os uteri, and in
this mstance it is generally mistaken for placenta praovia. This pro-
lapsus is always fatal for the child, while the prognosis for the
mother is better, because the h»morrhage is not so violent as that in
consequence of placenta prsevia. The collapse after delivery is due
to a perfect exhaustion of the central nervous system produced by
the efforts of labor. This exhaustion is mostly met with in tender,
irritable women, who are little used to muscular exertions. But it is
also observed in strong and healthy women, after very rapid deliv-
eries. In this latter instance, the syncope is explained by cerebral
ansBmiai in consequence'of a s^ng ud sudden congestion of the ab-

119

mI orgnnB. In both cases, chloroform is the remedy. The last

a of the work contains a deBcription of the different obstetrical

-ions. Altogether the work before us is all that can be

lected from a treatise of this kind. It wilt undoubtedly take a

cominf nt place amon^ the numerous manuals of obstetric a

■d art.

t Db. Waller's work contains a short esposition of obstetric B'

I is intended as a manual for students and young' practitioners.
Ik is extremely meagre and commonplace in its details — exhibits but
^le piower of analysis or condensation on the part of the author.
i qneation of the extraction of the placenta in certain cases of
lacenta previa, and the general employment of anaesthetics in mid-
■ifery, arc treated of more fully.

Dr. Sc*KzONi'3 work ia a concise treatise on the pathology of

" mule diseases, with the exception of Ihnsc occurring during prcg-

mcy, labor, and the puerperal state. The author ^recognises four

Uferent forms of ulcerations — 1. The (rorion, which owes its origin

k s previoDS or existent uterine catarrh. It sometimes ia preceded

7 a vesicular, aphthous eruption, and in this instance generally

ttinocled with an abnormal condition of the blood. M. Scanzoni

tended an otherwise healthy woman, affected with aphthro of the

luth, who, with every new eruption, exhibited also fresh blisters

I the mucous membrane of the Taginal portion. She was finally

red by country air and bathing in tlie river. 2. This erosion, after

) time, assumes the character of an vleeraiion, which takes a

!«nular appearance by consecutive hypertrophy of the papillae i

C mucous membrane. This kind of ulceration is always connected

rtth stmctural changes of the uterus itself, mostly with chronic en-

ivrgcment and catarrh, both of which must be considered, in some

iBcs, as the cause, in others us the conscriuence of this ulceration.

■ presence constantly keeps np a state of congestion of the womb

J i\a appendages, thus producing and increasing pathological con-

Hions in and around the uterus. These utccrationa never heal spon-

ineously, but have a tendency to spread in all directions. 3.

^utgout ulceraiiont are those which have a development of vascular

oellnlar tissue ; they proceed deeply info the cervical canal, and are

klways the seat of an abundant pnriform secretion, bleeding spon-

■i^neoDsly and when touched. 4. Variants ularations are rarely met

vith, having their origin in a chronic stasis in the uterine walls. At

""e beginning of the disease the vaginal portion has a blucish red

«, like the appearance in advanced pregnancy ; afterwards dark

lOts and varicous veins are observed, upon which the softened

s membrane forms slight elevations. Finally, tho epithelium

ecays, and the erosion, with a blueish red and vascular base, in-

i broad ulceration. The erosion is, in most instances,

rable in four weeks. The treatment should bo begun with the appli-

jbtion of leeches, to be followed by the application of a caustic solution

Jf*fE- "'tr 9i, aqu. Si) every five or six days. Tho granular ulcer-

■-MioD demands repeated local depletion every sixth or eighth day,

mma hip-baths, alum injections, stronger cauterizations, and the use

of aperient mineral waters. The excrescences of the fungous ulcer-

120

ation have to be removed as mncb as possible with scissors, and
afterwards a strong caustic solution ought to be brushed over the
diseased surface as far as it extends into the cervical cavity. Gene-
rally, the excision has to be repeated four or six times ; instead of
leeches, blood ought to be abstracted by scarifications.

One hundred and eight women, afflicted with cancer uteri, came
under the author's treatment, and seventy-two of them had borne a
large number of children (four to eleven). The most important pre-
disposing causes to cancer seem to be depressing mental emotions ;
it was possible to trace the origin back to this source in eighty-four
cases ; in fifteen patients excesses in venere were admitt^ ; in
eight patients chronic engorgement, with or without ulceration, pre-
ceded the development of cancer. Only three cases of neuralgia
uteri came under the author's notice, and only one of them was cured
— ^by marriage. In small, unilocular ovarian cysts, good results
were obtained by Kiwisch's method, a catheter being left in the
opened cyst ; eight patients in fourteen being radically cured ; three
leaving before the treatment was concluded ; one dying two months
after the operation from typhus fever ; while in two of them the cyst
filled anew. The operations performed for atresia vaginae had such
unfavorable results, that Dr. S. has abandoned operating upon the
vagina, and resorted to puncturing per rectum, in the hope that this
operation will prove more satisfactory.

Dr. West's work, although chiefly occupied by descriptions of and
discussions on ovarian disease, contains several chapters of other
subjects. The three last are on diseases of the external organs of
generation, of the urethra and vagina, and of the female bladder ;
while the two first are on inflammation of the uterine appendages,
seven chapters remaining for the diseases of the ovary. A great
number of cases, usually put down as acute or chronic ovaritis,
ovarian irritation, and pains in the unimpregnated female, are
actually very often the results of acute and very limited peritonitis.
In twenty-one out of sixty-six instances in which Dr. West examined
the uterus and its appendages, the ovaries themselves, or parts im-
mediately connected with them, presented changes, more or less
obviously due to inflammatory action. In ten of the twenty-one
cases, the main evidence of inflammation consisted in traces of old
peritonitis of the uterine appendages ; and in five of the number
there was no evidence of mischief. The amount of this peritonitis
varied accordingly. In some instances its results were nothing
more considerable, than a thin and partial layer of false membrane
on the surface of one or other ovary, and long, filamentous adhesions
between the ovary and fallopian tube. In other cases a complete
web of false membrane enveloped the ovaries, thickened the broad
ligaments, and by its contraction shortened the ovarian ligaments.
Acute inflammation of the proper tissue of the ovary is occasionally
a phenomenon of puerperal fever, as it occurs at an early stage of
ovarian dropsy ; but apart from this it is not a common afiection of
the unimpregnated female.

A frequent disease at this region is ovarian pain. It is generally
aggravated at the menstrual period, and often connected with dia-

p^ rinrc d gmwni health, in most cases easy to mitigate, bat very hard
1 4o euro. Lcecbcs and blisters sometimes afford ease for a sliortcr or
I bnsrr space of time ; chloroform locally applied gives temporary
IdHlief. The camphor linimeDt, with extract of belladoma, is another
UBtornal application wliich Dr. West haa found advantageoas ; and
Djltieu these means have been fruitless, the tiucturc of aconite has
Kpecn applied with advnnta^. Attention to tlic general health must
■■way a go hand in hand with tho local treatment — nuist indeed hold
Bpe first place. The tonics which do the must service are the sulphate
Bfcf nuiniue and the valerianate of zinc.

WL The appearance of ovarian cyst is obHorved almost invariably
Krithin the child-bearing period of life. The characteristic forms of
^ttis disease are believed by Dr. West to take their origin in one or more
Hpva&aii vesicles. Small ovarian cysts are often observed to have
HkoD tents, more or less like those of a graafian vesicle, and sometimes
^■pcn a little clot of blood, the analogue of a healthy condition of the
ffart, the g;r»alian vesicular menstruation. To complete the proof,
^ppkitansky has discovered an ovule in a young ovaiiim dropsy. But
Bui!<] the graafian vesicular origin of the disease in many cases is
Hflniittied, others cannot be citcluded ; at any rat« the question
^■mains nndecided. Dr. West is of opinion that a cyst, originally
Hfarren, may become proliferous ; that its continuing simple is rather
H^'happy accident than a condition, on the permanence of which wc
Humot calculate witli any certainty. The diflerent means for curing
Hat ovarian cyst are— 1. Excision. 2. Injection with a solution of
^bdiac. 3. Tapping of tlie main cyst. 4. The ovarian dropsy may
Hp let alone. After the researches of Dr. West, one of two dies after
^Eratiatomy. Of the cases in which the operation is attempted, it is
Wbii unfinished in about oue-tliird, and of these latter, again, about
^Etbird terminates fatally. Dr. West, therefore, rejects ovoriatomy,
^■Bd is greatly in favor of iodine injections The operation of tapping
H|vr vaginam, and subsequently keeping the wound o|>cn, has aa yet
Hmh little practiced, but the results seem to encourage further trials,
Hl Ifessrs. Sinclair and Johnston's work on Practical Midwifery, con-
B|lts of an account of 13,74S deliveries which occurred in the Dublin
^Ming-in Hospital during tlie seven years of Dr. Skeleton's niastei-
Hpqi, while the authors were assist ant- physicians for the greater
■nut of that period. The preface of the work contains an interesting
^Hcouat of the origin, progress, and management of the hospital, and
Hpdeecription is also given of the general routine treatment which
^■■iients undergo from the time of their entrance to tlieir discharge
^■BlCii convalescent. All labors are arranged under four principal
^kada : — 1. Natural. 2. DiGBcult. 3. FreternaturaL 4. Anomalous.
Hne proportion of male to female births is 105 boys to every 100
KicU. The total number of still-born children was 068, or about 1
^M «Tery 14 of lliosc born. Of these, however, 487 wero putrid at
Hie time of birth. Of tho 481 non-putrid children, 284 were males
Hnd 197 females, which shows that male children are exposed to
Bbreater risks immediately before and during birth than females.
The total number of maternal deaths from all causes was about 1 in
84 ; deducting, however, 17, which were admitted dying in the

122

hospital ; the mortality was 1 in 94. Of the 163 women dying from
all causes, 40 died from other than puerperal ones, thus leaving 1S3
deaths out of 13,748 deliveries directly traceable to the labor; or
about 1 in every 111 women delivered died from puerperal causes.
In the months of December in each year, the greatest mortality was
found to prevail, the ratio being 1 in 46, and the lowest in May, the
ratio being 1 in 184. Of those labors which terminated within the
first hour, 1 in 110 mothers died ; while of those women who wwe
delivered during the second and third hours, only 1 in 243 died. In
the first six hours the proportion of maternal deaths is 1 in every
178 ; from seven to twelve hours, 1 in every 144 ; and from thirteen
to twenty-four hours, 1 in every 124. In those cases where labor
was prolonged beyond twenty-fo^t hours, but in which there was no
interference, the mortality reaches as high as 1 in every. 20|.

The forceps deliveries amounted to 200, and the craniotomy cases
to 130. The mortality in the forceps cases amounted to 11 mothers^
or about 1 in 18 ; and IT children, two of the latter being putrid ml
birth. Of the craniotomy cases, 26 mothers died, or 1 in every 5.
In using the forceps, traction was made during a pain only, in the
direction of the axis of the pelvis, and no motion whatever was
permitted in a lateral direction. Craniotomy was never had recourse
to when the forceps could be applied, even if the child's heart had
never been heard during labor.

In prolapse of the funis, considerably more than one-half of the
children were lost. Accidental hemorrhage occurred in 81 labors, 4
mothers djing and 27 children being dead-born ; instrumental inter-
ference was needed in 8 cases. Of placenta presvia, only 24 in-
stances occurred in the entire number of deliveries. Of th€»e, how-
ever, 6 mothers died. Of the 8 cases of complete placental
presentation, only 3 recovered, and only 3 children were born alive.
The treatment adopted was according to the circumstances of each
particular case In all cases of postrmortem hemorrhage, a stream of
cold water was thrown into the uterus, and with the best success.
Induction of premature labor was performed in 4 cases, and each of
the mothers recovered, but only 1 child was saved. In two cases,
where it was induced on account of general dropsy, both mothers
died. Chloroform was given in nearly all cases before operation,
and during the seven years not a single accident took place that
could be attributed to the use of chloroform. Of puerperal fever,
which, however, never appeared in a severe epidemic form, 129
cases are reported, or 1 in every 106 of the whole. Eighteen cases
of trismus neonatorum are present in this report, and all died within
ten days ; it seemed to make its appearance in an epidemic form.

From Dr. Grexser's report we take the following data. In 1851,
433 pregnant women were received in the Dresden Lying-in Hos-
pital. Of 412 deliveries, 373 were efiected without surgical inter-
ference ; 20 by the forceps, 1 by turning, 5 by extraction, 3 by per-
foration and cephalotripsis, 1 by accouchement forcd ; while in nine
cases artificial removal of the placenta was required. All the women
recovered with the exception of 5 ; out of this number 2 died from
peritonitiB, 1 from pyssmia, 1 from urssmia, and 1 from mptura uteri.

123

r-liorn cbildrcn was 414, ainoDg whicn

Eire of twine, altogether 219 boys and 195 girls ; IS male and 6
aale children were Etill-boni, and all of tJuem reanscitated ; 13
boys and 9 girk died before delivery, 4 in far advanced maceration,
I immature, 3 from pressure of tliB cord, 1 from internal hcmorrbage
in coDscqucncG of uterine rupture, 3 from compression of the brain
during the passuge of the head through a contracted brim, 3 from
protracted labor, with consecutive craniotomy.
The presentations were as follows :

303 in I. eranlAl.
9 Id II.

1 la II. Bhoulfler.

In 4 c

the presentation was not noted.
The largest placenta was 8 and 9 inches in its diameters, the
.^allest 4, while 45 placentas had fibrinous, and b had calcareous
.deposits on their ulerine surface.

The indications for the 20 forceps operations wore : for increaa-

Ing diminution of the fcetal pulsation in force and frequency ; 6 for

.prolupsus of the funis ; 1 fur imminent suSbcation of the mother, in

^Dseqnence of a large struma lymphatica ; 1 for eclampsia ; 1 for

oiterual baimorrhage from ruptura uteri ; I for metrorrlmgia in the

imat stage of labor ; 3 for rhachitic contraction of the pelvis. Five

Mt of these 20 children were born dead ; 5 were still-born, and

ivived ; 2 mothers died ; 1 from eclampsia ; 1 from mptnra uteri.

From the statistical tables reported in Dr. Martin's report, we take

le following facts :

1855.— Of 88 new-born children (1 pair of twins and 4 stili-born),
i were of the male, 50 of the female sex. Obstetrical opcrationa
ero required 35 times, among which was 1 Coisarian operation
wt mortem, giving a dead child ; 15 forceps operations ; 4 crani-
Dtomy-forceps operations.

1856.— Of ill children born in the hospital, 4 were still-born, and
1 pair of tvins. In the polyclinic, 1 case of premature quadruplets
iraa observed. The examination of the afterbirth showed that three
had been fructified. There were altogether 98 cases of dya-
^, jia (out of 159 deliveries) and 37 operations, among which were
}8 forceps operations.

18S7. — Of 164 deliveriea, 7 cases of twins occurred, giving a total

Rr ni children born, among which were 100 males and 71 females ;
8 of tbem died before or during confinement. In these 164 caaea,
46 operations were required. The transfusion of blood was miccess-
tai]y performed in a case of hcetuorrhage from placenta prtevia.

KtKele'i I. CrsnisI preKDtatioi

TM«cidGd •' "

hrial preKDialion. I.
FteKntation of natea, L

Foot presenWtionB, 1 2

124

After 52 forceps operations, 2 mothers and 5 children died.

Dr. HABrr'a report contains the following : There remained from
last year 80 pregnant women, 77 in childbed, 67 children ; 3,835
pregnant women received in the hospital, of which 3,795 were de-
livered, 33 dismissed undelivered, 87 remained at the end of the
year. Of 3,872 women in childbed, 3,702 were dismissed healtfaj,
83 died, 87' remained. Of 3,727 children, 1,965 were males, and
1,762 females; 119 were still-born (65 males, 54 females) ; dis-
charged 3,568 children, 146 died, 80 remained ; 860 were so-called
" gassengeburten " (t.e., women delivered immediately before enter-
ing the hospital) ; premature confinements, 249 ; twins, 51 ; 3,663
cranial presentations, 27 face presentations, 95 foot and nates pre-
sentations, 52 cross presentations. The operation of turning upon
the head was performed in 21 cases, upon the feet in 32 ; inductions
of premature labor, 2 ; convulsions, 13 ; hemorrhages, 35 ; ruptora
uteri spontanea, 2 ; forceps operations, 43 ; perforation, 5 ; Ceasarian
operation post-mortem, 1 ; artificial removal of the after-birth, 15 ;
diseases of the puerperal state, 182 ; deaths, 83.

From Dr. J. B. Schmidt's report we give the following facts of 879

births ; 869 were simple, and 10 twin-births ; 839 children bom alive,

50 dead :

I. Cranial preeentation 606

11. " " 231

L Facial '* 1

jL " « 3

I. Breech ** !!!!!!!!!!!! 12

II. " ** 6

Atonic pains were observed in 42 cases, and treated with the col-
peurynter, the douche, carbonic acid, or ergot of rye ; spasmodic
pains, 24 ; treatment : opium, tepid baths, chloroform, colpcurynter
and douche ; ruptures of the perineum, 18, three being to the sphinc-
ter ani ; to prevent perineal ruptures, the labia were incised 85 times 5
pelvic deformities 15, 7 delivered naturally, 3 with the forceps, 2 by
perforations and cephalotripsis, 1 by extraction on one foot, 2 by
induction of premature confiuement. Eclampsia observed in 1 case,
chloroform used, mother died suddenly. Placenta preevia partialis,
3 cases, colpeurynter, opening of the membranes ; plac. pr. central.,
1 case, turning and extraction of the child ; three mothers recovered
— one died afterwards from puerperal fever — 2 children born alive, 2
dead. Prolapsus of the funis, 11, 6 with cranial presentations. In*
duction of premature labor was performed 3 times. Case 1. — Hydraa-
mia, catarrh of the kidneys, dyspnoea ; application of sucking-glasses
to the breast nine times in three day, inefficient pains ; douche twice
a day for a week, insufficient pains ; injections with secale comutum,
strong pains, os dilated to the size of a gulden ; membranes detached
with the sound, two hours afterwards birth of a dead child weighing
2} pounds ; mother recovered. Case 2. — Pelvic contraction, antero-
posterior diameter 3J to 34, induction of premature labor by six ap-
plications of carbonic acid to the vaginal portion in five days ; child
born alive, mother recovered. Case 3. — Contracted pelvis, sucking^
glasses, douche, colpeurynter, all without exciting labor pains ; tap-
ping of the membranes ; cross presentation, turning ; child dead,

Feet presentation €

CroB8 " 18

Uncertain *^ U

ter recorered. Caae i. — Contracted pelvis, carbonic (tcid gas,
injection nf dccoctam atthieie, plugging of the vagina (Sliceller,)
lining of tlic membranes (Meissner's method); child born dead, in
toot presentation ; motlior recovered after being taken witli endome-
tritis. Forceps operation 47, all molhers recovered except one, who
died from puerperal fever ; 43 children born nlive, 5 dead. Crani-
otomy 2, both from contracted pelvis ; one mother died from endome-
tiiUa and pysemia.

From Dr. Greoob ScRUtm's report it appears that during tlie six

J ears from 1850 to 1856, 1,639 women were delivered in the lying-in
ospitut, and among this number 27 twin births were observed, mak-
■ big a total of 1,666 children, of which 1,536 were born alive, ISOstill-
Imm ; llSofthe children born alive died afterwards in the hospital.

I. Cranial prescetalloni IIDD I Breeeli prcMntatloM 2S

IL " " as] Feci " 23

I. PatUl " e Crow " 24

"I. " " 4 1 UBoertniu " 16

Operations: 1. Inductions of premature labor, 6; mothers recov-
icred, 6 ; children born alive. 3 ; dead, 3. 3. Forceps operations, 100 ;
Bothers recovered, 94 ; died, 6; children born alive, 80 ; dead, 30.
|. Extractions, 39; all mothers recovered ; children born alive, 26 ;
lead, 13, 4. Turning by one foot, 24 ; mothers recovered, 22 ; died,
J ; oiiildien born alive, 12 ; dead, 13. 6. Craniotomy, 5 ; mothers
*ecovercd, 4 ; died, 1 ; operation with Van Uuevel's forceps-Bcie., 1 ;
UOthcr recovered.

Dr. Hdiaton'b report (iiscusscB in separate chapters the history of
Bidwifcry in Ohio ; its theory and practice, corapriaing a considera-
tion of " the frequency of midwifery" and natural labor ; tedious and
'diffictilt labors, more particularly in reference to ergot as a remedial
vent ; statistics of natural and preternatural laborn ; the diseases
tf puerperal women ; and obstetrical literature and education.
Dr. McMEE.'*'a report on uterine diaeaaes, consists chiefly of an ac-
pimt of four interealiiig caaes. One of hypertrophy of the womb,
itli excessive flow of the catamenia — mistaken for a case of poly-
Bua uteri. The second case is one of intractable dysraenorrhoea.
Illu) tliird case is one of intense hysteralgia excited by the use of
jot taken with a view to the production of abortion ; while tbo
ftrarth is one of extensive vesico-vagiual fistula, caused by inalprac-
in a resort to instrumental interference, merely to gain time.

[^ANATOMY AND PHYSIOLOGY OF THE UTEEUS

AND OVARIES.
Aran, F. A., Avntamtcal and ' AmUtimo-'palhological BistarcJies on the
" Slalvjiie " of Iht Wfnij.— Archiv. Giiuer., F('b. and March. N. Y.
Jour, of Med. VI. I.July.

8. Guyon, F., EtadMsur lu carU4t de TiUerus a Pilat devacuiU. Th&so.
Paris, Mars, 1858.

■Goyon, F., cm the Cmidition of the non-Pngnant VUrine Caiit,
lliesis — N. Y. Jonr. of Mod., V. 3, November.

126

3. Dumas, on tkt Uterus and Ovaries of a Vtrpn, toho died a few dmfs
after Menstruation. — Rev. thdrap du mid. xl p. 293.

4. Priestly, W. 0., Lectures on the Detxkpmeni of the Oravid Uierms,-^
Delivered at the Grosvenor Place School of Medicine. Med. Times
and 6az., 438, Nov. 20, etc.

5. Robin, Ch., Memoir on some Points connected vfith the Anatomy end
Physiology of the Mucous Membraru, and the EpUhdium of the Uknu
during Pregnancy, Brown Sequard's Jour, de Physiol., January,
and New Orleans Med. News and Hosp. Oaz., July and August

6. Dal ton, S. C, on the Anatomy of (he Placenta. — Amer. Med. Monthly,
July. N. Y. Jour, of Med. v. 3, Nov.

7. Luschka, on the Idouid Portion of the Oraafian FoUide. Wurtemb.
Naturw. Jahresh. Jahrg. 13. N. Y. Jour, of Med. V., 1 July.

8. Uterus and its Appendages. By Dr. Arthur Farre, London, 1858.

9. Bealc, Liquor Amnii containing much Urea. Archives of Med. No. IL

10. Hillyer, E., an Essay on the Physiology of Menstruation. SoutL
Med. and Surg. Jour, xiv., 12, Dec.

11. Spicgelberg, 0., on the Nervous Centres and the Motion of the Uteme,
— Henle and Pfeuffer, Ztschr. 2. N. Y. Jour, of Med. v. 1 July.

12. Savory, W. T., an Experimental Inquiry into the Effect upon the Mother
of Poisoning the FoUus, — Lancet, June. N. Y. Jour, of Med. v. 2 Sept

13. Giraudet, E., on the Valve of the Current Theories for the EspUee^
iion of the Causes of Menstruation. — ^raz. des H6p., June 15.

14. Kirsten, Th., on Glycosuria Lactantium. Monatschrft f. Geb. ix. 6.
N. Y. Jour, of Med. iv. 3. May.

15. Riedel, on Glycosuria in Pregnand and Parturient Women. — Monat>
schrft f. Geb. x. 2. N. Y. Jour, of Med. iv. 3. May.

16. Bi-Ucke, on Glycosuria of Women in Childrbed. — ^Wien. Med. Wo-
chenschrft 19, 20.

17. Hewitt, G., on Coagula Formed in the Veins during the Puerperal
State. — Lancet, April.

18. Savage, on the Erectile and Venous Systems of the Pelvic Organs.
Lancet, Feb. N. Y. Jour. iv. 3. May.

19. Rouget, Ch., on the Female Erectile Organs, amd on the Tuho-Ovariam
Muscular Apparatus in its Connection wiih Ovulation and MenstruatimL
Jour, de Physiologic, etc., No. 2, 3, 4.

20. Lee, R., on the Membrana Deddua which surrounds the Ovum tn
Cases of Tubal Gestation. — Lancet 1, April.

By far the most valuable contributions to obstetric anatomy and
physiology, which we have received from France, are Dr. Rouget's
article on the erectile organs of the female, and Dr. Aran's statisti-
cal researches on the " statique " of the uterus. They are replete with
new ideas and scientific researches. Next to these, we place Dr. Dal-
ton's article on the anatomy of the placenta, who by one bold experi-
ment seems to have decided the question with regard to the manner in
which the foetal part of the placenta is connected to that of the mother.

Under the name statique of the uterus, Dr. Aran comprises its sit-

127

nation as fitr as it is established by its anatomic&l condition, anct as
far as it is liable to be chan^d by different circunuttaQc^g. Think-
ing that even now the diBcnasion in regard to thia subject had by no
means come to a satisfactory result, the anthor intends to review the
opinions current, and to add new observations and opinions of his
own. Of the different ligaments believed to sustain tfae ntenis in its
position {two lateral, one anterior, one posterior — plicas Douglasii),
be thinks the latter alone deserve the title of ligament, because of
their 6brous testuro. His inqniriea in regard to these structures
differ somewhat from the description given of them by the most re-
liable anatomista : 1. It is not the inferior portion of the uterine
neck from which they start, but from the point where the collum and
corpus uteri meet. 2. Instead of two ligaments there exists in re-
ality but one, because the inner and posterior fibres form but one
continued layer, without any line of demarcation, while the middle
strata cross each other in tbc median line, and the external bundles
are mixed up on each side with the uterine tissue itself. 3. These *
ligaments do not always surround the cavnm recto-raginale, i.t., they
do not comprise in every instance the rectnm in their posterior de-
partment, t. They do not stop in the middle portion of the pelvis,
but extend their rami^cationn as high as the fourth, and sometimes
tbc fifth, lumbar vertebra. Moreover, the direction of the posterior
ligament is not from below npwards, but it runs in the opposite di-
rection ; nor does it extend in one straight line from the uterus to
tlie sacrum, but near the latter point it spreads outwards. Therefore
its inllnence upon the position of the uterus is to prevent descent
towards the outlet of the pelvis, retaining it over tlie neck near the
OS sacrnm. These ligaments almost disappear during pregnancy,
while they exhibit an enormous state of hypertrophy when ihe uterus
is retroverted. The ligamenta rotuuda are not intended to keep the
utema in its elevated position, but merely prevent the fundus from
falling backwards ; therefore the operation of shortening the round
ligaments, as proposed by Dr. Alquid for caring prolapsus uteri,
would prove a failure. Notwithstanding Dr. Stoltz's experiment,
who removed the entire vagina without producing aa alteration in
the position of the womb, it seems probable that the vagina has some
influence in retaining the uterus iu its position, as is proven by the
good result following artificial constriction of the vagina for the pur-
pose of curing the falling of the womb. Dr. Aran, far from under-
rating the importance of the vesi co-uterine ligament as a means of
influencing the position of the uterus, cannot agree entirely with
Prof Virchow's views, who seems to consider the adherence of
the uterus with the bladder to be one of the chief points of its sup-
port The conclusions drawn from these remarks are as follows : 1st.
The uterus is suspended in the pelvic cavity of the adnlt female by
a eompiet of different means of suspension, composed of the inser-
tions ofthe bladder and vagina in front.of the vagina and the posterior
ligaments in the rear, and laterally of the vagina and the lateral
fibres of the posterior ligament. 2d. The combination of these means
of suspension establishes a real axis — "axedt itMpeiwwMi" — around
which the movements of the uterus are completed. The retatioQ of

128

the uterus to this " axe dc suspension/' is not yet fully ascertained
In following the natural development of the uterus from the very finil
months of existence, it is an acknowledged fact, that in foetal life
the body of the womb is always somewhat bent upon its neck, whiok
flexion disappears the more the female advances in years, and above
all it is the pregnant state which corrects this flexion of the uteriim
body. Dr. Gosseliu found, in forty-eight post-mortem examinatioiit
of women who had never been pregnant, twenty-seven more or leaf
decided anteflexions of the womb, eighteen perfectly straight, aoid
three dubious cases. Dr. Aran found, among nine young^ virgin fe-
males, from n to 27 years of age, six decided anteflexions, two re-
troversions, and one straight uterus ; of ten married sterile women,
there were six below 24 years of age with decided anteflexions, two
with anteversions (one of them 48, one 49 years old), two with an
almost straight uterus (18 and 55 years old); of twenty-one women
who had borne children, seven exhibited unmistakable anteflexion
' (23 to 27 years old), three presented a slight inclination in front (88^
40, and 57 years old), two showed retroversion (age, 28 to 40 years),
in four the axis of the uterus followed that of the upper pelvis (ages,
26, 28, 33, and 44), in five cases the womb was retroverted (age, 88,
25, 40, 44, 45). In all of these cases no traces of uterine disease bad
been exhibited during life. This shows that 50 per cent, of the ex-
amined (post-mortem) women had an anteflexed womb, the cases
belonging almost exclusively to young women and those^who had
never borne children. Therefore, in childhood and puberty the axis
of the womb docs not follow the axis of the upper pelvis, but is more
or less inclined in front, which disappears the more the woman ad»
vances in years, and after she has been pregnant. In regard to Dr.
Cruveilhier's opinion, that the axis of the uterus in the living female
changes with the position of the body, Dr. Aran thinks that this state
of indifierent axis is not the rule, but the exception, it being only
met with in those cases where the means of suspension around the
uterus are in a state of weakness, such as occur in conseqeence <^
repeated confinements. One thing is certain, that the uterus of
healthy females may be found, in anteflexion or forward inclinations,
quite straight, and in the direction of the upper pelvis, or in an indif-
ferent position, following simply the laws of gravitation. The fcetal
anteflexion of the uterus. Dr. Aran considers to be the result of the
pressure of the abdominal viscera upon the extremely soft and flexi*
ble body of this organ. In more advanced age, the walls of the body
of the uterus thickening, and the point of union between body and-
neck settling lower down, the condition favoring a state of anteflex-
ion, disappears. In those cases where anteflexion remains after the
years of puberty, and, what is very rare, after pregnancy, the short-
ening of the round ligaments may be accounted for, in consequence
of which the uterus is unable to be sufficiently thrown backwards
by the bladder when filled with urine. There are two kinds of uterine
obliqity ; in the first instance the neck remains in its position, while
the body is bent upon it towards the right or left side ; in the second
instance, one of the superior comers of the uterus is drawn upwards
and in front, the other side of the womb being placed in the opposite

129

direction ; so in both cases the corresponding ronnd Ifgament, and
renerallj the utcro-sacral ligament, are shortened. The greatest
difiercnce between tlie two round ligaments, as observed by Dr. Aran,
^as 95™". ; the greatest number of these lateral inclinations is found
among children, which condition seems to disappear as they advance
in years. From these researches it appears that it is wrong to con-
lider and treat anterior and lateral inflexions in young females, as
pathological conditions, especially if they do not give rise to dys-
menorrhoea or sterility, in more advanced years.

Dr. Outon applied a stiffening substance for injecting the uterus,
in order to find out the shape and dimensions of its cavity at the dif-
ferent stages of life. The- rcsults obtained in this way may be com-
prised as follows : ^

1. From birih to the time of puberty, — ^The axes of the arbor vitsd are
greatly developed, especially towards the upper extremity of the
neck, so as to form an isthmus almost obliterating the cavity, from
whence they diminish rapidly in size, ramifying towards the cavity
of the body. A cavity of the womb does not exist, properly speak-
ing, because the elevations of its internal surface touch each other
entirely. The shape of the cavity is such, that it shows at its lower
end a larger size, while from this point it contracts gradually up to
the fundus, where the intcrtubular diameter is smaller than that of
the entrance. The cavity of the body measures a little less than
one-fuurth of the entire length of the organ.

8. Virgin and nuUiparous uterus. — ^The cavity of the body appears
to be divided in two sections, one starting from the neck, narrow
and long, the other intertubular, formed by two trigons connected at
their basis. The three sides of the cavity are convex ; 'tlie lateral
ones at first very obliquely directed, suddenly change their direction,
approaching a vertical line on the summit of this second portion of
t£e body.

The cavity of the neck is only a few millimetres larger than it
was immediately after birth ; it is enlarged somewhat in the middle,
restricted at the entrance, and not changed at ito upper extremity.
The shape of the mouth is generally that of a transverse slit, and
not circular. The lateral columns present the same elevation as in
the foBtus, in consequence of which the internal orifice is closed up
by the natural rigidity of the uterine tissue. The folds representing
the branches of the arbor vita) are arranged in such a way that
their free edge looks towards the orifice, so that they may arrest in
some instances the entrance of a probe. In virgins, tlie length of
the cavity of the neck exceeds that of the body, notwithstanding the
latter one has considerably increased. In women who are used to
sexual inteccourse, the difierence of both cavities is null, or a trifling
increase of the cavity of the body.

The isthmus represents a cylinder of 5 or 6°^ in length, measur-
ing 4™° in its transverse, and 3°*" in its antero-posterior diameter.
The total capacity of the cavities is from 3 to 5C7».

3. MuUiparoua utenu. — Cavity of the body perfectly triangular, in-
closed within convex lines, but less so than in the virgin uterus, so
that the uterine horns are enlarged at the expense of the inter-

130

mediate cavity. The vertical, as well as the lateral diameters are
increased, while the cavity of the neck is larger, bat shortened,
owing to the contraction of the vaginal portion.

The internal orifice (isthmus) is wider and shortened, but always
closed by the projections of the walls, and the arbor vitsd oontinueB
to be perceptible. Th^ capacity of the cavities is from 5 to 6CD»>.

4. tlUrus at the change of life, — ^The internal orifice is generally
obliterated. The cavity of the body, more or less distended by a
transparent mucus, has generally retained its shape, and has gained
a few millimetres' in hight The neck has decreased in length, so
much so that, as a general role, the vaginal portion has disappeared.
After the external orifice is closed up in old women, the cavity of
the womb exceeds in length that of the neck from 10 to 12™° ; in
multiparous females, 0.004™°* ; in nulliparous women, who have had
sexual intercourse, both cavities are almost equal in length ; in
virgins, the caVity of the neck is 0.003™° longer than that of the
body, and 0.006™*° in the foetus. From these researches, the author
concludes that the uterine constrictions are always seated in the
isthmus, and that they may result from a flexion, and more especially
from retroflexions with rotation. The penetration into the perito-
neum of intra-uterine injections, though manageable after death, is
prevented in the living female by contractions of ihe womb.

Dr. Robin remarks that most modem authors are of opinion that
the mcmbrana decidua serotina (m. caduca inter-utero-placentaris)
is discharged with the placenta, like the rest of the decidua wiUi the
chorion. This is not exact, nor is it quite true that the plaoentar
villosities are Jmbedded in the serotinous sinuses, like rooia of
plants in the soil. The inter-utero-placentar membrana caduca is
that portion of the uterine mucous membrane, at the level of which
the chorial villosities are hypertrophying for forming the placenta.
While the rest of the mucous membrane atrophies as membrana
caduca, this portion, in connection with the placenta, remains in a
state of great vascularity. Its enormous venous sacs are in direct
communication with the venous sinuses of the muscular layer. These
enlarged veines are in communication with the circular nnus of the
placenta, which is, in fact, nothing but one or more of the serotinous
veines. If a woman is delivered in her seventh or ninth month, the
membrana caduca vera and reflecta are entirely removed, but only
half of the serotinous caduca, because its sinuses are found divided
nearly in their midst, while the greatest portion remains attached to
the uterus.

The uterine surface of the jiacetUa^ when removed at the full term,
is covered with a thin, gpreyish membrane, of \ or 2°™. This mem-
brane is unquestionably nothing but the thickened tpUhdium of the
inter-viero-jlacentar mucous membrane of the uterus, and the most
superficial portion of the mucous membrane. Its microscopical
elements are hypertrophied epithelial cells, an amorphous substance,
molecular granulations, etc. This fact was first noticed by the
author of this article. Therefore, the placentar villosities are sepa-
rated from the serotinous sinuses by interposition of this thin mem-
brane, and the contact of the foetal blood wiUi that of the mothw is

181

by no meaiiB a direct one. The same diflpoaition has been obsenred
in a great number of different classes of animals, viz., that the vaa-
cular aystem of the foetus is on! j connected with that of the mother
hy juxtaposition. That portion of the uterus where the placenta was
located, is covered with the scrotina, even after the detachment of
the placenta, with the exception of that thin superficial layer which
adheres to the placenta. This remaining portion of the uterine
rnocous membrane is not exfoliated, its vessels being in immediate
eonnection with those of the muscular stratum, and, therefore, a
freah mucous membrane is not formed between the scrotina and the
uterine muscularis, as it exists between the latter and the uterine
cadnca. The serotinous membrane of a woman, who dies in the
seventh or nintl/ month of gestation, presents an aspect very different
from that of a woman who dies two or ten days after confinement.
In the former instance it is soft, as large as the placenta ; the sinu-
ses arc flattened ; their long diameter prevailing ; its surface is
slightly wrinkled, but comparatively even. After confinement the
serotinous surface becomes much smaller from the contraction of the
uterine walls ; its form, instead of bein^ circular, is irregularlv
oval, with a sinuous, incised border ; it is a thick, folded, rough
membrane ; its surface becomes after a while softened, and of a
mncous consistency. The irregular edges of this serotina are found,
a few days after confinement, to enter into connection with the soft,
new mucous membrane which lines the rest of the uterus. This red-
dish, irregular, flocculent appearance of the serotina has often led to
mistakes, as it was taken for a portion of the adherent foetal pla-
centa, in cases of death after puerperal fever. Several days after
confinement, this remaining portion of the inter-utero-placentar
caducous membrane is diminished in size and thickness ; it begins
to soften and decay, to be replaced by a new mucous membrane.

VHiile the epithelium of the uterine cervix retains its cylindric
character throughout the time of gestation, that of the cavity of the
womb passes gradually from the cylindric into the pavement fonn.
Tbis phenomenon must not be understood Urhe a strict transforma-
tion of one into another form, but it is rather an exfoliation of the
old cylindric cells, which are replaced by new epithelial cells of the
plated varietjif. But the most remarkable change is observed in
those epithelial cells which are placed between the placenta, and the
▼sscniar portion of the uterine mucous membrane (m. caduca inteiv
ntero-placentaris). They are not only hypertrophied, but alss
deformed, being A™° in lengthf instead of rf t™"* '^^ greatest
number of these aeformed cells are lengthened, terminating in one
or two irregular points. One or both of these cellular extremities are
found irregularly bifurcated. Some of these hypertrophied cells
contain two or three nuclei, some only one, and every nucleus has
inclosed one or two nucleoli. Besides these cellular formations, may
be observed nuclei, very much like those described as cancer-
ous or carcinomatous nuclei. Some of the hypertrophied cells re-
maiii as thev were in the normal state — ^finely granulated and trans-
parent, while others are filled with fatty molecules, with a brilliant,
yellow centre. Similar transformations are found in the epithelial
cells of the uterus in domestic mammalias.

132

Db.'Dalton, after entering briefly into the historical part of the
ytero-placental anatomy, proceeds to develop his views on the distri-
bution of the uterine vessels, with regard to those of the placenta.
In oppositio/i to Dr. Robin's views, he holds that the blood-vessels of
the uterus do really penetrate into the substance of the placenta, as
supposed by the Hunters, Dr. Reid, and Prof. Goodsir, and that they
constitute, with the tufts of the foetal chorion, an equal part of its
mass. The placenta is therefore a double organ, partly maternal
and partly foetal, and in order to arrive at a distinct understanding
of the arrangement of its vessels, a description of the development
of the chorion of the foetus and of the decidual membrane of the uter*
us, is necessary. At first, the villi of the charian are quite simple in
form and homogeneous in structure. Afterwards tHey become ram-
ified by the repeated budding of lateral off-shoots from every part,
and the external surface of the chorion presents a velvety appear-
ance*. Under the microscope these tufts appear to terminate by
rounded extremities, and the larger branches of the villosity are seen
to contain numerous oval nuclei, imbedded in a nearly oval homoge-
neous stratum, while the stnaller villosities appear simply granular
in texture. The blood-vessels coming from the umbiliod arteries
ramify over the chorion, and penetrate into the substance of the vil-
losities. They enter the stem of each tuft, and following every divi-
sion of its compound ramification, they reach at last its rounded
extremities. Here they turn upon themselves in loops, to unite
finally with the venous branches which empty into the umbilical
vein. About the third month the chorion becomes partially smooth.
This smoothness, which begins at a point opposite the situation of
the fodtus, increases in extent, and becomes more and more complete,
irpreading and advancing over the adjacent portions of the chorion.
At the opposite portion of the eggy the chorion is thickened and
shaggy, and takes part in the formation of the placenta, while the
umbilical arteries enter the villi, forming at the placental portion of
the chorion, a mass of ramified vascular loops.

The decidua is nothing more than the mucous membrane of the
body of the uterus. It consists throughout of minute glandular tu-
bules, ranged side by side. A few fine blood-vessels penetrate the
mucous. membrane from below, and encircle the superficial extrem-
ities of the tubules with a capillary network. A small qtiantity of
spindle-shaped fibro-plastic fibres is scattered between tlio tubules.
The egg, when descended into the cavity of the womb, is embedded
in this hypertrophied membrane, yid becomes attached to it The
villosities of the chorion insinuate themselves either into the uterine
tubules or between the folds of the decidual surface. In this way
the egg becomes entangled with both decidua reflexa and vera,
throughout the whole surface. Soon afterwards the umbilical ves-
sels penetrate everywhere into the villosities of the chorion. Each
villosity of the chorion, then, as it lies embedded in its uterine fol-
licle, contains a vascular loop, through which the foetal blood circu-
lates. At a later stage the vascular growth, both of chorion and
decidua, becomes concentrated at the situation of the subsequent
placenta, while elsewhere, over the prominent portion of the egg, the

133

chorion not only becomes bare of yillosities, but the decidda reflcza
&I80 loses itB activity of growth, and becomes expanded into a thii)
layer, nearly destitute of vessels.

The placenta, accordingly, is formed by the continued growth at
one particular spot of the villi and follicles of the decidua. The uter-
ine follicle enlarges with the villus, which has penetrated into it.
Bending out branching diverticula. Besides the follicles of the uter-
ine mucous membrane, also the capillary blood-vessels, which lie
between them, become unusually developed. At this time, therefore,
each vasculsr loop of the footal chorion is covered first with a layer
forming the wall of the villus, which is in contact with the lining
membrane of the uterine follicle ; and outside of this again are the
capillary vessels of the uterine mucous membrane, so that two dis-
tinct membranes intervene between both the footal and the maternal
capillaries. As the formation of the placenta advances, the general
anatomical arrangement of the foetal vessels remains the siime. But
the maternal capillaries become considerably altered ; they enlarge
excessively and fuse successively with each other, thus becoming
dilated into wide sinuses. At this period the development of the
blood-vessels, both in the fcetal and maternal portions of the placenta,
becomes so extensive, that all the other tissues, which originally co-
existed with them, fall into a retrograde condition and disappear al-
most altogether. The villosities of the chorion are now hardly any-
thing more than ramified vascular loops, while the uterine follicles
have become mere vascular sinuses, into which the tufted fcBtalr
blood-vessels project. Finally, the walls of the foetal blood-vessels
having come into close contact with those of the maternal sinuses,
become adherent to them, and fuse with their substance, so that the
two can no longer be separated without lacerating either the one or
the other. The placenta, at this stage, is composed essentially of
nothing but blood-vessels of the foetus adherent to the blood-vessels
of the mother ; the blood of the foetus is always separated from the
blood of the mother, which has resulted from the fusion of four differ-
ent membranes, viz. : the membrane of the foetal villus ; tliat of the
uterine follicle ; the wall of the foetal blood-vessels ; the wall of the
nterinc sinus. If a villus, from the foetal portion of the placenta,
be examined, it will be seen that its blood-vessels are covered with
a layer of homogeneous or finely granular material, ^At ^^ ^^ ^^^^^
in thickness, in which are embedded small oval-shaped nuclei. This
layer is all that intervenes between the foetal blood in the tufts of the
chorion, and the maternal blood in the placentar sinuses. • The ana-
tomical disposition of the placentar sinuses is verj*^ difficult of exam-
ination in the deUched placenta, because they are collapsed and
apparently obliterated, and the foetal tufts appear to constitute the
whole of the placental mass ; still they may be satisfactorily dem-
onstrated in the following manner. The uterus of a woman who had
died undelivered, near the full term, is opened so as not to wound
the placenta ; then, aftc»r the foetus is removed, it is placed under
watQTi with its internal surface uppermost. Then the amnion has to
be removed from the placenta. If the end of a blowpipe be now in-
troduced into one of the divided vessels of the muscular walls of the

134

\ uterus, and air forced iu, we can easily inflate, first the venouB sin- -

uses of the uterus itself, and next the deeper portions of the placenta.
If the chorion be now divided at any point by an incision, passing
merely through its thicknes, the air which was confined in the pla-
cental sinuses will escape and rise in bubbles to the surface of the
water. Such an experiment shows conclusively that the placental
sinuses communicate freely with the uterine vessels, occupy the en-
tire thickness of the placenta, and are equally extensive with the
tuft of the foetal chorion. This experiment has been, performed by
. Dr. Dalton on four different occasions. This method has many ad-
vantages over that adopted by the Hunters and Prof. Weber, espe-
cially because it is infinitely less liable to mislead by producing
extravasations.

The opinion of some authorities, that no vascular openings are to
be seen on the surface of the detached placenta, corresponding with
the mouths of the lacerated uterine sinuses, is explained by the fact
that these vessels penetrate in such an extremely oblique direction,
that their orifices may easily be overlooked.

Dr. Luschka remarks that the walls of a follicle consist, first, of
a membrane abundantly imbued with blood-vessels, the stroma of
which is a cellular tissue with elastic fibres, and which is separated
from the inner epithelium by an amorphous membrane, being at-
tached exteinally to the stroma of the ovarium by a thin cellular tis-
sue : secondly, of the epithelium — this consists of a great quantity
of round or angular cells in the different stages of development ;
they represent what is called the stratum granulotum. These cells
are most numerous on that portion of the sac, where the ovulum is
situated, which they surround on all sides, so that here a protrusion
is formed into the cavity of the follicle, generally called cumulus
proligerous.

The rest of the Graafian follicle is filled up by a yellowish, albu*
minous fluid — the liquor folliculi Graafiani. This liquor takes its
origin from the cells of the stratum granulosum, as can be proven
by microscopical examination of the different stages of development
of these cells. First of all a nucleus is formed out of the blastema of
the blood, around which molecular matter is deposited, and from
which the amorphous wall and the contents of the cell are separated.

The most superficial ones are the most developed. Their gran-
ular contents are changed into a clear albuminous substance,
from which the cells become larger and pellucid. These fluid
contents pass through the walls of the cell in the shape of clear
oily drops, which disolve after some time in water. In this case the *
cellular wall contracts, to be filled anew. In other instances the en-
tire cell is dissolved, without leaving any trace, or with continuance
of the nucleus, which serves for the formation of a new cell. But
not every one of the cells participates in the formation of the liquor,
some passing into fatty degeneration, some undergoing no change
whatever. This fluid is the original blastema from which the ovu-
lum originated ; it further serves as nourishment while the ovum is
being developed ; and lastly, being increased by direct extravasation
from the congested blood-vessels during the catamenia, it expands

185

and finally mptares the Graafian follicle. The oyum thus set free
has to subsist for some days on its own means ; for this purpose it
takes along a certain number of those cells which cover it, in the
Ibrin of what is generally called discus proHgerous,

Db. Farre's treatise on the uterus and its appendages is an import-
aat contribution to the anatomy, physiology, genesis, and patho-
lo^^ical anatomy of the entire sexual apparatus, with an additional
article on the structure and function of the placenta. The amount of
researches and facts laid down in these pages is so great, that we
most abstain from giving an abstract, recommending' the work to
every one who takes an interest in the study of anatomy and physi-
ol^KJ o^ ^® female genitals.

Db. Bkale relates a case of a patient in the eighth month of preg-
nancy, from whom about seven pints of liquor amnii were drawn
off. The specific gravity was 1,006. The deposit was fiocculent,
and consisted principally of epithelial cells and oil globules from
the surface of the skin of the fcetus. A few circular cells', probably
derived from the bladder, and some particles of dark green, and
brown coloring matter (meconium), were also present. The follow-
ing was the result of the analysis :

Water 98T.00

Solid matter 13.00

Urea 3.60

Albumen and salts 9.50

In another case. Dr. Bealc found in liquor amnii, drawn from a
woman in the eighth month, a number of coats of urinifcrous 1;.ubes,
scarcely half the diameter of those found in the adult

An analysis of a great number of experiments upon forty living
animals, in order to answer the question, What are the causes and
the seat of uterine movements ? led Dr. Spieoelberg to the following
conclusions : 1. The stoppage of the circulation, and consequent
stasis of blood, is the cause of the peristaltic movements of the utei*us.
As long as the heart is in activity, there are no movements seen at
all, or they are very trifling. 2. Through the nervi vagi no excita-
tions are conducted to the uterus. 3. By irritation of the medulla
oblongata, uterine movements can be effected. 4. The cerebellum
is the nervous centre which chiefly controls the movements. 5.
From every point of the spinal cord, but more especially from its
lumbar and sacral portions, movements of the uterus can be pro-
duced. 6. The excitations starting from the central organs travel
downwards along the medulla oblongata and the spinsu cord, and
proceed through the rami communicantes of the sympathetic, and
through the sacral nerves to the uterus ; and likewise excitations
rising from the uterus are produced through the same channel. As
to the order in which the uterine contractions follow, Dr. S. believes
frem his experiments, that first of alt the mesometrium begins to
contract, in consequence of which the uterus is fixed towards the pel-
vis ; after this the vagina and the cervix uteri contract ; this circu-
lar contraction proceeds up to .the fundus uteri, and from thence
returning, presses the foetus downwards, while the cervix and vagina
are enlarged.

136

Dr. Savory remarks, that although the qnestion as to the possibil-
ity of transmitting poisons through the foetal vessels of the cord to
the maternal blood, seemed to be settled in the negative by the ex-
periments of Magendie, many ph3'^siologist8 still believe, that the
foetal blood commingles with the general mass of the mother's blood ;
it inoculates her system with the qualities of the foetus ; and that, as
these qualities arc in part derived by the foetus from its male pro-
genitor, the peculiar constitutional vices of the latter are thereby so
engrafted on the system of the female, as to be communicable by her
to any offspring she may subsequently have by other males. And
as, moreover, the nature of Magendie's experiments appeared to Dr.
Savory objectionable, he followed another method, which was
crowned with affirmative results. His general plan was as fol-
lows : By opening the abdomen and uterus to expose and isolate a
living foetus ; then to inject into it, with the least possible violence,
some substance capable of ready absorption, and the operation of
which is marked by obvious and unmistakable effects, great care
being taken that no trace of the substance came into direct contact
with the maternal tissues. The foetus, thus injected, was placed in
a condition most favorable for the continuance of the circulation, and
symptoms of the operation of the poison upon the mother were care-
fully noted. The poison Dr. Savory selected was twenty-four grains
of strychnia, dissolved in seven drachms of distilled water, by the
addition of one drachm of acetic acid. The subjects of his experi-
ment^ were dogs, cats, and rabbits. Five experiments are reported,
from which it seems that proof is no longer wanting, of the direct
and rapid transmission of matter from the foetus to the mother
through the bloi)d in the placenta.

Dr. Kirsten detected the presence of sugar in the urine of
women in childbed, especially in those cases where lactation had
been interrupted. He examined some specimens from women, where
puerperal fever had cut short the secretion of milk, or where the
children had died soon after birth. The method he used for ascer-
taining the presence of sugar was, by reduction of the oxide of cop-
per through the watery solution of the alcoholic extract of the nrine.

For testing the truth of Dr, Blot's observation, according to which
sugar was a natural ingredient of the urine of women in childbed
and when pregnant, Dr. Riedel examined the urine of eleven women
in childbed, two of whom had lost their children, and three pregnant
women. In none of these fourteen cases was he able to detect the
slightest traces of sugar after Trommer's test.

In order to ascertain whether sugar was a constant ingredient of
urine taken from women in child-bed. Dr. BrUcke tested it on a new
principle, viz : ty formation of acetate of sugar, because the other
methods hitherto emploj-ed seemed to be of doubtful value. In this
way he detected considerable quantities of sugar in the tested uriife.
Still it remains to determine if similar quantities of sugar may not
be detected in the urine of healthy men or non-pregnant women.
Without having performed quantitative analysis, Prof. Brlicke is al- .
ready satisfied that the increase of sugar of healthy women after
delivery is by no means a constant and general phenomenon.

187

Dr. Obatlt Hswirr remarks that the circumstances preceding or
necessarily connected with the act of parturition, which may lead to,
OT favor the formation of coagula within the veins, are to bo found
X. In the Mate of the blood during pregnancy. Its amount of fibrin is
increased, the number of blood-corpuscula and the quantity of albu-
men diminished. This hyperinotic state of the blood of pregnant
^«n>men predisposes to the occurrence of those puerperal affections of
Vnich the so-called phlebitis forms a constituent part, in wliich co-
a^nlation of the blood in the veins is the starting point. On the
other hand, women who suffer in a great measure from diminution
of red corpuscula (chlorotic women) are very liable to puerperal
fever (Scanzoni). 2. Another cause for coagulating the blood is to be
found in the mechanical effects of the pressure of the enlarged uterus, in
consequence of which disturbance of the circulation, favoring stasis
of the blood in certain veins, is often observed. 3. The influence of
fttsmMTt during the act of parturition^ as performed by the head of the
child resting for a considerable time on the brim of the pelvis, in
such a position as to retard the venous current, passing from the
pelvic organs and lower extremities, be it by protracted labor or by
a misproportion of head and pelvis. 4. Deficient contraction of the
slersi and of the venous plexuses near it, after delivery. If the uterus
does not contract sufficiently after delivery, the blood contained in
the large sinuses stagnates, and a tendency to coagulation of
the contents of the vessels is produced. 5. The existence of physi-
tiogieal coaguia. The formation of these coagula in the orifices of the
uterine veins is favored by two circumstances ; there is a stasis of
blood within the veins, and in many cases exposure of the same to
the action of the air. The existence of these normal coagula has no
small share in forming the coagulations in the large veins of the pel-
vis, and parts adjacent to the uterus (Virchow). 6. The occurrence of
hemorrhage after parturition, because it interferes with the perfect
involution of the uterus, or when successfully arrested, after some
time, the coagula are loose and less consistent, thus favoring the ad-
mittance with the circulating fluid, of those deleterious and septic
matters which are occasionally formed on the internal surface of tho
uterus after delivery. T. Certain conditions of the internal surface of
the uterus following on parturition, such as mechanical injury to the
nteruB, inflammation of the internal surface of the uterus (particles
of the placenta remaining and decaying in the womb, E, N.)

Dr. Savage read a very interesting paper on the erectile and ve-
nous system of the female pelvic organs before the Medical Society
of London, in which he stated that he had discovered a new struc-
ture hitherto not demonstrated, viz.: the bulb of the ovary. This
body is inclosed in an unyielding fibrous envelope, an essential con-
tradistinction as regards a mere venous plexus, l^he bulb of the
ovtfry is a long, compact venous body, extending from the uterus to
the ovary, which lies upon and is partially buried in it. Like the
bulb of the vagina, it is provided with a special sheath, which estab-
lishes its erectile character. The office assigned to this body is that
of tending to push the organ itself towards the prehensile extremity
of the fallopian tube.

188

In a discussion which followed upon this subject^ Dr. S. allowed
that this bulb of the ovary had been described before (namely bj Dr.
Kobclt ; see his work : [Die WdbUcken u, Miinnlicken WMu^orf&mf
1843) ; but its character as an erectile organ had not be«Q pointed
out before he (Dr.>S.) had mentioned it.

AAor a full and scientific expose and a literary review of the facte
concerning the anatomical structure of erectile organs, Dr. RoueB
comes to the conclusion, that there are three constituents neoeasaly
for tissues of an erectile character, viz.: arteries with a spiral ooorae^
vast venous reservoirs, and muscular trabeculas. For tbe womb it
is very easy to demonstrate the presence of these three elements^
while it remains to analyze their mutual relation, and show that the
number of vessels is larger than is required merely for the process
of nutrition, and to prove that changes of volume, shape, and posi-
tion are effected by the distension of these vessels

The uteroK>varian artery, does not distribute its branches eqaallv
upon all portions of the womb. While near the neck of the womb
its ramifications are few in number, and run in a pretty straight
line, it divides abruptly near the fundus into a dozen or eighteen tor-
tuous branches, so numerous and so much pressed against each
other, that they cover entirely the lateral angles of the fundus uteri.
Towards the inferior margin of the ovary the utero-ovarian vessel
furnishes a series of a dozen branches, which start in rapid succes-
sion from the upper border of the artery, and in ramifying close to
their origin, directing their tortuous course towards the ovary, where
they form also spires. The venous system of the womb is so much
developed, that it looks, even uninjected, like a real sieve in many
specimens. These masses of venous sinuses, when empty, give no
idea of what they really represent, when fully developed by a com-
plete injection. If this vascular system is separated from the inter-
vening muscular stratum (by nitric acid) the erectile system c^ the
body of the uterus, and below the ovary becomes distinct This erec-
tile body represents the exact form of the fundus and body of the uter-
us, stopping short suddenly near the orificium internum (anatomia).
Independently of the uterine sinuses, the erectile mass is formed of
twisted and almost spiral venous canals, like those of the corpus
spongiosum penis. Near the angles of the uterine body the arteries
are so numerous that they form here the greatest portion of the vas-
cular system. Immediately below the ovary there is a real corpus
spongiosum, an erectile vascular tissue, containing spiral arteries,
venous tissues, and muscular trabecula. The corpus spongiosum
(bulbus) of the ovary is elongated and flattened, exceeding some-
what the long diameter of the ovary, whil& it is about 1^ thick,
and a little more than l°™high.

These are the only erectile organs inside the female pelvis, the
vessels of the tuba Fallopii not having the character of erectile or-
gans. While injecting the vessels of the tube, no change of form or
size, nor any movement whatever was observed, quite different from
what was seen in really erectile organs. Nor have the walls of tiie
vagina anything characteristic of erectile organs ; its arteries are
even not spiral, while its venous system consists of a very thin vas-

139

cular network. Only the plexus of large veins running along its
lateral bordera, and a vascular ring near its orifice, form a kind of
erectile body capable of being changed in form and size.

The erectile character of these portions can be demonstrated by
artificial erection, viz. : by immersing a fresh pelvis, with its con-
tents, in warm water, and injecting the ovarian veins. As soon
18 the injected mass begins to fill the vessels, the erectile portion
of the body of the womb is elevated in the cavity of the pelvis,
performing a movement like that of the penis in erection. At the
same time the uterus becomes more convex in front and behind,
ita borders round and smooth, while the cavity of the womb is en-
larged. The ovary is somewhat elevated by the injection, while
the tnbes remain unchanged in their position.

It remains to discuss the mechanism of this erection. In the womb
this is easily demonstrated. The muscular borders of the uterus
have the same rapport with the venous network, as the trabcculce
of the corpus cavernosum with its sinuses ; the same cause, Inuscu-
lar contraction, must produce the same efiect, viz.: the retention of
the blood in the sinuses. But in the corpus spongiosum of the ovary
it seemed to be impossible to bring it under the same law. An in-
dependent muscular tissue was nowhere found.

Dr. RouoET has found, by the study of eomparative anatomy, that
a muscular apparatus performs the expulsion of the egg from the
ovary, and its progress towards the tube. The sexual organs of
the lowest class of vertebrated animals (fishes) present two differ-
ent types. In some of them the egg, when detached from the
ovary, falls into the peritoneal cavity, which is lined by vibratile
epitbelium, and communicates externally by the way of particular
orifices. But the greatest number of osseous fishes have a geni-
tal apparatus, similar to that of articulated animals. The eggs '
are developed upon the walls of a special cavity, or sac, having a di-
rect external communication. Glands constructed on this principle
are covered with a muscular layer. In the vertebrated animals and
in the higher order of fishes, a special duct exists for transmitting
cat of the ovary the products developed in it, and this meatus is
sometimes situated a considerable distance from the ovary.

But the muscles covering these reservoirs and channels do not ex-
actly fit their shape, just as the muscles of the intestinum crassum
and of the seminal vesicles, do not follow the figure which their uneven
shape requires. Another general law, pertinent to these organs, is
that the terminal extremity of the organic muscles is always con-
nected with some portion or other of the locomotive apparatus of the
, animal system, such as bones, muscular aponeuroses, tendons, or
the body of muscles themselves.

After a short analysis of the anatomical structure which forms the
tabo<»Tarian muscular apparatus of the fishes, reptiles, and birds,
Dr. Rouget proceeds to describe that of the mammalia. As a sample
is taken, the disposition of these organs among the ruminants, and
that of the goat, is more particularly described.

The body and the cornua of the uterus are situated in the middle,
the tubes and ovaries in the lateral portions of a large membrane,

140

which, spreading in a transverse direction through the pelvic cavity.,
is attached by its ^two anterior extremities to the superior dorsaf
wall of the abdomen, by its two inferior and posterior extremiti
to the ventral wall. Throughout this membrane, even in its mos
transparent portions, the microscope reveals an extensive distribu
tion of muscular elements, a fact hitherto entirely overlooked b;
anatomists.

The middle section of this membrane is really nothing but the ex-
ternal layer of the muscular envelop of the uterus. In the median
line of this membrane it is easy to distinguish a decussation of the
muscular bundles from one side to another. The bundles which
come from the lumbar region, the superior of which, condensed
towards the free border of this membrane, are called ligamentum
rotundum superius — descendent towards the cornua and the body of
the uterus, and envelop the tube and the ovary in their course.
Meeting at the median line, they cross each other with those of the
other side, and in continuing their course, they are divided in three
different sections ; the inferior ones run backwards towards the
rectum and the anterior surface of the sacrum (ligam. recto-nteriu).
Those of the middle portion seem to connect themselves with a poi>
tion of bundles of the ligam. rotund, pubicum. The superior ones run
towards the lateral portion of the basin and the symph. sacro-iliaca.
It is the latter section which seems to receive a muscular bundle,
which forms the superior border of the ligam. triangul. ovarii, and
which, in passing above this organ, contributes to the formation of
the muscular cord, which does there attach the ovarian fringe of the
pavilion.

The ligamentum pubis rotundum is generally described as a mus-
cular cord, which, coming from the spina pubis and from the labium
majus, runs towards the coi*nu uterinum, or the superior corner of
the womb. But this is, in reality, not. the case. It is perfectly
wrong to separate it from the neighboring portion of the ligamentum
latum, with which it is in intimate connection. From the point
where this ligament touches the anterior abdominal wall, it con-
stantly sends forth muscular bundles, which spread fan-like over the
entire anterior surface of the womb. After traversing the median
line, those bundles, in an ascending direction, unite with the liga-
mentum latum of the opposite side ; a certain portion of them forms
the inferior board of the ligam. triangular, ovarii, and reach the ala
vesper til ionis of the tube.

The superior bundles of the round ligament form, by their " entre^
croisement," the muscular membrane which unites the uterine cornua,
from whence they spread towards the ala of the tube. With this
system are combined the greatest portion of the plic» semilunares
Douglasii, and of the ligamonta utero-sacralia, which embrace the
neck of the womb and crossing at the median lino, combine with the
opposite ligamentum latum.

But, besides this "croisement" in the median line, there exists an
antero-posterior entrecroisement in a line with the lateral borders of
the womb and the cornua, while there is another muscular system,
which remains only on one side throughout its course. This dis-

141

position is represeDted in different degrees of development in all
classes of the mammiferous animals.

All these muscular strata, as found among the different classes of
animals, may be easily detected with some modifications in the
woman. In order to establish the true anatomical character of the
so-called peritoneal folds in the female, a portion taken from th^ir
outer layers must be kept for a few days in diluted (l : 100) nitric
acid, and afterwards, with the addition of four more drops of the
acid, heated to commencing ebullition, by which process the inter-
vening tissue is destroyed, while the muscular fibres may be easily
recognized under the microscope. The best occasion to examine the
disposition of the sexual organs in the human female is not the time
of pregnancy, but that of foetal life and childhood. The uterus, with
its appendages, taken from a young girl and examined with the
loupe or under a small magnifying lens (from 20 to 200 diam.),
after it has been wet with a solution of nitric acid (1^ in water
(100), offers the best means of recognizing, that at this time of life
the human organs resemble, in many respects, those of the goat. The
bundles coming from the round (pubic) ligament are fan-shaped,
and spread over the entire length of the uterus, crossing in the
median line those coming from the opposite side. Those bundles
which are in connection with the ovarian ligament (mesoarium), are
mostly, derived from the posterior surface of the uterus. Descending
from the superior and ascending from the inferior portion, they run
in a convergent direction towards the ligamcntum ovarii ; but being
only more numerous at this point, they occupy the entire space of
what is called, the serous, or rather the muscular membrane, on
which the ovary is suspended. The bundles, interspersed with nu-
merous oblong nuclei, which enter into the construction of the stroma
ovarii itself, and inclosing the graafian follicles in their meshes, are
very likely nothing but a continuation of those from the ovarian
ligament (mesoarium), a fact well established in the ovary of the
reptiles and birds. Besides, it is easy to find out, that a considerable
portion of the bundles of this pretended ligament, proceed towards
the inferior border of the ovary, entering, at its exterior. extremity,
into the composition of the muscular membrane, by which the pavil-
ion of the tube is attached to the ovarian gland. The general fact
of tlie ovary, the fallopian tube, and the uterus being enveloped in a
common muscular membrane, is very important, more especially
with regard to the connections established by these contractile fibres,
between the ovary and its excretory duct These connections result
essentially from the double irradiation of the utero-ovarian and the
ovario-lumbar ligaments in the membrane which connects the ovary
with the trompe. It is easy to perceive that, by a contraction of
these muscular bundles, the tube and its orifice are approached
towards the ovary. The length of the peritoneal expansion nree bord-
er of the mesometrium), spread out between the ovary and the tube,
allows the pavilion to reach the remotest portions of the ovary. This
disposition counterbalances the small extent of the opening of the
tube, which scarcely covers one-third of the surface of the ovary. It
is nothing but muscular activity^ which forces the pavilion to adapt

142

itself just to that particular spot of the ovary, where the follicle i
ready to break. The direction of the two orders of muscalar buDcU
attached at the lumbar region and at the uterus itself, comprises
full length of the tube and its peritoneal extremity, and Buffioieutl;
explains the mechanism of the movement of the tube towards
ovary. The whole question is reduced to that of the mechanism,
whicii a purse is closed by strings, going across its free border.

These muscular expansions are not only destined to approach the^
tube to the ovaiy, but inclosing at once the large venous plexuses
the bulbus ovarii and those called plex. pampiniformis, they do com-
plete the erectile character of these spongious tissues, thus rendering"
the similarity between the male and female organs more perfect.
The erection of the spongious tissue of the uterus is immediately fol-
lowed by uterine h^porrhage. It is a fact that the body of th^
uterus always has been found swollen, full of blo^, more voluminous
in women who died during menstruation. The erection itself results
from a muscular spasm, which prevents the reflux of blood through
the sinus efferentes. Therefore, ovulation, uterine erection, and
menstruation have one and the same fundamental cause, viz., mus-
cular contraction. The adaption of the tube to the ovarv precedes
the dehiscence of the vesicle, which lasts sometimes for eight or ten
days after the beginning of the rupture of the follicle. All this time
the tube can only be retained close upon the ovary by a spasmodic
contraction of the muscular layers which produce the adaptation d
the tube to the ovary. But, at the same time, the venous sinuses
which are inclosed in this same muscular mesh-work, must neces-
sarily undergo a partial compression, the result of which is the dis-
tension and erection of the bulbus ovarii. The accumulation of
blood around and in the ovary must be of influence for the more
rapid development and maturation of the ovulum. These modifica-
tions in the circulation of the ovary do of course bring about a
similar change in the uterus itself, the uterine and ovarian sinuses
being in direct communication with each other. Both organs, there-
fore, are placed in a state of erection by the same cause. If the
erection of the ovary is not followed by a hemorrhage, this is owing
to the tunica albuginea and the thick stroma of the ovary itself.
But, in some abnormal instances, the ovarian erection may cause a
hemorrhage, and this is certainly the most frequent origin of retro-
uterine hematocele. The theory of the act of ovulation is exactly
the same as that of the act of parturition, vomiting, and micturition,
etc. As soon as the graafian vesicle has arrived to a certain degree
of development, the distention of the structures, which constitute
the stroma, is the exciting point of a reflex action, which is propa-
gated from the centres of the sympathetic nerve to the whole mus-
cular apparatus of the internal genitals, to the mesoarium and to the
mesometrium. But the ripening of an ovulum is not the only cause
of the phenomena just described. No doubt sexual intercourse does
very often produce a real, though transient erection of both uterus
and ovaries, and may, therefore, if often repeated, call forth more
frequent menstruation and ovulation. (In reading over Dr. Rouget's
article, we were struck as well with the novelty of the ideas present-

ed, mm with the ingeniiity of the experiments perfonned, and the vast
mmoimt dT knowledge developed in these pages. We cannot speak
too hifffalT of this uiesis, and we desire to urge our readers to a
penuu of the original article. — E. N.)

Dr. Ln, in andyzinff a number of cases of tubal gestation, stated
that in all of them the egg was surrounded by a deciduous mem-
brane, which closely adhered to the inner surface of the tube, while
no decidua could be detected in the cavity of the womb. In most of
the specimens exhibited, Dr. T. Clarke thought to find just the
reverse, viz., a decidua in the uterus, and no deciduous formation in
the tnbe. Still he admitted that in some cases a real decidua was
formed in the tubes. Dr. Tyler Smith thought it but natural, that the
macoos membrane of the tube was transformed into a deciduous
membrane, while the lining membrane of the uterus was developed
to such an extent as to resemble a decidua. Dr. Locock fully agreed
with Dr. Smith's opinion.

m.— PHYSIOLOGY AND PATHOLOGY OP PREG-
NANCY, LABOR, AND PUERPERAL STATE.

1. Mattel, an Diagnosis of Pregnofuy, — Rev. thdr. du Midi. 14.

5. Hecker, on Diagnosis of Pregnancy, — Mon. — Sqhr. f. Geburtsk. xii. 6.
Dez.

8. Thompson, T. E., of Roseville, Arkansas, Practical Bemarks on the
Endemx of Pregnancy, — New Orleans Jour., xv. 4.

4. Helfit^ Infiuence of the different Seasons upon Coruxption, — Mon. — ^BLf.
Med. Stotistik. 5. May 15.

6. Silbert^ on Betardation of Pregnancy, — Compt. Rend. — ^Bull. deThdr.
LV. »r Oct. 80.

6. Koch, C, Beientiofi of a Dead Foetus in Utero, 2 Months after the
Normal Time of Pregnancy had expired. — WUrtemb. Corr. — Bl. It.

I. Hewitt, 0., Menstruation during Pregnancy. — Lanzet I. 4. Oct.

8. Gazeanx, an the Condition of the Cervix Uteri during the Latter Half
0f Pregnancy, — }£€ul de la Soc. dc Chir. tom. iv.

9. Miner, tm a Case of the Birth of a Child without Pain.— Buffalo
Jour. xiv. 4, Sept.

10. Clay, Ch., Constitutional Diseaus as a Frequent Cause of Abortion, —
Midland Jour. Jan.

II. Marc^, Ii^utnu of Pregnancy and Delivery upon Insanity, — Ann.
MM. psych, iii. p. 359. — Amer. Med. Chir. Review II. 6. Nov.

11. Taupel, H., De strej^um origine^ qui audiunter in auscultando gra-
vido uiero imprimis de str^us placentaris origine, — 6ryphiswald»
8 pp. 82.

— Taupel, H., on the Origin of the Sounds Perceptible in the Pregnant
Uterus, ^ (Thesis.)

144

12. Schmidt, O., Origin and Practical Valuiofike Navd^Sirnig Somfff
Scanzoni's Beitr. Z. Geburtsk. B. 3, 1858. — New York Jour., V. "
Sept.

13. Lee, R. Clinical Midwifery.— Ued, Tim. and Oaz. 433, 435, Ac

14. McSherry, R., of Baltimore, Midwifery Cases. — Amer. Jon
LXII. Oct.

15. Shcdd, O., of Denmark, Iowa, BemarkahU Cases in Midwifay.
Amer. Jour., LXXII., Oct.

16. Houghton, R. £., Beporl of Cases in Obstetric Practice. — Peni
Bular Jour., I., 6., Sept.

1 7. Elliot, G. T., Jr., Diffiadl CaUs of Labor.— Sew York Jour., IV. ^
2. March, and V., 1, July.

18. Irvine, J. P., Second Impregnation at the Fonrth dUmtk of Pftfp^
namcy, — Med. Tim. and Oaz., 440, Doc. 4.

19. Fracture of the Sternum During Labor. — ^Bnll. Med., Fisiche. — ^Bull-
de Ther. LlV. June.

20. Gibb, on a fall across a Chair by an Eight Month Pregnant Wbman^
with Lactratio-a of the Genitals and Escape of Liquor Amnii ; Begener-
ation of this Fluid and Delivery beyond full Time. — ^Lancet, May.

21. Jones, T., Complete Evolution of a Child in Utero. — ^Lancet, L, 6.,
Dec.

22. Lauth, G., Presentation of a Leg ; Rotation of the FcBtus around its
Long Diameter during Extraction ; Birth of a Living Child. — Gaz.
de Strasb. 8.

23. Heise, C, Tympanitis Uteri. — Monatschrift f. Geburtsk. Febr.

24. Klaproth, Cases of Labor Complicated with Fibroid Tumors of tkt
TToiwA.— Monatschrift f. Geburtsk. XI. Feb.

25. lllustratious of Difficult Parturition.— By John Hall Davis, M. D.
London : Churchil 1858.

26. Porter, T. G., of New London, Connecticut, " Meddlesome Mid-
wifery is bad.^ — Amer. Jour. LXXII., Oct.

27. Gardner, A. K., the Cervix Uteri in its Obstetric Relations. — ^Amer.
Monthly, X. 3, Sept.

28. Moone, W. P., of Linwood, Tenn., on Obstetric Medicine. — Nash-
ville Jour. April.

29. Gray, T., Shortening the Duration of Labor. — Glasgow Journal,
Jan.

30. Du Bhumatisme de V Uterus^ envisagi specialemeni pendant la grossesM
et raccouchement. — Par le Dr. V. Gautier. Geneve : Jules-Gme Fick.
1858. 8vo. pp. 159.

— The Bheumatiam of the Uterus, Considered more especially during Preg-
nancy and Parturition. By V. Gautier, M.D., Ac.

31. Braun, C, Pathogenesis of Hydrorrhcea Gravidarum. — Wien. Ztschr.
I. 17. New York Jour. V. 3. Nov.

32. Massinat, R., on Hydrorrhea Gravidarum. — Gaz. de Paris 29, &e.

33. Harvey, on Watery Discharge from the Uterus during Pregnancy. —
Dublin Jour., Feb.

145

. Brown, B., on a Singular BesuU of a/n If^ry in the latt Stage of
Pngnmnaf. — ^Amer. Jour., April.

. Grall on the Action of the Diaphragma and (he Ahdomnal^useks dvr
ring Labor. — New Orleans Med. News, Feb.

36. Betz, P., on Afterpains and their Treatment, — Mcmorab. a. d.
Praxis. III. 9.

87. Gritchett, on Sudden Failure of Sight during Lactation,' Ophtalmo'
fcopic Examination, — Med. Tim. and Oaz., Jan. 30.

38. White, on a Case of Effusion of Blood into the cerebellum in a Woman
8iz Months Pregnant, — Buffalo Jour. XIV. 4. Sept.

39. Du traitement de la Syphilis chez les femmes enceintes, — Par Eug.
Berlin. Nancy : Grimblot Vve. Rabois & Co., 8. pp. 16. Compt.
R^id. des trav. de la Soc. de Mdd. de Nancy.

— Tke Treatment of Syphilis in Pregnant Women, — ^By Eug. Bcrtin, Ac.

40. Die vorzeitigen Athemhewegungen, Ein Beitrag zur Lehre von den
Einwirkungen des Geburtsaktes auf die JEYucht. Von Dr. Hermann
Schwartz, Privatdozcnt an dcr Universit&t zu Kiel. Leipzig:
Breiikopf und H&rtel gr. 8. pp. 308.

— The early Bespiratory movements. Being a ContribuHon to the Doctrine
of the Influence of Labor upon the Foetus. By Herm. Schwartz,
M.D., Lecturer at the University of Kiel, Lcipsic, etc.

41. Lehmann, L., on Bupture of the* Uterus amd the Vagina, — Monat-
schrift f. Geburtsh., XII. 6. Dec.

42. IPClintock, a New Symptom of Bupture of the Uterus, — ^Dubl.
Jour. — ^Edinb. Jour. Febr.

48. Letcnnier, Case of Rupture of the Womb. — Oaz. de Paris, 22.

44. Kelly, D., on Bupture of the Uterus, — Dubl. Hosp. Oaz. Jan. 15.

45. Maes, Bupture of the Uterus; Becovery, — LUnion, XIL 121.
Octob. 26.

46. Bayne, Bupture of the Uterus; Oastrotomy; Death, — Oazette de
Paris, 12.

47. De la mart svhite dans Vital puerperal. — Par le Dr. A. E. Mordret,
MMicin au Mans, ex-Professcur d'accouchements, Directeur do la
▼accine, Hembre du Conseil d'hygi^ne de la Sarthe, etc. Mdmoire
couronn^ par 1' Academic dans la Seance du 15. Decembre 1857. —
Hdm. de PAcad. de M^., Tom. XXII.

— Tke Sudden Death of Women in Childbed. Bv A. E. Mordret, M.D.,
etc. Pfize Essay of the Paris Academy of Medicine, etc.

48. Marc d'Espinc on the Frequency of Death among Pregnant and De-
livered Women and the Influence of General Causes upon this Accident.

— Gaz. de Paris, 19.

49. Eimer, Sudden Death after Delivery from Entrance of air into the
jB{0M/.—Aerztl. Mitth. S. Baden. XII. 1.

50. Beullac, Sudden Death Immediately after Confinement. — ^Bull. de la
Soc. MM. de Marseille.

51. Gavenne, Sudden Death at the Beginning of Labor. — Abeille M6d.
Pebr.

146

52. — Des maris subitts chiz Us femmts enoeinUs on rtctmmaU aceoutki^ m.
Par le Dr. Eug. Moynier. Mdmoire auquel FAcademie, Imper. &«
Mdd.y a accords une mention honorable, etc. Paris, Victor Massoim*
In 8. pp. 168.

— Sudden Deaths of Pregnafd and Becently Delivered Women, By S
Moynier, M.D. PrizeEssay, etc.

53. Sauvel, L., Appearent Death of Two Women, ddivered under very
Different Circunutances; Eecovery of Mothers and Children, — Ber.
Thdr. du Midi. XII. June. •

54. Lcescher, on Delivery after Death, — Yierteljalirschr. f. ger. Med
XIV. July.

55. Frentrop, on a Case of Delivery after the Death of the Mother. — ^Ibid.
XIV. Octob.

56. Fessenden, B. T., of Plymouth, N. C, a Case of Puerperal commi-
nons with Sponlaneou8 Expulsion of the Fastus after D&Uk, — North.

• Carol. Jour., I. August.

5t. Thornton, G. W., Extraction of a Living Child by IWnv^ after
Death of the Mother, — Cincinnati Lancet and Observer. Peb^.—
Amer. Jour., April. — New York Jour. V. 8. Novemb.

58. Rigby, E., on the Natural Position of Women during Labor, —
Schmidt's Jahrb.

59. Klopsch, Microseopioaland Chemioal Examination of a LUhopttdion, —
Beichard's Studien des physiol. Instit. zu Breslau. Leipzig, 1858.

60. Hall, T. W., on Stomatitis Matema, Cincinnati Lancet and Ob-
server, April. — Now York Jour. V. 3. Novemb.

The work to which we would direct the attention of our readers
more particularly among^ the numerous contributions to obsteterio
path6logy, is that of Dr. Schwartz on the influence of labor upon res-
piratory movements of the foetus in utero, which is equally impor-
tant from a scientific as from a practical point of view. From
France we have received Dr. Mordret's elaborate treatise on sudden
death of puerperal women, to which a prize has been accorded by
the French Academy of Medicine. This article touches upon the im-
portant question of entrance or development of air in the blood, an
accident which occurred, as we have reason to believe, in Dr. Elliot's
interesting case, mentioned below. The most important contribu-
tion from England is Dr. Davis's " illustration of difficult parturition,"
a faithful guide in the time of need for the practitioner and the sto-
dent. •

Db. Heckxb subjected 2593 pregnant women to an examination, in
order to test the correctness of the generally current opinion, that the
permeability of the internal mouth of the uterus, was a sure sign of ap-
proaching labor. But of this number 946 presented an internal orifice
sufficiency open for the passage of the forefinger ; 728 weremuUipa^
rous, and 223 primiparous women. In every instance the time of ex*
amination and that of beginning labor were noted. By a compari-
son of these, the value of the rule, as named above, was not materially
changed, with this vestricti6n, that only in 60 out of 100 primiparous

147

women the open condition of the ob can be taken as a sign of labor
in the next few days, and that only in 70 out of 100 multiparons wo-
men with open os, delivery was not delayed longer than fourteen
days after ^is condition was ascertained. These results show how
careful we have to be in our prognosis with regard to beginning la-
bor : especially if we consider the fact that 6 out of 100 primiparous
women presented on examination aa open internal orifice, although
they were only 9 (lunar) months pregnant, while the same was ob-
served in ten per cent, of the multiparons women.

After the researches of Db. Silbebt, childrep bom after protracted
gestation are unduly developed, and he therefore proposes induction
of labor at the end of the full term, whenever gestation is suspected
to be protracted.

Dr. Hewitt reports the case of a lady who menstruated regularly
every fourth week, and did not miss her courses in three successive
pregnancies. The discharge continued to appear every fortnight,
though of a paler color.

Db. Cazeaux thinks that ulcerations of the cervix are very fre-
quently found in biultiparous women, during the latter part of preg-
nancy. He has observed them in seven-eighths of the cases, confin-
ing this statement to the last third of pregnancy. This, therefore,
seems to be the normal condition, and should be considered as a con-
sequence of the progress of gestation, owing to the excessi^iBe con-
gestion proper to the pregnant state. Consequently all treatment
with regard to them is unnecessary. Corresponding with this view,
is the fact that five or six weeks afler delivery, no traces remain of
these ulcerations.

In regard to the statements of Boys de Laury, Bennett and others,
as to the frequency with which abortion and various puerperal causes
are produced by ulcerations, it is of importance to distinguish be-
tween ulcerations that have preceded pregnancy, and those which
have only become developed after the formation of the germ. Cazeaux
doubts the justice of Bennef s statement, that these ulcers are a fre>
qoent cause of obstinate vomiting in pregnancy. He has had the
opportunity of examining four primipare, reduced by vomiting to
. the last stage of marasmus, in whom the cervix remained perfectly
healthy.

Db. Clat reports three cases of women who after having miscar-
ried several times, underwent a mercurial treatment before the next
pregnancy, in consequence of which all three gave birth to full grown
living children. In the third case mercury was first g^ven during
pregnancy, but^the wom^n miscarried as usual ; afler this, she, as weu
as her husband, began to take mercury before she conceived again,
and she carried her child to the full term.

Dr. Mabcb thus concludes an interesting paper illustrated by cases.
1. We cannot protest too strongly against the practice of those phy-
sicians who advise or allow pregnancy in insane women, for it re-
sults from the facts mentioned in this paper that, in the great mar
jority of cases, pregnancy and delivery, so rar from exerting a favora-
ble influence on insanity, seem on the contrary, to hasten the
prog^ress of tiie disease towards dementia. If in certain exceptionable

148

cases (2 in 16) pre^ancy has suspended the progress of the disease,
the improvement has been only temporary, and the insanity has re-
appeared after delivery. 2. In some few cases (4 in 16) rcmaiicable
especially for the predominance of erotic sy mpt oms, preppaancy has
exerted a beneficial influence on the cure. 3. When insanity becomes
developed during pregnancy, it very often remains incurable, even
after delivery, or is cured so long after, that no influence can be at-
tributed to the latter in the termination of the nervous affection* 4.
Sometimes, however (8 in 10 cases), the disease disappears after
delivery, and these cases must be regarded as sympathetic. 6. De-
livery in the insane is often remarkable for the slight amount^ or
even complete absence of pain.

The opinions of the different authors, who have paid attention to
the navel-string souffle being divided, as to its true seat and natare,
Dr. ScmoDT feels justified in the publication of five instances of this
phenomenon, perceived before the child was bom, out of 500 obste-
trical cases, all of which were thoroughly examined with tiie stetho-
scope.

Case 1. — ^The child was bom in a state of asphyxia, and could
not be revived. The autopsy was performed by Prof. Virchow,
who found a decided hypertrophy of the right ventricle of the heart,
insufficiency of the valvula mitralis et tricuspidalis, and a deposition
of several red, gelatinous corpuscula on both valves.

Case 2. — ^When the head of the child was born, the navel-string
was found twisted around the neck twice, and so strong, that the
vessels of the neck were compressed, in 'consequence of which, the
face had a cyanotic color. The child died after a few short inspira-
tions.

Case 3. — ^The sounds of the foetal heart were heard clear and dis-
tinctly, immediately before the rupture of the amnion. When the
water had been discharged, a prolapsus of the umbilical cord was
discovered, upon which the head of the child was pressing with con-
siderable force. Auscultation applied at this moment, discovered not
the former sound of the foetal heart, but instead, a souffle, which dis-
appeared as soon as the prolapsed string was removed into the cavity
of the womb.

Case 4. — ^The sounds of the foetal heart were accompanied by a
strong souffle. Still, when the child was bora, the navel-string was
not twisted round the neck ; the child was healthy, and the soonds
of his heart found in good order.

Case 5. — Instead of the first sound of the heart a souffle was de-
tected by auscultation. When the head was born, the umbilical cord
was found tightened around the neck. The child was asphyxiated,
and it was half an hour before it could be declared otit of danger.

From an analysis of these cases, Dr. Schmidt comes to the conclu-
sion, that the so-called umbilical souffle may take its origin : a. From
diseases of the foetal heart, b. From circumvolution of the umbilical
cord around the neck of the child, c. From other compressions of
the navel-string depending upon the position of the child.

In regard to the practical value of the funio-souffle, Dir. Schmidt is
of opinion, that its presence, in most cases, indicates danger to the
life of the child.

149

Dr. McShebbt reports a case of delivery, at the full term, of a pa-
trid child, in a case of cancer of the womb ; the patient died soon
afterwards. The author proposes the GsBsarian operation in far-gone
cancer of the pregnant womb, in order to shorten the sufferings of
the mother and save the life of the child.

Dr. Shkdd reports a case of labor without pain, and one interest-
ing ease of hydrorrhoea uteri with enormous discharges of water
dnringpregnancy.

Dr. HouoHFON reports a case of shoulder presentation, which ter-
minated by spontaneous evolution. The vehemence of uterine con-
traction prevented the intended operation of turning, and could not
be checked by chloroform. The author wonders why chloroform did
not subdue uterine contraction. — It is a wcU-known fact, that uterine
activity, as well as that of all organic muscles, is very little influ-
enced by ansBsthetic agents. — E. N.

Db. Eiuot gives an account of several cases of difficult labor, some
of which are apt to excite the liveliest interest of the profession ;
above all, the case of Mrs. E., is an unicum in its way, thus justify-
ing^ a somewhat lengthy analysis. Mrs. E. exhibited already during
ffefltation unmistakable signs of existing morbus Brightii, so that Dr.
Elliot put her under a rational treatment, in order to avoid, if pos-
sible, the occurrence of puerperal convulsions during delivery.
When the first pains set in, it soon became manifest, that the os uteri
was 80 unyielding, that the warm douche was tHought necessary to
overcome this obstacle. But the os remained as undilatable as it
had been for twenty hours. Therefore the cervix was divided with
Simpson's uterotome, and the long forceps applied, by which Dr.
Elliot succeeded to deliver a living female child. After all was
over, the mother seemed to be doing very well, when suddenly an
alarmin|^ change came on in her expression, pulse, temperature, and
respiration. The last was slow, jerking, and abdominal ; the pulse
exceedingly feeble and slow ; the face and extremities very cool : the
uterus remained well contracted, no hsdmorrhage occurred. This
alarming condition was successfully removed by the use of stimu-
lants, and she had some refreshing naps, when suddenly a similar
change to that of the previous night came over her. She became ex-
tremely restless, throwing herself completely on her right side, rais-
ing herself on her heels and shoulders, and died immediately after-
wards. The body was kept in a room without fire, and the windows
open, the temporatute being near the freezing point.

Past morUm examnatum 27 hours after death, — The face was greatly
swollen by emphysema and the surface of the body down to mid-leg,
and to the wrists, crepitated in the most marked manner ; post mor-
tem lividity over the back, and greenness of decomposition, with
bull® q^er the lateral aspects of trunk. On opening the abdomen,
there was an unusually great escape of gases ; interior of the body
yet warm. Both pleuros universally adherent, nothing of interest in
the lung^. JBmri of normal size, apparently fatty with patches of
atheroma along the aorta ; no clot in pulmonary artery. Peri-
cardium normaj. Blood coagulated. Abdomen: No peritonitis,
subperitoneal cellular tissue everywhere emphysematous. On

160

greater curvature of the stomach, cellalar tismie around gastro-
epiploic vesselSy so aerated as to simulate distension of yesBels.
The intestines crepitated everywhere from emphysema of their sob-
peritoneal cellular tissue. Liver crepitated everywhere to the touchy
and was so friable, as readily to break down in tiie necessai^ manip-
ulations for removal. Spleen, with similar crepitation. Sdmj/t
excessively soft, crepitating to the touch ; their capsules dissected
by the emphysema. Uterus firmly contracted and emphysematous ;
displayed two subperitoneal fibrous outgrowths, which were diag-
nosticated during life ; no appearances of sphacelus . nor of lacera-
tion extending to the peritoneal coat were observable ; oavity
contained a small clot of blood. Microscopical examination con-
ducted by Drs. Clark and Isaacs. The numerous whitish spots on
surface, and in muscular tissue of the heart, consisted of granular
matter, 'with globules of oil. Liver fatty. Kidneys far advanced in
Bright's (fatty) degeneration. Dr. Elliot in the adjoined remarks,
ascribes tne sudden death, in this instance, to an effect of the exist-
ing disease of the kidneys. Lastly, Dr. Elliot remarks, Uiat the
entire literature, as far as it was in his reach, did not contain a
case of post-mortem decomposition of the same extent, or equal
rapidity. Added, are a number of interesting obstetrical cases,
under the following heads : Case, — ^Woman deserted by her phy-
sician ; child dead ; uterus distended with gases ; version ; deato.

Case. — ^Tedious labor ; Forceps ; Safety to mother and child ;
Novel views of uterine hsBmorrhage.

Case. — ^Neglected transverse presentation ; version ; death.

Case, — ^Deformed pelvis ; Forceps ; Death from perforation erf
uterus by sacral promontory ; child died two days after from apo-
plexy.

Case, — ^Forceps ; Puerperal fever ; Bronchitis ; Death from uterine
haemorrhage, eleven and one-half days after delivery ; child did well.

Case, — ^Hysterical convulsions and hemiplegia.

Case, — ^Puerperal mania.

Case. — Forceps : Puerperal fever ; Death ; No autopsy.

Four Cases of ; Puerperal fevpr ; Recovery ; (Morphium and Tr.
Ver. viridis treatment).

Case. — ^Puerperal fever ; Death and Autopsy.

Case. — Puerperal convulsions ; Recovery.

Case. — Rigid os ; Douche ; Forceps to head transversely placed in
pelvic excavation ; Mother recovered ; child dead before delivery.

Case. — Rigid os and lingering first sta^e ; Douche ; Forceps ;
Mother recovered ; Child di^ on third day from other causes.

Case. — Arrest of head by promontory of sacrum ; Forceps ; both
did well.

Case. — Forceps in superior strait ; both did well. ^

This is quite a number of interesting cases, illustrating b^ter the
rules to be followed in practical midwifery, than volumes of theoret^
ical treatises. Dr. Elliot, in advocating the douche for the manage-
ment of a rigid os, strongly recommends never to neglect manual
dilatation afterwards. Many of the cases in which the douche is sup-
posed to have failed, come within this category, the os preserving

161

the same dimensions, and the same deceptive feeVof rigidity Vhich
ori^nally motived the douche, but now yielding to the dilatation of
the fingers, as brown paper would do when wetted.

Dr. btviNc's case of superfoetation is of no value whatever. The
firvt fodtas bom was of a four months growth, which is certainly
nothing but a twin-child, which died when four months old, and was
compressed by the gprowing second child, without being decomposed.
Nothing is mentioned about the formation of the uterus.

Mrs. J. B. was taken in labor and at^tended by Dr. Jones, at the ex-
piration of her third pregnancy ; after fifteen hours of pain, she was
ocdivered of a male child, and about ten minutes afterwards, the
membranes of a second foetus began to come down. On this being
mptared, both feet ascended low in the vagina, when Dr. Jones
grasped both legs high above the ankles, and waited for the return
of an expulsive pain, which soon coming on, Dr. Jones began to
make some traction. But the legs were forcibly drawn from his

SAp, until they quite passed above the pelvic brim, and their place
n became occupied by the head, which soon descended (face to
the sacrum) and the labor was rapidly completed.

Dr. Hbise attended a lady in her confinement, during which, after
the discharge of the water, the uterus bccaihe suddenly enormously
extended and very painful, while the patient became excited and
feverish. Though the pains were pretty strong, the labor did not
advance any, and Dr. H. recognized a constriction of the in-
ternal uterine orifice round the neck of the foetus, which seemed to
yield after external application of extract of belladonna, for tRe head
of the child now^ advanced and was finally bom, during and after
which a great quantity of a stinking gas was discharged with a gur-
gling noise from the uterus, while all the distressing symptoms left
the patient immediately. The child was macerated, and the doctor
explains the sudden and unusual dilatation of the uturus from the de-
velopment of gases, originating from the contact of the dead foetus
with the atmospheric air, after the nipture of the membranes, while
their escape was prevented by the ensuing constriction of the orifice
of the uterus around the foetus.

Dr. Hall Davib's book deserves the greatest attention of the pro-
fession, being the result of a more than twenty years' observation in
private and hospital practice. The book is divided into two parts,
the first dogmatical ; the second illustrative. The former opens
with a short introduction, pointing out the causes of obstructed la-
bor, and generally indicating the principles upon which such diffi-
culties are to be overcome. The second chapter contains strictly
• practical matter, treating mostly of difficult forceps deliveries.
The author does not approve of Dr. Simpson's proposition of turn-
ing instead of using the long forceps in cases of contracted pelvis.
Next follows the subject of premature labor and of craniotomy. He
ascribes the fatality and evil results of the latter to neglect of not
sufficiently reducing the bulk of the head and other hard parts. Face
and breech presentations are next treated in their particular bear-
ings. With regard to the use of chloroform, he thinks that it pro-
duces, in most cases, the necessary relaxation, while at times it failed

152

in efifectuig that* object, although the patient was reduced to perfeet
unconsciousness. In some instances it appeared to have predisposed
to hemorrhage after delivery, the uterus being left in a state of ino^
tia. The second portion of this book contains, besides, a great nam*
ber of very interesting and valuable cases. From the statistics given
in the appendix it appears that the mortality &mong 1302 mothen,
who came under Dr. Davis's notice as patients of the charities, to
which he is attached, only amounted to sixteen. The book altogetlier
is a real English one, having throughout a practical tendency, and
being written in a stylo plain and to the point

Dr. Poster read a very elaborate and scientific article on meddle-
some midwifery, before the New London County Medical Association.
He advises the cautious use of the tampon in abortion, not, of conrse,
its disuse. He speaks of unnecessary venesection in pregnancy, not
denying that it may be properly resorted to in many cases. He fiu^
ther dissuades from unnecessarily converting one presentation into
another, if not imperiously demanded. The same is true in regard-
to rupturingltlie membranes, to management of nates presentations,
and to the dilatation of the os uteri.

Dr. Gardner, when speaking of rigidity of the os and its treat-
ment, strongly advocates mechanical dilatation by sponge tents, in-
cision and tao blades of the forceps in cases of need, where internal
remedies have failed to overcome its resistance.

Dr. Moore's paper, read before the Tennessee State Medical Socie-
ty, is an account of six complicated obstetrical cases, which were
successfully treated by internal medicines, or by turning. The arti-
cle is written against the spreading use of the forceps and the perfo*
rator, in this country.

Dr. Gray recommends to irritate the nipples as soon as labor
pains come on, and continue the stimulation as long as it lasts, in
order to increase the action of the uterus. — The same has been pro-
posed and executed by Scanzoni. — E. N.

Dr. Gautier's volume on uterine rheumatism is intended to repr&>
sent a complete description of the rheumatic affections of the womb ;
tliereforc, the author comprises in liis description the disease gener-
ally denominated neuralgia uteri, which he believes to be of a rheu-
matic nature. The book contains a considerable number of clinical
observations upon which the followiug conclusions are based : 1.
The disease described as irritable uterus, uterine neuralgia, etc., is
of the same nature, and offers the same symptoms, as that, called by
some authors, rheumatism of the uterus in its empty state. 2. This
same disease is observed at the time of pregnancy, from tl\e second
month up to the end of the ninth. 3. This affection has been gener^
ally described as uterine rheumatism, when it was observed during
pregnancy ; but its nature does not differ at all, from that of hyster-
algia in the non-pregnant uterus ;. it, therefore, would be just to
unite both affections under one designation. 4. Inasmuch as this
disease represents all the characters of a muscular rheumatism, tho
name of rheumatism of the uterus ought to be retained. 5. Those af-
fections described as cr.etliism, hypersesthcsy, convulsibility, trismus,
tetanus, cramps, spasmodic contractions, etc., of the womb, are all

153

nothing bnt vaneties of uterine rheumatism in their primitive form.
6. Bhenmatism of the uterus does appear with the same symp-
toms, in the non-pregnant state of the womb, during preguancy, dur-
ing labor, during and after delivery, t. Rheumatism of the uter-
us is not a simple inflammation of the uterus, nor an endometritis.
Both differ from each other in the respective symptoms, course, and
duration. 8. Bhenmatism of the uterus during pregnancy and
parturition, is not dangerous for the mother ; if death follows, this is
'owing to a complication. 9. Rheumatism of the uterus is at
times a cause of danger or even death for the child. 10. The prin-
cipal remedies for uterine rheumatism during pregnancy, are opium
and tepid baths. 1 1 . Inhalation of chloroform is the principal remedy
for rheumatism during labor. 12. From the identity which exists
between hysteralgia and uterine rheumatism, it is reasonable to as-
sume the identity of muscular rheumatism and neuralgias in general.

Dr. Brack says : Hydrorrhoea is a periodical discharge of a ^^ellow-
ish, sero-albumiuous fluid from the genitals of pregnant women,
which is unconnected with the rupture of tlio membranes, or tlio dis-
char^ of the amniotic liquor. Hydrorrhoea seldom occurs before
the tnird month, but generally at. a more advanced stage. It may
appear only ones, or more often, sometimes imitating the menstrual
types, ceases generally after delivery, or continues in a few instances
for a length of time during the puerperal state. In consequence of
the red color of the fluid, the hydrorrhoea has been often mistaken
for a menstrlial discharge of blood. Dr. Braun believes that
the hydrorrhoeal fluid is a secretion or rather albuminous exu-
dation of the inner surface of the womb, which appears in
an intermittent typus, elevating a portion of tiie chorion from
the decidua, or the latter itself, thus forming a reservoir for tte
flnid, from which it escapes occasionally through the mouth of the
uterus. Similar albuminous discharges have been observed in the
non-pregnant state, especially when fibrous'tumors were in the cavity
of the womb. Another proof that Dr. Braun's views are perfectly
right, is the fact that after delivery the foetal membranes are found
intact, and that the quantity of liquor anuiii is not lessened in cases
of hydrorrhoea. The microscopical examination of a placenta ex-
pelled after hydrorrhoea, detected a recently formed membrane of
cellular tissue on its convex surface.

' In a paper — ^read at a meeting of the Cork Medical and Surgical
Society — Dr. Harvey reports a case of hydrorrhoea uteri gravidi, and
gives it as his opinion, that the water discharged in similar cases,
comes from the amniotic cavity, owing to occasional solutions of con-
tinuity, admitting of discharges from time to time, which cither close
again, or admit refllliug to a certain extent, by a fresh secretion of
its peculiar fluid. — It would ho too lengthy to prove on tliis occasion,
that Dr. Harvey is entirely mistaken with regard to the explanation
presented. Sufiice it to say, that our experience in this matter leads
us to agree with the views taken by Mr. Braun. — E. N.

Dr. Brown reports a case of a very large thrombus of the vagina,
formed after a severe fall on the back, one day before delivery, which
suddenly increased after confinement, to an enormous size. The case

164

•

resulted successfully by hourly application of gallic acid, in simple
doses, combined with the use of strong anodynes.

Dr. Betz remarks, that the cause of afterpains is not alwa^ to be
found in a pathological condition of the womb itself. At tunes the
situation of the womb after delivery is such, that it presses ap^ainst
a part of the bones which form the entrance of the pelvis ; m this
instance the patient must be brought into a position which enables
the womb, to move away from its former place to a more harmless
location. Added is the history of a case, where afterpains originated
from the fact, that the uterus by its peculiar position exerted a press-
ure upon the left horizontal pubic bone ; the womb was removed from
the OS pubis, whereupon the afterpains disappeared. <e

Dr. Critchet examined the eye of a patient, who had suddenly lost
sight of the right eye, and found that a filmy, colored membrane of
considerable size floated in the lower half of the eye, at a little dis-
tance from iho retinal surface. Only one-half of the entrance of the
optic nerve could be seen, the other being covered from view by a
crescentic patch of what was probably extravasated blood.

Dr. Schwartz's work on early respiratory movements of the foBtns,
is one of the most elaborate and scientific researches we have met
with for years. The much contested question of foeftal respiration in
utero is discussed in a more thorough manner, than it has been done
up to the present time, developing quite new and well supported
views on the vital connections between mother and child. The dis-
cussion opens with a full historical sketch of the treatises published,
regarding the different points in question, and in a few preliminary
remarks the subject to be inquired into, is laid open to the reader.
The author's intention is to show the intimate connectioni between a
disturbed foBto-placentar circulation during the physiological or
pathological progress of labor, and respiratory movements of the
foBtus, with all its bearings upon theory and practice of every day's
and of legal midwifery. If this connection should be proven to be a
law, then the very act of parturition bears in itself the danger of
suffocating the foetus, and death of the child during delivery must be
considered as death by suffocation. These considerations constitute
the turning point of Dr. Schwartz's thesis, the elements of which are
treated in the following manner : He first proceeds to reconsider
the doctrine of placentar respiration, which he endeavors to
strengthen by conclusions, based upon the physiological manifestation
of intra-uterine life. After this he intends to show, by direct obser-
vations, that the next consequence of interrupted fcBto-placentar
respiration was the beginning of respiratory movements of the
foDtus. Next is considered the influence of the act of parturition
upon the early respiratory movements of the foetal thorax, and fur-
ther on the post mortem appearance of children, who died during or
shortly after birth, compared with the respective process of delivery,
by which their death was caused.

The question of foetal respiration in utero is far from being decided
in one or the -other way. The opponents considered a foetus in utero
as part of the mother, attributmg to it only an indirect respiration,
such as every single member of the body has its capillary respirar

166

tion, inasmnch as it receives an oxygenized blood, for which carbon-
nized blood, with the ashes of nutrition, is exchanged. But Dr.
Schwartz holds that the foetus lives a life for itself, with its own
sanguification, its own peculiar nutrition, and its own respiration,
i. e,, the foetal blood discharges in the placcntar capillaries carbonic
acid, and there receives oxygen, which it discharges in the capilla-
ries of its body for the former gas. For proving this the author
follows a double way, first showing the effects of respiration for the
fcBtos, and secondly, the influence of a suspension of this presump-
tive mode of respiration. After the researches of competent men,
the blood in both the umbilical vein and arteries exhibits
no differ^ce in color, not because the want of oxygen for
fcdtal life is so trifling, that its minute quantity is insufiicicnt
to brighten the coloration of the blood, but because we are un-
able to get at the blood contained in the umbilical vessels, without
disturbing previously the uterine and placcntar circulation, by the
manipulations necessary for this experiment. This same circum-
stance explains the impossibility of finding different gases in the
diilerent umbilical vessels. Therefore, another way must be followed,
to prove the reception of oxygen by the foatus. Oxygen is an indis-
pensable requisite for the formation of uric acid, and especially so
for nrea, two elements often demonstrated in the urine and kid-
neys of the foetus by several distinguished authors (Denis, W(ihler,
Prout, Virchow, Martin, Hoogeweg). Dr. Schwartz adds two more
observations of his. The generation of an increased temperature in
the living organism is due to the oxydation of matters, and it seems
an established fact, that the foetus for himself, is apt to produce
warmth, independently of that which is conveyed to it with the blood
of the mother. Another proof for the presence of oxygen in the foetal
blood is the excitability of the foetal nerves and muscles, which
fonction is inconsistent with the absence of free oxygen. In the
chapter 'on the immediate consequences of interrupted placentar cir-
culation, the author describes a number of experimental vivisections,
S- which it was demonstrated, that the beginning of inspiratory
brts was a constant, next, and immediate result of an injured cir-
culation of the blood in the placenta. But, if this is really the case,
the question arises, why the foetus does not make respiratory move-
ments during every labor, in consequence of the disturbed foeto-pla-
oentar circmation, as connected with every strong labor pain.
In order to dissolve this problem the following points are ventilated :
1. From what depends the first inspiration of the foetus ? Is the
inspiration observed, really the first one ? and if this be the case,
how can it be explained ? 2. Under which circumstances does the
act of parturition effect a deficiency of oxygen, and an increased
amount of carbonic acid in the foetal blood, and in consequence, the
beginning of respiratory movements and symptoms of suffocation, or
rather intoxication ? How can this be recognized ? What are their
evil influences upon the foetal and extra-uterine life ? 3. To what
degree does the act of parturition produce anomalies in the distribu-
tion of the blood in the foetus ? What influence do they exert upon
the condition of the foetus or the new-born child ?

156

The answer upon these questions was derived from a number of
1,800 deliveries. 'Out of uic children bom 14 died before beginning
labor ; 18 died during and in consequence of labor ; 172 were bora
still and resuscitated ; 60 were taken sick and died during the first
fortnight after delivery. By a very simple experiment (opening the
vein of the cord) it can be demonstrated that tiie foeto-placentar ci^
culation is cut off, as soon as the child is bom. The first inspiration
is observed at the moment, when the body of the child begins to pass
through the os exterum, or earlier (before the shoulders are bom),
when the intra-uterine circulation has been interrapted by a strong
pressure from the expulsive pain, by a circumvolution of the cord, by
an early detachment of the placenta, and so on. From thi^t appears,
that the tiiirst for oxygen is the chief factor for the inspiratory
activity of the new-born child, and the observations of Osiander,
Maitin, Hohl, and others, give sufficient evidence, that the access of
air to the new-born child, is not necessary for the beginning of respi*
ration. On the other hand, it happens very often, that respiratcny
movements of the foetus in utero can be perceived by the hand,
introduced for the purpose of turning, whenever the cord is tem-
porarily compressed by the operating hand. Several observations
are reported. The fact that the change produced in the ntero-fostal
circulation, by every pain, does not excite respiratory movements in
the child, may be explained in th^following manner : During a pain
the blood in the uterine sinuses is not only driven back mto the
maternal system, but part of it into the placento, from which it is
promoted wiUi greater force into the umbilical vein, while this same
compression of the placentar vessels prevents the foetal blood from
escaping with the same force, as it did before the pain, through the
umbilical arteries ; thus, during a pain, a comparatively larger quan-
tity of oxygenated blood is conveyed to the foetal heart, and allowed
to stay there for a greater length of time. This circumstance also
accounts for the diminished frequency of foetal pulsations, as long as
the pain is lasting.

From a number of fifty-nine observations, reported minutely, it
appears that the anatomical alterations of children, who died in con-
sequence of the act of parturition, are twofold. One series com-
prises the consequences and symptoms of a disturbed exchange of
gases in the foetal blood, and may be called asphyxia, while the other
shows the effects of a mechanical hindrance in the circulation.
Although in most cases, both of them are combined, each of them
has a distinct influence upon the foetal life. Asphyxia of the foatus
is an intoxication of the foetal blood, by a chemical alteration of its
ingredients, and is caused by an insufficient receipt of oxygen throuffh
the maternal blood. Circumstances which are apt to interrupt tioe
normal distribution of gases in the foetal blood, are : death, or severe
sickness of the mother, early detachment of the placenta, compres-
sion of the cord. But the most frequent and most insidious obstacle
for the foetal respiration, is a lasting and strong muscular action of
the parturient uterus, inasmuch as it diminishes the amount of oxy-
genized blood in the placenta, by compression of the uterine vessels.
That such is the case, is clearly proven, by several of the above-

157

named observations, and by the statistics of Dr. Yeit, from which it
^[ypears, that the danger for the foetal life increases in proportion
with th6 nmnber oT hours consumed for labor, and especially for the
last stage of labor.

The symptoms of foetal asph^ia are an altered composition of the
fiBtal blood, and the beginnmg of inspiratory movements. The
alteration of the blood can be easily recognised in*still-bom children,
the blood taken from both umbilical arteries and veins, is unusually
dark and £hin, while the extravasations of blood, deposited during
intra-oterine life in still-bom children, are void of fibrinous matter,
wliich mpearances are also found in adults, who died from asphyxia.
The eany respiratory movements of the foetus, in some rarer in-
ttanoes, could be perceived by some authors in the form of the so-
called vag^tus uterus, while in a considerably large number of cases,
these movements could be felt by the hand introduced into the womb
fiyr the purpose of turning, or for reposition of a prolapsed funis
j[ObBerv. 8, 5, 15, 16, 19, 54, 57^. A reliable symptom of respiration
in utero is the rattling noise, always perceived with the first inspira-
tions of resuscitated still-bom children. The intensity of these garg-
ling sounds depends, from the quantity of liquor amnii aspirated m
ntero, and consequently from the frequency and energy of the early
respirations. Accordingly, with these phenomena, the nose, choanes,
jbarynx^ larynx, and even the trachea and smallest bronchia, are
fimnd replete with a viscid mucous from the cervix, with liquor
amniii blood, meconium, or vemix caseosa, in almost every child which
died during labor. In very rare instances air is found in one or
another poxtion of the foetal lung CObserv. 1, 11, 15, 33). Another
constant result of asphyxia in children, is a more .or less marked de-
gree of ^ethora. and peripheric ecchymosis of the respiratory organs,
and, in man^ cases, a remarkable repletion of the superficial pul-
monaiy capillary vessels. These appearances are simciently ex-
pUdned by the suction of the thorax, when enlarged by the action of
the inspiratory muscles. These signs taken together, must be con-
sidered a very valuable addition to forensic examinations. Another
infloenoe of cUsturbed foeto-placentar respiration, is a diminution of
irritability by reflex-action ; it seems that the altered condition of the
blood tends to weaken the general irritability of the foetus. This
want Gt sensibility is always in accordance with the existent degree
of asphyxy in still-born children. The most important symptom of
fotal asphyxia, is the diminished activity of the heart, perceptible
before aelivery is completed, it is equally valuable for diagnosis
as for prognosis and treatment. With regard to the influence of
labor upon the condition of the foetal pulse. Dr. Schwartz came to the
following conclusions, based upon a large number of personal obser-
vations : In all cases • of normal labor, the frequency of the foetal
pulse remains unaltered from tlve first beginning, up to the termina-
tion of labor. In by far the greatest number of cases, the foetal heart
offered 144 strokes in a minute ; in one instance it was 180, in
some few 120. Circumstances, which are apt to modify the pulse,
are — movements of the foetus, pressure by uterine contractions, and
paralysis of the heart from asphytic intoxication. A sufficiently

168

strong pain has generally a retarding influence upon the foetal heart,
while in many cases, the foetal pulse is not at all altere4 in frequency
during the pains. With the remission of the pain, the pulse acquires
its former frequency, but if the pulse continues slow after the pain is
over, this must be considered as a sign of existing danger for the
foetal life. A lasting, gradual, or sudden decrease of the foetal pulse,
is always the consequence of beginning asphyxia, and must be con*
sidered as the most reliable sign of approaching death. This sudden
paralysis of the foetal heart, is always obseryea in those cases where
the union between mother and child is entirely annihilated, as it hap*
pens in cases of early detachment of the placenta, or of a sudden anii
lasting compression of the cord. The results of Dr. Schwartsfs
researches on the signification of the early passage of urine and
meconiimi, may be comprised in the following : 1. With children
who die during or immediately after labor, or with those who aro
still-bom and afterwards revived, the early passage of excrements is
the rule, and is observed more frequently among the former class.
2. Both meconium and urine are altogether, under equal circum*
stances, more often early discharged in girls than in boys. Neither
the state of development, nor the presentation of the fodtus, nor the
conditions of the soft parts, seem to have ceteris paribus, a decided
influence upon the early passage of urine or mecomum. From this it
appears that the principal influence upon this discharge, must be
sought in a modified vitality of the foetus, it is always an indication
of approaching danger for the life of the child. All the different
symptoms have to be taken into account, when we attempt to form a
prognosis with regard to the ultimate safety of the child, and, above
all, wo have to watch the diflerent changes occurring in the pulsa-
tions of the foetal heart ; we have to watch its strokes from the very
first beginning of labor, because in this way alone we will be enabled
to acquire a satisfactory ^'udgment of the true condition of the
activity of the heart The indications to be fulfilled, whenever the
life of the child seems to be in danger, are twofold ; first, to re((stab-
lish the interrupted foeto-placentar circulation ; secondly, if this
be out of our reach, to repair it by athmospheric tespiration. The
first demand can only be complied with in cases of prolapsed fdnis,
and a reposition must be attempted in all cases where the pulsations
are not below 60 or 70 in a minute. ; in the latter instance, the author's
experience has convinced him, that the only safeguard for the foetal
life, is a speedy delivery. Mechanical interference, moreover, is
called fof in all those cases where the paralysis of the foetal heart is
going on steadily in consequence of all those other causes, which are
apt to suppress a sufficient exchange of oxygenized blood. The
treatment of children born in an asphyctic conmtion, consists in en-
gaging and strengthening inspiratory movements, and in removing
such obstructions, as might be apt to prevent them.

A very valuable addition to our knowledge of uterine and vaginal
rupture, is Dr. LEmiANN's article on this subject. From an extei^
sive private and hospital practice, the author was enabled to collect
forty-one cases of rupture of the womb and the vagina. With re-
gard to their cause. Dr. Lehmann divides the ruptures into three dif-

169

ferent classes, calling them spontaneous, accidental, and mechanical.
In by far the greatest number, the predisposing cause of laceration
18 due to a morbid condition of thq texture of uterus. From a com-
pftrison of eleven observations, reported in this article, with the
opinions of other authors, Dr. Lehmann comes to the following con-
cfusions. The location of the rupture is generally confined to the
place, where the uterine walls are thincst, viz., near its lower seg-
ment, and in some exceptional instances, near the fundiis. According
to the disposition of the muscular fibres, the lacerations run in a di-
agonal, or in a horizontal direction. In some cases the rupture is of
a Tery small size, especially when it was caused by gangrena from
pressure, be it against the promontory, or a sharp osseous edge, or a
spina (pelvis spmosa Kilian). In incomplete, non-penetrating rup-
toie, md uterine wall is only partially destroyed, while the uterine
cavity remains closed. The remark, that uterine ruptures happen
more often in deliveries of male, than in female children, is confirmed
by Dr. Lehmann's observations. The first symptom of a rupture is
generally a violent and sharp pain, experienced by the parturient
woman ; she cries out vehemently, expressing|her sensation as if some-
thing had given away internally. Soon after this, labor comes sud-
denly to a stand still, and a more or less considerable quantity of
blood issues from the vagina : the patient has faintine spells, the
features have an expression or greatest anxiety, the piuse becomes
rapid, very thin, extremities cold and dyspnoea, orthopnoda, vomiting
of dark or bloody matters, seldom fail to make their appearance.
Sometimes irregvdar pains return with short intermissions, while the
mesentin^ part of the foetus is drawing back, instead of advancing.
Drs. SLiwiscui and M'Clintock have mentioned a rapidly developing
emphysema among the prominent symptoms of rupture. In by far
tine gpreatest numW of cases, death follows soon after the accident,
* and this same result often accompanies partial, non-penetrating rup-
tures, owing, as it seems, to the shock produced by the lesion of the
organ on its hight of physiological development and activity. Two
cases are reported, where ruptures of a considerable extent, allowed
the mothers to recover. With regard to treatment, Dr. Lehmann
strongly advocates the operation of turning, in cases where the head
is floatmff high above the brim of the pelvis, and gastrotomy in cases
where a uving child is deposited entirely in the peritoneal cavity.
The placenta ought to be left in the womb, if it cannot be removed
very easOy. Against the hemorrhage and anaemia, cold fomentations
of the abdomen, analeptica, mineral acids, etc., have to be adminis-
tered, •

Dr. IkTCuMTOCK draws attention to a symptom observed in a case of
mptura uteri, which he thinks, might hereafter be found of value
as a diagnostic of laceration of the uterus or vagina. This symp-
tom wte an emphysematous state of the integ^uments covering the
hypoKAstrium. Its existence was detected by the stethoscope while
sear<ming for the foetal heart. Examined for in this manner, the cre-
pitation was loud and distinct, but to the touch it was not so obvious,
except when firm pressure was made in the proper situation, then
the crepitus was evident, and was recognizea by Dr. Montgomery,

160

and by several pupils, who happened to be present. TJpcm
post-mortem examination, the left broad ligament was found em]^gr>
sematous, and a tear existed in the left side of the uterus, at the juw^
tion of the body and cervix. At some distance from this, the peri*
toneum was also lacerated, and a considerable quantify of blood
had been effused into the abdominal cavity.

Dr. DnxoN describes a case of uterine rupture, in which tlie
rent was so large, that the margin of the liver and a mass of smaD
intestines found entrance through it into the cavity of the uterus.

Dr. MoBDRET, in' his general remarks on the causes of death, as-
signs to them a triple seat,^viz., the brain, the heart, or thelunn, the
former organ always being primarily or secondarily affected when
death occurs, as it is the seat of the vital principle. Death maybe
brought on by a material and traceable, or by a dynamic lesion of
one or more of these central organs. The shock received may be bo
severe as to prove fatal, or a comparatively slight injury may com-
bine with a preexisting cause, to produce the fatal result
First of all, the digestive organs, at the very beginning of preg^
nancy, are at times the seat of considerable morbid affections, and
some cases of sudden death came to Dr. Mordret's notice, whicA
seemed to be owing to undue irritation of the alimentary canal ; ia
one instance by a strong cathartic, in the other instance by the re*
ception of an unusually large quantity of food. The chemical com-
position of the blood during pregnancy being characterized, by the
diminution of red globules and of albumen, by the increased quantily
of fibrin, phosphates, fat, and water, is one great source of patiiolo-
.. gical phenomena. The author thinks, that the physiological condi-
tion of the foetus during the first months of gestation, demands an
impoverished olood for its maintenance, and that the troubles from
the digestive organs, such as vomiting, dislike of certain eatableSi
very properly tend to the formation of a blood thus qualified. The
increase of fibrin in the blood of pregnant women is explained by
the enormous growth of the uterus, which demands this constituent
for its development, and nature endeavors to supply it. The diminu-
tion of the albumen may possibly be es^lained by the fact that part
of it is changed into fibrin, with which it is isomerous, but it is more
natural to attribute it to the constant drain to satisfy the demand of
the foetus. — ^The author's logic is not clear, nor are his deductions cor*
rect in such statements as these. The increasing uterus demands
fibrin, and, therefore, the blood contains more fibrin ; and the foetus
demands albumen, hence the blood contains Use albumen, than un-
der ordinary circumstances. — E. N. The increase of watA* is ex-
plained by the great want of water for the annexes of the fostua.
The bearing of this abnormal state of the blood upon* the
chances of sudden death, consists in the general debilitated con-
dition of system arising from this source, while the increase
of fibrin tends to favor inflammations and coagulations of blood
in the heart or the vessels. The increase of albumen and
water explains the frequency of hemorrhages and serous efiu-
sions. The disturbances in the circulation, which may lead to sud-
den death after and before delivery, take their rise from irreg^ar

161

difltribution of the quantity of blood present at certain moments, or
from compression of the large abdominal veins. Among the preter-
natural secretions the author mentions, ptyalism, night sweats, and
albuminuria. The latter condition (albuminuria), is treated in a few
lineSy and Dr. Mordret thinks that the presence of albumen in the urine,
is of no etiological importance in regard to sudden death — we feel
obliged to be of the opposite opinion, considering Bright's disease
and its consequences, as the most frequent cause of sudden death in
child-bed, except that coming from hemorrhage. — E. N. The innerva-
tion during pregnancy is often weakened, be it by the ansemic condi-
tion of the blood, or by the diflfcrcnt sufferings, to which women are
subject during labor.

An affection of the respiratory organs is one of the most frequent
causes of sudden death. The lungs are predisposed to morbid at-
tacks, by the pressure they have to suffer from the growing uterus,
and by tiie compression of the large abdominal veins; while on the
other band an impoverished blood circulates through them, by the
presence of which, their contractility is diminished. This is exempli-
fied in a case by Devilliers, published in the Bevue Medicale, where a
woman died suddenly, during labor, after a severe syncope. The
post^nortem examination showed a splenified condition of both lungs,
the head was not opened. In another instance reported by Dr. De-
villiers, the lesions found in the body, were cartilaginous induration
of the mitral valve, oedema in the apex of the riglit lung, apoplexy
in the inferior lobe of the same side, infiltration of the apex of the
left lung and red hepatisation in tlie inferior lobus of the left lung,
considerable quantities of scrum in both pleural cavities. (This was,
doubtless a case of embolia, E. N.). A similar observation, but
without post-mortem examination, has been published by Dr. Aran,
in the Bulletin de Thirapmtique, A case of sudden death in conse-

Sucnce of a double pleuro-pncumonia, is mentioned by Dr. d'Ollivier
'Angers. The following case, reported by the author as one of sudden
death from pleuritis, is clearly one of Bright's diseases ; the autopsy
is minutely reported, with the exception of the condition of the kidneys.
A case of sudden death after coiiiinement, from asthma, is reported
by Dr. Delamotte. Another cause of sudden death, is the rapid de-
velopment of emphysema pulmonum during labor. According
to Drs. Cazeaux, Leroy d'Etiolles, and Picdagnel, compression of
the lungs from outside, or by the elevation of the diaphragm,
(Dr. Lerrat) may lead to fatal asphyxis. Sudden death from an cf-
fection of the heart, arises mostly from a sudden bodily or mental
shock, or a trouble in tlie circulation, when combined with a pre-
vious disease of this organ. Dr. Pelago gives a description of a case
of sudden death from rupture of an aneurism in the last stage of la-
bor (Oaz, Mid.f 1841). Similar cases are recorded by Drs. Cazeaux
and McNichoU. Dr. Corvisart has observed a case of sudden death
after delivery, from a sero-purulent pericarditis. Tha chief symp-
tom of an affection from heart disease is the syncope, which, however,
may seizse a woman during confinement, while the heart is perfectly
sound. In both instances the accoucheur has to shorten labor artifi-
cially, be it by instruments or by simply rupturing the membranes,

162

thus establishing a freer circulation. Under the head poljpiform
concretions of heart and the large vessels, three observations are
recorded, one by Kieth, one by Havens, and that of the Dnehess of
Namour. Dr. Mordret considers the great quantity of fibrin in the
blood of pregnant women, and accidental hemorrhage, as the principal
causes in effecting these concretions.

Sudden death may be caused by the spontaneous production of
ffas in the blood-vessels, or by the artificial introduction of air
into the system. The first cause is sufficiently demonstrated by the
observations of Drs. Ollivier (d'Angers), Devcrgie, and Durand-Far-
del. One of Ollivier's cases is communicated. A young woman,
nearly nine months pregnant, died suddenly, with the signs of a vio-
lent dispnoea. Post-mortem examination forty-eight hours after
death. No alteration of importance to be found, but gas mixed in
considerable quantity with the blood of the subcutaneous veins of
the chest, which escaped with a whistling noise, upon incision ; cavi-
ties of the right heart considerably enlarged, no clot inside. Lungs
and brain healthy. An interesting observation of Dr. Durand-Par-
del is added, where a non-pregnant woman died suddenly, while
taking a bath, from spontaneous development of gas in the blood, as
exhibited by the post-mortem, performed twelve hours after death.
Two similar facts, one of which is recorded by Dr. Devergie, are men-
tioned by Dr. Mordret, who thinks that the predisposition for produ-
cing gas in the blood, d«iring the pregnant state, is due to the anae-
mic condition of the blood. The entrance of air through the uterine
veins has been demonstrated beyond doubt. Dr. Legallois has des-
cribed this accident in animals, one of which was starved for the
sake of an experiment, while two others were profusely bled. Two
observations are recorded by Baudelocque ; in both a hemorrhage
preceded death, and gas was found, in the heart and the large veins,
although the autopsy was performed only five or six hours after death.
Dr. Nelaton, while making an injection into the uterus of a dead
woman, saw the injected mass enter one of the veins of the ligamen-
tum latum, pushing a quantity of air-bubbles before itself. Dr.
Bessems communicated a similar fact to the SodHe de Medicine d^An-
vers. In the latter instance a woman died after an injection of aqua
oxymuriatica into the womb, and afterwards air was found in the
heart and in the vena cava. Drs. Wintrich and McClintok have pub-
lished several observations, proving the entrance of air into the uter-
ine veins. The air absorbed by the uterine veins may be atmospher-
ic air entering the uterus while in a relaxed state, or putrid gases
formed from decaying matters in the womb. The entrance of air
into the system is the more dangerous, in proportion as the quantity
of blood is diminished by previous losses, a fact sufficiently proven
by experiments upon animals, and thus, sudden death, after a com-
paratively small hemorrhage, may be caused, in some instances, by
the entrance of air into the uterine system. The symptoms of en-
trance of air into the system, are a characteristic noise, a deep syn-
cope, extreme paleness, pulse and respiration imperceptible, and
death soon afterwards. In these cases treatment of course is out of
the question. We are sorry to find the author perfectly ignorant,

163

it seems, of the important theory raised by Frerichs, regarding
the connection of Bright's disease, with the presence of carbonate of
ammonia in the blood of pregnant women. Among the lesions of the
nervous centres, apoplexy is the most frequent affection causing sud-
den death. Dr. Ikfordret favors the opinion, that pregnancy and labor
bear in themselves a predisposition to cerebral affections, a fact, de-
nied by Dr. Negriel*. This predisposition is attributed to the com-
pression of large veins and arteries from the womb, as well as from
the contraction of muscles during labor-pains. Sudden death from a
latent puerperal fever has been frequently observed. Dr. Dubois
describes a case of sudden death from a latent sero-purulent peri-
tonitis and lymphangitis in the Journal de Midicine pratique^ art.
2832. Drs. Sundelin and Delamotte have published similar observjft-
tions. Death following upon these accidents is explained by the de-
pression of the ganglionic system.

Sudden death without any pathological lesions may be caused
by a nervous apoplexy, by a syncope, or by an idiopathical
asphyxy. As a sample of nervous apoplexy, the author men-
tions a case of puerperal convulsions, followed by a deli-
rious and comatous state, which is described by J. Frank ; the woman
was saved by the use of stimulants. Interesting cases of lethargy,
from which the patients recovered accidentally, are those of Ph. Peu
and Puigandeau. In the Abeille Medicale Dr. Po(iflman has published
an interesting observation of nervous apoplexy fourteen days after
confinement; a perfect paralysis of the right side, and all the other
symptoms disappeared in a few hours, while a trouble in the speech,
and absence of the radial pulse in the right arm, continued for some
time. Other cases of nervous apoplexy are recorded by Drs. Dax
(AbeUle Midicale, 1849) and Artaud {Bevue. TUr. du Midi,, 1850). Sud-
den death in these instances, is very often prompted by a wrong
medication, in consequence of a wrong diagnosis. The differential
diaraosis is taken partly from the antecedents, partly from the ac-
tual condition of the patient. It generally occurs in lymphatic, deli-
cate, nervous, and hysteric women ; the face is pale, pulse feeble, par-
alysis and coma are generally of short duration, often alternating with
convulsions. Idiopathic asphyxy and nervous syncope are accidents
which kill rapidly without any appreciable cause. In the first instance
death occurs by the sudden suspension of respiration, its first and chief
symptom is asphyxy, while idiophathic syncope are called those
cases where the action of the heart is primitively suspended. A
common character with both these affections and nervous apoplexy is
the want of anatomical lesions. • The heart is generally found empty,
and in two observations the vena cava was in a state of vacuity,
while in many instances the heart was far advanced in fatty degen-
eration. Many cases of death from syncope are doubtless ow-
ing to the exhaustion of the system from exceedingly violent
pain after protracted confinement. Three observations illustra-
ting this explanation are offered by Dr. Delamotte {obs. 218
and 389), one by Dr. Moreau {fraite d'acouehements torn, ii.), and one
by Dr. Mordret himself. Besides pain, a violent mental emotion,
may cause sudden death. Dr. Peu mentions several instances,

164

where anger had a disastrous effect upon women in confine-
ment. More than anger, fear is to be dreaded in its influence up-
on the patient, and many fatal cases are owing to this latter circum-
stance, as Dr. Frank had ample occasion to witness. The author
gives the history of a woman who died suddenly, after an easy con-
finement from the annoyance she experienced, when she learned tiiat
her offspring was a girl, instead of a boy, as she expected. Still this
case is not so very striking, as, besides a considerable hemorrhage,
the placenta was not removed for six hours after delivery. Several
other lesions existed, an enormous tympanitis, distension of the heart,
uterus, stomach and intestines by gas ; bloody serum in the pelvic
cavity, hypostasis in the lungs, and so on. The observation is taken
from Morgagni. Dr. Travers has noticed a case of sudden death after
an easy confinement, in a lady, who, during the whole of her pregnan-
cy was impressed with the idea, that she was bound to die in child-bed.
The postrmortem discovered no anatomical lesion whatever. The
observations taken from Dr. Gartlan is all but conclusive — abdominal
pains and tympanitis were present, no post-mortem had been per-
formed, and still the case is considered among those of sudden death
from fright. The observation of Delamotte (observation 230) is of no
greater value, as no autopsy is mentioned. To the 106th observation
of the same author, we must make the same objection. A woman
was frightened by a disagreeable nightmare three days before deliv-
ery; when the child and afterbirth were extracted, they were found
in the highest degree of putrification ; no autopsy. The following
observation communicated by a midwife, who at the time of the
occurrence, ten years ago, had no knowledge whatever of midwifery,
is of no value at all. As an instance of death from protracted chill,
the 27th observation of Madame Lachapelle is mentioned, although
it was proven by the post-mortem that " all the serous membranes,
but more particular the peritoneum, were bathed in a sanguinary
liquid, while the entire blood was exceedingly thin and watery."
Under the head of "fatal chill ^^ another observation of Madame La-
chapelle is put down, which is clearly nothing but a rapid peritonitis.
Dr. Mordret says that nervous syncope is often the result of a
gastric irritation, similar to the syncope of old men, from the same
cause, and he thinks that the immediate cause of death, in similar
instances, comes from a paralysis of the ganglionic system of the
abdomen. Cases of sudden death shortly after delivery, without any
anatomical lesions, are reported by Drs. McClintok, Chevalier, Davis,
Denman, Sandras, Chailly. In some of these observations, an insig-
nificant hemorrhage preceded death, and Dr. Mordret very justly
remarks, that a violent hemorrhage is at times well enough supported
by otherwise strong women, while even a slight hemorrhage after a
protracted and painful confinement, is sufficient to cause death. Most
of the observations here reported are — as it appears to the writer —
perfectly valueless, owing to the absence of post mortem examina-
tions. Sudden death not only occurs immediately after or during
labor, but in some cases, a great while afterwards. Dr. Robert has
communicated to the SocUie de Chimrgit fipur cases of sudden death,
of which one occurred nine days, two sixteen days, and one twenty

165

days after a normal confinement. Only in the last case the autopsy
was performed, bat nothing worth notice was found, besides slight
vascnlarisation of the pericardium, in the cavity of which, a spoon-
fal of serum was found, the heart was somewhat more fatty than
usual. In treating of the condition of women after delivery. Dr.
Mordret very justly remarks, that the strict diet, as recommended by
physicians in France, at this period, is, as a general rule, more inju-
rious than beneficial, inasmuch as it tends to prolong the constitution
of blood peculiar to pregnant women, viz., anssmia.

Dr. Villeneuve has published an observation in the L* Union
Mkdicale, where a woman died suddenly on the twenty-sixth day
after her delivery, after an access of tumultuous movements of the
heart ; no autopsy. Dr. McClintok records two cases of sudden death
a few days after delivery ; the post mortem examinations revealed
nothing, but an anormal fiaccidity of the heart, with complete
absence of blood in its cavities, which condition Dr. Mordret attrib-
utes to an anaemic state of the blood.

In summing up. Dr. Mordret reviews the different causes of death
before, during, and after confinement, and comes to the following
conclusioDS :

1. If a woman dies suddenly during the puerperal period, it is
very probable that her death was owing to this condition, an organic
lesion producing death being present or not.

2. If a woman dies suddenly during confinement, a latent organic
lesion may have existed before she became pregnant, or it may have
been developed under the influence of pregnancy.

3. The introduction of air into the uterine veins is possible shortly
after delivery. This introduction of air is a material cause of sud-
den death, which must have escaped recognition in many instances.
The spontaneous development of gas in the blood seems te be favored
by the puerperal state ; but the facts known are not sufficiently con-
dusive.

4. It seems very likely, that the puerperal state predisposes to
sanguinary concretions in the heart and the large vessels, a material
cause of death very often not appreciated.

5. The chloro-aneemic condition, very frequent in pregnant women,
seems to favor sudden death ; it is at least a weakening influence,
which is apt to diminish their vital resistance.

6. All weakening influences seem to predispose women in childbed
to sudden death ; it seems, at least, that this accident has been ob-
served more frequently in multiparous women, than after the first
confinement, and more often in lymphatic and nervous, than in robust
persons.

7. Every instance of sudden death, which cannot be explained by
an anatomical lesion, seems to be the result of a nervous affection,
which may have its starting-point in the cerebro-spinal or in the
ganglionic system.

8. The pernicious effects of pain, of mental emotions, of an unfit
diet, etc., are incontestable in pregnant women. In every one of
these circumstances, the nervous element is severely affected, and
many cases of sudden death may be the result of one or more of
these same circumstances combined.

Br. Karo rf GsPistfa treatise containa a statiatical analysia of deaths
occurring during, or shortly after delivery, from which he concludes,
that the large lying-in hospitala were dangeroua inslitutious for the
safety of motherg, and he, tlierefore, recommends to have the womeu
delivered in private dwellings.

In a case attended by Dr. Thornton, the mother died suddenly
while in labor from some unascertained causo. Forty minutea
elapaed after the patient's death, before Dr. Thornton arrived. On
examination, he found that the membranes had been ruptured,
that the head was in the cavity of the pelvis, the vertex presenting
at the inferior strait. Dr. Thornton raised the fcetal head, passed too
hand into the flaccid womb, turned the child, and extracted it as ft
as the head without delay ; at this point it momentarily hung
assisted by the fingers in its mouth. Thus forty-five minutes clapt
from ttie last expiration of the mother to the complete extraction
the child. The child did not breathe, and was of a blueisU color ; bot
a slight ticking could be heard on placing the ear over the heart.
The fances were cleared, Uarshall Hall's ready method then diligent"
ly practic«d for half an hour, when a convulsive inspiration took
place. This method was persevered in, assisted by aspersions and
frictions, and at length respiration was established. The child, a
boy of the average size, sucked vigorously at the bottle, and lived
for three weeks and two days ; its death probably resulting from
want of aufiScient caro.

Dr. RioBv ventilates the question, what position a woman would
assume, when left alone daring labor ? From the history of older
times it appears, that women used to sit or kneel down. Dr. White,
of Manchester, was the first who proposed to place parturient womes
on one side, as the most natural and most comfortable position for
delivery. Dr. Naegele left a young primiparous woman entirely I
herself in a room, wliich contained several chairs, one delirery-chai)
one sofa, and one bed. During the first part of labor she adopt
several attitudes, loaning against the wall, stooping over a chair,
on the sofa. Towards the end of labor she first lay down npon t
sofa, then on the bed, where she remained. Here she threw herself
around, now on her back, now on one or the other side ; but when
the head began to pass the external orifice, she took to lying on the
left side, in which position she remained till all was over, Thia
experiment induced Dr. Naegele to choose the left side as the moet
convenient position for women in labor.

Dr. Klopsch analyzed a lithopsedion, with a view to examine
into the nature of a regressive metamorphosis, which presents tbe
most physiological features of an entire organism undergoing retro-
grade changes, under the most perfect seclusion from the atmosphere.
The specimen, taken from the womb of a cow, is rather a dcrmatop»>
dion, than a lithoptedion ; a corrugated, indurated foetus, withont
calcareous deposits. The uterus from which it was taken exhibited
not the slightest trace of cotyledones or pJacenUr formation. The
inside of the uterus, as well as the fcetus were covered with a
yellowish-brown substance, which, on chemical analysis, appeared
bo a mixture of melanin, htematosin, fatnlrops of a reddish color,

for

KAir I

a thick, ^^^J
eared tO^^^H
lor, and^^^l

167

(rfhsBmotoidin. This substance must be considered as the
remnants of an hypertrophy of the entire mncons membrane, which
oondition is explained by the absence of cotyledones or placenta.
MTHe fleshy parts of the foetus were as hard/ as leather, containing a
yellow, thick, fatty matter, to a great extent, but no earthy salts ; all
"tihie intestines covered with fat ; the greatest portion of the cranium
filled with white or yellow fat ; the brain, very much reduced in size,
*wa8 a solid, dry, fatty mass ; the organs contained in the thorax and
abdomen very hard, dark, and covered with fat. A microscopical
examination of the epidermis and chorion gave proof of their perfect
integrity. The muscles had undergone fatty degeneration ; the fat
ooold be traced between the sarcolemma and the primitive bundles,
while the proper contractile muscular substance remained intact.
The tendons and fibrous membranes, dura mater, cartilages, and
bones, were perfectly normal in structure — no fatty or calcareous
metamorphosis. The heart was a solid, hard body ; the vessels con-
tracted and perfectly empty, with the exception of the larger venous
sinuses of the head, which were filled entirely with a fatty substance,
consisting of fat without fatty acids, and a very small quantity of
earthy salts. The presence of this enormous quantity of fatty blood
the author explains as well from the absence of the placenta, an
organ intended for oxygenizing the foetal blood, as from the great
amount of fatty matter from the blood of the mother. The microsco-
pical elements of the brain and spine were unchanged, but both
replete with fat and cholestcrin.

Dr. Hall remarks that ulcerative inflammation of the mouth does
not nnfrequently appear in women during the closing months of
utero^estation. It is rarely met with in particular localities, while
in others it seems to be endemic. The afiection seems to be of an
aphthous nature, and associated with a disordered system, as that of
ansmia combined with a scrofulous diathesis, dyspepsia, etc. It
attacks the mucous membrane indifferently, and is even migratory
in its character. It sometimes becomes chronic. The treatment
consisted of astringents, acids, and tonic medicines.

IV.— PATHOLOGY OF THE OVARIES.

1. Peaslee, E. R., on Tioo Successful Cafies of Ovariotomy by the Large
Abdominal Section, — Amer. Jour., LXXII. Oct.

2. Atlee, J. L., Removal of an Ovarian Tumor with the JEcraseur. —
Amer. Med.— Chir. Review, July.

3. Hewitt, Ch. N., Successful Case of Ovariotomy ; Performed by Dr,
H. E. Fotter.— Amer, Jour., LXXII., Oct.

4. Nelson, R., a Case of Ovariotomy Successfully Performed. — Amer.
Monthly, July.

6. Humphrey, Case of Successful Ovariotomy. — Med. Tim. and Gaz.,
June 12.

6. Spencer Wells, Cases of Successful Extirpation of (multHocvlar)
Ovarian Cysts.— Ucd. Tim. and Gaz., 426, Aug. 28 ; 43T, Nov. 13 ;
441, Dec, 11 ; 332, March.

168

7. Hutchinson, Three Cases of PolycysHc Ovarian Tumor; Ovariotomy,
—Med. Tim. and Gaz., 440.

8. Case of Ovariotomy ; Death, ( Under the cart of M, Eriehsen,) —
Med. Tim. and Gaz., 441, Dec. 11.

9. Polycystic Ovarian Dropsy — Ovariotomy — Death from PeritcniHt
on the Fourth Day, ( Under the care of M, B, ChUds,) — Med Tim.
and Gaz., 441, Dec. 11.

10. Barnes, Statistical Bemarks on Ovariotomy, (Read before the
Western Med. Soc. of London.) — Med. Tim. and Gaz., June 12.

11. Simon, G., an Analysis of Sixty-one Cases of Ovariotomy Performid
in Germany, — Scanzoni, Beitr. zun Geburtsk., etc. B. 3.

12. Boinet, on Injection of Iodine in Ovarian Dropsy, — Rev. de thdr.
mdd. — chir. T.

13. Lacroix, Ovarian Cyst developed simvXtaneously with OestaHon —
Radical cure by one Injedion of Iodine. — Bull, de Thdr., June 15.

14. Warin, Three Cases of Ovarian Dropsy ; Injection of Iodine; AU
Cured, — Gaz. des Hop., 111.

15. Sausset, on Injections of Iodine in Cases of Non-Purulent Ovarian
Cysts. — Rev. de th^r. mdd. — chir. 4, 5.

16. Bickermann, Ovarian Dropsy treated by Injection of Iodine. — ^Med.
Tim. and Gaz., 415, June 12.

11. Brower, T. H., Two Cases of Ovarian Dropsy Successfully Treated,
Chicago Med. Jour.

18. McDaniel, R., on Tapping in Ovarian Dropsy, — New Orleans Med.
News, Aug.

19. Oppolzer, Ovarian Dropsy Cured by Puncture of the Cyst. — ^Wien.
Wochenbl. 32.

20. Death after Paracentesis of an Ovarian Cyst. — Med. Tim. and Gaz.,
415, June 12.

21. Lumpe, E., Ovarian Cyst Cured Spontaneously by Rupture into the
Rectum. — ^Wien. Ztschr., May 31.

22. Melhose, A. L., Dissertatio de tumorHbus ovariorum cystuns, adjecta
morbi historia. — Gryphiswaldae. 8, p. 5*1.

— Melhose, Thesis on Cystic Ovarian Tumors, etc.

23. Pernod, C, Essay sur les kystes de Vovaire, consideres surtout au
point de vue du traitement. These. Strasbourg : Benger-Levrault, 4,
pp. 62.

— Pernod, Thesis on Ovarian Cysts, Especially vMh Regard to Treair
ment, etc,

24. Jacob, P. E., Nounulla de ovariorum tuinoribus difficile dignoscen-
dis, Gryphiswaldae 8, pp. 32.

— Jacob, Thesis on Ovarian Tumors wUh Regard to Diagnosis, etc,

25. Driver, V. G., Report of a Case of Ovarian Dropsy vxith Malignani
Disease of the Uterus. — Lancet II., 4, Oct.

26. Friedreich, N., Compound Dermoid Ovarian Cyst with VibratHe
EpiiheLium and Formation of Nervous Tissue ; Constitutional Syphilis,
Extensive Amyloid Degeneration. — ^Virchow's Archiv., XIII. 4, 5.

169 ^

^'f . Beichel, H., Dissertatio de ovarii carcinomate, subsequenH carcino-
^rjnate secundaria uteri, hepalis et omenti, — GryphiswaldsB 8, pp. 29.

— Reichel, Thesis on Carcinoma of the Ovary vrith Secondary Carcino-
9na of the Uterus^ Livery etc,

Ouersant, Double Hernia of the Ovary, — 6az. des H6p., T4.

Paunet, Ovaritis wUh Formation of Pus; Artificial Opening ofihe
Abscess above the Areas Pubis. — Jour, de Toul., Jan.

So. Differential Diagnosis of Hydrops Ovarii and Hydrops Ascites. —
Med. Tim. and Gaz., June 5.

The most important article, with regard to ovarian disease, is Dr.
Simon's analysis of cases of ovariotomy performed in Germany, which
reveals a frightful rate of mortality. In opposition to this we are
liappy to report a considerable number (14) of operations, performed
exclusively in England and America, the favorable result of which is
partly owing to a modification of the method, hitherto followed, with
regard to the management of the peduncle. For this the profession
is indebted to Drs. Atlee, Hutchinson, and Wells. The cases of
ovariotomy are thus distributed : Hutchinson, 4 ; Wells, 4 ; Brown,
2 ; Peaslee, 2 ; Atlee, 1 ; Nelson, 1 ; Hewitt, 1 ; Humphrey, 1 ;
Erichsen, 1 ; Childs, 1. Of the eighteen, fourteen recovered and four
died. In two cases the tumor was not removed ; both patients died.
In eight cases the end of the peduncle was brought out externally ;
in one it was severed by the dcraseur ; of these seven recovered.
Most of the cases were polycystic, and had firm adhesions. The
account of operations published by Dr. Peaslee is sufficiently inter-
esting to justify a somewhat lengthy abstract.

I. — In the case of Miss Susan K. Russell, the operation of paraccn-
.tesis was performed, preliminary to settling the question of the pro-
priety of removing the mass of the tumor, which was evidently mul-
tilocular. After thirty-four pounds of fluid were removed from the
two larger sacs, the mass could be moved somewhat in the cavity of
the abdomen. The patient was in a very debilitated state (she had
been tapped nine times previous to this), and so it was decided to
give her the only remaining chance of living, viz., by the operation
of ovariotomy.

Before commencing the operation the atmosphere of the room was
rendered moist by the evaporation of water, and kept at a tempera-
ture of 80° F. The patient being under the influence of sulphuric
ether, an incision was made through the abdominal walls, eight
inches long. The tumor was found to be firmly adherent everywhere
anteriorly above the level of the umbilicus, and by strong bands also
to the stomach, the omentum and the right iliac fossa. Commenc-
ing, however, below the umbilicus, the hand, previously immersed
in artificial serum at a blood heat (composed of water giv. ; white of
eggs, 5vi., and common salt 5iv.), was introduced and forced up
between the tumor and the parietal peritoneum, thus tearing away
the adhesions. This was effected slowly, since, in most of their ex-
tent, the operator's whole strength was repeatedly applied before
accomplishing the object. Prof. Peaslee attempted to separate the

170

adhesions at their inner extremity (that in contact with the tumor),
in every part, so that if any hemorrhage ensued, the bleeding vessels
could be easily ligated. No ligature was however required, though,
for a few minutes, there was a general oozing of blood over the
whole surface. Next, the tumor was lifted out of the abdomen, an4
a double ligature of four threads of saddler's silk, waxed, but not
twisted, was passed through the middle of the pedicle ; each portion
was tightly tied round its respective half of it, and the latter was
then divided. The pedicle (V wide) was so short, that the ligature,
when tied, came in contact with the tumor. The operator, therefore,
cut it through to the substance of the tumor on both sides of the
latter, at the distance of one-third of an inch from the ligatures, and
dissected out the lower portion of the tumor from between the two
layers of the pedicle. The tumor was a mass of sacs, containing
fluids of different shades. The clots of blood and the remaining fluid
were carefully removed with a fine sponge from the pelvis.

The incision was now closed by nine needles and six sutures ; the
two ligatures were brought out below the lowest needle at the end
of the incision ; a compress, wrung in blood-warm water, was
applied and covered with oiled silk. The temperature of the room is
to be kept at 10° or 15° Fah. ; none but the water-dressing is to be
applied, this being changed once in six hours ; panada, milk-porridge,
or broth, for nourishment ; and stimulants and opiates to be given
as may be required ; the catheter to be used once in six hours.

At the third day after the operation, the whole incision was united
by first intention. The ligatures came away one three months, the
other four months after the operation. The patient recovered per-
fectly. In the course of recovery several abscesses formed in the
subcutaneous areolar tissue, around and to the left of the ligsr
tures.

II. — In the case of Mrs. -Hannah Holt, a large tumor could be felt
in the abdomen, apparently surrounded by fluid in the cavity of the
peritoneum. After tapping the patient, thirty-four pounds of gelati-
nous fluid were obtained, when it was decided that the remaining
unusually solid mass was a diseased left ovary, quite firmly attached
at several points by adhesions. On the 28th of October, 1856, the
tumor was removed by the large abdominal section. All the prepar-
ations of the apartment were made as in the preceding case. After
the patient was brought fully under the influence of ether, an inci-
sion, eight inches long, was made through the parietes of the abdo-
men, whereupon several pounds of fluid escaped from the peritoneal
cavity. The tumor consisted of a number of small sacs, and it was
firmly adherent above on the right side, and these adhesions were
torn away. But, at the lower part of the tumor, were two adhesions
on the left side and one on the right, so strong as to resist the opera-
tor's whole strength in the attempt to tear them ; and as they were
in the form of tendinous bands, three-quarters of an inch in diameter,
a strong double ligature was passed through the centre of each, and
tying each of its two portions round one-half of the baud, the latter
was divided. Thus, six ligatures had already been applied. To the
pedicle, being but five inches wide, and nowhere more than one-

171

amrter of an inch thick, a double ligature of three threads of sad-
Ijer's silk was applied, and the tumor removed.
While attempting to tear the adhesions, the substance of the mass
^"^self gave way at one part, and so much blood escaped among the
^^cnvolutions of the alimentary canal, that at least three-quarters of
^Ui hoar were spent in making sure of its entire removal, the exposed
^nirface being all the while kept moist by the free application of the
artificial serum. All the ligatures (two for the pedicle and six for
lands divided) were brought out at the lower end of the incision.

The tumor removed weighed nine pounds ; it being of the areolar
variety, or a congeries of small sacs, connected together by a large
amount of areolar tissue. Eleven pounds of fluid also were removed
from the cavity of the peritoneum at this operation. With the
exception of a cough and excessive flatulence, no unpleasant symp-
toms occurred. The former one was relieved by opium, the latter by
tte application of the rectal tube. *

Dr. Peaslee insists upon the importance of the artiflcial serum in
aid of this operation, and says he would not hesitate to keep the
cavity of the peritoneum exposed to view for any required length of
time.

Dr. Atlee removed a multilocular cyst in the usual way, through
a cut in the mesian line, and the pedicle was severed from the tumor

5f the ecraseur in six and a-half minutes, and the external wound
osed up by silver sutures. On the seventh day the sutures were
removed, the wound being united throughout the whole extent. From
this day the patient sat up daily, and recovered perfect health. Dr.
Atlee has performed ovariotomy seven times, but in none of his cases
was recovery so rapid, and constitutional disturbance so slight, as in
this last one, treated by the ecraseur and silver sutures, which were
applied in such a way that the peritoneum was not touched.

In the operations performed by Dr. Spencer Wells, he used a tro-
car, contrived by Mr. Thompson, in the midst of the canula of which
an elastic tube can be attached, so that the fluid is conveyed away
quietly and neatly, without unnerving the patient. The pedicle was
secured between the blades of a metal clamp (Dr. Hutchinson's sug-
gestion), very much like Ricord's penetrated forceps for circumci-
sion.

In the third of Dr. HurcmNsoN's cases the free edge of the liver
seemed to be depending into the upper part of the cyst, and, there-
fore, any further attempt at removal was abandoned.

At the annual meeting of the Western Medical and Surgical So-
ciety of London, Dr. Barnes made some remarks with regard to the
statistics of ovariotomy. He had been led to this subject by a case
of unilocular cyst, in which he had lately successfully operated.
Having given the details of this case, he adverted to his individual
experience of operative proceedings for the radical cure of. ovarian
dropsy, which extended over 13 cases. In 8 of these the cyst was
removed from the abdominal cavity ; in the remaining 5, the tumor,
on account of adhesions could not be removed. Of the 8 removed,
2 of the patients died from the immediate effects of the operation,
and 6 recovered, showing a mortality of 1 in 4, or of 26 per cent.

172

Of the 5 cases in which the tumor could not be removed, all lecoY-
ered from the operation, thus in the 13 cases the mortality was ooly
2, or 1 in 6i. Dr. R. Lee's cases of ovariotomy were the mostiuh
favorable ; out of 162 cases, 60 could not be removed ; in 5 of these
no tumor was present ; of the 60 cases, 19 proved fatal, or ratto
less than 1 in 3. In the remaining 102, the disease was remoTed;
in 1 of these cases both ovaries and the uterus were excised, and in
another the ovary, with part of the uterus, and in 2 cases both ovar
rics ; of these 102 cases, 42 proved fatal, or about 1 in 2|. Dr. Clay,
of Manccster, had had more experience. He had operated in 19 cases,
and 55 proved successful, the mortality being about 30 per cent., or leas
than 1 in 3 ; so far as his experience went, the existence of adhesiona
did not interfere with the successful result. Dr. Atlee, of Philadel-
phia, had operated on 36 cases, 12 of which were fatal, or 1 in 3. In
13 cases, where the cyst was removed, occurring in the practice of
Dr. F. Bird, 4 were fatal, or rather less than 1 in 3. In 21 cases re-
corded in Banking's Abstract, and Braithwaite's Retrospect, since
the date of Dr. Lee's paper, 1 proved fatal, or 1 in 3. Hence, Dr.
Barnes believed, that we were not only warranted in performing the
operation in properly selected cases, but that it was our bounden
duty to recommend it.

Dr. Simon's review of operations performed by German Burgeons
has been prepared with a great deal of care and judgment, in order
to establish the true value of the operation. It contains not only
those cases which have been published previously, but besides, 83
cases are added which were communicated to the author by private
letters, mostly from the operators themselves. In reporting each
case, he does not confine himself to short notices, but gives a history
of every one of them. The results of the operations are divided un-
der three heads, viz. : 1. Operations followed by a radical cure. 2.
Operations resulting in death. 3. Operations from which the pa-
tients recovered at first, the ultimate good result of which was only
temporary, dubious, or of no consequence at all. In the latter divi-
sion are counted those cases where the operation had to be given up
in consequence of too strong adhesions or a wrong diagnosis, or
where the patients died at a later period from the operation, or from
the original disease.

In all the former statistics (American, French, English) the cases
coming under No. 3 are reported among the successful operations.
Dr. Simon's analysis should therefore claim the undivided attention
of the profession. Moreover, as most of the operations were per-
formed at a recent date and by eminent surgeons, good diagnosis,
scientific performance of the operation, and skillful after-treatment,
were commonly secured.

Results : Of 61 patients operated upon, 44 died immediately after
the operation, or *I2^ per cent. In 5 patients the operation was of
transient or no benefit at all, and only 12 were radically cured, or
19{-f per cent. These results are by far less favorable than those of
former statistics, and, from a comparison, ovariotomy is more dan-
gerous than the Cassarian section, because only 63 per cent, died in
consequence of the latter, according to Dr. Kaiser's statistics, or

173

about § per cent., according to some other authors. (See Naegele's
(M)urtsk. B. 2.)

Dr. Lacroix reports the case of a woman who was affected with an
ovarian cyst of the left side for two years, and the tumor had re-
mained stationary during this time, being of the size of a child's
head. When this woman became pregnant, the cyst began to de-
velop considerably. At the full term regular pains set in, but labor
did not advance. Therefore, the attending physician punctured the
enormously distended abdomen, and drew 16 J litres of an albumin-
ous fluid, and ten hours afterwards the woman was delivered in the
natural way. Two months after this, Boinef s iodine solution (Tinct
jardi 150 grm. kal. hydrojod. 4 grm. aqu. destill. 150 grm.), was in-
jected. After the injection was made, the orfice of the canula was
closed for ten minutes. But when the opening of the canula was un-
corked, in order to let the iodine escape, not one drop of the solution
came away, though every efibrt was made for this purpose. Not-
withstanding the inflammation following was very trifling, and dis-
appeared after the sixth day. Three months after the injection, the
patient was discharged perfectly cured.

In a case of ovarian dropsy, treated by Dr. Hutchinson, in the Me-
tropolitan Free Hospital, a concentrated solution of iodine was em-
ployed, and allowed to remain in. The injection was practiced twice,
with an interval of about a month, and on each occasion after the
cyst had been as completely drained as possible, a scruple of iodine,
and half a drachm of iodide of potassium, dissolved in an ounce of
water, constituted the injection, and was wholly retained. The rea-
sons which induced Mr. Hutchinson to employ so concentrated a solu-
tion, were, first, the belief, that, what was wanted to prevent re-secre-
tion, was destruction of the epithelial lining membrane of the cyst
by iodic cauterization, and that the stronger the fluid, the more cer-
tainly would this be effected. Secondly, the hope that so concentrated
a solution would be less likely to be absorbed quickly, and might
therefore bo left in, to produce its full effect with greater safety.
Thirdly, the consideration that it is almost impossible to empty an
ovarian cyst entirely by the trocar, and that, therefore, a dilute solu-
tion is yet further reduced by mixture with the remaining fluid.
Fourthl3'', that it is not desirable to introduce so much alcohol into
the system, as is contained in from half a pint to a pint of tincture.
With regard to the results it may be stated that, although four months
have elapsed since the last injection, the patient remains quite well,
a tendency to refilling being manifested.

A case of ovarian dropsy is reported from the practice of Dr. Bick-
ERMANN, where eight ounces of the tincture were injected and retained,
but with no success.

Two cases are reported by Dr. Brower, in which Dr. T. B. Brown's
method of compression after tapping were resorted to. After the cyst
has been emptied by a large trocar, compresses of lint are so arranged,
as to present a convex surface, and adapted as nicely as possible, to
the concavity of the pelvis ; over these, straps of adhesive plaster
should be applied, so as to embrace the spine, meeting and crossing
in front, and be extended from the vertebral articulation of the eightb

rib to the Bacrnm. Over this strapping, a broad flannel roller, or
band witii strings and loops, which tie or lace in front, may be
plied.

The first case treated in this way by Dr. Brower, was that of a
unilocular cyst, in which ten pints of clear fluid had been drawn off "
by the trocar. It resulted in a radical cure of the ovarian disease,
and restoration of general health, six months having elapsed with-
out any appearance of a return of the disease. In 1845, the same
operation was practiced opon a similar case, in which two distinct
cysts occupied the right hypochondriac region. In the course of the
first forty-eight hours, severe peritonitis set in, which was promptly
subdued, and the case progressed to a final and radical cure. [The
writer is of opinion that the last mentioned case cannot be counted
at all. We do not know whether it was the pressure or the perito-
nitis, that effected the cure. — E. N.]

Dr. McDaniel reports a case where a woman was tapped for ova-
rian dropsy, 219 times, from 1841 to 1858. In this space of time 41^
gallons of water were evacuated.

A case of death after paracentesis of an ovarian cyst has lately oc-
curred at St. Thomas's Hospital, The operation was performed by
Mr. WoAKEs, and about a pailful of thick fluid removed. The tumor
was reduced in size, but a considerable bulk still remained. The wo-
man gradually sank afterwards, and died exhausted on the fifth day.

As it often happens that hydrops ovarii and ascites are mistaken
one for another ; it is of importance to have an unfailing diagnosti-
cal symptom. This is presented by the percussions of the lateral
lumbar regions. If in a case of ascites, tne patient is brought in a
sitting posture, the percussion in the lumbar regions ofiers an equal
(generally dull) sound on both sides. In case of ovarian dropsy
one side is found dull, and the opposite resonant. This is explained
by the fact that in hydrops ovarii, the intestines are driven towards
the healthy side. In this way we are also able to decide, which of
the two ovaries is diseased.

V. PATHOLOGY AND THERAPEUTICS OP

UTERINE DISEASE.

I. GENERAL DIAGNOSIS AND PATHOLOGY.

1. Beitfdge zur Oeburtskunde und Gynaekologie. Von Dr. F. W. von
Scanzoni. III. Band. (Mit 10 lithographirtenTafeln). Wlirzburg,
1858.

— Contributions to Midwifery and Diseases of Women, By F. W. von
Scanzoni, M.D. 3d Vol. (With 10 lithographs). WUrzburg, 1858.
(The single articles contained in this volume have been distribut-
ed among the respective heads.)

2. Histoire phUosophiqiie et viddical de lafemme-^ consideriedans dans totUes
les epoques principales delavie avec ses diverses functions, avec les change-

175

merU qui surrienneiU dans son physique ei son moral, avec Phygiine
applicable a son sexe el loules les maladies qui peuvent fallendre aux
different ages. Par Dr. Menville de Panson. Tom. I — III. Paris,
J. B. Baillifere. 8vo. 1858.

— A Philosophical and Medical History of Woman, etc By Menville.
de Panson, M.D.' Paris J. B. Bailliere. 3 Vols. 8vo.

3. Rosier, Dissertation sur les prindpales affections de la tnatrice, Paris,
1858. 8vo. pp. 47.

— Rosier, Thesis on the Principal affection of the Womb. Paris, 1858.
8vo. pp. 41.

4. Cartwright, Sam'l A., Practical Remarks on Epigenesis and Sterility,
— New Orleans Jour. XV. 4.

5. A Treatise on the Employment of the Speculum in the Diagnosis and
Treatment of Uterine Disease, uilh three hundred Cases. By Robert
Lee, M.D. London, John Churchill. 8vo. pp. 132. 1858.

6. Burgess, Vaginal Stethoscope. — Jour, de Bord. April.

7. McRuer, D., of Bangor, Me., an Inquiry into the Merits of Modem
Doctrines, regarding the Prequency, Importance, Pathology, and Treat-
ment of Abrasions, Excoriations, and Ulcerations, of the Os and Cervix
Uteri. — Maine Med. Report. I. 4 and 5.

8. Clos, J. A. on the Influence of the Moon upon Menstruation. — Jour,
de Toul. May.

9. Marable, J. T., of Memphis, Tenn., on Cases of Early Catamenia. —
Memphis Recorder. February.

10. Scarburgh, G. T., on a peculiar Case of Retention of the Menstrua
from Occlusion of the Os Uteri. — Virginia Med. Jour. XI. 3. Sept.

11. Farre, on a periodical Neuralgia of the Womb and its Appendages;
Daily and Annual Periodicity. — Gaz. de Lyon. June.

12. Becquerel, on Neuralgia of the Uterus. — Gaz. des H6p. 41.

13. Banks, J. T., on Partial Black or Blue Coloration of the Skin. —
Dubl. Quart. Jour., May.

14. Busquet and Gestin, on Partial Coloration of the Skin (Chrom-
hidrosisj. — Gaz. des Hop. 109.

15. Coote, Ch., on InfrarMammary Pain. — Med. Tim. and Gaz. 421.
July 24.

16. Plaskitt, J., Treatment of Infra-Mammary Pain, by Electricity. —
Med. Tim. and Gaz. 433. Oct. 13.

11. Schlager, on the Influence of Menstruation and its Anomalies upon
the Development and Progress of Mental Derangement. — Allg. Zeit-
schrift ftir Psych., von Damerow. B. XV. 4 and 5.

18. TraUi de la Follie des Femmes enceintes, des nouvelles accouchSes et
des nourrices, ei considerations medic-legales qui se rattachttnt it
ce sujet. Par Dr. L. V. Marc^. In 8vo. Paris, 1858.

— A Treatise on Insanity ^ Pregnant Women, etc. By L. V. Marcd,
M.D., etc.

19. Brosius, on Uterine Congestion and Mental Derangement. — Central
Zeitung, 21.

176

20. JRecueil desfaUapour seruir d rhistoire dea ovairea et des (fyectUmi
hysteriques de la femme. Par Dr. N^rier. Angers : Gosnier et
Lachfeze. In Svo. pp. 176. 1858.

— Arudysis of Facta connected vrith the Bxatory of the Ovariea and
Hyateriad Affecticna, By N^grier, M.D., etc.

21. Pidoux, Bronchiiia xtjiih Laryngoapaamua and Aphonia, Several
Faralyaea and Neuralgias in a Byatencal Woman; Diaappeara/nce (f
aU these Symptoma during a Typhua Fever, and their Beappearance
after Eecoveryfrom the Fever. — L'Union 11, 14, 16.

22. Drewry, on Fathdogy of Hysteria, — Atlanta Jour., Jan.

23. Briquet, On Anesthesia in Hysterical Women, — L'Union 87, etc.

24. Nonat, a Case of Hysteria and Symptomatic Betention of Urine, in
Consequence of Endometritis and Perimetritis, — Gaz. des H6p. 31.

25. Althaus, T., On Hysterical Aphonia. — Med. Tim. and Gaz. 433.
OctB.

26. Aran, P. A., General Remarks on the Treatment of Uterine Disease.
—Bull, de Thdr. April 30.— New York Jour. VI. 1. Jannary,
1859.

27. Storcr, H. R., Cupping the Interior of the Uterus. — ^The Amer.
Jour. Oct.

28. Trend, H. G., Abortion produced by Arsenic, — ^Brit. Med. Jour.

29. Broca, Fatal Peritonitis after Application of the Actual Cautery to
the Uterine ^eci5;.— Monit. des Hop. VI. 129. Oct. 30.

30. Scanzoni, on a Case of Death occuring after Injection of CaHxmic
Acid into the Cavity of the Womb, — ^Beitr. zur Geburtsh. B. 3.
p. 181. — New York Jour. V. 2. Septemb.

31. Mackenzie, F. W., on the Action of Galvanism on the ContractQe
Tissue of the Gravid Uterus^ and on its Employment in Obstetrical
Practice, — Lancet. March.

32. Warren, Occlusion of the Uterus — Rupture of the Left FaHopian
Tube, — ^Boston Jour. July.

33. Blair, on Vicarious Menstruation, — Oglethorpe Jour. April.

34. Kirsten, T., on the Education of Midunfes in Saxony. — Monat-
schrift f. Geburtsk. XII. 3. Sept.

35. Churchill, P., on Obstetric Morality. — ^Dublin Quart Jour. L. 1.
August.

Dr. Lee is the representative of a certain clique in England, and
his treatise on the employment of the speculum will meet with a
favorable reception among his adherents. Prom this point the work
must be considered, it having no other value. Par from proving the
necessity of restraining the use of the speculum, it reveals a deplor-
abl# state of practical sense and medical education among English
practitioners. Nothing could have done more harm to the reputa-
tion of our brethren abroad than this little book. Every reader, who
shall take the trouble to peruse it, must come to the same conclu-
sion ; and even Dr. Lee's great example, as recorded in the prelimi-
nary remarks, where a woman died eight days after an examination

177

With • Bpeculmn, from meningitis spinalis, proves nothing but the
groBS ignorance and barbarism of tho attending phjrsician.

Db. Bubokss has modified the shape of the ordinary stethoscope, so
•• to make it somewhat larger, for the purpose of introducing it in-
to tho vagina. In this way he was enabled to jadge of the foetal
life in the third and even second months of pregnancy. In the cases
exmmined, a sound was perceived similar to that called placentar
souffle.

After a very elaborate analysis of the points contested by our lead-
ing' men in uterine pathology, and after fully exposing his views
upon the subject. Dr. McRuer sums up in the following way :

1 . Ulceration is a lesion presenting an excavation or solution of

continuity, produced by a molecular death, the lifeless elements

"being absorbed back into the circulation through the action of the

abeorbents, and it is generally the result of a constitutional cause :

while abrasions and excavations are produced either by mechanical .

or chemical agents, by the attrition of foreign bodies, or the escha-

rotic effects of morbid secretions, usually the product of other parts,

and coming in contact with the ulcerated surface.

2. While abrasions or excavations are of frequent occurrence on
the cervix uteri, especially in tho pregnant female, ulceration rarely
exists on that appendage, excepting from mechanical or specific
causes, and all of these lesions, when not of a special character, are
of themselves of trivial importance, only demanding by their com-
jdication with other more important diseases, the serious attention
of the medical practitioner.

3. The premonstrative use of the speculum, or the direct applica-
tion of caustics, are seldom justifiable or required in the diagnosis
or treatment of diseases of the cervix uteri, for tactile demonstration
is more to be relied upon than specular examination, and the appli-
cation of caustic agents for the cure of simple lesions, ought never
to be made destructive, but only to produce a modification of the
molecular action of the parts diseased.

4. As abrasions, excavations, and ulcerations are in a great ma-
yxiij of cases, the result of constitutional disease, or functional de-
rangement, therefore the treatment of these lesions must be prin-
cipally directed to the general vitiation, or the physiological disturb-
ance ; and to pronounce the local affection a disease per se, is to
encourage a practice, which, while it does not remove the organic
eril, subjects the patients to a greater injury by doing violence to
their moral sensibilities.

Dr. Marable reports four cases of early catamenia in negro girls
from seven to eleven years of age, and suggests the inquiry, whether
they arise from a recurrence to the original constitutional type of
of tiic race, or whether these cases are idiosyncrasies.

Dr. Scarburgh's case reads as follows : Mrs. H. E., a negro wo-
man, suffered from occlusion of the os since her last unusually pain-
ful labor. On examination, a large, pear-shaped tumor was found
extending from the symphysis as far up as above the umbilicua.
Through the speculum the os appeared to be entirely closed by a
false membrane. With a straight bistoury an attempt was made to

178

cut through the occluding membrane, but so dense and fibrous was
it, that the effort was abandoned. Recourse was next had to a sharp
trocar. This, too, after many unsuccessful efforts, was also abandoned.
From the external toughness of the membrane, it was deemed use-
less to attempt to cut through it, and no further effort was made.
The patient died soon afterwards from exhaustion.

Autopsy. — The abdominal tumor was soft and fluctuating in its
lower two-thirds. The abdominal walls were closely adherent to
the tumor, requiring nice dissection to separate them ; so were the
intestines. The neck of the uterus was with great difficulty cut
through, and on entering the cavity, about a quart of muco-purulent
fluid escaped, and lying in it was an oblong ball of coarse, matted
hair, about four inches long, and two and a half inches in diameter.
Attached to the walls of the cavity were found several smaller pieces
of hair. The whole fundus uteri seemed to have been converted
into a largo cyst, which, upon being opened, was found to contain
steatomatous matter, with numerous bands and some few bloodves-
sels traversing it in several directions. Dr. S. is of opinion that the
hair was used as a tampon to stop a post-partum hemorrhage.

In the case reported by Dr. Farre, the attacks of neuralgia ap-
peared at about the same time in three successive years, and were
at last successfully treated by valerianate of quinine.

In opposition to many physicians, who consider uterine neuralgia
rather as a symptom, connected with pathological conditions of thlfr
organ. Dr. Bequerel believes it to be an idiopathical disease, not un-
frequently met with. Its mauifes'tations are intense, violent, lancin-
ating, and intermittent pains, the seat of which is in most cases the
uterus itself, from whence they are spreading at times to the lumbar
region, hypogastrium, perineum, and fundament. The pain is gener-
ally increased by the touch. Continued and quick walking, as well
as cohabition, are apt to increase the suffering. Very often the
entire nervous system shows an increased sensibility, owing to the
diseased state of the womb. The author distinguishes a symp-
tomatic, a utero-lumbar neuralgia, and a neurosis of the uterus.

The course of the disease is always of a chronic character, and
mostly intermittent ; the duration of symptomatic neuralgia always
depends upon the primitive affection. Tiie diagnosis must be de-
rived from digital and from specular examination; in tliis way mate-
rial changes may be easily recognized; the neurosis must be diagnos-
ticated b^'' way of exclusion, its presence may be stated from the
absence of organic disease and painful irradiations, the presence of
the latter indicating an utero;lumbar neurosis. In regard to prog-
nosis, it may be said that the disease is very difficult to remove,
in exhausted anaemic subjects.

The treatment of symptomatic neuralgia has to be directed against
the primative disease ; besides this, the neuralgia itself must be
treated with the different narcotics ; of great value, are the use of
full baths, and in cases with a manifest intermittent character, the
sulphate of quinine can be recommended. The method of Gruveil-
hier, who applies a mixture of linseed meal to the cervix uteri, is
not praised by the author. He tries to apply the remedies to the

179

cservical canal, or to the cavity of tho womb itself, by introducing
imall conical rollers formed of castor oil, gum-arabic, and tannin,
into the womb ; after ten or twelve hours they are melted down,
kfans leaving the tannin to act upon the mucous membrane. This
baa to be repeated every third or fourth day. The author li^s ap-
plied in the same way opium, belladonna, etc., with great benefit,
thas Inlling in a short time the most violent pains. Other impor-
tant remedies arc cold water-cures, the baths of St. Sauver, Ems,
and Bca-bathing.

From Dr. Bajiks' article we give the following abstract: Dr. licroy
de Mericourt first of all, described a peculiar coloration of tho skin,
"which he encountered in several women at Brest. A case belonging
to this class of diseases, has been already published by Dr. James
Totras in the " Philosophical Transactions " of 1 709. A similar case is
reported by Dr. Billard, in 1831, who called it " cyanopathie cutan^e."
In all these instances the abnormal color was observed in young
women from sixteen to twenty-two years of age. Out of ten cases,
where the condition of menstruation is recorded, dysmenorrhoQa or
amenorrhoea, had preceded the morbid condition of the skin. This
ooloration ranges between the black of Chinese ink and a deep blue.
In those cases observed by Banks, tho place affected looked as if
painted with Berlin-blue. It is rarely confined to the eyelids alone, but
spreads over the cheeks, the lateral portions of the nose and fore-
head. In Billard's case the coloration extended over the neck, chest,
and abdomen. It is very remarkable, that in most instances pieces
of linen, which cover the affected portions, are dyed with the blue
color. In almost every case known disturbances in the menstru-
ation had existed. Mental emotions, over-exercise, increased tem-
perature have a tendency to increase the intensity of the color. Mar-
ri^ec and pregnancy seemed to have no influence with some of the
patients ; in one case, nursing seemed to modify the affection favor-
ably. The shortest duration of the disease was three months ; in
one of Leroy's cases the disease lasted for seven years. Some of
the cases were connected with hematemcsis, hemoptae, and other dis-
tressing symptoms. Banks' patient had been insane already two
years, before tho blue coloration of the eye-lids made its appearance.
The nature of the affection is unknown up to the present time. ' Bil-
lard considers a modification of the transpiration from the skin
as the source of the disease, while Neligar believes that the color-
ing matter is formed in the sebaceous glands, and hence he called it
stearrhosa nigricans. Law called it bicpharomelaena and Leroy,
blepharomelanosis.

Dr. Bousquet's article contains a historical sketch of the disease
called chromhidrosis, with an addition of some new observations.
Tho cases known up to the present time, are to the number of
twenty-two : viz., Dr. Younge, of Portsmouth, one ; Dr. Billard, of
Oorz^, one ; Dr. Tcewan, of London, one ; Dr. Bousauet, of Mont-
oalier, one ; Dr. Neligan, of Dublin, one ; Dr. Law, of Dublin, one ;
Dr. Banks, of Dublin, one ; Dr. Leroy de Mericourt, of Brest, thirteen
Dr. Goate read a paper before tho Harveian Society of London, on
infrarmammary pain. Having discussed in detail each of the

180

ciiaracters of the pain, he examined briefly the most popnlar hypoth>
eses, which had been devised to account for it. A very plausible
hypothesis connects this pain with uterine or ovarian disorder. The
pam is certainly of rare occurrence in the male ; but the author
thought he had noticed two unambiguous cases of it, within the last
eighteen ^months. Assuming for argument's sake, that it was limited
to females, he proceeded to inquire, whether in them it was depend*
ent upon uterine disorder ; with respect to age, he found that the
period of uterine activity was the favorite, but not the exclusive
epoch of the pain. Overlactation and excessive child-bearing were
recognized in a few instances only. Four women (out of fifty cases
analyzed) were sterile ; seven had a liability to abortion. The
menstrual function was physiologically absent in twenty of the re-
maining thirty ; it was perfectly normal in eleven ; regular but
scanty in seven ; regular but profuse in four ; irregular or absent in
eight. Leucorrhoea was acknowledged in ten cases only ; in six of
which, uterine disease existed. These facts appeared oonolnsive
against the hypothesis. That uterine disorder frequently accom-
panied mammary pain was certain ; that it should be the cause of it
was impossible. The next hypothesis, that of spinal irritation, was
wholly unproved. The next hypothesis, that of Ollivier, and of
Brown, of Glasgow, was, that the pain was the result of pressure
upon the roots of spinal nerves, from a congestion of the intra-verte-
bral plexus of veins, or from a transient curvature of the spine, oc-
casioned by disproportionate fatigue of some one set of spinal
muscles. Another explanation, also based upon the idea of pressure,
had been propounded by Henle, which accounts in some measure for the
localization of the pain. The anatomical character by which the left
infra-mammary region was distinguished, was the peculiarity of its
venous circulation ; the effect of which was, that if any obstructipn
existed to the return of the venous blood by the azygos vein, the brunt
of the pressure would fall upon the intermediate intercostal spaces of
the left side. Henle thought that such pressure, acting upon the peri-
pheral extremities of the intercostal nerves, might occasion the pain,
and he suggested that the first impulse to disturbance of the circula-
tion might be given by uterine or ovarian congestion. Dr. Ooates'
own explanation of the phenomenon in question, was given as fol-
lows : The constitutional character of the patients was well marked ;
being universally that of defective nutrition. Twenty-one were
ansBmic. The concurrent diseases were phthisis, secondary syphilis,
and diabetes mellitus. The functional derangements accompMknying
infra-mammary pain, were disorders of the vasomotory system of
nerves, and of other nervous departments. Paralysis of the motor
nerves had, as its immediate physical result, exalted temperature
and local congestions. Hence, he inferred, that infra-mammary pain
was a symptom of a generallv depressed state of nervous power, and
a symptom of vasomotory derangement. The conclusions drawn,
were as follows : supra-mammary pain was a peripherical neuralgia,
having its probable origin in mal-nutrition of the nerves of the part.
This again resulted from disordered circulation, affecting the left in-
fra-mammary region especially, by reason of its peculiar anatomical

181

relations, as exposed bj Henle. The immediate cause of this vascu-
lar deraiigoment, consisted in disordered enervation of the smaller
arteries of the whole body ; a condition which, while in the infra-
mammary region, it occasioned neuralgia, in other parts gave rise to
chills and flushes, to palpitation, to disturlied secretion, heemorhages,
and flushes. The female was far more liable to all these derange-
ments than the male. Therefore, the indications for treatment, were
to stimulate the vasoiyotory nerves into temporary activity, so as to
relieve special symptoms ; secondly, to give them pennanent vigor,
by improving the general nutrition, by electricity, counter-irritation,
good food, air, rest, and tonic medicines. Topical applications to the
uterus and vagina had produced no effect upon the pains.

Dr. Plaskht reports that two patients, suffering from inter-mam-
mary pain, were partially and temporarily relieved by wearing
Pulvermacher's chains, while one was relieved by electricity.

Dr. Schlager, in his treatise on the influence of menstration upon
mental derangement, comes to the following conclusions, drawn
from a considerable number of observations. In a large number of
cases, the commencement of normal menstration, exercises no influ-
ence upon the existing disturbance of mind, especially so in cases of
hyperphrenia and aphrenia. But whenever an influence was mani-
fested, it was that of increased cerebral and sexual excitement^ even
in those cases where the Irftter was absent at any other time. Some
irregularities in the monthly courses, occasioned the development of
psychical derangements, or modified their course. The primitive
menostasia effected congestions of the brain with consecutive mental
affections, or convulsions, which ceased with the show. The conse-
cutive menostasies take a considerable share in the development of
mania pro gravid itate. The cessation of menses from pregnancy,
provoked in many instances a mental derangement, whicli disap-
peared after delivery and reiippparance of the flux. Of considerable
importance is the sudden suppression, which is generally followed
by acute mania, chorea, catalepsy, or a relapse of those who had re-
covei-ed their senses. Epistaxis seemed to afford a great relief in
cases of imminent menostasia. The so-called imperfect menstruation
has been often observed in women stricken with alienation of mind,
and mostly in melancholia. Painful congestive and nervous men-*
struation were often observed. Premature involution promoted
rapidly the primary mental affection into the consecutive form, under
the symptoms of vehement cerebral congestion. In cases of this
kind, the prognosis is very unfavorably. Diseases of mind originatr
ing at the normal change of life, are generally characterized as
melancholia. In some cases, the disease already existing, changed
very rapidly to aphrenia. Profuse menstruation was found in
patients suffering from hyperphrenia and aphrenia.

Dr. Aran, in his article on treatment of uterine disease, remarks
that both local and general treatment for curing diseases of the
womb are of equal importance, and everv single case has to be
treated individually. The different abnormal conditions of the womb,
as detected by examination, do not always demand medical treat-
ment, but only in those instances where they really disturb the

182

health and comfort of the patient they have to be removed as far as
possible. In most cases we must be satisfied with a palliative
treatment, because it is very rarely desirable, or within the limits of
our art, to push treatment so far as to reduce the womb to ita natu-
ral condition. All that is required for a perfect cure conBists in a
lasting and entire removal of the functional disturbances.

The principal therapeutical indications to be attended to, in the
greatest number of uterine diseases, may be comprised as follows :
congestion, pains, profVise secretions, hypertrophy, and alterations in
the position of the womb.

As the congestion has its chief source in the monthly afflux of
blood to the womb, we have first, to diminish the state of congestion
during the catamenia, and second, to remove the state of congestion
that remains after every period up to the next time. To diminish
congestion during the menstrual term. Dr. Aran recommends the
application of leeches, and cautions against the rule of hydrotherap-
ists who use cold-water baths, because he has seem alarming symp-
toms following their application.

The state of congestion after menstruation may be active or

passive. In the former instance local antiphlogistics are to be used,

\ while revulsive remedies (cold, external irritantia) are to be applied

in passive congestion, depending upon a general or local state of

atony.

The pain often depends on congestion or other lesions, and dis-
appears upon the removal of the causes. In other instances, we are
unable to find out the causes of pain, or it is so predominant, that we
have to direct our remedies against this symptom alone. If the pain
is more of a spasmodic character (coliques-ut^rines), the castoreum,
camphor, and the dificreut preparations of ammonia are generally
prescribed successfully. But more often we are called to combat
nypersesthesia and neuralgia, and Dr. Aran highly recommends the
local application of opium to the neck of the womb. He believes
that he has rendered a great service to the profession by this advice,
because it is free from evil consequences, such as nausea, constipa-
tion, etc., circumstances always following its general administration.
[The writer's experience is opposed to Dr. Aran's proposition. I
iiave often applied opium to the neck and to the inner surface of the
womb. If it was given in a suflSciently large dose to soothe uterine
pain, its influence upon the system seldom failed to manifest itself.
In the case of a lady to whom I applied it lately, it gave rise to
alarmiVig symptoms, as violent vomiting, and speaking as if in a
trance, for many hours. — E. N.] Other remedies, but with a much
more transient effect, are cold, chloroform, and carbonic acid gas.

Profuse secretions have to be attended to especially, because their
presence alone is often sufficient to produce irritation and ulceration
of the tissues with which they are in contact. Therefore, injections
are of great value, be it of water alone or of medicated solutions.
Besides injections, the application of revulsive remedies, such as
vapor baths, and more especially strong purgative injections, are of
the gnreatest value.

Against the hypertrophy a local and general resolutive treatment

183

•

las to be resorted to. The latter comprises the cutaneous and in-
'i^estinal revulsives, and the internal administration of alteratives,
rach as mercury, iodine, arsenic, etc. These remedies are not only
so be appliedLtill the uterus is reduced to its natural size, but till the
nmctional disturbances arising from hypertrophy are removed.

*The difffilacemenUi of the womb ought to be attended to as soon as
ttiey begin to disturb the patient's health. For this purpose the
womb has to be replaced and maintained in its right position. In
▼eiy DoaAy cases it is sufiBcient to unload the intestinal tube in order
to prevent its pressure upon the uterus. Besides attending to falling
of the womb itself, we have to treat the functional derangements of
ike meighboring organs. Above all, constipation is a most common
coincidence with uterine disease. The best way of regulating the
activity of the alimentary canal, is by tha use of plain or medicated
iiyections once or twice a day.

Dysuritty in uterine aifections, is very often owing to an abnormal
state of tlie urine itself, being overloaded with urea, or uric acid. If
this is the case, the alkaline mineral waters are of the greatest use.
The best way to regulate the disturbed functions of the stomach is a
proper diet. Dr. Aran recommends roast meat above all, hydro-
therapy, mineral waters, and sea-bathing. While hydrotherapy may
be used at every stage of the disease, the use of mineral waters, and
■ea-bathing must be dispensed with until the first and gravest local
fffmptoms are removed. [Altogether, Dr. Aran's notions of* the
therapeutical value of mineral waters are unsettled. He thinks that
there is no difference in recommending a sulphureted, or a merely
alkaline water, provided one is recommended. The application of
waters containing iron is proposed as something new, while Dr.
Aran ought to know, that they were in use in Germany for the cure
of uterine disease half a century ago. — E. N.]

It often hi(ppens, at the close of treatment, that while the local
lesions seem to be removed, the patient is troubled with violent
pains. These pains, after some time, disappear spontaneously, and
it would be wrong to subdue them by another energetic medication.
This is the time when the patients are sent to the country or sea-
shore with the greatest benefit.

The treatment of uterine disease has to be continued for a great
leng^ of time before the physician can be satisfied that the good
effects obtained will be lasting, and the disease, if not cured entirely,
will not fail to return soon and severely.

Dr. Storer describes an instrument for cupping the interior of the
uterus. It consists of an aii^pump, with a perforated tube, which is
introduced into the cavity of the womb. Two cases of amenorrhoea
are reported, where the instrument was successfully applied.

The carbonic acid gas has been applied of late as a local means
more frequently, and Dr. Scanzoni himself has proposed its use for
inducing premature confinement. The following case, therefore, is
ci no little interest, and will caution practitioners in the use of a
remedy which hitherto has been considered void of danger, when
locally applied. Dr. S. was called in consultation to see a lady who
suffered from an enormous hypertrophy, with prolapsus of the cervix

184

uteH. He therefore recommended the removal of the diseased por-
tions by an operation. The attending physician fully agreed with
this proposition, but thought it a good plan to apply a remedy which,
in his opinion, had an influence upon the contraction of the vascular
system, in order to lessen the chances of excessive hemorrhage, after
the amputation of the cervix. He therefore proposed to introduce
the carbonic gas into the cervix uteri for several days. Dr. Scaa-
zoni, though not believing that this remedy would have any con-
siderable influence upon the quantity of blood to be lost-after the
operation, consented to its application, more out of regard to the at-
tending physician. A dried pig's bladder, to which a canula was
attached, was filled with the gas, and the mouthpiece introduced
into the gaping orifice, and the bladder gently pressed. But scarcely
two or three cubic inches had entered tlie cervix when the patient
screamed out, saying, "I feel air entering my stomach, head,
throat." These, her last words, were followed immediately by a
violent, general tetanus, respiration became very difficult and rat-
tling, the pulse weak and frequent, and notwithstanding everything
was done by several physicians present, to save her life, she died 1|
hours after the application of the gas.

The post-mortem, two days after death, revealed no pathological
condition whatever, besides a far advanced OBdema of the lung^.
But a pregnancy of four months was discovered, which was not
detected during life, on account of certain peculiarities of the uterus,
for the walls of the uterus were not much thicker than a piece of
card paper, so that it looked at first like a large cyst, filled with
water. The hypertrophy generally connected with pregnamcy seemed
to be restricted to the uterine neck in this instance, and the distance
between the external and internal orifice of the womb measured 3|
inches. The ovum was found in a perfect condition. No traces of
peritonitis were found, and Dr. Scanzoni is of opinion,^ that the gas
must have entered one of the larger uterine vessels.

After a number of experiments and observations. Dr. MacKenzic
comes to the following conclusions : 1. A sustained current of elec-
tricity, directed longitudinally through the uterus from the upper
portion of the spinal cord, exercises a remarkable influence in in-
creasing the tonicity and contractility of the uterine fibre. 2. In
such increased tonicity or contractility of the uterine fibre, so excit-
ed and sustained, we have a powerful and reliable means of moder-
ating and controlling uterine hemorrhage, and of simultaneously
accelerating the dilatation of the os uteri, and the general progress
of labor. 3. Such sustained current of electricity may be continued
for a lengthened period, when the object to be attained requires it,
without any appreciable pain or inconvenience to the mother, or
danger to the child.

Dr. Warren's patient had a very severe confinement about four
years ago, and had never menstruated since. On examination, a
large prominent tumor was found in the abdomen, and not the slight-
est trace of the os uteri in the vagina. Soon after the vaginal ex-
amination was over a bloody or tarry discharge commenced to flow
from the genitals, being accompanied by forcing uterine pains, and

^ith a great diminution of the abdominal swelling, which, however,
^%« confined only to the right lobe of the abdominal tumor, while
the left portion of the sweUing remained unchanged. The following
^^y Boddcnlj she was seized with a violent pain in the abdomen,
^Hd she died in about two days. The post-mortem examination
showed that the right lobe of the tumor had been formed by the
Sterns, which had emptied itself through the vagina. Tlic left lobe
OODBisted of the left Fallopian tube enormously distended into a very
delicate sac by the retained menstrual fluid. There was no commu-
xiication between the Fallopian tube and tlie uterus, and the tube
liad ruptured and discharged its contents into the abdominal cavity,
eaasing death.

The subject of Dr. Blair's observation was a young lady of fifteen
years, who never menstruated, but at each period had all the evi-
dences of approaching menstruation, which would suddenly disap-
pear, and she would be attacked with accute inflammation in the
right eye. By appropriate treatment the patient began to menstru-
ate freely, and was entirely restored.

Dr. Churchill's article is an able defense of the operation of cra-
niotomy, if the child be alive, in those cases where it is physically
impossible, that a living child can be delivered per vias naturales.
We fully sustain Dr. Churchill in defending the practice of des-
troying a child, which by no means can be born alive. We
always acted on the same principle, and shall continue to do
BO. The few opponents of this practice, hold that craniotomy is

CX as dangerous for the life of the mother as Cassarian operation,
ing their assertions on the statistics in tiieir reach. In order to
put the respective statistics on a fair footing, the circumstances un-
der which the operations were executed, ought to be taken into con-
sideration. Most of the number of Ctesarian operations recorded in
our annals have been performed under comparatively favorable cir-
cumstances, i. €, when the patient's strength was not impaired by
previous protracted labor. If an equal number of early craniotomies
would be compared with Caesarian operations performed under the *
same circumstances, the result would be quite difierent, t. e. the ave-
rage of fatal cases would be hardly more than one per cent, for crani-
otomy. But all this is theoretical reasoning and has only indirect
bearing upon every day practice. Let the sister or the wife of our
opponents be placed in the dilemma of craniotomy or Caesarian ope-
ration, and all their sophistical reasoning will melt away like snow,
before the warming rays of a feeling heart. — E. N.

2. RETARDED DEVELOPMENT, MALFORMATIONS AND DIS-

PLACEMENTS.

1, Krieger, on Atresia Ani and Uterus Bicornis, — Monatschr. f. 6eb.

xn. 3.

2. Picard, Retention of Menses. Owing to Imperfbraied Os Uteri;
Operation; Recovery. — 6az. des H6p. 64. >

186

3. Caillat, ImperfaraJted Hymen, — Gaz. des H6p. 17.

4. Tuppert, Case of Atresia Uteri Congenita, Scanzoni's Beitr. z.
Geburtsk. B. 3.

5. Hoist, Pregnancy with BilocuLar Uterus, Scanzoni's Beitr. z.
Geburtsk. B. 3.

6. Van Holsbeck, Amenorrhea, owing to Imperforated Hymen, — ^Presse
m($d. 17.

7. Patin, G., Atresia Vagince; Operation during LtjboT, — Med. Ztg.,
KuBsl. 24.

8. Coates, Ch., Tctat Absence of Vagina. — Lancet, II. July.

9. Sorbets, L., Anteversion of the Womb during Delivery and JSkxriy
Rupture of the Membranes, — Gaz. des H6p. 71.

10. Betz, F., Incarceration of an Anteverted Pregnant Uterus, — Memor.
a. d. Praxis. III. 2.

11. Bonnet, A., Dn soiUevement et de la cauterization prcfonde du cul-
de-sac retro^uterin dans les retroversions de la matrice, Lyon, Ving-
trinier. 8vo. pp. 30.

— Bonnet, 07i Replaeement and Deep Cauterization of the Betro-Ulerine
Cidrde-Sac in Cases of Betroverted Uterus^ etc,

12. Villeneuve, on Constipation as a Cause of Retroversion of the Womb
during Pregnancy. — Journ. de Bord. April.

13. Chapplain, on Retroversion of the Pregnant Uterus, — Gaz. des
H6p. 57.

14. Sims, M., a New Uterine Elevator. — Americ. Jour. LXIX.
January.

16. Wliite, on a Case of Obliquity of the Uterus during Labor,
(Read before th^ Buffalo Med. Assoc.) — ^Buffalo Jour. IV. Vol
XIV. Sept.

16. Hoist, F., on the Treatment of Flexions of the Uterus. — Scanzoni's
Beitr. z. Geburtsk. B. 3.— N' Y. Jour, of Med. V. 2. Sept.

17. Castex, Complete Inversion of the Uterus, Replaced by the Arabian
Method.— Gaz. med. de PAlgerie.— UUnion XIL 103. Aug. 31.

18. Verity, F. S., Inversion of the Uterus Successfully Reduced, —
Montreal Chronicle. Nov. — Americ. Jour. LXIX. January.

19. Tyler Smith, W., on a Case of Complete Inversion of the Uienu
of nearly Twelve Years^ Duration, Successfully Treated. — ^Lancet
June. — N. Y. Jour, of Med. V. 2. Sept.

20. White, J. P., of Buffalo, Report of a Case of Inversion of the Uierus^
Successfully Reduced after Six Months, with Remarks on Reduction
in Chronic Inversion. — ^Amer. Jour. July.

21. Westmoreland, on Prolapsus of the Uterus. — Atlanta Jour.
February.

22. Jobert de Lamballe, Lectures on the Falling of the Womb, —
L'Union XIL 95. Aug. 12.

25. Mayer, C, Prolapsus of the Uterus Complicaied vn(h Hypertrophy
of the Uterine Neck; Treatment. — Monatschr. f. Geburtsk. March.
— N. Y. Jour, of Med. V. 1. July.

187

24. Huguier, on Hypertrophy of the Uterus and its Neck in Connection
with Prolapsus IMeri; Amputation of the Collum Uteri. — 6az. hebd.
May, 14.

25. Bonorden, on Prolapsus Uteri and its Treatment by Internal Bern-
edies.—Fr. Ver.-Ztg. 2.

26. Kunkler, on Treatment of Prolapsus Uteri. — Gazette des H6p.
June, 15.

27. Steele, H., the Pessary and other Mechanical means in Prolapsus
Uteri. — Oglethoq>e Med. and Surg. Jour. June and Oct.

28. Olivier, CI., The Pessaries in the Actual Slate (f Science. — Gaz.
des Hop, 91. Aug. 5.

29. Noeggerath, E., Remarks on the JSmployment of Pessaries with the
Description of a New Instrument. ( With Illustrations). — New York
Jour. V. 2. Sept.

30. Mayer, A. Jr., on Uterine and Vaginal Prolapsus, Us Treatment by
Dr. Zicank's Listrument, and the Conditions which prevent its Ap-
plication. — Monatschrift f. Geburtsk. July. — N. Y. Jour, of Med.
VI. 2. March, 1859.

3>. Savage, H., Clinical Experience on the Nature and Treatment of
Uterine Deviations, more especially of Prolapsus. — ^Med. Tim. and
Gaz. 398. Feb. 13. — Lancet. June.

32. Bendot, Cli. P., Essai sur les moyens chir. employis pour la cure
radicate du prolapsus de VvUrus et sur Vepisiorrhaphie en particulier.
These de Strasbourg. Impr. Silbermann. 8vo. pp. 55.

— Bendot, on the Means employed for the Radical Cure of Prolapsus
Uteri, mere especially on Episiorrhaphy. Thesis.

33. Toland, H. H., Procidentia Uteri. — Operation; Cure. — Pacific
Med. and Surg. Joum. I. 9. Sept.

34. Vernon, H. H., Remarks upon 31. Baker Broum^s Operation for the
Cure of Prolapsus and Procidentia Uteri. — Lancet. February.

35. Brachet, on the Curative Effect of Pregnancy upon Retroversion
and Prolapsus of the Uterus. — Gaz. de Lyon. Aug.

36. Rigby, E., the SquaUing Cferu«.— Med. Tim. and Gaz. Jan. 30.

37. Hecker, A Remarkable Case of Retroversion Uteri in the Sixth
Month of Pregnancy. — Mon.-Schr. f. Gebmrtsk. XII 4. Oct

38. Crosse, "W. T., Pathological Appearances fourteen years cfler the
Removal, by Ligature of an Inverted Uterus. — ^Med. Tim. and Gaz.
413. May, 29.

With regard to treatment of uterine displacements, we have re-
ceived very encouraging reports from Prof. White of Buffalo, and
Dr. Tyler Smith of London. Both of them were fortunate in the re-
duction of an inverted uterus of long standing, and each by a some-
what different proceeding. Further, we must call the attention of
our readers to Dr. Mayer's and Hugnier's articles on operative treat-
ment of prolapsus uteri. The most important contribution to the
doctrine of retarded development we have received by Dr. Krieger,
of Berlin.

188

Dr. K.G1EGEB, after a eynopsis of tho cmbryolojfical development O
the urngenital system, pruccede to oxplnin the coincidence of atresia
ani and uterus bicornta, by tlic noii-d is appearance of the canalis nro-
genitalie, and mentions' tiie not yet decided question of superfoeta-
tion. A number of cases Las been published, in which a second
child was born a few weeks or months after the birth of a first ciiild.
These cases nrc very few in number, and in most of them no ana-
tomical examination of the uterus was performed. Those in which
the condition of the uterus had beeu satisfactorily explored, are the
following : In a thesis written by Dr. Casaan (Recherrh^ aiiatomiques
el pkysiologiques sur lescaad' uterus double el de superfelatum, Paris,
1826^, il cases of uterus duplex are mentioned. Among them, sev-
eral instaDCCS of double fetation are reported ; and the post-mortem
examination of a woman, 40 years of age, whoso doable uterus had
the appearance of two inverted pears, which were united at their
neck, with a common os uteri. This woman had giveu birth to 14
children, none of which had been born at the full terra. After hav-
ing been delivered of twins of 4J months' gestation with one pla-
centa, she had another 6 weeks' ftetiis, one month after th« fiist con-
finement In an article by Dr. Fordyce Barker ( The American
Medifftd Mordhly, November, 1855), a case is reported dating about
the middle of the last century, which the author himself thinks to be
rather apocrypha!. Mary Anne Rigaud, of Strasburg, 37 years old.
was delivered on April 13, 1T48, of a living, full grown male child;
lochial and milk secretion stopped soon afterwards. On September
16th, t. p., 5 months afterwards, the lady gave birth to another full-

ffrown, living, female child. The autopsy, which was performed pub-
icly, gave evidence of one single unicornous uterus. Dr. Barker,
in the Brit, and Foreign Med.-Chir. Beoiew, V. HI., m'ntiona auother
case : G;:ittcra Baratti, mother of G children, was delivered on Feb-
ruary 15, 1817, of her seventh, and on March I4th, in tlic same year,
of her eighth child. Shortly before conBnement, it was observed
that her abdomen presented two distinct swellings, separated from
each other by a longitudinal depression in the mesianline. After the
first delivery, only the right tumor remained. The woman died of
apoplexy in the year 1847, when a nornial os and cervix nteri was
found, while the uterus had two cornua, each of which was to con-
nection with a Fallopian .tube. The specimen is deposited id the
Museum of Uodena. The following case was observed by Dr. Barker
himself. Mrs. X., was born in New lork, in May, 1827 ; her menstrual
courses appeared first, when she was 14 years old, and returned at
regular intervals at 18 days, lasting from 7 to 8 days. After being
married in October, 1854, she had her courses only twice, when on July
10, 1855. she gave birth toa healthy, full-grown male child. ThclocUial
discharge lasted for only one week, and she nursed her baby well. Still
her abdomen continued unusually large, and she thought she felt
quickening on the left side. On September 22d, 74 days after the
birth of the first child, she was delivered of a female child. Tho
lochial discharge lasted for three weeks, still the mother continued
nursing both her children. Upon examination on Oct 24th. v&gina
and uterine neck were found in normal condition. Simpson's probe

189

iatrodaoed into the womb, conld be felt through the abdominal walls
tiro inches above the symphysis pubis in the left fossa iliaca, the
ctrity of the womb measured 4} inches. After the probe was with-
dm^rn it conld also be introduced into the other cavity, its point
Oonld be felt one half of an inch above the symphysis pubis, towards
the rigbt side of the abdomen, for a distance of about one inch from
the mesian line ; this second cavity measured 3 J inches. Dr. Kannon,
{Hew Orleans Medical and Surgical Journal^ May, 1855), was called
to a woman in child-bed, who had been delivered on the mom-
iap of the same day. The womb was empty and well contracted,
the afterbirth removed. Dr. K. in examining the patient, detected a
aecond os uteri near the symphysis pubis and a head presenting. As
no pains were present, the operation of turning was tried, but could
not be executed, and as the child was dead, it was removed by the
hook. Both uterine cavities were separated from each other by a
horizontal septum, of which the posterior one had a normal position,
"wbile the anterior one was situated much higher. This case is inter-
eating, because the womb was divided in one anterior and one pos-
terior cavity, instead of two lateral compartments. After these ob-
servations, a superfetation in a uterus bipartitus seems to be possible.
Dagniolle {Jour, de Med. de Bruxelles, March, 1843), remarked that
a yonng woman with double vagina and double vaginal portion, had
a bloody discharge from both sides during the menstrual period.
Oldham {Oays^ Hasp. Reports, October, 1849), has observed the same
coincidence, and in the case alluded to, during pregnancy of the
one womb, the other stopped menstruating.

From this it appears, that a decidua is formed in both sides of a
ntems duplex, by which also the empty cavity is closed, thus pre-
venting another conception ; therefore, the chances for a superfeta-
tion in cases of this nature, exist only for a short time, i, e., up to
the formation of the membrane decidua.

Dr. Sms' uterine elevator is intended to be used for elevating a
retroverted uterus. The instrument is about thirteen inches long,
and consists of a handle, a shaft, and a uterine stem inserted into a
ball, which revolves at tlie end of the shaft, its axis being at right
angles with that of the instrument. The ball is of ivory, about five-
ei^ths of an inch in diameter, and has a belt of perforation three-
Bixtecnths of an inch apart, extending around in a line with the
stem. The shaft is a hollow cylinder containing a rod which is re-
tracted at will by the slide, or pushed forward by a spiral spring, so
that its point may lodge in any one of the perforations in the ball,
whereby the stem may be held firmly at any desirable angle with
the shaft. In using the instrument, the stem is set at the required
angle with the shaft, and thus passed into the retroverted uterus,
with the ball close up to the os tinc». Then by pulling back the
slide, the rod is drawn out of the perforation in the ball, when it is
ftee to revolve in the direction opposite to that of the motor power,
and thos the uterus is revolved directly upwards.

AAer a short analysis of the causes, symptoms, and pathology of
uterine flexions (ante and retro-flexion), Dr. Holst proceeds to explain
his mode of treating these affections. The treatment must be a gen-

190

cral and a local one. Id the &rst cases wliich came under Dr. Holsl
obBervation, he applied the aelf-retaining instrument (redresBeur) of
Kiwiach Mayer. — ^Thc iutroductiou of the instrument and the rcpoBitiao
of the womb was never connected with any difficulties. Bat most of the
woincn under treatinent could not eudure the presence of the instru-
ment for any length of time. Violent pains, and spasmodic and hysteri-
cal disorders followed every protracted application. He therefore di-
miniBhcd tlie size and elasticity of the two nppcr arms, by which plan
he succeeded 80 well, that most women could bear it sufficiently in the
ntcrus. But, although he applied it for three or four hours daily, dur
ing several months, he could not record one ftiogle case of recovery,
□otwithstandiog the simultaneous application of proper internal
remedies. He therefore entirely changed liis former plan of treating
these malpositions, and. with far better results. Above all, a course
of general treatment was ordered, with a view to strengtlien the
system and relaxed state of the womb. The remedies used were
cold and sea bathing, iron, ergot, and injections of cold water, by
means of a strong douche. By making use of these remedies for
many months, and even years, the patients became strong and
healtiiy, menstruation regular, without pains, and the fluor albas
stopped entirely. Of fourteen patients who were treated in this
manner, all derived great benefit, while in two of them, the local
disease (one ante-flexion, one retro-flexion), was entirely cured.

In the case reported by Dr. Castbx, the inversion took place im-
mediately after confinement, and was reduced in tlie following way :
Two strong men seized the patient, and kept her suspended by the
legs, head downwards. In this position, the womb was brrtugbt to
its proper place, after it had been well oiled, by a midwife.

Dr. Vebitv's case is so interesting, and so graphically described,
that we give its history in full. Mrs. U. was about forty years of
age, and the mother of nine children ; her figure was squat and
round, showing a largo roomy pelvis ; the abdomen pendulous ; her
health strong and rugged. She was taken in labor with her tenth
child, and, wTiile walking up and down, a sudden pain expelled the
child, which fell on the floor, and was not materially hurt. Not so,
however, the mother : the same pain which forced the fcetus from
the uterus, " brought dqwn," to use the words of the messenger who
came for rae, " the whole of her inside." I arrived at the scene of
the accident about an hour afterwards. ' I found the woman lying on
her back, on a mattress placed on the floor, deluged in blood, ^w
was moaning and sighing, tossing her arms wildly. about, and gasp-
ing for cold air. Her pulse could scarcely be felt at the wrist, and
her countenance was blanched and ghastly. When the nurse turned
down the bed-clothes, I was stunned ; I saw before me my first, and
I devoutly hope my last case of " inversion of the uterus." Occupy-
ing the space between her tliigha, and nearly reaching down to her
knees, was a large red membraneous looking mass, from wiiich blood
was oozing, and at its lowest part (tlic fundus), almost disguised by
clotted blood, was attached the placenta. I immediately admiois-
iatercd a tumbler of spirit and M-ater, with tr. opii in it ; applied
warmth and friction to the extremities, and, without waiting, fortit-

191

with proceeded to reduce the uterine mass to its proper position.
•After cleansing it from the clotted blood, the question arose in my
piind, shall I reduce without removing placenta or not? Fearful of
increasing the hsBmorrham?, I determined to reduce with the placenta
^tached. Recollecting the rules laid down in the books, I began the
attempt, and an attempt it was only. As soon as I touched the
nteraSy it contracted and shrank, and gave me the feeling as if I was
Iioldiiig a live eel in my hand. I tried two or three times gently, but
firmly, to reduce it according to the usual directions ; but I made not
the least impression on it. The weight of the placenta bothered mo
greatly ; for, on aj^tempting to return the part that had last pro-
troded, it was constantly dragged out of my lingers by the weighty
placenta. I now determined to remove the placenta, and reduce the
nteras by pressure on the fundus. I quickly detached the placenta,
and was most agreeably surprised to find there was very little
bsmorrbage ; in fact, after it was removed, the mass shrank in
volume. I now placed my left hand and forearm under the organ, and
sapporting it in a line with tlie proper axis, with my right hand half
■hat, I pressed the tips of my rounded fingers firmly against the fun-
dus, and pushed it upwards, while my fingers were arrested by the
constricted os. I made firm, but cautious pressure against it, and in
about half a minute I felt it yield. I then boldly carried my hand
upward in the axis of the pelvis, and when my wrist was passing
the constricted os, the fundus suddenly shot from my hand, and the
organ resumed its usual position. Retaining my hand within the
ntems for a short time, constriction took place, and the uterus
returned to its proper state and condition. The woman did well at
first, but died on tlie third day, suddenly, after sitting up in the bed,
for changing her nightrdress.

The subject of Dr. Surrn's case was delivered, at the age of
eighteen, of a first child, and inversion occurred at that time, but
was not suspected by her attendant. All attempts at replacing the
uterus failed. The patient was sent to the author of the paper, in
September, 1856, and symptoms of anaemia existed in the most
marked degree. She was subject to epileptiform convulsions and
frequent faintings. On examination, the uterus was found to be
completely inverted, the neck of the uterus and the os uteri being
very small and rigid ; the author determined to attempt its reduc-
tion by continuous pressure, with the intention of dilating or develop-
ing the 08 and cervix uteri. With this object, the right hand was
passed into the vagina, night and morning, and the uterus squeezed
and moulded for about ten minutes at a time. Chlorofonn, which
had been found so useful in cases of inversion of shorter standing,
was not used, because of the feeble state of the heart and circulation,
and the comparative absence of pain. In the intervals between
these manipulations, the vagina was distended, and firm pressure
exerted upwards by a large air pessary. These means gradually
dilated the os uteri to such an extent, as to allow of the partial return
of the uterus, and on the eighth day from the commencement com-
plete reinversion took place. The subsequent recovery of the patient
was perfect. She has since menstruated regularly, and is in excel-
lent health.

Db, Wbitk's article opens with the histoiy of a case where h^^^^
duced the inverted uterus of a woman who had been delivered eigfet
days previously. The reduction waa perfected at one trial by the
method of dimpling the moat prominent part of the fundus. The
patient died three days afterwards. The post-mortem examination
revealed no cause of death, unless the ansBmic condition of the
t issues may be considered as such. A second case under the
author's care was reduced soon after the accident. A third case was
not Tisited until the fifteenth day, no efibrt at reduction bein^
attempted.

On the 12th of March, 1858, Dr. \\'hite was requested, and saw a
case of inversion of more than five montJis' standing, in consultation
with Drs. Robinson, Rcynals, Batten, and Dimick. On examination,
the fundus was found just within tlie ob exteiTium, tlio body and neck
of the organ occupied the vagina ; the inversion was recognized as
complete, and the organ scarcely larger than when in its natural
position six months after delivery. The patient being placedhori-
zontully acrosB the bed and chloroformed, Dr. White introduced his
right hand into the vagina, and firmly grasped the entire body and
neck of the uterus. At the same time a large rectum bougie was
carried up and also received into its palm, and held firmly in contact
with the fundus of the uterus. Continuous gentle pressure was oow
made upon the external extremity of the bougie with the left hand,
whilst the right compressed the uterine tnmor. In this way the force
was directed in the axis of the pelvic cavity, putting tlie vagina
completely upon the stretch. After persevering in this effort as long
as the strength of the operator could afford it, the tamor at length
began to shorten at its neck, and the month of the nterus to pnah
upon the upper surface of the hand. No depression of the fundus
waa at any time pcrceptihle. At last the fundus passed out of the
hind, and was easily pushed liy the bougie through the neck of the
organ up to its proper posiiion. The full reduction of the uterus
was afterwards demonstrated by the ulerlne sound and the spec-
ulum. The bougie was retained in the uterus till the next day by
the attending physicians, and ergot given to promote tonic contrac-
tion of the uterus. The patient afterwards recovered entirely.

In concluding this highly interesting paper. Dr. White remarks
that the reduction by dimpling the fundus ought to be restricted to
recent cases, as in those of old standing the uterine cavity left is too
small, and the organ too firm, for any depression to be made upon
the walls of the fundus.

Dr. JoBEPT, in a lecture on prolapsus uteri, rejects the use of pessa-
ries altogctlier. He does not seem to have given them a fair trial, not
does he seem to bo sufficiently acquainted with the different fonns of
instruments in use for prolapsed uterus.

At a meeting of the Berlin Obstetrical Society, Dr. Mater read a

faper on the removal of the uterine neck for the cure of prolapsus.
n those cases of falling of the womb which are accompanied by en-
largement of the neck of the uterus, every sort of ntechanical treat
ment is contra-indicated, partially because the pessary cannot be
placed in a fit position, partially because in most cases it can be

193

eodnred only for a short time, owing to the great pain following its
application. The best and safeet remedy for this hypertrophy is am-

Etation of the neck, which has been executed several times by Dr.
^yer. In performing it, the womb is drawn downwards as far as
possible by strong hooks, and the diseased portion removed by the
knife. This is generally followed by profuse hemorrhage, which is
promptly arrested by the actual cautery. The after-treatment is that
of a plain cut wound ; pledgets of lint, well covered with oil, are
applied to it ; the vagina is to be cleansed frequently by injection ;
the 'wound to be brushed over with a solution of nitrate of silver, and
the womb, which generally contracts after the operation, to be retain-
ed by a lint plug.

These views were illustrated by the report of a number of cases in
which this operation was performed, and have proved successful. In
discussion which followed, it was suggested and accepted, that
operations might have been performed, just as safely, if not
more so, by the dcraseur.

fThe use of the dcraseur is now in the very hight of fashion ; but
when the excitement has cooled down, its use will be restricted to
the proper cases. The writer is of opinion that the amputation of the
neck of the uterus for curing prolapsus, when executed by the knife
and actual cautery, will be followed by better results than when per-
fcHined by the dcraseur. In the cases referred to, the entire womb
participates more or less in the hypertrophy of the neck, and, there-
fore, a godlL depletion following the cut, and the application of so
strong an agent as the hot iron, must be of good service to the
remaining diseased portion, while the dcrasement is followed by
scarcely any reiiction. — E. N.J

Dr. HuouiER remarks that, m most cases where the womb appears
oatside the external orifice, this is not owing to a prolapsus, but
generally to a partial or total hypertrophy of this organ, the fundus
uteri remaining in its usual position, while its cavity is enlarged. The
neck of the womb is lengthened only in its vaginal portion or in its
fiiU extent. To prove the correctness of his opinion the author
reports a number of observations, and expresses his belief that,
among thirty cases, scarcely a single true prolapsus may be found.
The only remedy justifiable for this condition is the amputation of the
neck of the womb, which he performed successfully in thirteen cases.
Dr. BoNORDEN believes that the most common cause of prolapsus is
hypertrophy of the womb, and relaxation of the round and lateral
ligaments, and he tries to remove these morbid conditions by the fol-
lowing treatment : the patient begins to take every day the following
powders : R. secal. comut. gr. iii., gummi galbani, gr. x., decreasing
the quantity as the disease lessens ; at the same time a mistura
oleoso-balsamica is rubbed over the mons veneris, the thighs, and
▼niva several times a day. Two cases are reported in* which the
treatment proved successful.

Dr. KuNKLER reports three cases of prolapsus uteri, which were
benefited by the local application of tannin. He recommends a strong
solution of tannin in glycerine, to be applied with a cotton plug, and
rest in a recumbent position till a cure- is effected.

194

Dr. Steele, iq bie able article on prolapsus ateii, strongly r
mends tbe so-called radical plan for treatment, consisting ciueQj of
rest, local antiphlogistic, and adstringent remedies. If theso means
should fail to effect a cure, the use of a uterine supporter is recom-
mended, similar to that proposed by Dr. C. Mayer, of Berlin.

From Db. A. U«teb's article it appears, that Dr. Zwank's hjaterophor
was applied in two hundred and three cases. Fourtecu of tbcae
women diacontinued treatment, because the instruments did not
agree with them, producing ulcerations and pain ; two patieuta re-
moved the instrument on their own account, and sent it back with-
out giving it further trial ; two preferred an abdominal supporter ;
and seven cases only offered invincible difficulties to the application
of the instrument. One of these suffered from a far advanced by-
drops ascites. The second patient was so deformed and stiff in her
limbs, that it was impossible fur her to remove and introduce the in-
strument; a third one could not have an instrument for tbe same rea-
son, because her arms were paralyzed. With two patients the vagi-
na was so irritable, that evci-y instrument created violent pains, after
it had been born for a short-time. In two very old patients the
vagina was so short and rigid, that even tbe smallest size could not
be entirely shut when introduced.

Before an instrument was applied, those complications as could
be healed (metritis, hyperemia, hypcrsiesthcsia, ulcerations), were
first removed. The greatest difficulty was experienced in the treat-
ment of those occasional ulcerations which are located in the walls
of the vagina. The application of caustics, nitrate of silver, etc,,
was always followed by an aggravation of tlie symptoms, while re-
peated scarifications, and the use of acid. pyroHgnos. succeeded
better, though after a considerable length of time.

Simple hypertrophies of the womb, as a general rule, did not inter-
fere with the successful application of Dr. Zwank's instrument, while
in tliose cases, where hypertrophy and lesions of tho womb were
combined, the greatest difficulties presented themselves to the use
of the hysterophor — such as violent back-ache, bearing down, in-
creased painfulness of tbe womb, ulcerations of the labia and vagina.
In these instances the womb has to be first replaced by the probe,
and retained in its position for some time by a plug, introduced into
tbe vagina, after which an Jnetrnment may be tried again.

The leading point in searching for the right size of tbe instrnment
is tlie space and direction of tbe arcua pubis, an average shape of
which may be acquired by the introduction of tbe secoud aud third
fingers, thus establisbing tho distances of tbe two pubic bones. Very
often a comparatively email instrument is required for retaining
very extensive prolapsus. This remark applies also to cases of pro-
lapsus combined with rupture of tbe perineum, which are very often
benefited by a small instrument of Zvvank, while all the other kinds
failed to retain the womb in its position. Still tbe qnestion, if the in-
strument is of a fitting size, will be lastly decided by the sensations
of the patient when she has worn it for several days, after the very
first disagreeable impression of a foreign body in the vagiuai,j
overcome. If the instrnment chosen is of the right size, the ]
after some days, will be scarcely aware of its present

: vagiuai,j|^^
the patifl^^H

195

Sometimes it happens that a portion of the vagina works itself
beneath the anterior edge of the instrument and appears outside the
ragina. To remedy this, an instrument must be chosen, the greatest
breadth of which is situated in the centre, i. e. where the two lateral
Hrings are joined. By the invention of Dr. Zwank, the bloody opera-
ion, cpisiorrhaphy, elytrorrhaphy, the pincement du vagin, etc., have
been supplanted, because by Zwank's hysterophor (dmod all cases of
prolapsus are retained, of whatever shape and size they may be, pro-
vided the right instrument has been chosen. The conditions which
forbid the application of Dr. Zwank's hysterophor are : carcinoma
ttteri ; hypertrophy of the neck of the womb ; very narrow, rigid
vaginal walls, as often met with in very old women ; large pelvic
tumors ; far advanced hydrops ; some very rare cases of distorted
pelvis.

Dr. Savage, in a clinical lecture on prolapsus uteri, mentions the
following experiments on the dead body. The pelvis having been
exposed to view, traction was made on the os uteri by means of a
forceps, introduced by the vagina, so as to make the uterus take the
ordinary course of prolapsus. A descent of an inch and a half ren-
dered the cervical ligaments very tense, another half-inch and they
began to yield. They were now cut through and the uterus descend-
ed at once another inch. The strain was now found to be sustained
by the pelvic peritoneal lining, which yielded slowly onwards to-
wards the broad ligaments, which lastly was only put on the stretch
when the uterus was drawn well out of the vulva. From these, and
several other exi)eriments, it appears that the uterus under normal
circumstances, is retained at a certain elevation in the pelvis by the
cervical ligaments — these ligaments, and these only, tend to prevent
prolapsus. The vagina does not in the least support the uterus.
When not inverted, the direction of the superincumbent pressure
tends to keep its sides together. In this sense only can it be said
to prevent prolapsus ; even so it can have no share in doing this«
until the uterus has lost the support of its cervical ligaments ; on
the contrary, it is these ligaments that preserve t^ie elongated posi-
tion of the vagina, which would otherwise, as it does in fact in pro-
la pso s, shorten into numerous transverse folds.

With regard to pessaries. Dr. Savage remarks : Simpson's com-
pound pessary answers perfectly when the patient can bear it,
which, alas, is very seldom, if ever. The ball pessary is the best of
all, when the perineal end of the vaginal cone retains its elasticity.
The best stem pessary, the only active support, is readily made by
fastening firmly a piece of sponge to one end of a piece of gutta- .
percha tubing. The opposite end has attached to it four pieces
of elastic vulcanized caoutchouc, which pass up, two before and two
behind, to a band round th() abdomen, or to the ordinary corsets.

This latter form is invaluable in some cases, particularly for tem-
porary use. A small quantity of any injection can be thrown up
through the tube. It can be introduced and removed by the patient
herself. Dr. Zwank's pessary finds its way invariably where it is
intended to go. The patient can manage it herself without difficulty.
The screw was found an objection, and Mr. Russell, an instrument-

\ which Tenders Zwank'a pessS^^

maker has made a subatituti
most perfect yet devised.

Ill those cases where peasarics cannot retain the prolapsus, the
cpisiorrhaphy, must be performed. After a short historical analysis
of the various surjfical plans for treating prolapsus uteri {Marshall
Hall, Di^enbat:h, Emry Kennedy, Phitlipst, Deigranges, Fricke, Oed-
dings, Brown), Dr. Savage proposes his own metiiod, wbich is a
slight but important modification of Geddings' operation and which
was applied successfully in eleven cases. UariDg, by pinching up
more or less of the flaccid vulva, carefully ascertained how much in-
tegument may be removed, a flap of suitable size is marked off by a
sharp scalpel, and then dissected away, commencing with the skin,
and ending with the vagina ; the erUire thickness of which, however,
it) taken away as far as the perineal fascia, after which the raw ear-
faces arc united by quilled suture, and five or sis points of inter-
rupted suture, which are removed on the siith day.

Dr. TouND reports a case of prolapsus uteri treated by excision of
stripes from the vaginal walls. The patient is pronounced cured
two weeks after the removal of the sutures. fW'c are of opinion
that four weeks is a time too short to judge of the efficiency of au
operation of this kind. If a patient with prolapsus uteri has been
laid up for four weeks, this alone will bring on a considerable
change in the condition of tho parts, compared with their previous
displacement. This remark not only applies to Dr. Toland's case,
but to almost oil the caaes reported in periodicals, and we will never
get at a fair estimate of what the surgical operation does fur prolap-
sus uteri, unless the operators will give us accounts of tbeir patiei '
conditions at least one or two years after the operations were
formed.— E.N.]. '^

Dr. Vernon's article is written witli a good deal of feeling agi
Dr. Baker Brown, who seems to have touched our author's "c
sensible." Two cases are reported of relapsed falling of the w«
lifter Baker Brown's operation.

Dr. RiGBY decribcs a peculiar condition of the womb, which
(■alls the " squatting Uterus," where the body of the uterus is
weak to sustain the fundus and the pressure of the intestines upon
tlie latter ; it thenceforth must yield in every direction, so that ^lve
fundus approaches the orifice. The following symptoms are connect-
ed with the disease : pain behind the symphysis pubis, increased by
the upright position, extending to the bladder or rectum ; tlie menses
are generally very copious. The uterus, upon examination, is found
. enlarged, of a spherical shape, very soft, while the cervix feels hard,
and is short and painful. The probe passes the orifice easily, while
its further advance is generally connected with pain ; the cavi^ is
found enlarged, and after the fundus has "been elevated to its full ex-
tout, the probe measures generally 3" at the external orifice, even in
women who have never been pregnant. The patient feels immediate
relief as soon as tho fundus has been brought to its right position by
tlic sound. Tho treatment of this disease consists chiefly in the
application of general and local tonics, and rest of the body.

Dr, CsossE presented a specimen in the Norwich Fatholoj

rolap-
:ietU^^

tliologi^^^l

Society, which was taken from a woman, whose uterus had heen re-
moved in 1843 by ligature, by the late Mr. Crosse, in consequence of
its having become inverted after labor. In Aug^t, 1849, this patient
suffered an attack of profuse hemorrhage, which was checked by the
internal administration of ergot and plugging the vagina. In 1856
she became an inmate of the Norwich Betnel, having become des-
pondent and melancholic and possessed of many delusions. From
this place she was discharged cured at the expiration of six months,
bat she suffered a relapse the year following, and iu October, 1857,
destroyed herself by hanging. At Uie post-mortem the ovaries were
found to be of natural size, occupying a central position, and lying
almost side by side in the cavity of the pelvis. They had their usual
relation to the fallopian tubes, which were similarly displaced and
fonnd to be pervious for several inches. The vagina was perfectly
healthy and very capacious. The os uteri was normal in its situa-
tion ; there were several abrasions of its surface ; a probe could be
passed in through it, to the extent of about one inch and a half. The
remaining tissues did not appear to have undergone any other mate-
rial alteration, either in position or structure.

Dr. Heckrr was called to a woman in full labor pains, who was iu
her sixth month of pregnancy ; the fundus uteri could be felt dis-
tinctly below the umbilicus ; but, by examining internally, no os
could be perceived, only a slight depression in the anterior laquoar
▼aginae, just behind and above the symphysis, while a large, fluctuat-
ing tumor protruded in the midst of the pelvis, which hardened and
enlarged considerably with every pain, thus giving apprehension of
its liability to rupture. While the woman was under the influence
of an aneesthetic, the doctor introduced his hand into the vagina, and
at last succeeded, after repeated trials, in pushing the tumor in ques-
tion up into the upper pelvis. As soon as the tumor began to move,
another tumor came down from behind the os pubis, which was
nothing but the presenting bladder. It burst immediately, and two
feet came down into the vagina, when a living six months' child was
extracted.

Dr. Brachet reports the case of a woman who had been treated for
retroversion of the womb, during thirteen years, without deriving
any benefit. Being recently delivered of a child, she was ordered
Dot to leave her bed for forty days, and to use at once adstringont
injections, which treatment effected a permanent cure. Another
woman, suffering from prolapsus uteri, underwent the same treat-
ment with equal success.

3. UTERINE AND PERI-UTERINE HEMORRHAGES.

1. De rhemcUocele peri-uterine et de ses sources. Par Albert Puech,
Doct. en medic, etc. Montpellier: Boehm, 1858. In 8vo. pp. 102.

— On Peri-Uterine. Hematocele^ and its Sources. By A. Pueck, M.D.,
etc., etc.

2. Puech, A., Hemorrhage of the Fallopian Tube. — Rupture of the
Utero-Ovarian Plexus follotced by Thrombus of the Pelms. — Gaz.
Hcbd. V. 22.28.

198

3. Puech, A., on Apoplexy of the Ovaries. — 6az. des H6p. 88.

4. Oulmont, on Hematocele Betro-Uterina. — L'Union. June, 8.

5. Nonat, on Peri-Uterine Hematocele. — Gaz. Hebd. V. 23.

6. Trousseau, on Catamenial Retro-Uterine Hematocele, — Gaz. dc
H6p. 12. June, 2.

I. Becquerel, on Hematocele Peri-Uterina. — Gaz. des Hop. 41.

8. De Vhematocele retro^dirine. Par Dr. Aug. Voisin. Paris, Ac
Delahaye. In 4. de 127 pp. et 4 tabl. 1858.

— Retro-Uterine Hematocele. By Aug. Voisin, M.D., etc.

9. Du varicocele ovanen et de son influence sur le devdoppement de
Vhematocele retro-utirine. Par lo docteur Devalz. Paris, Delahaye.
In 4. de 24t pages. 1858.

— On Ovarian Hematocele and its Influence upon the Developmeni ef
Retro- Uteriiie Hematocele. By Devalz, M.D., etc.

10. L. Genouville, on Peri-Uterine Hematocele. — Arch. gdn. Oct.

II. Bennet, H., HemorrJiage during the first Months of Pregnancy. —
Lancet. January.

12. Routh, on three Cases of Menorrhagia, two of them depending upon
the Presence of Uterine Polypi, Successfully Treated. (Samaritan
Hospital).

13. De la metrorrhagie symptomatique. Thfese. Par Dr. Letellier,
Paris, 1858.

— On Symptomatic HemorrJiage. By Letellier, M.D., etc.

14. Stanley, A. F., Uterine Hemorrhage from Hour-Olass Contraction,
after the Expulsion of the Placenta. — Maine Report. I. 5. Octob.

15. Recherches sur la transfusion du sang. Thdse soutenue devant
la Faculty de mddicine de Paris. 1858. Par Dr. P. H. Quinche, de
Dijon.— L'Union, XII. 122. Oct. 14.

— Researches on the Transfusion of Blood. Thesis. By P. P. Quinche,
M.D., etc.

16. Wheatcroft, J., on Uterine Hemorrhage, Successfully Treated by
Transfusion. — Lancet. January. — ^Brit. Med. Jour. April 16.

11. Labatt, S. B., on Treatment of Menorrhagia. — Dubl. Jour. May.

18. Griffith, J. S., on Treatment of Metrorrhagia. — Med. Tim. and Gaz.
January, 23.

19. Strange, W., on the Use of Alcoholic Stimulants in Cases of Me-
trorrhagia. — Lancet. April.

20. Thomas, W., Alcoholic Stimulants against Post Partum Hemor-
rhage. — Lancet. June.

21. On Compression of the Aorta Ahdominalis as a Means of Arresting
Post Partum Hemorrhage. — Monatsclu*. f. Gcburtsk. January.

22. Breslau, on a Case of Extremely Obstinate Menorrhagia Cured by
Injections of Liquor Ferri Sesquichlorati. — Monatsclur. f. Geburtsk.
Oct. 1851. — New York Jour. May.

23. Savage, H., on Obstinate Menorrhagia. — Lancet. Feb. — New York
Jour. May.

199

It has been often observed, that some diseases find a more fruitful
soil in certain countries than in others. Such is the case with peri-
uterine hematocele, an accident considered almost exclusively by
French physicians. And among these it is Dr. Puech, who has en-
tered quite an original and ingenious way of facing the subject,
^hile Drs. Oulmont, Xonat, Trousseau, Devalz, Genouville, and Bec-
querel, have issued very interesting and important articles on the
nature of this singular phenomenon.

Dr. Puech remarks that the disease called peri-uterine hematocele,
may take its origin from three sources. 1. From a lesion of the
ovary. 2. From a lesion of the fallopian tube. 3. From a lesion
of the utero-ovarian plexus. With regard to the first of these causes,
he remarks that ovarian apoplexy ;was characterized by an afflux
of blood towards the ovary, and by a partial or total destruction of
the stroma, or of the graafian follicles. From the force exercised by
the afflux of blood, it depends whether the membrane which encloses
the ovary, is ruptured or not. If the rent opens into the peritoneum,
the hemorrhage may be instantly fatal, or it may cause a peritonitis
leading to death, or to an "enkystement" of the extravasated blood.
If the rupture be formed towards the sub-peritoneal cellular tissue,
the peritoneum is detached, and an extra-peritoneal pelvic tumor is
the consequence. But as long as the outer membrane is not severed,
the blood coagulates in the gland, the serum is absorbed, the fibrin
remains, and the swelling may finally disappear. In other cases the
ovarian apoplexy is followed by inflammation, and the pus may be
discharged through the rectum, or the vagina. In the chapter which
treats of retention of menses. Dr. Puech reports several cases of rup-
ture of the uterus, or of rupture of the tubes distended with blood,
that could not be discharged in consequence of an occlusion of the
OS uteri. Three cases are reported of propagation of the blood from
the uterus into the fallopian tubes, without occlusion of the os uteri.
The fallopian tube may be the seat of two different kinds of hem-
orrhages — one of a physiological, one of a pathological nature. If
death ensues from the latter cause, the tube is found dilated only
partially or to its full length, its cavity contains a vermicular clot of
blood, its mucous membrane has a dark red color, while the entire
organ is of a violet hue. In some instances, the tube is ruptured.
The blood extravasated in the tubes, may be emptied into' the uterine,
or into the peritoneal cavity. This tubar hematocele has been ob-
served in a considerable number of cases, and often in connection with
ovarian apoplexy. The rupture of the utero-ovarian plexus — ^be it
in the course of a uterine or an extra-uterine pregnancy — has the
same cause, and the same termination as the thrombus of the vulva.
A varicous disposition of the vessels has not been observed in the
great majority of cases. The consecutive hemorrhage may be intra
or extra-peritoneal — always fatal in the former, seldom fatal in the
latter instance. A hemorrhage of this kind always precedes, but
does not always constitute a hematocele, a name only proper for
those instances, where the blood is about to become encysted. Uterine
hematocele must not be mistaken for a rupture of an extra-uterine
foetal cyst, an accident described by the oldest authors, and which

200

may be called pscado-hcmatocele, tho sources of a real heSSto
being an ovarian apoplexy, a hemorrhage of the tubes, or a rupture
of the utero-ovacian plexus.

Mr, Puech terminates his mcmoire on rupture of the utero-ovarian
plexus, with the following conclusions : 1. Whether occurring dur-
ing or independently of pregnancy, prior to or Boon after delivery, tbe
rupture of the utero-ovarian plexus is due to the same causes, and
leads to the same terminations as that of vaginal thrombus. 2. A
varicose condition observed in four cases, was wanting in a larger
number. 3. If deatli does not take place from the hemorrhage, a
hypogastric tumor or sanguineous cyst is produced, with the same
seat, symptoms, and termination as rotro-ut«rine hematocele. 4.
Judging from the cases collected, this rupture is the most common,
and tlie least dangerous cause of retro-uterine hematocele, and like-
wise it is the one which does least mischief to the generative func-
tions. The other less common sources of this hematocele arc ova-
rian apoplexy, and hemorrhage of the fallopian tubes.

Dr. Odluont gives a very interesting account with a postrmortem
examination of two cases of rctro-uterinc hematocele, both of which
almost recovered under antiplilogistic treatment, when they were
taken with dysentery. One of the patients died from its effects, while
the other one was rescued and died afterwards from an extensive
gangrenous abscess, situated near the uterus. In the latter case,
both fallopian tubes were enlarged and filled with disorganized
blood. This circumstance induced Dr. Oulmont to believe, that the
patient had at first a tubar hemorrhage, in consequence of which
one of the tubes burst, thus giving exit to tbe blood into the abdominal
cavity. In a discussion which followed uponthe exhibition of the speci-
mens in the Soci<!t(i M^dicale dcs Hopitaux de Paris, Dr. Aran re-
marked that surgical interference was, generally speaking, injurious.
His advice was to apply daily a large numt>er of leeches upon the
abdomen, decreasing their number gradually ; this to be continued
for eight or ten days. By following tliis plan ho had often seen
these tumors lessen rapidly in size, although they never disappeared
entirely. On the other hand, Drs. Bartiiez and. Bourdon reported
each a case, which was successfully treated by puncture and injec-
tions ; while Dr. Oulmont again pointed to the fatal results observed
after active interference, from the practice of Drs, Nelaton, Oosselin,
Vidat, and Voilleraier,

Dr. SoKiT lays a great stress upon the distinction of intra and
extra-peritoneal hematocele. In the latter form the tudior descends
between rectum and vagina, below tbe os tinea ; tbe neck of tbe
womb is pressed against the symphysis, while the fundus nteri ia
sometvhat elevated. By means of a speculum a violet tumor may
be seen in the vagina, a symptom of great importance for diagnosis.
In cases of h, intrarperit., this color is never found in tlie laquear
vaginee, and the tumor does not come down very far, while the
'Uterus is not pressed forward, but seems to be implanted in the tnmor
itself, which may be perceived surrounding the womb from all sides.
This distinction is important from a prognostical and therapeutical
i|K)int of view. The hemorrhages extra peritoneum are much more

201

favorable. The most important conAiderations in regard to treat-
ment are : rest in a horizontal position, strict diet, mustard-poultices
repeatedly applied to the upper extremities, softening cataplasms
upon the abdomen, mercurial frictions, slight cathartics, cold water
dressings upon the hypogastrium and inner part of the thighs, espe-
cially at the beginning of the disease, in order to stop the hemor-
riiage. In phethoric women bleeding from the veins may be repeat-
edly resorted to, while local blood-letting does not seem to do much
good. Blisters applied to the abdomen are of service in cases where
file reduction of the tumor proceeds very slowly. With regard to
tapping, it is imjyortant whether the blood is deposited intra or extra-
peritoneum. This operation will always prove fatal in the former
instance, while in cases of extra-peritoneal hematocele, the blood has
to be removed in this way, whenever urgent symptoms seem to de-
mand our actual interference. Dr. Xonat has applied the trocar
three times under these conditions, and in every single instance suc-
cessfully. Like Laugier, he introduces an elastic canula through
the opening made by the trocar, in order to have the fluid entirely
removed, and to make injections of water or of tincture of iodine.
Out of fifteen patients who came under Dr. Norat^s care, only one
died, and in this instance the hematocele iutraperitoneum was com-
plicated with extra-uterine pregnancy.

Dr. Trousseau, in a lecture delivered at the Hotel Dicu, urges to
make a distinction between catamcnial and accidental hematocele.
The author does not think that the blood in catamenial hemat<)cele
was discharged from a ruptured graafian follicle, but rather from the
mucous membrane of the abdominal orifice of the tube. This is con-
firmed by the following facts : 1. In post-mortem examinations of
women, who died from this accident, no lesion of the ovary is dis-
covered (three cases of Tardieu). 2. In some instances the tubes
were filled with blood (Oulmont). 3. Mucous membranes are more
inclined to bleeding than serous membranes. 4. Hematocele is most
commonly observed in women with an abimdant menstrual flux.
Accidental hematocele occurs only once in the same person, while
those females, who had one attack of catamenial hematocele, are apt
to have relapses of the same disease. These remarks were oflfered
on occasion of a young lady being received in the hospital with
hematoc. retro-uterina. This woman was admitted two years ago
with the same complaint, and dismissed as cured.

The thesis of Dr. Voisix contains a review of the papers published
on hemotocele retro-uterina, to which a series of new cases is added.

Dr. Deralz's paper gives a good anatomical description of the
utero-ovarian venous plexuses and their varices, while the second
portion of the work shows the influence of ovarian varicocele
upon the development of hematocele peri-uterina, which he designs
as the most conmion source for this disease. The ovarian veins in
women affected with varicocele have a decided influence upon the
tissue of the ovary itself. The lesions, from this disposition, are
chronic oedema and an excessive engorgement of the entire tissue of
the gland, because the blood, under these circumstances, scarcely
circulates in these rigid canals ; it accumulates more and more, but

202

especially under the influence of the menstrual congestion, near the
ovarian vesicles, where it finds the least resistance. The organ thus
swelled with blood, is compressed between its enlarged bulbus and
the uuelastic peritoneum of the small pelvis. If this compression is
very considerable, the laceration of the ovary, instead of being con-
fined to one graafian follicle, extends to several of them, in conse-
quence of which an effusion of blood into the peritoneum is ineyitft-
ble. In other cases, the wound left after the rupture of a follicle,
instead of being tlosed up, becomes swelled and fungous, thus pre-
senting a veritable varicous ulcer of the ovary, analogous to that of
the leg.

Dr. Genouville's thesis on periuterine hematocele is a critical and
historical analysis of all- that has been written in France on the snb-
ject in question. The honor of having first called the attention to
this disease is due to Drs. Nclaton, Vigu^s, and Bernutz Cl^^)»
while Trousseau, Puech, Devalz, Gallard, Laugier, and others, have
contributed considerably towards the solution of the points contest^
ed. The entire article seems to be devoted to the defense of the
ovarian theory against M. Trousseau, who considers a tubar hemo^
rhage as the principal source of hematocele catamenialis. Two
observations are reported in favor of this theory — one of M. Gudrard,
and one of M. Puech. The latter had occasion to perform several
autopsies of women, who died during the menstrual period. In one
of these observations a clot of blood protruded from a ruptured vesi-
cle ; in the other a clot was found between the ovary and the fallo-
pian tube, and in a third instance, it was lying in the recto-uterine
cul-de-sac. The chief symptoms of the disease are a sudden pain in
the lower part of the abdomen, a rapid discoloration of the skin, and
a considerable decrease in the menstrual discharge. The abdominal
tumor is situated generally behind the uterus, in a few instances on
both sides of this organ, while the womb is dislocated upwards or
laterally. Most of the women suffering from hematocele perinterina,
had symptoms of dysmenorrhoea before the first attack of th'b disease,
owing to a morbid condition of the ovary. The conclusions which
the author draws from his researches are as follows : — 1. The hcma*
toceles may be divided into two classes — the catamenial and the
accidental haematocelcs — the former being more frequent than the
latter. 2. All hematoceles are represented by hemorrhages, with a
tendency to a formation of cysts. One kind takes its origin from the
rupture of a blood-vessel, one from an alteration of the ovary, and,
perhaps, from a hemorrhage of the trompe. 3. The treatment of this
affection must be confined, with some rare exceptions, to allay the
symptoms and to absolute rest.

With regard to the cause of bleeding in the first months of pregf-
nancy, Dr. Bennet remarks that it is very often the consequence of
chronic inflammation and ulceration of the womb. Therefore, it is
necessary to apply the speculum in cases of this nature. If, on the
contrary, the cervix uteri is found free from inflammation, and the
bleeding goes on unconnected with uterine contractions, it is very
probable that a mole or hydatides are present. Hemorrhages, if con-
nected with chronic inflammation during pregnancy, have generally

203

* jro<><l effect upon the diseased condition of the womb, in lessening
the state of congestion. Dr. Bonnet is of opinion that, in all cases of
leturning catamcnia during pregnancy, the uterine orifice is the seat
of inflammatory ulcerations, so that the bleeding cannot be properly
called a menstrual one. Therefore, a woman who believes herself in
the family way, notwithstanding the continuance of her courses, is
▼eiy likely not so, if, after careful examination, the cervix is found
healthy.

Dr. Rorra's article contains an account of tKrec interesting cases
of uterine haemorrhage. An unmarried lady had flooded considerably
for some time past, but it was impossible to find out by examination
the cause of the bleeding. The patient was ordered to take five
Krain doses of acetate of lead, with five minims of tincture of opium,
ttome dilute nitric acid and water every hour ; every night a purge
of sulphate of magnesia, acidulated with sulphuric acid. This eflected
^ perfect cure, after a host of other styptic remedies had failed. In
"Wie second case, a polypus was removed by the draseur. In the
'third case, the inside of the womb was fouiid studded with small
polypi ; the uterine cavity was therefore dilated, and the ex-
crescences removed by a curette with sharp edges. After this, iodine
injections, and the application of solid caustics, completed the cure.

Dr. Wheatcroft considers transfusion as the most eflicicnt remedy
we possess for subduing violent flooding. After giving a descrip-
tion of the operation, he remarks that the injections ought to be con-
tinned until the pulse becomes full, and the activity of the heart
regular. Two cases of successful performance of the operation are
reported.

Dr. Wheatcroft reports another case of successful transfusion of
blood, in a woman who had a violent attack of haemorrhage which
could not be controlled, neither by the ordinary styptic remedies, nor
by the use of the tampon. The entire body of tlie patient was cold
and blanched, the pulse scarcely perceptible, the breathing gasping,
great agitation, loss of sight, eyes sunk and leaden. Under these
circumstances, about two pounds of blood, taken from the husband,
irere injected, which was followed by a remarkable change, the
color returned, the eye became brilliant, the pulse was perceptible,
and the agitation disappeared. With the exception of a sensation of
giddiness and tightness across the brow, the patient felt quite well.
The tampon was removed, and no blood was lost afterwards.

In a discussion of the obstetrical section of the meeting of German
physicians and naturalists, on the value of Drs. Lee and Seutin's
method of arresting uterine haemorrhage, the obstetricians came to
the following conclusions : By the compression of the aorta abdomi-
nalis, a contraction of the uterus is eifected, and consequently haem-
orrhage stopped. But in order to obtain a lasting and sufficient
contraction, the compression of the aorta must be performed : 1.
For a certain length of time. 2. It must be perfect. 3. Executed on
the right spot, i.e., above the issue of the abdominal vessels ; and
4. The vena cava has to be avoided. As these cannot be accom-
plished in the living female, this method loses its value in practice,
while its physiological basis is undeniable.

C
J

204

Dr. Breslau reports the following case of hsemorrhago, cured by
an intra-uterine injection. In a woman forty-five years of age, wbere
the ordinary means had failed to stop an excessive menorrhag^a, Dr.
B. discovered the uterus soft, enlarged, and perfectly bent upon itselt
He resolved to apply the liquor fer. scsquichl. to the inner surface of
the uterus. Having first straightened the retrofiected uterus, andifr
serted an elastic catheter as far as the fundus, he injected one onnoe |'
and a half of the liquor ferri, diluted witli an equal quantity of water.
The injected fluid wets retained in the uterine cavity for a minute and
a half, by the pressure of the fingers at the os around the catheter.
During the operation, the patient felt a dull, labor-like pain, which
lasted for two hours. The hdemorrhage now suddenly stopped, ani
was not renewed. After some days, brown crumbling clots were
discharged, but no fluid blood. Seven months afterwards there had
been no return of menorrhagia.

After some preliminary remarks on intractable menorrhagia, Bb.
Savage reports two cases, illustrating a- new way of treating this
complaint.

Case 1 . — ^A chlorotic woman had never noticed an irregularity in
the catamcnial function till six months after her second and last con-
finement, when she began to flood, and continued to do so for eight
months, with the intermission of only one week per time. Every-
thing was tried, but in vain, by several physicians. Dr. S., on ex-
amination, discovered nothing but a slight enlargement of the utems,
which had a soft feel. Cold hip-baths, oxide of silver, Indian hemp,
made but a slight impression. An injection of tannin and alum into
the womb, brought the menorrhagia to an almost perfect stand still,
which lasted for four months, when it returned as bad as ever. Now
the cavity of the uterus was enlarged successively by sponge-tents,
and the whole of its internal surface scratched away by Recamier's
curette, by which only a very limited quantity of vegetations was re-
moved, but instead a good quantity of a jelly-like white, tough,
transparent mucus. The haBmorrhage first increased, but lessened
considerably after half an hour, and was still less on the following
day. With a view to destroy more eflcctually the polypoid vegeta-
tions, two injections of tinct. iod. 5iii-» &t intervals of three days, into
the uterine cavity were applied, after which the haemorrhage stopped
instantly. Dr. S. saw the patient nine months afterwards, when he
learned from her, that the catamenial periods had been perfectly
natural ever since. Case 2. — A pallid, debilitated woman complained
of excessive loss of blood at the catamenial periods, during the past
two years, since the time of a miscarriage. The uterus was soft
and enlarged. The os uteri was artificially dilated, and two ounces
of tincture of iodine, witli two ounces of water, were injected into
the uterus. The same injection was repeated every third day for a
fortnight, after which the haemorrhage ceased entirely, and the
uterus began evidently to return to its right size.

4. TUMORS AND STRUCTFRAL DISEASES.

I. Sayage, PriesUey, Warthington, Hall, Cases of Successful Opera-
Hons for Ulerine Polypi. — ^Med. Tim. and Oaz. Jan. 30. — ^Lancet.
Jan.

i. Hallp A., Report of three Cases of Uterine Polypi; Succes^ul Operor
Hons. — Lancet. April.

S. Shove, ^S., a Case of Uterine Polypus. — Amor. Monthly. X. 3.
Sept.

4. Beck, Removal of a Polypus Uteri, icith the Aid of Internal Reme-
dies. — Echo M^d. Suisse. 2.

5. Nesfield, St, Excision of a Polypoid Tumor of the Uterus^ with the
Attached Portion of the vervix Uteri. — Lancet. II. Dec.

6. Lumpe, E., Removal of a Fibrous Polypus by the Oalvanocau8tic
Apparatus, — ^Wien. Zeitschr. 35. Aug. 30.

7. Wells, Spencer, Cystic Tumor of the Cervix Uteris Removed by the
Ecraseur. — Med. Tim. April 17.

8. Johns, R., on the Use of the Ecraseur for the Removal of Uterine
Polypi. — ^Dub. Jour. May.

9. Breslan, Extirpation of a Polypus Uteri. — Monatschr. f. Oeburtsk.
XI. May.

10. Breslan, Removal of a Carcinomatous Vaginal Neck by the Ecra-
seur. — Scanzoni's Boitr. III.

H. Lewinsky, on Amputation of the Collum Uteri by the Oalvano-
caustic Apparatus. — ^vVien. Zeitschr. 34. Aug. 23.

IS. New Instrument. — The Polyptome. — Med. Tim. and Gaz. 392.
Jan. 2.

13. Ramsey, A., on a large Fibrous Tumor of the Uterus : Enudeation
and Expulsion. — Edinburgh, Med. Jour. July.

14. Binz, Fiprous Tumor of the Uterus, Weighing Sixty-Ihvo Pounds.
— ^Deutsche Klinik.

15. Sloane, J., Oastrotomyfor the Removal of a Fibrous Tumor of the
Womb; Death.— BxM. Med. Jour. Feb. 27.

16. Cazenave, J., Differential Diagnosis of Polypus and Invernio Uteri.
— Jour, de Bord. April.

It. Cremen, on Hydatids of the Womb. — ^Dubl. Jour. May.

18. Taylor, T. M., Removal of a Tumor from the Neck of the Womb,
formed by a Portion of the Membranes^ Thirty-Six Hours after De-
livery. — Amer. Jour. April.

19. Der OdMrmutterkrebs. Sine Pathologisch-Analomische Monogra-
phie. Von Dr. Med. Ernst Wagner. Privatdozent an der Univer-
sitftt zu Leipzig. Mit 3 Tafeln in Stahlsticli. Leipzig : B. G.
Teubner, 1858. gr. 8vo. pp. 169.

— The Cancer of the Womb, Being a Pathologico-Anatomical Mono-
graph. By E. Wagner, M.D., Lecturer at the University of Leip-
Ric. Leipsic, B. G. Teubner, etc.

206

20. Wagner, E., Remarks on Tumors of the Uterus, — Arch. f. phys.
Hcilk. I. pp. 504.

21. Kciller, A., Remoxxdqfa Cancer of the Neck of the Uterus 6jf the
Ecraseur. — Edinburgh, Med. Jour. April.

22. Isaacs, C. E., Case of Cancroid Ulcer of the Os Uteri — Excismtf
the Entire Cervix — Recovery. — New York Jour. IV. 1. January.

23. Schuh, CauHfloioer-Excrescence of the Cervix Uteri and (f the
Vagina, Removed by Oalvanocaustic. — Oesterr. Zeitschr. f. prakt
Heilk. IV. 42. Oct. 15.

24. Armstrong, on Cauliftmcer-Excrescence of the Womb, — Brit. Mci
Jour. January, 16. pp. 51.

25. Laurence, L., on Rodent Ulcer. — Med. Tim. and Gaz. 436.
Nov. 6.

26. Parker, L., on a Syphilitic Disease of the Uterus, — ^Brit. Med.
Jour. May.

2*1. Namias, G., on Tuberculosis of the Womb and its Appendages
Venezia. In 4. (Con Tavola.)

28. Cooper, II., Case of Rupture of the Uterus in the Third Month (f
Pregnancy, from Tubercular Degeneration of the Fundus. — ^Bnt
Med. Jour. Oct. 9.

Dr. Wagner's work on cancer uteri deserves the greatest atten-
tion of the profession, and we believe that the researches and expo-
sitions, laid down in these pages open a new era for the study of
cancer uteri. If we must consider Dr. Virchow as the path-finder
for the new genesis of structural metamorphoses, we must consider
Dr. Wagner as his most clever interpreter with regard to uterine
cancer. Prof. Virchow is the man, who, with one stroke, annihilated
Dr. Swann's and VogePs theory of blastema, which up to the present
day was the turning-point of our pathological researches. The for-
mation of cells out of a blastema was a theory, Dr. Virchqw'a " omni»
ceUvla e cellula " is a well demonstrated fact.

The new methods for the removal of tumors, viz.: the dcrasenr
and the galvano-caustic apparatus, have been applied very succesi^
fully this year in a number of unusually difficult and complicated
cases.

Dr. Hall reports three cases of uterine polypi, successfully re-
moved by ligature. In one of them ergot was given at every men-
strual period for eight months, by which contrivance the polypus
was expelled from the womb so that it could be reached by the in-
struments.

Dr. Lumpers very instructive article gives a striking representation
of all the difficulties connected with the operation of tying a poly-
pus. Although everything was tried, and a very ingenious appa-
ratus was purposely constructed to bring the cutting loop around
the body of the polypus, it could not be effected, and therefore the
tumor had to be removed in two sessions, first its lower and then its
upper segment. Another trouble, almost worse than the first act of
the operation, was the removal of the first portion from the vagina,

207

after it was cat off with the burning loop. At last it was removed,
but not without rupturing the perineum up to the sphincter ani.
The patient was a virgin, and the polypus of unusually large size,
extending the vagina to its utmost capacity.

Dr. Breslau's case of ^crasemcnt lindairc is instructive, inasmuch
as it shows the necessity of applying the instrument as remote as
possible from the healthy tissue, in order not to injure the vagina or
bladder. After the patient had been cliloroformed and placed in the
position for lithotomy, the diseased portion was fixed by several
hooks and a forceps of Muscux^s, and the uterus pulled down so
that the tumor came in sight. Now the chain of the dcrascur was
placed around the tumor, so that it was situated right in the middle
between the diseased and the healthy portion. The time consumed
for the removal of the degeneration was about twenty minutes. But
an examination of the excised growth showed, that a portion of the
vagina had been cut away with it, and consequently a hole of con-
siderable extent was found in the anterior vaginal wall, through
which a portion of the intestines protruded. After the vagina had
been thoroughly plugged, the patient was placed in bed and put un-
der the influeuco of opium. The rent in the vagina, although at
least one inch in diameter, closed entirely, and the patient recovered
very fast considering the circumstances.

Dr. Lewi.vsky, after a short historical synopsis of the methods in
use for the removal of the vaginal portion, remarks that the prin-
cipal advantage of the galvano-caustic method with Middeldorf 's
apparatus was not the absence of hemorrhage, but rather the possi-
bility' of easily removing the collum uteri, without bringing it down
before the os externum. The autiior believes that by pulling down
the uterus, the peritoneal f^Ids constituting the spatium Douglasii
might be possibly injured by over extension, or peritoneal adhesions
severed from their place of insertion. The peritonitis often observed
after this procedure may be owing to this expansion of the perito-
neal membrane. An illustration of this incidence is mentioned by
Scanzoni {Lehrbuch krankh. d. tceibi. iSexMo/orgrane. p. 254), occurring
in a patient who had undergone the operation just mentioned. After
death a rent two inches long was found running across the lowest
section of the spatium Douglasii. Two similar cases are reported
by Mik.schik. Therefore every method of amputation of the neck,
which demands a previous dislocation of the womb, is an unsafe
proceeding. Added is the history of a case, where the vaginal neck
was removed by galvano-caustic, for a papilloma portionis vaginalis
( Clark's Cauliflower excrescence).

A new instrument intended to facilitate the operation of removing
broad-based uterine polypi has been invented by Dr. Lever. It
consists of a semicircular blade, cutting by its concave edge, which
plays freely round a circular joint, placed at the end of a shaft five
and a half inches long, when worked by a trigger and thumb piece,
which pushes a slide and lever acting on the blade forward and back,
the edge of the blade being then passed over the part which is to be
excised ; the operator may now make gentle traction by means of
the handle, while by pulling the trigger he causes the blade to

208

sweep forward with a cutting movement, for about one and one*
eight inches. The instrument now becomes, a cutting hook ; the op-
eration may now be completed with this hook by simple traction, or,
if the base be too broad for this to be done, the lever may be with-
drawn with the thumb, and the first step of the operation repeated

A primipara, under the care of Dr. Ramsey, was delivered in t
natural labor, of a healthy child, when the doctor in the act of re-
moving the placenta, detected a large intermural tumor. Anexplo^
ing needle was introduced for diagnosis, but no fluid escaped. The
opening of the trocar, after some days, was found considerably ex-
panded so as to admit the point of the forefinger, by which the open-
ing was gradually enlarged, and separation was effected fully 8)"
around it in all directions, except that a thick and strong fibrous
band extended from the lower and back part of the tumor to the an-
terior lip of the OS uteri. This band was afterwards divided by the
urethrotome. Five days afterwards the tumor came away on its
own account ; it was a large flaccid mass, of about 2| lbs., with a
strong white investing membrane on all its surface, except where
its attachments had been separated by direct interference.

The following is an abstract of Dr. Wagner's monograph on uterine
cancer : Cancer of the womb is represented by different forms, vii.
— 1. Primary cancer (of the vaginal portion ; of the cervix or body
of the womb, without or with subsequent affection of the vaginiJ
portion). 2. Cancer communicated to the womb from neighboring
organs. 3. Cancer of the womb originating simultaneously wiu
cancer of other organs. 4. Secondary cancer of the womb.

As to the different characters of cancer, it may be divided into
scirrhus, carcinoma medullare, epithelial, and colloid cancer.

The primary cancer of the vaginal portion is more frequently
met with than all the rest taken together. Its structure is generally
an intermediate form between scirrhus and carcinoma. Very often
the carcinoma contains large microscopical alveols (cancer pultaotf
ardolaire). Epithelial cancer is of rare, genuine scirrhus, of veiy
rare occurrence, while alveolar cancer is the least frequent of all. All
these different forms may combine with the formation of small or
larger tufts on the free surface of the vaginal portion, in which latter
instance it represents the so-called cauliflower excrescence (Clarke).
[The writer does not think Dr. Wagner justified in counting the cau-
liflower excrescence among the cancerous growths. To say the
least, this point is not yet decided, neither in an anatomical nor in a
practical point of view. — E. N.]

Cancer of the vaginal portion takes its origin very likely as often
from the anterior as from the posterior lip. It is difficult to give a
decision on this point, as the chance to examine cancer of the womb
at its early stages is very seldom offered. It seems to be a settled
fact, that cancer of the vaginal portion does not start from the mucoiifl
follicles, but rather from the areolar tissue between the muscular
fibres. This at least is the result of Dr. W.'s researches from a con-
siderable number of microscopical examinations. In all the cases
examined, the glandular organs were not diseased ; in most instances
the cancer had a greater extension in the muscular portion than in

209

the lining membrane. The carcinoma medtiUare appears, in its first
stages, as an infiltration of the vaginal portion, with a white, hard,
cmrtilaginoiis, or a loose, encephaloid substance, in which the
original tissue disappears. The cancerous infiltration of the
▼aginal portion, after some time, proceeds towards the neck of the
^Uerua, generally seizing upon its entire length and thickness. In
the greatest number of cases the affection comes to a stand-still at
the orificium uteri internum, while in some instances the body of the
'Womb itself is taken. Sometimes smaller or larger cancerous de-
posits are found distributed in the body on different points, independ-
ent of the primary infiltration of the lower uterine segment. The
decay of the cancerous infiltration consists partly of the common
softening, partly of its gangrenous destruction. In the latter in-
stSDoe it looks sometimes like a primary uterine gangrena.

After the mollification has begun, the vaginal portion is covered
with superficial or deep ulcerations ; at a later stage the vaginal
portion has entirely disappeared, representing one extensive ulcer-
ation, covered with a dirty, grayish fluid. In other instances the en-
tire cervix is wanting, so that the body alone is being left Cases
of this kind have been taken for tUcus corrodens (phagedaanicum)
uteri.

[The author is of opinion that most cases recorded as vJctis phage-
imicum are nothing but secondary stages of cancer, and only very
few authors (Rokitansky, Walshe, Ash well, FOrster) sustain its specific
character. We are surprised to find that Dr. Wagner does not
mention a well established fact, viz., that by far the greatest number
ci so-called corrosive ulcers are of a syphilitic nature. — E. N.]

In some few cases the entire uterus, up to its vertex, was de-
itroyed.

Generally, the simple mollification is combined with so-called
wiaM gangrena, partly as a consequence of disturbed circulation and
nutrition of the cancer and the original tissue, partly from a putrifi-
cation of the cancerous fluid, being exposed to the air.

The gangrenous places of the ulcerated surface arc covered with a
thin, stinking, yellowish or greenish fluid. Sometimes the surface of
• softened cancerous deposits, or of the gangrenous tissue, is covered
with warty, granular, and very vascular excrescences, which are
often hidden under a layer of pus, blood, or ichor. These secondary
growths have to go through the same process of softening or gan-
grenous destruction as the original cancerous infiltration. The con-
sequences of softening and sphacelous, are hemorrhages from the
ulcerated surface, cancerous cachexy,, secondlary diseases (peritonitis,
thrombosis), and, perhaps, a more rapid development of the cancer.

In very rare instances the gangrenous process comes to a certain
line of demarcation, probably owing to a formation of pus in its
neighborhood, and representing one form of the so-called partial self-
heiuing of some authors. The spontaneoue heding- of uterine cancer
it very dubious. Only very few observations (Rokitansky, Kiwisch,
Schuh, Bochdalck) deserve the attention of the profession. Among
the varieties of cancer which are rarefy met with,, may be counted the
epithelial cancer. Dr. Wagner saw this fornL only twice among

210

twenty-five cases. This is at variance with the opinion of mt&y
authors, and of Virchow especially, who holds that the greatest num-
ber of uterine cancers belq^g to the epithelial form. Dr. Wagaer
thinks that Virchow's cancroid is not an epithelial cancer, properij
so-called, but only a variety of carcinoma containing a! veols, with t
regular disposition of the peripheric cells. As long as this point ii
not cleared up, the discussion about its frequency cannot be settled.

The real scirrhus is seldom found in tne vaginal portion. But,
generally, a harder form of carcinoma is called scirrhas ; and m
many cases of hypertrophy, induration, and fibroid have been d^
scribed as scirrhus uteri, it is very difficult to decide as to its &•»
quency.

Of gelatinous cancer only some few cases are known. The author
gives the details of some cases, which came under his own observation.

Among the changes to which the noncancerous portion of (he ulsrut
is subjected, whether before the cancer manifested itself, or after its
appearance, hypertrophy of this organ is most often met with. It
consists of a uniform increase of all the tissues of the uterus, but
more especially of the inter-muscular areolar tissue. In some excep-
tional cases, the superior non-carcinomatus portion of the womb is of
normal size, pale, flabby, and extremely soft. The mucous mem-
brane lining the non-affected portion, shows in most instances tfie
different forms of caJtarrh. Fibroid tumors are often found together
with cancer uterL The serous membrane of the womb exhibited, in
all the cases examined, adhesions and false membranes of different
shape and size, in consequence of whicn the womb is attached more
or less to its neighboring organs.

Primary cancer oi the vaginal portion, involves almost constantly a
smaller or larger portion of the vagina, where it retains its original
character. In very exceptional cases, cancer of the vagina has oeen
observed, without any immediate connection with the uterine affec-
tion.

Cancer of the bladder, propagated from the vagina, is of frequent
occurrence (38, p. c).

Secondary cancer of the rectum is not so frequently met with as
that of the bladder (l6 p. c), and generally that portion of the rec-
tum is taken, which is situated opposite the superior third of the
vagina.

Carcinomatous vesical, vaginal, rectal fistulsd, and so-called car-
cinomatous cloaks, are not frequently met with (3 or 4 p. c). Cancer
of the ovaries and the fallopian tubes is not unfrequently met with,
but mostly in those cases wnere the fundus uteri has been affected.
The areolar tissue around the uterus and the small pdvis is very oflen
carcinomatous, thus propagating the disease from its original locAr
tion to the neighboring organs (bladder, rectum, urethra, pelvic
muscles, periost, and bones of the pelvis^. As a consequence of car-
cinomatous infiltration of the areolar tissue around the womb and
vaeina, may be considered the immobility of the womb, important in
a diagnostic point of view.

Cancer {fthe urethers is pretty often found, its location being gen-
erally at toeir lower terminus.

211

Oareinoma cf ike lym/AaHc f^nds may be found in about half the
Bvmber of cases of primary cancer of the vaginal portion, of which
the glands of the pelvis (plexas iliacus extcrnus, plexus hjrpons-
tzicus, plexas sacralis medius and those in the immediate neighoor*
liood of the womb, li^mcnta lata, etc.), take the greatest share.
The carcinomatous inflilti-ation of these glands is most often coinci-
dent with a considerable extension of the uterine cancer, and when
it is far advanced in the process of destruction. This fact is
explained by the intimate connection of the lymphatics with the cells
ef the areolar tissue. Cancer of tite inguinal and me^enleriial glands
belong to the secondary affections, as they are in no direct communica-
tion with the diseased womb. Cancer of lymphatics has been found
in some rare instances. In some cases the carcinomatous deposits in
the liver are so numerous, that the symptoms of the disease seen) to
point more towards an original affection of the liver, than of the
womb.

Cancer of the Uoodrvessels is of very rare occurrence, a few cases of
cancer of the veins are recorded. It is very remarkable that the
smaller arteries and veins, running through cancerous portions of
the womb, have been found unchanged in structure. The spreading
of the cancer towards the neighboring organs does not at all follow
the course of the blood-vessels or Ivmphatics., Before the intimate
■tmctnre and connection of the areolar tissue and its cells were suf-
ficiently known, this fact could not, by any means, be explained
latiafactorily.

From these researches, the great frequency of the propagated and
of tlie secondary cancers becomes evident, a fact generally dis-
believed by other authors. Altogether, uterine cancer offers many
points of comparison with cancers of other (hollow) organs, in the
composition of which organic muscles take a prominent part (oeso-
phagus, stomach, intestinal canal).

The nonrcarcinomaious diseases originating from cancer of the
vaginal portion, are of equally great clinical and anatomico-patho-
logical importance, and many symptoms in a case of cancer uteri are
derived from these consecutive diseases, while ttie fatal result is very
often owing to these secondary non-cancerous affections.

One of uie most common diseases in consequence of cancer uteri,
are the periUmitides, which are often localized, and of an adhesive
nature. These seizing upon the [peritoneum in its full extent, are
almost always of pnriform or septic character. The latter are most
often caused by the softening or decaying of the carcinomatous infil-
tration, and are found mostly connected with perforation of the peri-
toneum, though general peritonitis is not always the consequence of
this accident, but of other diseases (Cystitis, dilatation of the
urethers, croup of the rectum, etc. )

The diseases qf the btoodrvessds^ especially of tlie veins^ are the most
frequent non-carcinomatous diseases occasioned by cancer uteri, and,
above all, thrombosis of the veins, the cause of death in one third of
all cases. The veins most commonly affected, are the venn uterinales,
vesicales, hypogastricae, iliacae communes et crurales. This throm-
bosis is most frequently owing to a pressure of the carcinomatous

212

areolsr tisBoe of tfie pelvis, and of carcinoro&touB lymphatic gltbds
upon the medium-sized veins. This may be concluded from the
fact that these three conditions are remarkably often fonnd con-
bined. Besides this compression — thrombosis, Virchoufs manntic
thrombosia i&Tcry often met with. It has its foundation as wdlin
the general marasnuis, which ' almost constantly follows the liat
stages of uterine cancer, as in the diminished activily of the heart,
which is partially owing to fatty degeneration, partially owing to
the violent heemorrhages from the genitals. In other instances,
many thromboses are the consequence of a dilatation of the rectal,
uterine, and vesical veins, or of a purulent inflammation of the ves-
sels. The results of these thromboses arc : oedema of one or both
legs ; purulent destruction of some portion of the cellular tissue ; a
more rapid softening or gaugrcna of the superficial layers of the can-
cer ; ascites ; occlusion of the arteria pulmonalis, with consecutive
oddema pujmonum, or lobular infiltration of the lungs, or pneumonia ;
infarctus of the spleen, liver, and kidneys. Other non-cancerous dis-
eases, in consequence of cancer uteri, are : inflammation of the heart
and tiie vessels ; inflammation of the pericardium ; inflammation of
the eudocardium ; inflammation of the lymphatics ; acute hyper-
trophy of the lymphatic glands in almost every case ; chronic bron-
chitis, with; emphysema of the lungs ; inflammation of the rectum ;
dilatatioui of the urethers and hydronephrosis, owing to a compres-
sion of the uretliers by cancer of the pelvic areolar tissue, or by
cancer of the lymphatic glands of the pelvis ; other causes are cancer
of the bladder, cancer of the lower end of the urether, cancer of the
entire uterus, with considerable hypertrophy ; cancer of the retro-
peritoneal glands : acute purulent nephritis and morbus Brightii ;
diseases o£ the bladder ; diseases of the urethra ; oedema and ascitis ;
diseases of the bones (erosioues, caries, osteomalacia) ; tuberculosis
of the lungs.

Primary camcer of the neck of the womb is exceedingly rare. Three
cases arc reported fCruveilheir, Brachet, Virchow).

Primary Qtmcer of the body of the uterus is also very seldom ob-
served. The body of the womb is goneraly more or less hyper-
trophied, the inner layers of which seem to be mostly affected. One
or both tubes are degenerated at their lower end ; in some cases
carcinoma of the ovaries was observed, in some carcinoma of the
retroperitoneal and mesenterial glands, of the pelvic cellular tissue,
of the peritoneum , bladder, rectum, intestines.

Cancer propagaied vpoji the uterus from neighboring orgams is the
most frequent /orm of cancer of the uterus after the common cancer
uteri. Its starting point is generally in the vagina, — not so often in
the cellular tissue between uterus, vagina and bladder, or between
vagina and rectum — in the other pelvic cellular tissue ; in the ova-
ries ; in the bones of the pelvis ; in portions of the intestinal tube ; in
the bladder and rectum. This secondary uterine cancer is always a
so-called cancerous infiltration.

Cancer cf the uterus forming at the same time ioith cancer of other
organs. A few cases are known where cancer of the mamma or the
ovaries originated jointly with cancer of the womb (Rokitansky).

218

Seeondary cancer q^ the womb. It happens most often after cancer
of the mamma and ovaries, in some instances after cancer of the
cnaophagns, stomach, intestines, liver, lunes etc. It is generally
represented in tlie form of one or more small knots, and most com-
vu>Bly found in the serous membrane of the body of the womb.

Microeoopical dimotntion of cancer of the uterus^ Cancer of the

^woaib IS almost always a so-called infiltrated cancer ; t. e. in the

tissue of the organ are deposited alveoli, filled with the cancerous

jaioe, 80 that in most instances no formation of so-called cancerous

stroma is present. If stroma is found, it always retains the character

of a mere hypertrophy of the intermuscular areolar tiMiiCi so that

the original structures arc not considerably altered.

The cancerous alveoli are almost constantly found deposited in
the areolar tissue, connecting the muscular bundles, never inside of
them. From that point they spread in every direction, especially
towards the substance of the muscles themselves, not so much to-
wards tlie inner or outer surface of tlie organ, so that its lining mem-
brane is often found intact in a far advanced stage of tlie disease.
The areolar tissue near by very large alveoli, does not exhibit a very
decided fibrous structure, its corpuscula are small, losing their cell-
ular appearance, and looking more like nuclei. These changes are
the conaeq(ience of a pressure arising from tlie growing alveoli.

These alveoli offer different types of construction in different forms
of cancer.

I. Inside the normal or very little altered tissue of the uterus, as
well in its muscularis, as in its mucous membrane, or in the subse-
rons and serous tissue are found alveoli of a glandular, tubular, jag-
gedp ovoid, or spherical form. The shape of these alveoli depends
partly from their mother organ (corps fibro-plastiques) partly from
the disposition of the neighboring muscular layers, or from the quan-
tity and situation of the alveoli themselves. The alveoli are closed
up from jail sides and seemingly limited by a membraua propria (the
condensed border of the areolar tissue). They contain chiefly cells,
very seldom an intercellular substance (cancerous serum). Those
cells situated near the periphery of the alveoli are of a more or
less cylindrical form, and a regular disposition like cylindric epithe-
lium. They are generally in intimate connection with the alveolar
margin. Ihe central cells have no exact shape, being polygonal,
ovoid or round. Sometimes the centre contains nothing but nuclei.
The increase of the cells proceeds very likely from the cellular layer
near the alveolar margin : this is proven by the absence of mother
cells in the central part, and by tlie presence of cells with double or
more nuclei and dichotomic cells in the peripheric portion. This is
confirmed by the observation, that the fatty metamorphosis and decay
of the cells does begin in tlie central portion. The growth of these al-
veoli follows up the line of the cellular fibres. Still they increase
not only in a longitudinal, but in several directions, by branching
out in one or more points. The larger alveoli very often contain
smaller compartments. The intrapalveolar partition-walls consist of
fibrous or homogeneous cellular tissue, with several knots, which
corresponded, perhaps with the location of the formerly existent cor-

214

puBcnta of the cellaUr tisatie. The framework itself is very likdj
not of recent formation, bat a residunm of the normal, atrophic t»
sue, resaUirtg from the formation of very namerous alveoli in a imiU
circuit The alveoli have no connection whatever with the nonnil
glands of the mncous membrane of the womb, they originate fronta
endog^neons growth in the corpnscula of the cellular tissue. This
is the most common form of cancer uteri. TThe same stractun ii
exhibited in some cases of cancer of the stomach and liver.

2. The cancer ar^olairo pultac^ (Gruveilhier) is no particular fona
of cancer, but offers the same anatomical structure under the micro*
scope as that described above. The thick juice which may be
squeezed out of it, k maui^re de vemiisseaux, consists of decayed
cells, nuclei, albuminous and fatty molecules, with a slight admix-
ture of cholesterin.

8. The common carcinoma is not found in the uterus, as ofteo, as
the first mentioned variety. Its alveoli are seldom very large ; their
shape is not so very regular as quoted by the majority of authors.
Its alveoli contain at times very little, at times a considerable quan-
tity of scrum. But, in numerous cases, the cancerous serum is, for
its greatest porAon, an artificial production, owing to a bursting of
the softer cancerous cells, by manipulation or addition of fluids for
microscopical examination. The cells of the carcinomatous serum,
i. e, the soK^lled cancer-cells, are in many cases single, being loca-
ted side by side, without any further connection, while in other
instances two or more of them are firmly coherent with each other.
This is perfected by the pointed or broad brandies, especially of the
famous cellules caudat». In the common carcinoma the contents of
the alveolus seem to have no other connection with its stroma, than
the contents of a serous cyst with the wall of cyst Still, in many
cases, the intra-alveolar cells are in an intimate connection with
the wall of the alveolus, with which they arc firmly united.

4. Of so-called scirrhus uteri, only one case came under Pr. Wag-
ner's notice. The cellular tissue was considerably increased in
quantity, denser, with fewer nuclei and fibro-plastic corpuscula.
The muscular stratum between it could not be detected by the eye,
while it appeared under the microscope, in some places, chang^ in
fatty degeneration. The very few alveoli present were generally of
a large size. Their cells were partly unchanged, partly atrophied.

TliA development of the cancer from fibro-plastic corpuscula, the
author could trace in almost all cases'of cancer uteri examined : all
the different stages, from the undeveloped corpusculum up to a
mother-cell, with many nuclei and alveolus, could be traced.

The m(^ific(Uion of the cancer proceeds from the most superficial
portions, and is altogether the same process going on in cancers of
the skin and mucous membranes. Its nature is not yet sufficiently
explained ; it very likely consists in a rapid growth of the cancerous
cells, and a copious increase of the so-called cancer-serum, which is
the result of a stasis of the venous blood in most cases. During
the softening process of cancer, the cells undergo several modifica-
{ions, among which the diffluence of the cells is the most important.
While suffering this metamorphosis the cells become somewhat

216 '

and more uphprical ;.the cellular membrane is lefls distinct,

tiiiniier, disappeanng at last entirely ; the contents of tiie cell become

mora transparent and copions ; the molecules are lying at a greater

distance one from another ; next the nucleus and nucleoli undergo

"the same metamorphosis.

In Tory rare instances Dr. Wagner observed the soK^alled mucoua
meiamorphosis cf the cdncerowt c^.

The/aUy metamorphoais (^the cdls is of frequent occurrence, but is
altogether of very little influence upon the development of the
eanoer. The degeneration starts from the centre of the alveoli, from
whenoe it proceeds towards the periphery.

The atrophy cr tvberculixation of the cancerous cells is found alone,
or combintid with the other metamorphoses. Its microscopical char-
icters present nothing extra in cancer uteri.

J|ftm<ms (f blood into the cancerous deposits are often ob-
ssrved. Abundant apoplexies are doubtless one of the causes of
gangrena cancri.

Formation (^pus is often found on the surface of cancerous ulcer-
ations ; its origin is not known. In some cases granular growths
were observed very much like those of common ul^rs in the skin.

nie microscopical characters of non-primary cancer of the womb
are not yet suflBciently known, but very likely they do not differ
mach from primary cancer of the vaginal portion.

^This is in short an exposition of the different topics treated of in
Dr. Wagner's thesis ; it is replete with very numerous microscopical
examinations ; replete with the best of previous literature ; replete
with practical hints, and altogether written in a strictly scientific
and elegant style. We seriously recommend it to everybody who
takes an interest in the progress of pathological anatomy and gyna^-
odogical science.

Dr. Isaacs removed the entire cervical portion of the uterus, trans-
formed into one mass of cancroid ulcer by the knife, after which ope-
ration the severe dragging pains, and other symptoms referable to,
the nterus disappeared entirely. Dr. Isaacs is of opinion that the
cperation will be permanently successful, as cancroid cancer is less
liable to return than any other form of malignant disease.

Of the three cases of cauliflower excrescence reported by Prof.
Sohuh, which were removed by galvano-caustic, one recovered, one
died from peritonitis, owing to a perforation of the peritoneum, near
the spatium Donglasii, occasioned by the caustic wire. In the third
case the operation was followed by a severe cystisis and peritonitis,
from whicn the patient ultimately recovered.

Dr. Laubbncb gives an account of a rodent nicer, with a postr
mortem examination. Os and cervix were completely destroyed, the
remains of the organ of normal size, its tissue somewhat soft and
pale, but not infiltrated by any morbid deposit. The lining mucous
membrane of a deep claret hue, and of a pulpy consistjence. The
author hoj^s, that this affection is not of a cancerous or cancroid
natare, but a disease sui generis. An important symptom during
life is the state of mobility of the uterus, a condition never present
in a cancerous affection.

216

A case is reported by Dr. Cooper, wh^re a woman died sndd^si^
in her third month of pregnancy. On post-mortem examination ffe
body was found very plump and well nourished, having nearly two
inches of fat on the abdominal parietes. The uterus was found to le
ruptured at the left angles of the fundus. The wall of the nterm^
fundus was so thio, that the part of the plaqcnta remaining in the
cavity could be distinctly seen through it. The proper structore of
this part of the uterus was converted into a friable, cheesy, or curdy
mass, which rubbed away readily under the finger. At the part of
the fundus above indicated, this change had gone on till only flie
membranous investment was left, and in one part even this had
given away and produced the catastrophe. The cervix was quite
healthy and closely contracted. The lungs were not examined.

VI. PATHOLOGY OP BLADDER, VAGINA, AND

EXTERNAL GENITALS.

1. Silver Sutures^ in Surgery, The Anniversary Discourse before the
New York Academy of Medicine, etc* By S. Marion Sims, MJ).,
Surgeon to the Women's Hospital. New York : Samuel S. and
WiUiam Wood, 1858. 8vo. pp. 19.

2. Bozeman, N., Case of Vesico-Vagindl Fishila, with ArUever$km and
Incarceration of ihe Cervix Uteri in the Bladder, Beplaoement cf
the Uterus and Closure of the Fistulous Opening, by Means of Ae
"BuUon Suture," — Communicated with Bemarks by Alex. Keiller,
M.D.— Edinb. Jour. XL. Oct

3. Wells, Spencer, Urethro-Vaginal Fistula; Cure by SHver-Suhtre. —
Med. Tim. and Gaz. 431. Oct. 2.

4. Brickell, W., of New Orleans, Two Cases oF Vesico-Vaginal JPistida
Cured, — New Orleans Med. News. V. 9. Nov.

5. Toland, H. H., Vesico-Vaginal Fistula] Operation and Cure, — Pacific
Jour. I. 4. April.

6. Brown, J. B., Three Cases of VesicO'Vagimd Fistula, — Cured. — ^Med.
Tim. and Gaz. April It.

7. Herrgott, Two Cases of Vesico-Vaginal Fistula; one Cured by fll^
ture and Cauterization; One Healed Spontaneously, — ^G^tz. de Stnuh
bourg. 4.

8. Esmarch, on Operation of Ves/vco-Vaginal Fidula, — ^Deutsche Klin.
21. 28.

9. Two Vesico-Vaginal Fistulce in the Same Patient; Operation; Cure. —
Med. Tim. and Gaz. Sept. 18.

10. Simon, G., the Treatment, of Fistula Vesioo-Vaginalis^ and Vesico-
Ulerinalis, — Monatschrift f. Ueburtsk. July.

11. Simpson, J. Y., JronrThread Sutures and SpHnJts in Ve^^Vaf/inal
Fistulas. — Med. Tim. and Gaz. 440. Dec. 4.

12. Savage, on a Mixture of CoUodium and Castor Oil for BeHeumg
{he ExcoriaHons^in Cases of Vestco-Vaginal Fistula. — ^Med. Tim. and
Gaz. Jan. p. 119. — Med.-Ghir. Mon.-Hefte. Sept

217

18. Hamm, E,,j(m OtKteraiion of the Vagina for the Cure of Vesico-
vaginal Fidula. Thesis. Marburg, 1858.

14. NendOrfer, T., on a Tumor in the Urethra of the size of a Figeon^s
Egg, — Oesterr. Zeitschr. f. prakt. Heilk. IV. 36. Sept. 3.

15. Wells, S., on DHataiion of the Female Urethra by Fluid Pressure
—Med. Tim and Gaz. 421. July 24.

16. Farrc, A., on ExfoiUdum of the EpUhdial Coai <f the Vagina, —
Beale's Archiv. of Med. II.— Brit Rev. XLIV. Oct.

11. Schmidt, £., on a Case of Traumatic Ocdueion of the Vagina.^^
Chicago Jour.

18. Corse, on Cancer cf (he Clitoris; Operation, — ^Transactions of the
Philadelphia College of Physicians. — Amer. Jour. LXXII. Oct

19. Falloon, Edw. L., Adhesion of the Labia after Ddivery, — Lancet.
June.

20. Baker, Brown, T^ Ten Cases of Ruptured Ferineum Cured by
Operation, — Med. Tim. and Gaz. 420. July It.

21. Erichsen and Adams, Cases of Succes^ul Bestauration of the Ferin-
eum after Baker Brown^s Method. — Lancet April

22. Storer, H. R., AdaptMn <f the Clamp and Button Suture to Fro
k^fpse of the Vagina, — ^Amer. Med.-Chir. Review. January.

28. Schaltze, B., on Bupture of the Ferineum, (With Plates.) — ^Mon.-
Schrift; f. Geburtsk. XII. 4. Oct

21. Mat^i, on Laceration of the Ferineum, — ^Prag. Viertelj.Schr.
October.

25. Moreland, W. W., Laceration of the Ferineum During iJabor;
Operation, etc. — ^Boston, Jour. LIX. 16. Nov. 18.

26. Priestley, W. 0., on a Feculiar Form of Laceration (f the Ferine-
um During Labor. — Med. Tim. and Guz. 429. Sept 17.

27. Breslau, Incontinentia Drince^Cured by the Bemoval <f Both

Hypertrophied Nymphoe. — Scanzoni's Beitr. B. 3. 1358. New York

Jour. Sept

38. Breslau, Beoto-Vaginal Abscess; Becto-Vaginal Fistula; Sponta-
neous Closure of the Opening. — Mon.-Schr. f. Geburtsk. XI. May.

S9. Ladreit de la Gharri^re, on Cysts Developing in the Vaginal Wails.
— ^Arch. Gen.

80. Ltlders, Eemcval of a Fessaryfrom the Sjpatium Douglasii, where
it had boen Implanted and Formed strong Adhesions for several
Fears.— Deutdie Klinik, 10.

This is the age of scientific wire-pulling. In former times they
were accustom^ to use leaden wire — ^now, in our country, the silver
wire is universally tried, while on the other side of the Atlantic they
begin to show a predilection for the cheaper met«l, viz.: iron wire.
The question arises, whether this occupation will be finally bene-
ficial to suffering humanity or not ? We are happy to be able to re-
ply in the affirmative. We have received already numerous accounts
of succeaiful operations for vesico-vaginal fistula. A large number

218

of cases which had been abandoned as incurable, were taken up
with renewed energy, and many an unhappy woman has found per-
manent relief, who would have been condemned to constant miaery,
had it not been for the excitement produced by the wire. And still
this blessing is not due to the wire alone. Awakened energy of the
operators ciTcctcd the work. The same seemingly happy results
have been obtained in former times by the silk ; but these have been
forgotten. The account of operations given by Langenbeck, Dieflfen-
bach, Kiwisch, Wutzer, Simon, Maisonnevue, can boast of the same
success, of the same average number of cures, although they made
use of the silk-suture.

The chief advocate of this modem doctrine is Dr. Sims, of this city.
His views on the subject are fully expressed in his anniversary dis-
course before the New York Academy of Medicine. It contains
some very interesting facts, while the spirit which pervades the
whole work forcibly reminds us of the times of Oliver CromweU.
The speech opens with an anathema against Dr. Bozeman, which re-
veals a good deal of deep malice towards a man of generally acknowl-
edged merits, a malice strangely constrasting wim the ardent g^od-
lincss displayed in the rest of the work. After declaring that "the use
of silver as a suture is the great surgical achievement of ttie ninteenth
century " (sic !) the author proceeds ib present the proper method of
using it for the cure of vesico-vaginal fistula. It is called a " clamp
suture " on account of its method of action, in clamping firmly to-
gether the surfaces to be united. By perforated shot, compressed
upon the silver wires, they are secured to leaden crost^rs, or
" clamps,^ which burrow in the vaginal tissue ; the whole remaining
till union by first intention becomes firm, when, by clipping off the
shots, the sutures are removed. Dr. Sims insists upon passing the
sutures so far from the edges of the fistula, that the cross-bars would
burrow in tlie vaginal tissue. Lately Dr Sims has discarded the
clamps and shot, securing the suture by simply twisting the wire.
The wire must be made of virgin silver, annealed, and small enough
for a suture. In the majority of operations about the vagina, it is
better to pass silk ligatures first, and with these to draw the wire
after. The sutures should be passed in near the edge of the fistulsi,
taking care to embrace the whole denuded surface, but not to pene-
trate the mucous lining of the bladder. They should, in general, be
about ^ of an inch apart, and each tied separately, by twisting the
two ends of the wire together, then cutting them off, and leaving the
twisted ends at least half an inch long, to facilitate their removaL
But the most useful improvement, says Dr Sims, is in the position of
the patient during the operation. A few require to be placed on the
knees with the head and thorax depressed ; but in the great mi^jori-
ty of cases the patient may lie on the left side, while the operation
will be executed with equal facility to the surgeon, and of course
with more facility to the patient.

With regard to the importance of silver sutures applied to injuries
of the vagina, Dr. Sims remarks : "Before this discovery, operations
for vesico-vaginal fistula were often attended with risk of life, while
a cure was a mere accident." This bold assertion can only find its

210

^^Imnation in the following words on pag^ 48 : "I investigated the
case (of fistula vesico-vaginalis) thoroughly, reading every author I
conid find on the subject, but to no purpose, for all was darkness
mud confusion." The writer is of opinion, that even a man living as
fur south as Alabama, should not commit himself to the acknowledge-
ment in such plain terms of his utter ignorance of previous litera-
tare. But when words like these are pronounced in the city of New
York, before such a learned body as the Academy of Medicine ; when
this is expressed in the midst of a professional community, in posses-
sion of every facility for literary instruction, we can only say, si tacuis-
. If Dr. Sims had taken the trouble to look at the Deutsche

ik, or Prager Viertdjahnschrift, or MonaitMchr^ for Oebutsk^ or
Kilian's Operative Midwifery, or La Gaxetie dee ntpitaux, or one of
the Engliih Jfevieuw, or even the American Journal of Medical
Sciences^ he would have been easily convinced that every thing he
has proposed with regard to this operation was known to others be-
fore him. Neither the needle-holder, nor the speculum, nor the
Eisition of the patient, nor the results obtained by his way of per-
rming the operation, are new attainments. The only new propo-
sition remaining, is the word " silver," instead of silk, lead, or gold.*
The writer of this was assistant-surgeon to the surgical and obstet-
rical department of the clinic of the University of Bonn, in 1850, and
during this time ample occasion was offered to witness the mode and
results of Prof Wutzer's operations, which are published in a great
number of German and English journals. These are so much like
those laid down in the pamphlet before us, that Wutzer himself could
not have described them more accurately. Wutzer's position of the

Ctient is entirely the same ; he formerly used the same needle-
Ider, which is now exchanged for a more useful instrument ; his
speculum represents the same idea, while it allows of even a more
spacious development of the vaginal sac, as it consists of three in-
stead of one spatula ; his way of scarifying the edges, and applying
the sutures, is entirely the same ; and notwithstanding Dr. Wutzer's
taking silk instead of silver-sutures, his results are entirely the same
as those claimed by Dr. Sims, t. e., he perfects a cure in the great
majority of cases. Fig. 6, of Dr. Sims' pamphlet, represents the
sketch of a fistula, very like one which Dr. Wutzer operated upon
successfully, in the presence of the writer, by antero-posterior obliter-
ation of the vagina. But it is not Wutzer alone ; Kiwisch, Simon,
Langenbeck, Baker Brown, and many others, are equally successful ;
fad if we must admit, from our own experience, that silver-wire is
less injurious to the living tissues than silk-thread, wo are free to
say, on the other hand, that the silk-suture does the same service
with regard to ultimate results.
The case reported by Dr. Keiller was a fistula of very consider-
' able extent (half a crown in circumference), so that several gentle-
men, among whom Dr. Spencer Wjells, thought it one of the most
desperate cases for operation. Therefore, no operation was attempt-

* Dr. Mettaner applied leaden-wiro for the same porpoae in 1847. Dr. Gossett, of
L<mdoD, eared a case of redco-Taginal fistula, hj gold wire in 1834.

220

ed, and in the coarse of years the cervix uteri worked itself thromgii
the opening in the bladder, in consequence of which the womb WM
retroverted and incarcerated, — a condition not detected, while en
examination the vagina was supposed to be occluded, as no os or
cervix uteri could be detected. On August 4tli, Dr. Bozeman, of
Montgomery, Alabama, U. S., undertook the difficult task, and opet^
ated in presence of Drs. Simpson, Weir, etc. He commenced by eB»
larging the opening on either side, by carefully dividing its extmm^
ties in a lateral direction by means of an angular-bladed knife* By
these lateral incisions the cervix uteri became disengaged from thi
bladder, so as to allow its being more readily restored to its normal
position in the vagina. By means of a small hook the right angle of
the anterior edge of the fistula was raised, and the mucous mei»
brane dissected off transeversely towards the left angle. The ant^
rior lip of the cervix uteri was then pared far in upon the vesical
side, so as when the sutures were introduced and ai^nBted, the teop
dency to the previously existing uterine displacement might bt
overcome. By means of an ingenious porte-aiguille, seven silk
sutures were passed through the now denuded lips of the fistula, to
the cud of each silk thread a silver suture was attached, and the
former then drawn through, so as to bring ihe latter into their posi-
tion. After this Dr. B. cut out a leaden button, shaped and penor>
ated it on the spot, and immediately applied it over the sutures,
fixing the former to the latter by means of seven small leaden barsi
In manufacturing the button, Dr. B. took care to make a deep notch
in its posterior edge, for the purpose of better accommodating and
preventing injurious pressure upon the denuded anterior lip of the
now replaced cervix uteri. A catheter was now introduced throa^^
the urethra, to be taken out every twelve hours, and the exter^
parts to be syringed with warm water, and again introduced. After
the operation symptoms of peritonitis set in, and the patient died on
the sixth day after the operation. The cause of this fatal result was
found to be a cellulitis starting from a sloughy condition of a small
portion of the mucous coat of the bladder, at which point cellular ii^
flammation had kindled up, extending 'subsequently into the sur-
rounding tissues. The union of the fistular edges wiilB found to be
perfect, and the position of the uterus all that could be desired.

Dr. Bbickkll's cases of vesico-vaginal fistula were successfully
treated after Bozeman's method. For diminishing the phosphatic
deposits in and around the catheter, the author administered bensoic
acid internally and by injection into the bladder. As to the applica-
tion of the sutures, Dr. B. passes the needle through the mucous
membrane of the bladder, and he has observed not the least irritation
from this procedure.

Dr.'EsMARCH reports five cases of vesico-vaginal fistula successfully
treated bv silk suture. He proposes to detach the anterior wall of
the bladder from the posterior surface of the pubic bones, by the
vestibular section, in cases of firm adherence of the fistula with the
ossa pubis. •

A case is reported in the Med. Tim, and Oaz., where two small
fistuln existed, communicating with the bladder, a little beyond the

221

iMt part of the urethra. Both were Bucoessfullj operated upon by
Dr. Foster.

Dr. SnioK read his paper on resico-vagpnal fistala before the meet-
ing of the Rhenish physicians at Darmstadt, and in order to prove
more satisfactorily the results of his method, he had invited all the
women operated upon within three and a half years, and most of the
number presented themselves to the Society, in order to be examined
by the members present.

Of nineteen fistnlae, ten were healed completely ; five incompletely*
i. e., they had to undergo a coarse of caustic, treatment for small
openings of the size of a pin's head, left open after the operation ;
only one fistula was sent back uncured ; two women died after the
operation ; a third woman died after a preliminary operation. Of
the perfectly cured cases, six were treated by ihe wet suture in
eight operations ; two by the wet suture, and after-treatment with
caustic ; two originally very small fistuln were cured by the appli-
cation of caustic alone. These difierent fistule were seated in very
different locations.

One was a case of fistula vesico-uterina, i. e., the cavity of the
uterine neck was connected with the bladder without touching the
vagina. The incontinence of urine was treated by antero-posterior
obliteration of the os uteri. The woman is at present quite at her
ease, while the menstrual blood is discharged through the urethra
every four weeks.

Another woman was affected with a so-called deq> vedahuterine'
vaginal JistiUa, t. e., the anterior lip of the uterus, and a portion of the
bladder and vagpna, were destroyed. The fistula was cured by
uniting the posterior lip with the wall of the bladder. In this case
the menses also flow through the bladder.

A third woman had a very larg^e fistula, which extended from the
neck of the bladder up to the os uteri. In this case the loss of sub-
stance was covered by the anterior lip o( the uterus. This woman
vras entirely cured, and afterwards gave birth to a living child.

Those fistulas cured by cauterization alone were of a very small
sise.

Of the almost entirely healed fistulse, three were so large that the
loss of substance involved the entire base of the bladder up to its
urethral portion, so that the only means left for operation was the
aniero-po9terior MUeration of the vagina. All of these women were
greatly benefited by this operation, t. e., they only lost a few drops
of urine when exercising too much.

The only case not cured was that of a woman with a fistula of
enormous size, where also the sphincter vesicae was destroyed. As
the union of the fistulous edges could not be effected after several

Sierations, episiorrhaphia was resorted to, but a small opening
ways remained, and could not be healed up.
Two of the women who died after the operation were seized with
pyasmia, while one perished seventeen days after the operation from
purulent inflammation of the cellular tissue surrounding the bladder,
uterus, and rectum, with coBsecutive perforation into Sie peritoneal
cavity.

222

•

The conditions on which the Buocessfal operations for vemcO"
vaginal fistul» arc based are two — 1. The edges of the woond haTS
to be approximated in such a manner that they offer a broad and
healthy surface for subsequent union. 2. The edges moat be united
80 that they cover each other entirely, and suffer no uudoe pressure
from the suture. As simple as these principles appear to be at first
sights they offer very often much difficulty in execution. Some of
these difficulties have lately been diminished by the mancsovre of
pulling down the uterus, by the more complete artificial protrusion
of the fistula, and bjr the application of specula better adapted to the
purpose.

In order to obtain a sufficiently broad rear surface, the fistula
must be cut in the shape of a funnel, the point of which is tamed in*
wardly, while its long diameter runs in the lateral diameter of the
vagina in the greatest number of cases. In cutting out this funnel,
Dr. Simon pushes a pointed bistoury through the mucous membrane
of the bladder in a diagonal direction towards the vag^al wall, and
enlarges the opening around the fistula with the bistourv. He thinks
that this method (wounding the wall of the bladder) does more
towards healing, than Wutzer's method, who cuts only the vag^inai
wall.

For the suture. Dr. Simon applies exclusively a silk thread, be-
cause the other sutures applied, such as pins, are more difficult to
use, and often impracticable when the fistula is situated laterally.

Dr. Jobert's ** operaHon plastique par glisaemerU,^ by which the latr
eral tension of the wound is intended to be ov^come, is no longer
practiced by Dr. Simon. He attains the same purpose by a few sut-
ures, piercing the vagina at points a considerable distance from the
wound, while the other sutures, intended for the healing of the
wound, are placed close to the edges.

Fistul» of so great a size, that a direct union of their edges can-
not any more be thought of, must be treated by ardero-pasteriar dh
literation of the vagina. The same operation is to be perforAied when
they are situated in such a location that a direct union is dangerous
and giving no chances of success, viz.: those in the roof of the vagi-
na, where at once the uterus is immovable.

In performing this operation, all that is left from the lower portion
of the vesico-vaginal wall, is united with the posterior wall of the
vagina, thus forming a sac surrounded by the upper portion of the
vagina, and the anterior and lateral sections of tho bladder.

The antcro-posterior obliteration of the vagina has many advai^
tages over the other methods (episiorrhaphia and transplantation),
hitherto applied in the same classes of cases ; 1. It offers more
chances for healing ; 2. It is connected with no danger, as onlv
superficial layers of the membranes have to be removed ; 3. It ful-
Glls perfectly what is required, by arresting the incontinentia urin« ;
4. It has no distressing influence upon the health or comfort of the
patient afterwards.

Dr. Simon has performed this operation six times, and the result
was better than he expected, viz., only exceedingly small fistulsd (of
tho size of a pin's head) were left in some cases, and in all the urine

228

perfectly retaiiied, except when the patients indulged in too hard
work.

Five very small fistul» were cured by the application of Innar
csostic, three of which were left after the operation. In order to
have the desired effect of the caustic, the stick must enter into the
iistala itself, and touch its deeper portions. These cauterizations
have to be repeated only every second, third, or fourth week. If ap-
plied more often, the good effect is destroyed.

In a letter to the editor of the Medical Times and OazeUe, Dr. Simf-
•oir of Edinburgh, remarks that he has lately operated successfully

y>n several cases of fistula vesico-vaginalis, by using iron instead
silver sutures, and substituting iron-thread splints instead of Mr.
Boeeman's lead-button. The button-suture is intended to prevent the
lipe of the wound being moved by the constant muscular contrac-
Uona in the vesical walls. Dr. Bozeman's plan effectually prevents
the disturbing effect of such movements lengthwise, or in the longi-
tadinal direction of the wound. But it has no power to prevent the
evil effects of such movements, if they occur crosswise, or trans-
Tereely to the direction of the wound. The slender oval, iron-thread
splint, which Dr. Simpson has employed in throe cases, overcomes,
as he thinks, this difficulty, as it so far consolidates the lips of the
wound, as to prevent them being moved, either in a longitudinal or
transeverse direction. It is made by twisting ten or twenty wires
of the size already indicated into an oval circlet or ring, capable of
including the lips of the fistula-woand, and a few lines of the vesico-
vs|pnal septum, on either side, within its concavity. By a common
borer, two, three, four or more small openings can be made among the
wires on each side, so as to correspond to the number of sutures used.
After the edges of the wound are brought together by the adjuster
of Dr. Bozeman, the splint is fixed by passing first the iron-thread to
its place ; accurately fitting and adapting it there to the parts by
the finger, and ultimately fixing the sutures across it, tying or twist-
mg them over the lower bar of this apparatus. When duly adjusted
and fastened, it appears to compresss and consolidate the lips in a
way which the plans previously adopted have not so completely
effected. Besides it is easily made, easily applied, and easily re-
moved. The wire used for this and as a suture-thread, is the com-
mcm blue iron-wire. It is stronger, cheaper, and altogether more
easily worked with than silver-wire.

For relieving the excoriations produced by the urine flowing con-
stantly over the external genitals and thighs, in cases of vcsico-va-
nnsl fistula, Dr. Savage recommends the following applications :
One part of collodium and two of castor oil are mixed together and
hmshed over the excoriated surface of the labia perineum, thighs,
ete. The mixture forms a soft, smooth coat, which resists for many
hours the influence of the urine.

Dr. Muiof in his preliminary remarks on obliteration of the vagina,
gives a historical sketch of the operations performed (by Vidal, Yel-

CrU, Ldnoir, B^rard, Maisonneuve, Simon, Roser, Breslau, Wem-
, Wutzer, Sims), and expresses his opinion that the operation
OQ^it to be applied only to those cases, where the other usual meth-

224

odfl are impracticable. After considering the effects of the contract-
tion following cauterization of wounds, and comparing them with the
results of some of the operations performed, the author proposes to
leave the final closure of the wound entirely to nature, tlias rendex^
ing unnecessary the application of sutures, provided the mucous
membrane of the vagina has been pared off to a sufficient extent
Not in one of the operations alluded to, union per primam was ob-
served, the obliteration having been always effected secondarily,
after the sutures had been removed. But in order to promote this
contraction it is necessary to make the wound sufficiently larg^ to
obtain a circular instead of a longitudinal contraction. The breadth
of the surface pared off, must exceed one inch in diameter. In this
way the operation is considerably simplified ; no particular after-
treatment is required, and this wound will be closed up, even with-
out a catheter, as readily as that performed in the perineal operation
for stone.

Dr. Spencer Wells has modified Dr. Amott's instrument for com-
pressing the prostate by dilating the prostatic portion of the urethra,
so as to make it serviceable for the dilatation of the female urethra.
It consists of a female Catheter, a piece of india-rubber tubing fit-
ting closely over the catheter, an clastic tube furnished with a stop-
cock, and syringe. On filling the syringe with water, fixing it to the
end of the elastic tube, and injecting the water from the syringe into
the catheter, the water is forced through small openings near the end
of the catheter, and distends the india-rubber tubing which covers it
When the syringe is emptied, the stop-cock can be turned, and the
syringe refilled. The india-rubber dilates at first in a globular form,
afterwards in a more oblong direction, especially if any lateral pres-
sure be made on it. In this way the uretlura may be very gradually
dilated until its diameter exceeds an inch. The instrument is intro-
duced as an ordinary catheter, and so held that the centre of the
distending portion is kept just within the meatus. In the only case
where M. Wells applied the instrument the effect was admirable,
the pain was by no means excessive, and the dilatation did not
occupy more than ten minutes.

Dr. Farre had occasion to examine three membranes discharged
during menstruation, which in their triangular form were taken at
first for mucous membrane of the womb. However, they were larger
than the non-pregnant uterus, and no openings could be found on
those places where the Fallopian tubes enter, nor the sieve-like ap-
pearance. Under the microscope it appeared to be one continuous
layer of fiat nucleated epithelial cells, while all the characteristic
elements of the uterine mucosa were wanting. A second membrane
of this kind exhibited the same characteristics, and had an undulated
surface, answering the folds of the vagina. Its shape was cylindri-
. cal with an impression at its upper end from the cervix uteri The
third membrane came away from a married lady during menstrua-
tion. Before it dislodged, the body experienced a pressing sensation
round the anus, difficulties in the sitting position, and itching in the
vagina. All these symptoms disappeared with the discharge of this
membrane. Its character was perfectly -analogous to we above

225

mentioned, and the depression at its upper termination was a per-
fect cast of the cervix and labia orificii uteri. From the shape of
this membrane it appear that the vagina is a short, flat canal, the
anterior and posterior walls of which do touch each other, its length
being 3" ; the width 1" or 1 J".

Dr. Schmidt communicated an interesting case of traumatic occlu-
sion of the vagina, before the Cork County Medical Society. The va-
gina had been totally occluded in consequence of a protracted labor,
r. Schmidt made an incision with a concave tenotome and enlarged
the opening by a compressed sponge. It was afterwards success-
fully kept open by a catheter.

Dr. Schulzk's article on perineal rupture contains some very inter-
esting and orginal views on the subject. During the passage of some
of the larger foetal parts, the os externum is necessarily violently ex-
panded. In order to have this dilatation proceed as safely as possi-
ble, three conditions must be observed :

1 . The extension, which the os externum has to undergo, must be
as little as possible, t. e., the head must present to the os the small-
est possible circumference. 2. The extension must be effected in
such a way, that the elasticity of the surrounding parts is brought
to bear in its fullest extent. 3. The tension of edges must be dis-
tributed equally on the periphery of the os, in order to avoid over-
extension of some of its sections (perineum).

With regard to the first named condition, it must be remembered
that a large size of the head with a small os, and the presentation of
the head in its small diagonal diameter, with fronting large fonta-
nels, are circumstances uivoring a perineal rupture. The head has
the same disastrous influence, if it is prevented from passing with its
small diagonal diameter, in or near a horizontal direction (sutura
sagi talis in the lateral diameter of the outlet). In thi§ latter in-
stance the rupture can be prevented by changing the position of the
head with the forceps. In other instances the head is prevented
from passing with its smallest diameter by a too rigid perineum,
which prohibits the free development of the occiput underneath the

Eubic arch, in consequence of which, it will present with its large
iteral diameter. In this instance the occiput must be brought for-
ward under the pubic arch, by a pressure with the fingers to-
wards the perineum. An early pressure of the perineum by the
supporting hand must do more harm than good, as it might prevent
a self-regulation of this malposition. This abnormal direction of the
head is often caused by a too high symphysis pubis. At times the
ligamentum arcuatnm inferius (ligamentum triangulare urethrae of
the male ), has the same effect, as a too large symphysis pubis.
This hindrance is often successfully overcome by a powerful press-
ure with the hand against the perineum.

The forceps, instead 'of favoring a rupture of the perineum, is
ratlier a remedy by which we may prevent it, in pressing the occiput
strongly towards the arena pubis. To press the left hand against the
perineum during the extraction of the head with the forceps, is of no
use at all. The second condition will be satisfactorily complied
with, if we let the head have a sufficient length of time to pass the

226

08. This can be effected by direct pressure upon the adyaocing
head, by two or more fingers. With regard to the third condition, it
must be said, that under ordinary circumstances, the lower point of
the axis of the foetus, when passing towards the outlet, rests upon
the anus, from which part it is directed upwards, so as to exert an
equal pressure upon the circumference of the outlet. If the os sir
crum is veiy little curved, if the parts, forming the pelvic baaiSy
are too flaccid and pliable, if the pelvis is very little inclined, if the
pubic arch is too narrow, the axis of the foetus is more or less re-
tained in its original direction, thus perfecting an undue pressure
upon the perineum. This evil is often successfully remedied by
applying the hand to the perineum, and pressing the head towards
the symphysis pubis. These latter considerations have an equally
strong bearing with regard to the passing of the shoulders. The
upper shoulder must first pass, before the lower one leaves the per-
ineum, to which we have to apply one hand in order to elevate the
second shoulder, thus preventing a laceration. From these con*
siderations, it appears that a pressure of the perineum with the
hand, is only justifiable in case of a too broad ana rigid ligameDtum
triangulare, or, under the circumstances, as mentioned under No. 3.
But in many instances, these and other manipulations are insufficient
to save the perineum ; and we must have recourse to incisions,
especially in those cases where the head is too large, or the vulva
too small and rigid. One or two incisions of five or six lines in
length have to be made in the posterior circumference of the vulva,
in a direction towards the tuber ischi. In very rare instances, where
two incisions are not sufficient, a third or fourth incision has to be
added. At times the ligamentum triangulare is so much elevated,
that the head is prevented from approaching the pubic arch, and in
this case, the ligament must be cut into in a lateral direction, and
about one inch distant from the urethra, in order to avoid the large
veins in its neighborhood. When these incisions are neglected, t&e
upper circumference of the vagina is inclined to rupture, thus gfiving
issue to violent and uncontrollable bleedings, when the rupture hap-
pens to be near the urethra, an accident observed in four instancee
by Dr. Schultze. The most justifiable time for the lower incisions is;
when the frenulum begins to give away, while those touching the
ligamentum triangulare must be made, as soon as the impediment
begins to show its influence upon the progression of the head.

But when the perineum has been ruptured, the question arises, At
what time have we to resort to a surgical operation for its restora-
tion ? This question seens to be settled now-a-days, viz., the opera-
tion must be performed immediately after the accident. Dr. Schultse
openly confesses, that perineal ruptures, injuring the middle or pos-
terior third of the perineum, had not been of unfrequent occuyence
during his obstetrical career. Smaller lacerations heal on their own
account, while those touching the middle, or even a more consider-
able portion of the perineum, demand an immediate operation. With
regard to the latter point, we cannot agree with the author, as we
have seen repeatedly, that perineal ruptures heal perfectly, even
when they involve more than two-thirds of the perineum. E. N.-^In

peifonniDg the operation, it is generally necessary to cut away those
portions of the edges whicii run very uneven, and have suffered from
pressure. From a comparative application of serres-fires and thread*
satare. Dr. Schultze came to the conclusion, that the latter gave a
more perfect union. In thirty cases operated upon, twenty-eight
united her primani intentioncm. With regai-d to after-treatment, Dr.
Schultze thinks it unnecessary to keep the patient lying on her side,
as the lochial secretions, flowing over a well united wound, will not
prevent a safe union. It is sufficient to make an injection every few
hours into the vagina, and apply cold water dressings to the per-
ineum. Equally unnecessary is the application of the catheter, or
the use of opium, for retarding a motion of the howels, provided tlic
rectum itself is not injured.

Dr. Mattei presents the following views as to the means of pre-
venting laceration of the perineum. It is especially necessary, that
the head passes the vulva in a favorable direction. Tin's can only
happen when it passes with the necessary degree of flexion. Whilst
the occiput passes under the pubic arch, the face has not yet quitted
the pelvic outlet ; as soon as the upper part of the neck comes under
the pubic arch the extension of the head (or the separation of
the chin from the breast) begins. If the distension of the perineum
begins too early, the head must pass the vulva with unfavorable
diameters, viz., with the great oblique, or great or straight diagonal
diameters. Such a passage easily causes laceration. Hence, it is
the task of the physician to prevent a premature distension by the
liead. This he effects by placing two fingers between the labia, or
in seme cases between the pubic arch and occiput, so as to bring
the head downwards and outwards, at the same time laying the
other hand on the hinder part of the perineum, upon which the face
is lying. This manoeuvre is to be executed during the pains, which
will thus protrude the head forwards in the requisite position. A
very simple means of expediting the birth of the head consists in
compressing firmly the distended perineum with the whole hand.
This resembles the squeezing-out of the kernel from the cherry.
On the passage of the shoulders, care must also be taken lest the
two shoulders pass together.

Dr. Morlanb's paper on Laceration of the Perineum is one of un-
usual interest. He insists upon early operation and the use of
quilled sutures with interrupted sutures — the latter for the union of
tne deeper porticos of the wound. Dr. Morland alludes to the un-
usually long and broad and rigid perineum as a frequent cause of
laceration. — ^We would suggest that this conformation of the perin-
eum is the very thing where early incisions may prevent the
rupture.

The. object of Priestley's communication on a peculiar form of
laceration of the perineum, is to call attention to the occasioual
occun'ence of a horizontal or transverse form of laceration, not
indeed extending necessarily to the cutaneous surface of the perin-
eum, but implicating the upper or mucous layer, which is situated
mtemally, and yet constitutes an important element of the perineum.
In first labors, as the head descends on and lengthens the perineum,

228

two well-defined ridgca arc found on its anterior free border. Tliese
ridges correspond respectively — the upper one to the usual attach-
ment of the hymen or carunculsa myrtiformes, the lower to the line
of union between the mucous membrane and the skin. Thus, at the
orifice of the vagina, posteriorly, a circular resisting band presents
itself, which, in exceptional cnsee, and especially if reinforced by an
iocompletely ruptured hymen, offers considerable opposition to the
completion of labor, and here the mucous membrane is sometitnes
lacerated in a horizontal direction along the resisting line, implicating
the orifice of the vagina as if an incision had been made in a circular
direction, severing the inferior extremity of the vagina from its
usual junction with the perineum. One case is reported.

Dr. Breslac's patient suffered from constant slillicidium tirinw
since her last confinement, complained of a very distressing irritation
around the pudenda, and a feeling of bearing down in the lower
pelvis. When examined, the circumference of the external genitals
and the inner surface of the thighs were found excoriated, very pain-
ful to the touch, and drenched with urine. Both nymphe were con-
siderably thickened and several inches long, while the orifice of the
urethra was enlarged, so as to admit the introduclion of the fifth
6nger. A vaginal examination discovered nothing hut slight leucur-
rhcea. Therefore, Dr. Breslau thought that the enormous hypertrophy
of the uymphie bad a paralyzing infiuencc upon the urethra in
dragging the latter constantly downwards. This was confirmed by
the report of the patient, who felt the greatest distress when she
was in an upright position. Under this impression. Dr. B. removed
one of the nymphse by the ^craseur, and the other some time after-
wards by galvanocaustic. The patient left the hospital entirely re-
lieved of all her ailings.

After a short analysis of the literature, and a minute ana-
tomical description of the vagina, which presents nothing new,
Dr. Laoreit enters upon the consideration of those cysts which
are imbedded in the deeper portions of the vagina. They are
always situated one inch at least beyond the hymen, and are consid-
ered by moat authors to originate from the vaginal follicles, while
the author believes the cellular tissue of the vagina to be very often
the seat of their development. In other instances tbcy may com-
mence between the muscular layers of the rectum and vagina, or
between the bladder and vagina. By microscopical examinatioD he
was enabled to prove the absence of an epithelial layer in those
more remote vaginal cysts, which is an esseik,tial portion of the
glands and of those cysts, which are situated in the neighborhood of
the vaginal orifice. They are composed of cellular, fibro-cellular,
fibro-plastic, and vascular tissue. They result from an inflammation,
the deposits of which are not transformed into pus, but into a bursa
mncosa. The most favored place of development is the anterior wall
of the vagina, and in by far the greatest number of cases parturition,
or sexual intercourse, had preceded their origin. As long as the
cysts are small, and situated far above the entrance of the va^ua,
they scarcely give any trouble, and their prescnc* is not noticed by
the patients. Some have been found as large as a hen's egg ; they

229

are mostly of an ovoid shape, with smooth surface ; those origiuatiDg
from one of the vaginal glands have a pedicle, and are movable, and
present themselves at times near the orifice of the vulva. Unless
they are of considerable size, they do not eflfect any inconvenience
whatever, while at times they give rise to a distressing sensation of
dragging, to fluor albus, or dysuria ; they even, in some instances,
have presented an obstacle to parturition. The liquid contained in
these cysts is of a yellow or brown color, and generally contains
granular globules, which are composed of simple granulations. The
outer layer of these cysts consists of the mucous membrane of the
vagina, which is very much distended and discolored. The inner
layer is composed of cellular and elastic tissue, with a vascular
stratum, intermixed with a few muscular elements. These tumors
have been mistaken for prolapsus uteri, hernia vesicae, or recti,
tumors of the ovaries, etc. Still, by a minute examination, it is not
difficult to come to a right diagnosis. The treatment of these cysts
is the same as that applied in hydrocele, be it by excision or injection
of a stimulating liquid. The article is concluded with the history of
&ye cases.

VII. PHYSIOLOGY AND PATHOLOGY OP THE

BREASTS.

1. TraUi des maladies du sein el de la region mammaire. Par le Dr.
Velpeau. 2 me edit. In 8. Avec figures dans le texte et planches
en taille douce. Paris. 1858.

— Treatise on the Diseases of the Breast and the Mammary Begion.
By Velpau, M.D. 2d edition, etc.

2. Albert, A., de diagnosi morborum mammjoe. Thesis. Gryphiswal-
dffi. 8vo. pp. 31.

— Albert, A., Diagnosis of ike Diseases of the Breast, etc. Thesis.

3. Berkett, T., on Tumors (f the Breast, — Med. Tim. and Gaz. Jan 16.

4. Fischer, C, UnusuaUy Large Abscess of the Breast, — ^Zeitschr. f.
Chir. u. Geburtsh. XI. p. 27.

5. Harpeck, K., Remarks on the Pathological Anatomy of Cysto-Sarcoma
Mammw, espedatly with Begard to its Belalion toith the Normal
Structure <fthe Mammary Oland, — Reichert's Studien. p. 110.

6. Lee, R., Pregnancy in a Woman, nohose Mammas had been Extir-
pated some years ago, — ^Med. Tim. and Gaz. July.

7. Breunig, G., CoUodium against Mastitis, — Med. — Chir. Mon. — ^Hefte.
' Sept.

8. Newman, W. ; Trend, H. G. ; Miller, and Blythman, Bdladonna as a
Means of Arresting the Secretion of Mills, — ^Brit. Med. Jour. Feb.,
etc. — ^Brit. Jour. July. — New York Jour. Nov.

9. Roussel, Iodide^ Potassium for Diminishing the Secretion of
ifttt;.— Gaz. des H6p. 15.

230

10. Skinner, Th., Arsenic as an Antagdadicum. — Brit Med. Jour.
SepL n. ,

11. Pratt, N. A.. Vicarious Action, of th^ Kidneys in the Secretton Vf
Jfiifc— ^avanuah Jour. I. 4. Nov.

12. Lewald, G., on ihc Faamge tf Drugs into the Milk. ThesU.—
Prager Vihracrft. XV. i.

Dr. Vblpeau baa published a new edition of kis work o
of the Brcaat ; eight hundred new observations are here added to his
former ones. These are a few of hie general conclusions : about on&-
fourth of the tumors of the breast are benign ; though the time is not
far distant, when they were all regarded as malignant. The left
breast is rather more frequently than the right breast the seat of
cancer, and for this tlicre is no assignable cause. It ia not com«t
to say tliat married women are more subject to the disease tfatn
others. It is also an error to suppose that women who do not nurse
their children, are more exposed to diseases of the breast than those
who do ■ on the contrary, these affecliona arc three limes more fre-
uuent in those who nurse. The constitution, the temperament, the
character, the social position, the hygienic condition, the mode of
life, the country, exercise no influence over the production of cancer.
The naturo of cancer, notwithstanding all the efforts of the micro-
Bcopists, is still absolutely unknown.

Ub. Habpbck, in his very ingenious article on cystosarcoma, before
entering upon the subject itself, presents a minute description of the
microscopical appearances of the normal mammary gland, its nipple,
areola, and proper glandular tissue, being taken for the representa-
tives of a mwiified integumentum commune. The existence of
organic muscular fibres in the papilln, which has been denied by
several authors, can be easily demonstrated, by treating horizontal
ctttB with nitric acid. The lactiferous ducts consist of an epithelial
layer and a stroma, the structure of which enters into that of the
gland itself ; the latter consists of vessels, and of a large number of
longitudinal elastic fibres. A cysto-sarcoraatous tumor of the breast
consists of larger or smaller cavities, imbedded in a bright, fibrons
stroma, which is accompanied by large vessels. From the inner gar-
face of the cavities, covered with papillary excrescences, » layer of
epithelial cells may be easily dctaclied. These cells are replete
with fat-globules, arranged in a line near the circumference, Tbeee
cavities could be injected with a red substance from the openings of
the excretory ducts in the papilla. There are two distinct forms of
the tumor in question, one of a more solid structure, one where the
cystic structure prevails, which, however, are only different stages
of development of tlie same disease. Among the solid forms, those
of a papillary habitus are the most frequently met with. The pa-
pillte again are ramified, branching out in different directions. The
stroma of those ramiScations is arranged in two layers ; an inoer,
darker, striated, and an outer granulated deposit of a lighter yellow-
ish hne. The darker, or immediate stroma of the papilla, contains a
large number of elliptic, spindle-shaped bodies, arranged in a
parallel direction with the longitudinal axis of every papilla ; the

S31

(rater granulated tissno is formed by a hyaline blaatema, with numor-
on* short, oval nuclei. From this it appears that the papillie are
fomied by an embryonal cellular tissue, which, towards the central
part, U combined with a hyaline blastema. Besides this papillary
speciea, an areolar one is often observed, the aveoli of which, lined by
ate fibrous, and filled with the granular tissue, pursue a longitudinal
and ramified course. Another kind of these hollow forme, is charac-
terized by the want of ramifications and the appearance of a proper
iiniag membrane. From a comparison of the mlcvoscopical appear-
ance of cysto-sarcomatoiia disease, with that of the tissue of the
normal gland, it appears that it is nothing but a metamorphosis of
» original constituents of the female mammary gland ; th« ductus
retorii and large milk-ducts being hjpertrophied, while papillary
:cnces are formed, which increase by spronting out in dilTcrent
■ctioos, a process often observed in the cutis and the mucous
mbranes. This excessive growth proceeds from the larger chan-
ieU towards the smaller ones, thus leading to atrophy of the original
lotures of the original cavities in the gland.
Dr. Lbb reports the case of a woman who had given birth to five
dtildrea after her breasts had been removed for scirrhus. In every
childbed she experienced a strong congestion towards the axillary
j^Unda two days after delivery.
■ . Successful applications of extract of belladonna, for arresting the
Icretion of milk, are reported by Drs. Newhasn, Trend, Mille;h, and
Ilttbhak. The latter gentleman applied it in two cases to one breast,
""t the mothers continued to nurse their babies with the other
The best preparation for this purpose is a mixture of equal
■ of extractum belladonna and glycerine.
' Dr. Bbeuning has successfully treated two cases of mastitis by
■rnahiDg over the diseased part and neighborhood, collodtum every
tbree hours.

Dr. RocBssx recommends the internal use of hydro-iodide of potash
for arresting excessive secretion of milk. A woman who suffered
'ttita chapped nipples, engorgement of the mammee, combined with
Dmc fever, was ordered to take the iodine, and by the next day the
■in iind fever had disappeared ; its employment for three days ron-
■rcd the cure of a tumefaction, that threatened abscess, complete,
r. Roussel has since then tried it in twenty cases, and always with
B. The flow of milk returns always three days after the sns-
n of the iodide. Its action is mora decided in ttie dose of from
I to eight grains per diem, than if it is given in larger quantities.
Dr. Pblait's case of milky secretion from the kidneys is one of those
which must be received and judged with greatest caution. Allhongh
tho Bpecioien examined was drawn with the catheter, we believe
that somo deception must have occurred. We never can believe
that milk-globules pass through the vessels of the kidneys into the
bladder, or even from the breast into the blood. Up to the present
tigM no milk-globules have been found in the blood, and never will
be. There is one great defect in the analysis of Dr. Pratt, via., " No
area was found and no uric acid" Now, the woman in question had
altogether three attacks of this milky secretion, every one of them

232

lasting from five to six months. What has become of the urea, and
is it possible that a woman can live five months without passings anj
urea or uric acid ?

Tlie following experiments were performed by Dr. Lewald : The
tincture of chlorid of iron was given to a goat, in the dose of 80
drops for a length of time, whereupon the analysis of its milk showed
clearly the presence of irp^. After administering 0,915 grmm. of the
nitrale of bismiUhf this drug could be traced in the milk 36 houra
afterwards ; three days after the last dose it could no more be de-
tected. Tincture of iodine^ given in the dose of 15 grmuL, appeared
in the milk 96 hours afterwards, and disappeared 72 hours after-
wards. Two and a half grmm. of hydro-iodide rf potash were now
administered, and iodine traced in the milk 7 hours afterwards, and
only on thu twelfth day it disappeared. At this time 2^ grmm. c^
the tincture of iodine were given, and 5 hours later the milk con-
taineil again some iodine. During these latter experiments more
milk was secreted than before. The iodine was never detected in
the serum, but always in the casein. Arsenic (45 to 50 drops d
Fowler's solution, repeated twice) was found in the milk after 11
hours, and disappeared after 60 hours. Sugar of lead could be traced
after 18 hours. Oxyd of zinc, in the dose of 1 grmm., appeared in 4
to 18 hours, but disappeared in 60 hours. Tartarus stibiatus w%b
traced very soon after its administration, and disappeared after 80
hours, while the stib. sulfur, aurant. remained 5 days after the last
dose. After repeated doses of 2 gr. of calomd, mercury was found in
the milk. Alcohol could not be detected. The milk of a goat, which
took opium and morphine for three weeks, had no efiect upon rabbits,
which partook of it.

VIIL— THE PELVIS.

1. LambI, of Prague, the Nature and Origin of l^ndylolisiesi^ —
Soanzoni's Beilr. Z. Geb. Bd. 3. — New York Jour., Nov.

2. Broslau, a Contribution to the Knoidedge of Spondylolistesis. —
Soanzoni's Boitr. Z, Gob. Bd. 3.

3. Ilohl. on Kilians Hali;ftt>:rtic Pelvic, — Deutsche Klinik 24. ^Crit-
ioal analysis. ^

4. Whitaker, of Lewistown. N. Y., on Fracture of the Pdcis
rrrgnamy.

5. Mann. F.. i>ti a Funnei-^aped Pelcis. Thesis. Sfarburg gr. 8.

All the pelvis presenting the vertebral sliding, pointed ont for tke
first time by Prof. Kilian ysee the AVir Tort Journal if' Medicime ot
May, 1S57. p. 3S9\have been subjected to another thorough initOM.
ioal examination by Dr. Lambu in order to find out a law explanatoiy
of tlie nature and rise of spondyl-jlistesis, in comparing it wiin si^^
lar deformities in othrr sections of the spinal column.

1. The pelvis of Prague ^described by Kiwisch, Seyfert, Kiliaa^
Gurlt^. is remarkable for the total absence of disease in tl^

^^^ 233

system, thus leading to the supposition that the remote origin oF the
maiformatioti has to be sought for in the original development of the
pelvis. The cause of the deviation is founded on the presence of au
alercalary vertebrR, which is a rudimental piece of bone, incuneated
from behind into (he sacro-lumbar juncture.

S. The pelvis of Munich (described by Brealau) is in many points
aimilar to that above mentioned, especially in regard to the anatomi-
cal diaposilioD of the lumbo-sacral juncture. It presents a h^drorh&-
chttic opening in the spinal canal, and a supernumerary vertebral
body with consecutive lordosis and partial synostosis of the dis-
located vertebra with the os sacrum. These BUpcrnumerary vertebrte
may be found at different places iu the spinal column, thus effecting
deviation in many directions.

3. A large female pelvis in Vienna (described by Rokitansky and
xncDtioned by Kilian). The cartilaginous disk of the lumbo-sacral
jancture has disappeared entirely; the articular surfaces are uneven,
■very hard, and covered wiih warty excrescenses. These osseous
protuberances are owing to a new formation, and are the cause of
the thorough anchylosis of both vertebrse ; upon the anterior edge of
the first sacral vertebra may be found osseous masses, supporting
tho upper vertebra, which are located symmetrically on both sides of
the mesial line, thus preventing the vertebral column from sliding
down any farther.

4. A small female pelvis in Vienna (described by Rokitaostty,
Spaeth). The most striking feature in this specimen is the compres-
sion of the first sacral vertebra and the reduction of its hight ante-
riorly to 3'", BO that the lower margin of the last lumbar vertebra is
situated just opposite the upper margin of the second sacral vertebra.
Besides this, the pelvis presents hydrn-rhachitis sacro-lumbalis,
with consecutive elongation of arch of the fifth lumbar vertebra,
parallel to the vertical position of the articular surfaces of the proc.
obliq. inf , dislocation of the same vertebra in front, lordosis lumbalis
snd pytemic destruction of the symphysis pubis after metro-phlebitis
puerperal is.

5. The pelvis of Patcrborn (described by Kilian). It is of a very
symmetrical form, presenting a clean lordosis of the lumbar portion
Kit tlie vertebral column, without any lateral inflexion. The bones
look veiy much like those in osteomalacic baaina. No intercalary
"vertebra is present. The fifth lumbar vertebra is elongated in its
sagittal diameter, forming a semicircle with upper convexity. The
arch of the fifth lumbar vertebra is of a hydro-rhachitic construction,

and this is, no doubt, the primary point which caused the dislocation

of the vertebral body and the lumbar lordosis.

After a minute description of these five specimens, Dr. Lambl
mentions — 1, Dr. Robert's observation (Monattachriftfur Qtb., 1855,
Bd. 5, Sept. 2, p. 81). 2. The pelvis of Brussels, a description of
~ which was obtained by Prof Gluge. It belonged to a rhachitic
woman, 48 years old, who was pregnant with her third child, the
second one having been delivered with the forceps. The last time,
doath occurred suddenly during labor, from rupture of tlio womb.
Id a post-mortem examination, all the pelvic symphyses were found

234

very movable, the boijes of the pelvis were very thin, the lower Ini
bar verteb^sB have an anterior flexion (lordosis)* narrowing tl
entrance of the pelvis so much, thiit the fourth vertebra takes
place of the promontory. Tlie upper part of the os sacrum is in ai
atrophic and spongy condition, no doubt resulting from a locaE~ ^
caries, in consequence of which the sacral bone shrunk, thus
ting the vertebral column to slide forward. Therefore, this peb
(mentioned by Kilian) cannot be counted among the spondylolistetic
pelves. Among the pelves with vertebral sliding may be counted—
a, a pelvis in Paris in the cabinet anatomique de la mais
d'accouchement ; b, a preparation in the amphith^&tre des hdpitanx
in Paris ; c, a preparation in the anatomical museum of Bonn.
In opposition to these formations there is a deformity from

dylistesis and caries, in consequence of which the vertebral bodie^^ i
and their disks are destroyed, while at the same time an osteophyt^^^e
begins to grow up, which tends in a great measure to repair in boi
degree the primary evil ; a preparation of this kind may be seen al
Montpcllior ; lastly, a curious destruction and deviation uf the vei
tebral column is observed in some instances, viz^ kyph(»i8 of
lumbar vertebrae, with compensating lordosis of the pectoral vei
tebrse.

Dr. Breslau gives a description of a preparation taken from
Mus^e Dupuytrcn at Paris, which is intended to show that the pelvii
deformity called spondylolisthesis (Kilian), may be possibly produc-
ed by a fracture of one of the vertebrae. The specimen examinecK.
belonged to a laborer who fell from a tree, first upon his feet and^
then upon the back. The immediate result of the fall was a paraly-*
sis of both lower extremities. Thirteen months later he died in con-*
sequence of pyaemia from a bed-sore. The twelfth dorsal vertebra
was found fractured in a diagonal direction, presenting an upp^r
fragment, which had been re^tbsorbcd in the course of time, and &
lower fragment of a triangular shape, the basis of which was direct-
ed and protruded towards the spinal canal. Upon this planum in-
clinatum the eleventh vertebra had glided down upon the first lum-
bar vertebra, thus effecting a considerable change in the axis of the
spinal column. If this same fracture had occurred in the fifth lam-
bar vertebra, it would have occasioned the same pelvic deformity as
described under the name of spondylolisthesis.

Dr. Whitaker reports the case of a fracture of the pelvis daring
pregnancy. A lady, in the seventh month of gestation, fractured
the body of the left os pubis, by a fall upon an open barrel. The
fracture united in six weeks, but reopened during labor at the full
term, and united again.

IX. GENERAL DISEASES OP WOMEN DURING
PREGNANCY, LABOR, AND CfflLDBED.

1. De la/iiure puerpirdle, de sa nature, et de mm traitemerU. Commu-
nicaiion8 & VAcaiemie Iviperiale de Medicine, Par MM. Oudrard,
Depaul, Bean, Piorry, etc., etc. Paris: T. B. Bailli^rc et Fils, 1858.
. In gr. 8. pp. 462.

— The Discussion en Puerperal Fever in the Paris Academy of Medi-
cine, etc. Paris: T. B. Bailli^re et Flls, 1858, etc.

S. On Puerperal Fever, — Discussion in the New York Academy of
Medicine, — New York Jour. II. 3 ; III. 1 ; IV. 1, etc.

5. Laftivrepuerpirale et P Academic Imperiale de Midicine, Par Dr.
L. Pleury. In 8vo. Paris: LaW, 1858.

— On Puerperal Fever and the Paris Academy of Medicine, — ^By L.
Fleury, M.D., etc.

4. Stoltz, A., The Puerperal Fever in (he Paris Academy of Medicine,
— 6az. de Strasb. 6.

5. De lafikvre puerpirale devant r Academic de Midicine de Paris et
des principes du vitalism hippocratiques appliquis a la solution de
ceite question. Par Dr. E. Auber. — In 8vo. de 110 pp. Paris, 1858,
chez Oermer-Bailli^ro.

— The Puerperal Fever before the Paris Academy of Medicine and
the Hippocratic Vitalism urith Regard to this Disease. By E. Auber,
M.D. Paris, 1858, etc.

6. DeJafiivre puerpirale observie a V Hospice de la Materniti, Par Dr.
S. Tamier. Paris, 1858. In 8vo. de 208 pages.

— The Puerperal Fever, as it ujos Observed in the Materniti. By S.
Tamier, M.D., etc.

•r. Pidoux, Remarks on Puerperal Fever. L^Union, June 5, etc.

8. Behier, T., on Puerperal Fever. Letters addressed to Prof. Trous-
seau. — ^L'Union. 46, 49, etc., etc.

9. Murphy, W., on Puerperal Fever. Translated in French by Gentil,
M.D. Paris, 1858. 8vo. pp. 32.

10. Helot, Ch., on Puerperal Fever. Thesis. Paris, 1858. 4to.

11. Wrotnowsky, J., on Puerperal Fever, Thesis. Paris, 1858. 4to.

18. Dor, H., on Epidemic of Puerperal Fever at Prague, — Gaz. Hebd.
V. p. 146.

18. Surmay, on Puerperal Fever, — L'TJnion. XII. 99.

14. Bertillon, A., on Puerperal Fever. — LTJnion. 85.

15. Cros, E., on Puerperal Fever, — Gaz. des Hop. 63.

16. Dubois, P., on Puerperal Fever,— G2i,z, Hebd. V. 18, 19.
11. Joux, A., on Puerperal Fever. — Ibid, 49, 5T.

18. Pechalier, on Puerperal Fever. — Rev. Mdd. March, 31.

19. Levy, G., Relation de Vepidemie de fUvre puerpirale, observie aux
diniques d^accouchcment de Strasbourg, pendant le 1. semestre de
Vannie scolaire 1856-5T. These. Strasbourg, Christophe. 4.
pp. 119.

236

— TjCtj, 0., Beport on Hie Puei-per^ Fever, Observed at the Oftsfcfrw!
Clinic of Slra^urg during 1856-57, etc,

20. Macari, Fr., on Puerperal /"eyer. — Gaz. Sarda.

3l. Brochin, on Puerperal Fever. — Gaz. des Hop. 81, 84.

22. Legroux, on Puerperal Fever. — Bull, de Th^r. LV. Jaly.

23. Virchow, on a Puerperal Fever Epidemic. Observed in the ChariU
of Berliii. (TranaactioiiB of the Berlin Obstetric Society). — Modi
Schrift f. Gcburtfik. June. — New York Jour. Sept.

24. Lehmami, L.. on Puerperal Fever. — Jour de Brux. Septoi
and October.

25. Qu'eal ce que la JUvre puerpiralef Etudes eur les maladiea
femmes en couche. Par Dr. F. Gallard in Evo. de 30 pag.
Lab^, 1858.

— What is the Nature i^ Puerperal Fever* Bemarhi on the Diaetuea
of Women in Childbed. By F. Gallard, M.D., etc.

26. O'Reilly, T., Obgervaiiona on the Identity of Erysipelas and Piter-
peral Fever. — Diffuse Ii^mmalion consequent on Ert/gipelae. —
Poisoning of the Blood after Parturition. — Anier. Med. Gaz. IX.
12. Dec.

27. Noizet, R., Prof. Simpson's Viexes on Contagion and Propagation
of Puerperal Fever.— G&z. Uehd. V. 21.

28. Prosper de Pietra Santa, on the Pathology of Puerperal
the Fiorence School. — L'Uuioii. June, 24.

29. Tamicr and Yulpian, on the Pathological Anatomy of
Feuer.— Gaz. Hebd. V. 17.

30. ^a.r\nan, on Puerperal Metro-Peritonitis. — TLefiis. Paris, 1858.

31. Etudes sur la nature et te traiiemeni des JUvres puerpirtdes, dee Se-
sorpCions purulentes el des Sesorpliona putrides. Far de Mattel,
Prof, partic. d'accouchemente. In 8to. de 51 pag. Paris, 1858.

— The Nature and Treatment of Puerperal Fever, Purulent and Pu-
trid Resorption, By Mattoi, M.D., etc., etc.

32. Koch, on Puerperal Metastasis to the Thyreoid Oiinrf.— WUrtemb.
Corr.-Bl. No. 10.

33. The UrcBmio Convulsions of Pregnancy, Parturition, and ChUtOted.
By Dr. Carl Braun, Prof, of Midwifery, Vienna. Translated from
the German, with Notes, by J. Matthews Duncan, F.R.C.P.E., Lec-
turer on Midwifery, etc. 12mo., pp. 182. New York, S. and W.
Wood, 1858.

34. Pirrie, on Puerperal Convulsions. — Dubl. Jour. February.

35. Isham, R. N., of Chicago, III., on Sotne of the Causes of Puei
Convulsions. — Chicago Jour. I. 10. Oct

36. Litzmanii, New Contributions to the Doctrine of Uramiia during
and after Pregnancy, — Mon..Sclir. f Geburtsk. June, — New York
Jour. Sept.

37. Lindslay, C. A., on Puerjteral Convulsions. — Trans actiona of
Connecticut Med. Society. May.

hariU

rropogiattm

d Fever I^H

•T'l^

237

38. Pesch, Ca»e of Puerperal Edampsia; Becovery.—T£on.^hT. f.
Geburtak. XII. 8. Sept.

SS. WeffBcheider, Case of Puerperal Edampsia. — ^Mon.-Schr. f. Ge-
bnrtsk. XII. 3. Sept.

4€. Paget, Case cf Eclampsia, — Gaz. des H6p. 14.

^1. Findlay, W. S., of Fazcwell, Tenn., on a Case of Puerperal Con-
vuhions, — Med. Report. March.

^2. Boorsier, Eclampsia during the Sth month of Pregnancy; Delivery
of two Children, United by the Sides. — L'Union T4.

43. Croskery, H., a Case of Puerperal Convulsions; Recovery, — Med.
Tim. and Gaz. Juno 19.

44. Carville, Eclampsia during the bth month of Pregnancy in a Chh-
rUic Primipara; Phld)otomy; Recovery. — Gaz. des H6p. August IT.

45. Dale, W., Three Cases of Puerperal Convulsions; Death and Au-
topsy, — ^Med. Tim. and Gaz. 393. January, 9.

46. Levergood, S., Puerperal Convulsions from Oastric Irritation. —
Amer. Med.-Chir. Review. II. 2. March.

46. Welling^D, W. W., Puerperal Convulsions. — ^Boston Jour. LIX.
18. Dec. 2.

4T. Chapman, E. N., of Brooklyn, N. Y., Cases of Puerperal Convul-
sions with Remarks upon the Treatment of Eclampsia, — New York
Jour. V. 3. Nov.

48. Moreau, L., Compression in the Treatment of Phlegmasia Alba
J)olens.—Gsa. des H6p. 100.

49. Atthill, L., on a Case of Puerperal Mania. — ^Dubl. Jour. LI. Aug.

60. Lebert, Puerperal Chlorosis uxith Fatal Result. — Wien. Med.
Wochenschr. August 21.

51. Gaulson, W., on Secondary Affections of the Joints in Puerperal
Women. — Brit. Jour. March. — Amer. Med.-Chirurg. Review. May.

52. Clemens, Th., on Color-Blindness during Pregnancy; with Re-
marks. — ^Arch. f phys. Seilk. H. I.

53. Ulrich, on a Case of Vomitus Gravidarum; Death in the 4tth Month
of Pregnancy, — Mon. Schr. f Geburtsk. February.

54. Buckingham, Vomiting and Purpura during Pregnancy. — Boston
Jour. LIX. 5. Sept. 2.

The most important event of the year was the discussion on
puerperal fever in the Paris Academy of Medicine. The incident
which called forth the discussion was of a trifling nature. Dr.
Ou^rard lost a patient from puerperal fever, and this accident induc-
ed- him to bring the subject of puerperal fever before the Academy.
The first orator moved in very limited circles, which growing larger
and larger gave origin to some of the most interesting and elaborate
Communications on record. The old guard took the lead in the
battle, the fight was hot and spirited, agitating this learned body
IVom centre to circumference. The great attraction of these academ-
ical discussions is due to the fact, that the members of this Society
<io not confine their study to their respective speciality, but are able

238

to speak on any subject of general interest, while, on the other hand,
the great oratorical capacities with which almost every member of
the French Academy is gifted, renders these speeches often more
lengthy than desired. With regard to the final result of the discut-
sion before us, we must say that science has been very little ad-
vanced by it, cither from a theoretical or a practical point of view.
The ideas as to the nature of the disease are just as unsettled ai
they were before, the only point upon which all agreed being the in*
efficiency of all the means hitherto proposed for treating the fever.
The spirit exhibited in this centre of medical science spread all over
the country, and roused the medical press, and called forth a more
or less important treatise from the pen of almost every prominent
member of the French profession.

The points offered by Dr. Guerard, on which the discussion centered,
are comprised under three heads — 1. Nature of the duease. 2. Modt
of propagation, 3. Treatment.

1. Wliat part do the local inflammations have in the production ci
the fever ? It is a fact that in many cases of puerperal fever no
local lesions whatever are to be found after death (observations of
Tonneld, Voillemier, Bourdon) ; while in those cases of a ** foudroyant"
type there is no chance for the development of any local disease.
The puerperal fever begins, in many instances, during confinement
or soon afterwards, while the first symptoms of local inflammations
always occur after a certain length of time, and these lesions vary
in number and intensity following the peculiar nature of eadk
epidemic. Therefore, these local inflammations are of a secondary
order, and the consequence of a general cause. Is the cause of puer-
peral fever a purulent infection ? The starting-point of purulent in-
fection is the presence of pus in the veins and lymphatics. But, in
many cases of puerperal fever, neither phlebitis nor lymphangoites
are met with ; and, on the other hand, a phlebitis may occur after
confinement without producing puerperal fever, and several persons
have injected pus into the veins, but failed to produce serioutt
lesions. Therefore, puerperal fever is not due to purulent infection.
The blood of every pregnant or parturient woman has a particular
constitution, which is liable to generate specific vims in mother and
child, under favorable circumstances, the symptoms of which are
comprised under the name of puerperal fever. 2. Mode of propaga-
tion. There is a sporadic and an epidemic form under which the
fever manifests itself. One way of propagation is by infection^
because, as soon as an epidemic arises in an hospital, it has been
found a good plan to shut it up ; because women near their full term
leaving the city when an epidemic rages, are benefited by this
change ; because women living for a length of time in an infected
place arc less liable to the disease than those who have recently en-
tered it. Those facts reported by Dr. Depaul seem to establish the
fact, that puerperal fever is transmissible by some kind of inocula-
tion, or by the emanations coming from the patients. 3. Treatment,
The chief remedies proposed for the cure of puerperal fever are — 1.
Antiphlogistics. 2. Narcotics. 3. Sulphate of quinine. 4. Ipecacu-
anha and mercurial ointment. At the beginning of the disease, local

239

aotiphlog^tics have been used successfully in some foims. The
experiments with narcotics are not numecpus enough to decide on
their valne. The opiam seemed to have a good effect in some
(sporadic) cases, in the dose of 20 or 25 centigrammes pro die.
[Thia is a remarkably small dose. — E. N.] Drs. Beau and Lcudct
have used, -and, as it seems, successfully, the sulphate of quinine.
Ipecacuatiha, used even now extensively, has been employed very
raccesBfully (Tonneld) for some months, while after this time not
one* patient was benefited by emetics. Therefore, we have no specific
remedy for puerperal fever, and different epidemics demand a differ-
ent treatment

After thus opening the discussion en feu de tirailleur, Dr. Depaul
prepares to make the first charge. There is, no doubt, a peculiar
disease that must be called puerperal fever, the seat of which is
primitively in the blood. The disease is of an epidemic nature, it
developes and behaves like most of other general diseases (typhus,
cholera, etc.). It spreads most extensively in places crowded with
women in childbed. Its outbreak is often preceded by other general
diseases, such as diphteritis, purulent ophtalmia, erysipelas, etc.
The disease called puerperal fever at times seizes upon persons who
are not in the puerperal state. During violent epidemics it happens
that pregnant women are taken, and die from it even before labor
hid commenced. In other instances the poison particular to this
disease developes during labor or shortly afterwards, and death fol-
lows in a few hours. The foetus, while in the womb, may be affected
by this poison, and at times some of the local alterations belonging
to puerperal fever are found on its body. Sometimes all women who
sre delivered on the same day are stricken with the disease, while
those who are confined the following day escape, though they are
apparently under the same condition.

In almost every serious epidemic, some cases may be observed
wliere no local lesion whatever is present. Dr. Depaul recollects
one case of this kind, where the patient died 15 days after the begin-
ning of the affection — some alterations in the blood were all that
oonld be detected. In some epidemics the inflammatory affections of
the peritoneum prevail, in others presence of pus in the lymphatics
or pleuritis, meningitis, arthritis, etc., are prevalent.

The epidemic nature of the disease cannot be doubted ; in some

?laoe8 it recurs every year. From the statistics of the Maternite de
^aris, it appears that from 13,826 women confined during 5 years,
880 died from puerperal fever, i. e,, 1 out of GO. This is a small
number compai'ed to the average number of deaths of the other
obstetric hospitals. Of 2,478 women who were delivered at the
Maternity during 1856, 114 died from puerperal fever, t. e., 1 out of
19, while in the city (12me. arrondissement) only 1 out of 322 died
from puerperal fever in the same year, which proves that the mor-
tality in the city was seventeen times less than in the Maternitd and
Glinique. Of all the obstetrical hospitals the Hopitul St. Louis
shows the smallest number of deaths, even a smaller than the 12me.
arrondissement. The explanation of this fact may be taken from the
small number of confinements, or from the disposition of the single

240

wards, the obstetric department of this hospital being exposed to
the west and east. It contains two large rooms, each of 8 beds, and
8 small rooms, with one' single bed. The Hopital Lareboisi^re, on
the other hand, shows a large amount of fatal cases, though it has to
excellent situation and a favorable disposition inside. ]^:x>m 31,661
women in the different hospitals, 644 died from puerperal fever, t. &,
1 out of 48 women. Puerperal fever, like all general diseaaei,
becomes contagious under certain conditions. Two cases are record-
ed where the nurses took the disease from women affected with p1le^
peral f^ver. At times it happens that all women delivered in certain
beds die one after another from puerperal fever, while those lyinr
beneath them in other beds escape. Two observations are reported
by Dr. Depaul, which seem to show that the disease might be tram-
ported from one to another place by healthy individuals after fre-
quent intercourse with the sick. Another fact speaking in favor of
the essentiality of the disease is the altered condition of the blood,
as observed by Depaul, Yirchow, Scanzoni, Lehmann.

'With regard to diagnosis of puerperal fever, it may be said that
it has no pathognomonic symptom of itself, and it is rather the coin-
cidence of several symptoms which characterizes the disease. The
fever generally appears 48 or 60 hours after delivery — seldom after
the eighth day. One of the most constant symptoms is a chill at the
beginning, wliich in most cases appears only once, or recurs after
24 or 36 hours, while sometimes it repeats at regular intervals, thus
simulating intermittent fever. After this the pulse rises generally
up to 140 or 160 strokes in a minute. The temperature of the skin
is not increased in a very remarkable degree, while it is generallv
dry, the cold sweat making its appearance towards the fatal end.
The trouble in the respiration is very significant, it being shorty
hasty, and intermixed with deep inspirations. The change of expres-
sion in the features has been observed by most physicians to be per-
ceptible from the beginning of the disease. With this are combined
certain intellectual troubles, the patients seem to awake from a
slumber when accosted, and speak often with a peculiar trembling
voice. In some of the most unfavorable cases, pains around the
joints or in different muscles are observed, not unfrequently combisr
cd with a red hue of the skin, a disposition which unavoidably leads
to a fatal result. Diarrhoea is seldom absent ; abdominal paina, in
some instances, very violent, in others wanting. To distinguish
puerperal fever from purulent infection, the following points have to
be considered : purulent infection is not known to set in before the
8th or 10th day ; the chills are generally multiple, followed from the
beginning by copious, viscous sweats ; they repeat for several days
in irregular intervals ; the skin takes a dirty icteric appearance ;
the urine has a peculiar stench ; there is a great tendency towards
formation of abscess in the areolar tissue or the cavity of the joints ;
the disease lasts at least 8 or 10 days, often many weeks. Another
affection akin to puerperal fever is the putrid infection, which
depends from different circumstances ; at times it arises from decern*
posed clots of blood retained in the vagina or uterus ; in other in-
stances retained pieces of the membranes or of the after-birth are^the

cause of it, or it comes from the dead fcetus itself. In putrid infec-
tion the chills are not seycre, the tongue becomes dry and furred,
the expression terrified ; when this condition has lasted for awhile it
dianges to a hectio fever, with diarrhcea. The typhoid fever is
easily distinguished from this affection. With regard to treatment,
the right way has yet to be found ; wc have no remedy which can
be relied upon. The very few cases (2 or 3 out of several hundreds)
which Dr. Depaul saved, were treated with mercury, althougli in the
greatest number of cases this remedy had not the least influence,
and not one case of genuine puerperal fever has been benefited by
qnininc. With regard to vcratrum viride, Dr. Depaul suggests that
tills remedy will not sustain for a length of time the sanitary in-
fluence attributed to it by Dr. Barker. As a prophylactic remedy,
the sulphate of quinine has not rendered any better services to Dr.
Depaul, though other authors seem to have derived considerable
benefit from its administration. Up to the present time, no prophy-
lactic measure has been found which was apt to influence the pro-
gress of the disease. The only way to diminish the number of
victims would be, to abolish all lying-in hospitals, and have the
women delivered at their own residences.

8. Dr. Beau defended his medication (sulphate of quinine in high
doses) against Dr. Depaul's aggressions, who asserted that the cases
cared by Dr. Beau were not exactly what is called puerperal fever.
Dr. Beau professes his belief that puerperal fever is a symptom con-
nected with peritonitis, or some other inflammation. The existence
of a so-called inflammatory diathesis cannot be doubted. This same
diathesis exists in puerperal women, and this is the pathological in-
ilacnce to which must be attributed the production of the manifold
local inflammations during childbed. The symptoms of this condition
vary with the different local aficctions. Besides this diathesis, there
exists an epidemic influence, jill now perfectly unknown in its
natnre ; both combined produce the difTbrent phlegmasies of the
puerperal state, and of these the peritonitis is met with in 19 out of
20 fatal cases. Follows a description of the peritonitis, of which he
distinguishes the supra-umbilical (general) and infra-umbilical form ;
the former alone is sufScient to produce, like general pneumonia, all
the disastrous symptoms attributed to puerperal fever. The inflam-
mation of the peritoneum depends from a previous general trouble of
the system ; this is for Dr. Beau the inflammatory disposition, while
it is for Dr. Depaul and the rest the puerperal fever itself. To give
farther proof of h|i assertions. Dr. B. ^oes on to show that puerperal
peritonitis bears the character of a phlegmatic, and not of an erup-
tive fever, as claimed by his adversaries. Moreover, there is never
an eruption to be found as it is in typhoid and similar aficctions.
The typhoid symptoms, as observed occasionally during puerperal
fever, prove nothing against the theory, many other inflamma-
tory diseases presenting the same typhoid symptoms. The blood
has the same qualities as that in other inflammatory diseases, viz.,
increase of fibrine, just the reverse of what is found in eruptive
fevers. With regard to puerperal fever without local lesions, it
must be remembered — 1. That these are exceptional cases. 2. That

242

the local disease is oftein unobserved, even after a rigid post-mortem
examination (two cases reported). 3. It happens that women in
childbed die from a fever which is by no means of a paerperal dla^
acter, as might be seen at times in a Ijing-in hospital at a time
when no puerperal epidemic is prevalent. 4. If the blood of manyof
these so-called puerperal fever patients was to be examined, many
cases would turn out to belong to the •eruptive class.

It is of greatest importance to begin with the treatment of piunv
peral peritonitis as soon as possiUle. First of all/ an emetic has to
be given, consisting of ipecac, I grm.; tartar emetic, 10 cgrm.; one*
half of it to be taken every half hour. This is to remove the billons
habit often connected with the fever, and in order to better prepare
the stomach for the reception of the quinine. The first dose of sul-
phate of quinine, 1 grm., is given after all nausea has passed over ;
8 hours after this, l^b cgrm. are given, and the same quantity after 8
other hours. During the following days, this treatment is continued
every eighth hour ; as soon as the physiological effects of the quinine,
drowsiness, deafness, etc., begin to show, all the symptoms of the
disease lessen in a remarkable degree. This treatment must be con-
tinued for some time, and if the powder is rejected it must be given
in another form, in pills, etc. Besides this, a flying vesicatoire may
be placed upon the most painful spot of the abdomen. The curative
effects of quinine are restricted to those cases where the peritonitis
has not reached the superumbilical region ; and it is also of no avail
when a concretion of blood has formed in the heart. The non-emcoess
of this remedy in the hands of Dr. Depaul, is explained by the fact
that his doses were not sufficiently large ; it ought to be g^ven in
the dose of from 2 to 3 grammes in 24 hours.

4. Dr. Piorrt, after a sketch of the different conditions generally
comprised under the name of puerperal condition, and a description
of the peculiarities of the puerperal state, comes to the conclusion
that puerperal fever is not '' une un&i morbide,^' but the reflex of one
or more of these puerperal phenomena, exaggerated to a real disease.
And after all, there might be a virus which propagates the fever,
which, however, spontaneously developes in patients who had no
communication previously with other puerperal patients. We, there-
fore, have not to deal with a specific puerperal fever, but with a
patient suffering from septic uteritis, phlebitis, modified by the pres-
ence of putrid matters in the womb, metroperitonitis, septic peri-
tonitis, septicemia, pyaemia, plcuritis, arthritis, retention of foBces
and gas in the intestines simulating peritonitis, hypemia, or a coor
siderable elevation of the intestines and the diaphragma, owing to
aforesaid circumstances, with difficult respiration, dilatation of the
heart, pulmonary congestion, accumulation of phlegm in the air-
tubes, hyposemia and death. By taking this view, the indication
for treatment is not derived from a disease called puerperal fever,
but from its elements, and against every one of its elements, as
pointed out 'above, the treatment must be directed. In specifying
the remedies to be applied against every one of the original diseases,
the author lays great stress upon the necessity of cleansing injections.
Dr. Piorry has not lost one single patient in the piti^, from puerperal

243

peritonitia, for fiyo years, owing to these iiyections. Against accu-
malation of gases or faeces, cathartic injections and oily frictions in
the direction of the intcstinum crassum, have had a wonderful effect.

5. Db. Hervkz de Cheooin declares for the specific nature of puer-
peral fever, it being a disease for itself, which can exist independently
firom any inOammatory affection. There are two varieties of puerpe-
ral fever ; one a putrid, one a purulent puerperal fever ; putrid or
pumlent infection starting from the uterus being the cause of the
disease in question. All prophylactic remedies are of no avail be-
fore we know which form we will have to deal with. After even
the safest delivery, injections into the womb have to be made when-
ever we suspect that small particles of the placenta or the mem-
branes are left behind, or a foetid discharge begins to issue from the
genitals. But as soon as the putrid infection or puerperal fever is
established, we have to fulfill three indications, viz.: 1. To remove
the cause. 2. To neutralize it. 3. To put the organism in a proper
condition to resist the toxic influence. The remedies for this pur-
pose are injections, cathartics or sudorifics, antiseptics and tonics.
In the purulent form, at the beginning, an energetic antiphlogistic
treatment must be applied.

6. Dr. Trousseau does not acknowledge a fever peculiar to women
in childbed, but only a fever peculiar to wounded men and women.
In the epidemic of 1855, when so many women died from the f(iver,
it was very remarkable that an unusually large numl>er of children
fell under umbilical phlebitis, peritonitis, pleuritis, etc. ; children of
mothers who were never taken with the disease, besides many chil-
dren still-born with peritonitis from a healthy mother. The men,
upon whom operations had l>een performed in the surgical wards,
died in great numbers from inflammations of the serous and synovial
membranes, from putrid fever, as soon as in the adjacent lying-in
irards the puerperal fever began to develop. The fever appears in
different forms, as a purulent, a putrid, or a nervous typhus. These
different affections do not belong exclusively to women in childbed,
but are observed in the foetus as well as in male patients. In the
epidemic which Dr. Lorrain has described, 7 or 8 children died in utero
with pns and false membranes in the peritoneum. In 1842, Dr.
Trousseau described as puerperal fever of the foetus, certain forms of
erysipelas, phlebitis, and muguet of new-born children. Also, Dr.
Lmrrain has already pointed out the resemblance of the foetal and
the puerperal state, comparing the umbilical wound with the denuded
smrface of the womb, and calling the purulent secretion from the
navel, umbilical lochia. From this point, absorption followed by
phlebitis is easily established, and these children die from erysipelas,
putrid inflammations, or diphtheritis. But some women are taken
with puerperal fever at the beginning of labor, no wound being as
yet established (Tarnier, Dubois, Danyau), and even mid wives
attending fever patients, during (Depaul, Delpech, Danyau, Dubois),
or even some time after menstruation (Tarnier), have been taken
with the disease. In women who died from puerperal fever, pum-
lent metastatic collections have been found in tlie pleura, in the
articulations, etc. Dance and Tessier found the same lesions in the

244

men who died from traumatic fever. This traumatic fev43r of womeo,
children, and men, has a specific cause ; it is a morbific substance
which enters the system, finding especially upon wounds a fertile
soil for development, from whence it is diffused throughout the sy>-
tem. This specific materia does not always originate from the
female, and does not belong to her exclusively. The only thing that
makes women in childbed more apt to get this fever, is the peculiar
condition, by which she is less liable to resist the influence of morbid
causes. With regard to treatment, not a single remedy has given
satisfactory results ; a remedy successfully applied to-day in end
locality, fails to-morrow or in another quarter.

7. Dr. p. Dubois distinguishes two groups of morbid phenomena in
puerperal women. In the first instance, the disease begins with a
chill, followed by fever, flushed cheeks, violent headache, a moist
whitish or yellow tongue, quick respiration, a moderate pain in the
lower part of the abdomen, while the womb is painful when touched
through tlio flaccid abdominal walls, the secretion of milk is dis-
turbed. The second form is in some respects similar to the foregoing
condition ; it has a chill at the beginning, fever, headache, alteration
of the features and respiration, abdominal pain, suppi'ession of milk ;
and still the character of all these symptoms differs considerably
from those of the first order. The chill is more intense, of loneer
duration, and nearer to the time of delivery ; the face, instead of bemg
red, is pale and greatly altered, the respiration rapid and oppressive :
there is a constant agitation ; the abdominal pain is stronger, ana
taking a larger surface, the abdominal walls are bulged froni meteo-
rismus, and, instead of constipation, diarrhoea is present ; the dis-
ease is almost always fatal. It is the second form only that comes
under the head of puerperal fever, while the former affection may
increase to such a degree that it becomes equivalent to puerperal
fever in its ultimate results. The only cause of puerperal fever is a
primitive alteration of the blood, . the nature of which is hitherto un-
known ; neither the theory of purulent nor of putrid infection as a
cause of the fever are admissible.

8. Dr. CRUYEiLmER. — There are two forms of puerperal fever ; a
benign and a malign form. The former consists of a uterine phle*
bitis, not surpassing the obliterating or adhesive stage, which is at
times combined witli partial peritonitis ; the other form, or the classic
puerperal fever, has four striking characters, viz.: 1. Chill at the
beginning. 2. Pcritonitic abdominal pains, before, during, or after
the chill. 3. Profound alteration of the features. 4. Extreme weak-
ness, frequency, and softness of the pulse. During the five epidemics
observed by Dr. Cruveilhier, every kind of treatment was tried, but
to no avail. In the epidemic of 1832, from 15 women affected with
the fever, 10 were dead on the fifth day, and the cholera which pre-

. vailed at the same time in Paris, left not by far an impression upon
the orator's mind similar to that of puerperal fever, which he used to
call puerperal typhus. The only remedy that could have an influ-
ence upon this dreadful scourge, is the closing up of all lying-in hos-
pitals, and have the women attended at their residences. It is a
contagious miasmatic disease, like the hospital gangrene. With

246 •

regard to the pathological anatomy of puerperal fever, it is astoniBfa-
ing how little time is wanted for the produotion of pus in this disease.
Dr. Gmveilhier has found pus in the peritoneum 24 hours after tlie
iuTasion of the disease. The tendency to formation of pus is the
great feature of puerperal fever. After peritonitis, purulent subper-
itoneal cellulitis is roost frequently met with. The second chief
lesion owing to puerperal fever, is purulent lymphangitis. This is
specific to puerperal fever, and met with in no other disease. The
presence of pus in the uterine veins is by no means as often found as
pus in the lymphatics. In all, or almost all, post-mortem examina-
tions performed from June, 1830, to September, 1832, purulent
lymphangitis was found, while only 8 cases of purulent phlebitis
presented themselves ; and while purulent phlebitis is often observed
unconnected with pen ton it is, the lymphangitis is almost always found
in connection with peritonitis or cellulitis. The metastatic abscesses
in liver, lungs, etc., are always the consequence of phlebitis, but
never originating from lymphangitis, as the interposition of the
lymphatic glands prevents the spreading of purulent infection.. It is
easy to distinguish both lym^^hangitis and phlebitis from each other ;
the purulent veins always exhibit traces of inflammation, their walls
are thick, brittle, injected all over their external tunic, adherent to
the adjoining tissues, surrounded by a pseudo-membranous layer, or
containing fragments of coagulated blood. The lymphatics have very
thin and generally transparent walls, and are in no connection with the
neighborhood ; the pus they contain is of a very pure quality, looking
like milk, and in tracing their course they are found to run towards
the lymphatic glands, which are injected with pus. Besides these
chief characters of puerperal fever (peritonitis and lymphangitis)
the third in frequency is uterine phlebitis, the fourth, purulent phle-
bitis. With regard to the question wHether the fever is the primitive
element, or the local inflammations, Dr. Gmveilhier proposes that
puerperal fever is fever and inflammation at once, both being the
consequence of one common cause, viz.: miasmatic infection. The
best name to express the nature of puerperal fever would be : trau-
matic fever (^ toomen in childbed, as a recently delivered woman may
be compared exactly to a person upon whom a great surgical opera-
tion has been performed.

9. Dr. Danyau. — Puerperal fever is a disease of miasmatic origin,
which entering and poisoning the blood, renders it liable to produce
in most cases, very rapid inflammatory deposits. It is a remarkable
fiict, that the epidemic spreads at times over whole cities, countries,
tnd even continents. In 1819, for instance, the fever was observed
It the same time at Vienna, Prague, Dresden, Wlirzburg, Bamberg,
Ansbach, Dillingen, in many towns of Italy, at Lyons, Paris, Dublin,
Olasgow, Sterling, Stockholm, Petersburg. Some of these epidemics
even extended to the domestic animals, to the bitches, for instance,
during the epidemic of 1787 and 1788, at London ; at Edinburgh, in
1821 ; at the same time cows were afflicted in several parts of Scot-
land, and hens in the neighborhood of Prague, in the epidemic of
1835. To prove the miasmatic character of the disease, Dr. Danyau
reports several cases where children died shortly after confinement,

246

from mothers who were taken with puerperal fever. With regard to
the Question of transmissibilitj of the miasma from one person to
another, Dr. Da^iyau reports a great number of facts, which seem to
show that an accoucheur, who attended a lady stricken with the
fever, is apt to propagate the disease to other women in dhildbed.
Dr. Scmmelwcis' theory of cadaveric infection is not considered
as established beyond doubt, still it would be unsafe to attend a
woman in confinement immediately after performing a post-morten
examination, without taking such precautions as may seem efficioBt
to lessen the probability of transportation of putrid effluvia. The
sulphate of quinine has been tried by Dr. Danyau, but not fulfilled
what was expected from it. Dr. PiddagnePs phophylactic remedy
(sulphate of quinine and carbonate of iron) was tried in three bundled
women, near their full term, and the result was, that the proportion
of severe cases and deaths was smaller among the women who were
treated in this way, compared to those who underwent no prophylac-
tic treatment, while on the other hand, the value of this remedy bo-
comes very questionable, when eight women out of one hundred
exhibited serious puerperal diseases, f^d five died from tiuree hun-
dred women confined in a hospital, which at the time of the experi-
ment was not subjected to the epidemic. The only effective remedy
would be, perhaps, the suppression of all lying-in hospitals, but in
doing so, the great advantage for instruction would be lost, a host of
homeless women would be delivered under equally disadvantageous
circumstances, and very likely the fever would spread more exten-
sively in the cities than it has done before. Instead of abolishing
the hospitals entirely, it would be better to increase their number,
and use the different wards in rotation ; airing, fumigating, and *
whitewashing the rooms as they arc emptied.

10. Dr. Gazeaux insists upon the alteration of the blood in puer-
peral women, and its influence upon the production of the disease in
question, the inflammatory character of which cannot be doubted.
He does not admit a puerperal fever as coming from a specific on^
side influence. It is the intense alteration of the blood that renders
inflammations of women in childbed so disastrous. All diseases tak-
ing women in childbed take a very severe course, such as scarlatina^
smallpox, pneumonia, pleuritis, etc. ; why should not inflammations,
peritonitis, lymphangitis, be more disastrous with women in child-
bed than otherwise. This propensity to disastrous diseases, nat-
urally increases at the time an epidemic prevails, as is the case with
bronchitis, pneumonia, etc., and it is not necessary to acknowledge a
specific inflaence producing puerperal fever. With regard to treat-
ment, Dr. Gazeaux asserts, that he never saw a woman die who
could be salivated by small doses of calomel, but it is difficult to
bring on salivation very quickly.

11. Dr. Bouillaud declares for the non-essentiality of puerperal
fever ; he does not consider it as a fever sui generis ; it is a traumatic
fever, modified by a peculiar condition of the blood of women in child-
bed. The puerperal state is a kind of intermediate condition be-
tween health and disease (un ^tat semi-pathologique) ; its likeness
with the condition of wounded )>ersons is so generally admitted, that

247

no Berioiu contradiction has been sustained on this point ; the puer-
peral Btate constitutes a morbid predisposition in general, and an
erident predisposition to certain local and general affections, viz.,
inflammations and feverish reliction ; inflammations developing dur-
ing the puerperal state, have a marked tendency to suppuration ;
tlie paerperal state does not only influence the generative organs,
bni has a bearing upon the entire system ; therefore the puerperal
state is an aggravating circumstance in all inflammatory or other
diseases arising during its existence. From these considerations, it is
evident that the word puerperal may be applied for those local inflam-
mations with a fever which seize upon the puerperal woman ; it repre-
sents the modifications which the puerperal state contributes to
these afiections. Dr. Bouillaud proceeds to give a historical sketch
of the previous discussions on puerperal fever ii^France, and con-
siders some of the weak points of the speeches of his adversaries,
especially of Drs. Trousseau and P. Dubois, and shows that puci*peral
fcver is not a fever sui generis , because neither its seat, nor cause,
qrmptoms, evolution, course, treatment, mortality, or denomination,
bave anything peculiar. The purulent and putrid infection of the
blood are sufficient to explain the general phenomena which consti-
tute paerperal fever.

18. Dr. Dubois, in a second communication, subjects the facts
called forth to prove the possibility of transmission by contagion, to
a rigid examination^ and comes to the conclusion, that this way of
propagation is far from being established beyond doubt. He be-
lieves that the conditions necessary for the development of puerperal
fever exist already, before labor begins, in a certain number of sub-
jects, a fact which can not be explained either by putrid and puru-
lent infection, or by the so-called uterine tranmatisme. With regard
to treatment, nothing can be done against the veritable puerperal
fever (Dubois's second class. Beau's peritonitis supra-umbilicalis),
while its milder form may be overcome by different remodies, such
as qainine, ipecac, tartar emetic, bleeding, etc.

18. Db. Piorbt, in a second communication, insists upon the fact,
that in a gpreat number of cases the decaying contents of the uterus,
sadithe putrid infection of the blood from this source, constitute the
so-called puerperal fever, and he thinks that the discussion in the
Academy is only a fight about words, as the different speakers agree,
witbont knowing it themselves, upon the nature of the disease. He
proposes the name of septicemia, as best designating the sources of
the diseasO) viz., from putrid infection from the uterus, and by the
respiration of an atmosphere pregnant with septic particles. The
septicemia originates as well from a wound cut with a scalpel, con-
taming cadareric blood, as from a bed-sore in putrifaction, and from
tplaoe overcrowded with patients. The admission of this septicemia
explains the putrid accidents, as observed in men, the foetus, and
wounded persons during a puerperal epidemic.

14. Dr. Dubois, in a third communication, expresses his belief, that
the suppression of the lying-in hospital would not effect a consider-
able change in the rise and spreading of the disease, as it is well
known that very often the epidemics in hospitals are preceded by

248

severe outside cases, and epidemics in even the smallest cities have
been observed of a more disastrous character than those seizing upon
hospitals. The only justifiable means to prevent the disastroos
spreading of the disease, consists in a profound modification of the
present lying-in asylums. In the neighborhood of the present baild-
ings, new ones ought to be erected fit to receive six or eight hundred
women every year. These should be divided into two principal sec-
tions of equal capacity, each one of these sections to be subdivided
into difierent rooms, each capable of receiving ten beds, which must be
separated from each other by a larger space than is generally allowed
in ordinary hospitals. To this construction, the best mode of ventila-
tion is to be added. The small rooms ought to be used in rotation,
each of them to be thoroughly aired and cleansed after having been
in use for a length of time. At a time when an epidemic begins to
make its appearance, the hospital aficcted ought to be closed entirely,
and the women attended at their homes.

15. Dr. Trousseau, in a second communication, resumes his views
under the folio wing heads : 1. The puerperal fever does not differ from
the so-called chirurgical fever (" purulentc, de resorption"); 2. In
the great majority of cases, the placentar wound occasions the dis-
ease ; 3. Its cause exists in a specific principle, only known in its
efiects ; 4. It is not impossible, that even a person not wounded,
might be afiected by the disease during an epidemic. A healthy
woman coming from the country to Paris to be delivered in a few
hours, is taken there with a violent fever and dies in a few days :
a disposition in the blood is not required ; she catches the disease
as she would the cholera, the yellow fever, or the intermittent
fever. In puerperal fever the general afiection does not exist pre-
vious to the local lesions, except in a few very rare instances, nor
is the vascular inflammation of that great importance imputed to
it. Phlebitis exists in almost every case of delivery ; it is to be
found with every wound ; the adhesion of the coagulated blood with
the walls of the vessels, is a sign of present or past inflammatioit
Phlebitides of great extension, spreading from the foot up to the
vense iliacss, the pHegmasia alba doleus, make very often not the
least impression upon the system, producing scarcely any febrile re-
action. Why, then, should phlebitis be of such vast importance in
the puerperal state ? Some other specific influence must be added
to the phlebitis, in order to render its presence so very disastrous as
it is in puerperal fever. Moreover, it has been demonstrated that
the pus-globules are too large to pass through the capillary vessels ;
even the presence of laudable pus in the blood does not make any
considerable impression upon the system, a fact well proven by ex-
periments, while putrid particles injected into the blood prodnoe
violent general accidents. Nor does the serum of pus, if absorbed, as
it happens in tuberculous patients, produce symptoms similar to
puerperal fever, but only what is called colliquative symptoms. At
times it happens that the most insignificant operation, as the de-
pression of a cataract, the opening of an abscess, leads to traumatic
typhus and death ; there must be a specific cause to produce these
fatal eflfects. Why is it that women outside the hospital, where they

249

lire in filth and dirt, in the most anlicalthy locations, do not die from this
fever? Why is it that at times when the hospitals arc over-crowded,
not a case of fever is observed, when at other seasons they die by
the dozen, although the number of women in confinement is compara-
tively small ? Dr. Trousseau firmly believes that the contagious mias-
ma of traumatic and puerperal typhus, remains in a latent state, in
the Burgical and obstetrical wards, rising to activity at certain days
under certain unknown conditions. If the hydrophobia proceeds
from an infecting bite, the syphilis from an infecting ulceration, then
the traumatic fever must proceed from an infecting wound, and the
poerperal fever from an infecting placentar wound. In some very
rare instances, the infection in puerperal fever might be established
" d'emblde,'' i. e., not entering through the wound, but thro.ugh the
longs or skin.

16. Dr. Yelpeau read some portions of his former articles on
imerpcral fever, written about thirty years ago, thus showing
that all that has been said pro and contra is not much more
than a repetition of former ideas. For his own part, Dr. Yelpeau
has not changed his mind since the time of his first writings.
Puerperal fever is a peritonitis, a lymphangitis, a phlebitis, a puru-
lent or putrid infection, modified by- the puerperal state. The dis-
ease is a specific disease, inasmuch as every disease has a more or
less specific character. With regard to treatment. Dr. Yelpeau ad-
lieres to his old propositions, viz. : bleeding, calomel in small doses,
mercurial inunctions (10 grms. every two hours), and afterwards
an enormous flying vesicatoire upon the abdomen.

IT. Dr. Ouerik considers the more or less perfect contraction of
the womb after confinement in connection with puerperal fever. In
ordinary cases the fundus uteri is situated in a line with the umbili-
cna immediately after delivery, while, during the following three or
fbor days, it gradually contracts so that its vertex sinks down as far
as the symphysis pubis. In puerperal fever patients, the fundus not
only remains near the umbilicus during the entire existence of the
disease, but the womb even contracts or swells up according to the
dianges of the disease for good or evil. The consequence of this
flaccid state of the womb is the permanent existence of the cavity in
the nterus, which is filled witli clots of blood or the lochial secretion ;
the placentar wound is extended, the vascular orifices remain gap-
ing, and a permanent contact with the atmosphere is established.
Owing to this, the uterine wound instead of being closed and healing,
qoasi per primam, is exposed to the air and suppurates ; the contents
of the uterus decay by the touch of the atmosphere, and the womb is
filed with a fluid mass in a state of putrifaction. Hence the fatal conse-
quences : chills, fever, poisoning of the blood, secondary inflamma-
tions. This condition of the uterine wound alone would not be suffi-
cient to produce the puerperal fever ; the consequences of this abnor-
mal condition are complicated and influenced by the peculiar dispo-
sition of women in childbed, by the condition of the air in which the
patient is placed, and by many other casualities. The liquids con-
tained in the womb do not only infect tlie blood by resorption, but
pass into the abdominal cavity by way of the tubes, which are often

250

found filled with pus, without offering^ themselves the slightest
trace of inflammation. This explains the fact that the peritooesl
exudation has its principal seat upou the superior layer of the intes-
tines. The weight of the atmosphere, in free communication with the
womb, presses the liquids contained in the womb through the tubes
to counterbalance the diminished intraperitoneal pressure. For
treatment Dr. Guerin proposes the ergot of rye to be given immedi-
ately after confinement, and those remedies which apply to every
single secondary symptom as it makes its appearance.

18. Dr. Cazeaux, in a second communication, answers to some
objections raised' against his theories by some of the former speak-
ers, and endeavors to demonstrate the incorrectness of Dr. Guerin^s
views.

19. Dr. Depaul, in a second communication, defends himself against
the aggressions of several orators, and goes on to show that Dr.
Guerin's new theory of puerperal fever is absurd and unworthy of a map
of his standing. lie continues to defend his opinion, considering pmi^
peral fever a specific disease. He points to the fact that the disease
in question makes its appearance in an epidemical form, as a general
rule, analogous to all specific diseases, cholera, typhus, typhoid
fever, and adds another example to prove the contacposity of Uie
disease. In all post-mortem examinations the same alteration of the
blood is found and can be easily demonstrated, this being in some
instances the only pathologico-anatomical result, while the local
lesions are of a very varying character. The principal character of
this alteration is a change in the blood-globules, which have become
unfit for hematosis, not being reddened any more by the influence of
oxygen (Vogel). Hence the great anxiety observed in puerperal
fever patient^), and the great hindrance in respiration. Dr. Depaul
asserts that he, for himself, has already met with 15 cases where
no local lesions could bo found, although the post-mortems were made
with the greatest care possible. Another fact worth mentioning, is
the multiplicity of local lesions and their peculiar character, a puer-
peral peritonitis, ofiering a very difierent aspect from a simple or
traumatic peritonitis. The only point of comparison of purulent in-
fection with puerperal fever, is the fatal termination. It is wrong to
find analogies between the inner surface of the womb after the delivery,
and an artificial wound. Where is the pathological condition, where
the divided skin, muscles, nerves, bones and arteries ? Very justly
Dr. Depaul remarks, that there is no such thing as milk fever ; where-
ever a woman has chills or is feverish, there is some pathological
influence present, which we have to find out. The putrid infection
is equally difierent from puerperal fever in its symptoms and cause,
which may appear in a chronic or an acute form; it is never connect-
ed with a peritonitis, as is puerperal fever. Neither Dr. Beau's quinine,
nor Dr. Velpeau's large blisters, have an influence upou the real puer-
peral fever ; the very few cases cured were those treated with mer-
cury. In conclusion, Dr. Depaul repeats his conviction, that the only
justified and efiective prophylactic remedy is the closing of lying-in
hospitals. In 1837 a Society was formed under the name of Socidt^
M^icale d'Accouchment. From this time to 1841, 1,258 poor women

251

were attended st tbeir homes, and what was the result, not one
woman died, while at " La Ciinique " 22 died out of 623.

20. Dr. GcEKtM, in refuting the attacks of Dra. Cazcau and Depanl,
says that he cxiDaidcred the want of retraction of the womb only aa the
local cause of all the many eecondary erolutiona of puerperal fever,
admitting another infiuence which produced thia permanent awelling
of the uterua. To prove his theory of migration of pus into the peri-
toneal cavity throup:h the tubes, Dr. Gucrin mentiona several experi-
ments of his own, demonstrating that the peritoneal cavity may con-
tain a quantity of air in certain conditions, and quotes from Dr.
Bchier's and Dr. Tacquemier's works on poritcmitis, observations con-
firmatory of his own views.

21. Db. Beau, in a second commuuicati on, insists upon the inSam-
matory nature of puerperal fever, of which the peritonitis ia the
principal character. Phlebitis is often connected willi peritonitis;
when found alone, it is a phlebitis, and not a case of puerperal fever.
With rejsrard to treatment, Dr. Bean insists upon the earii/ ailroinistra-
tion of the quinine ; it must be given at the very first symptoms of the
fever. During an epidemic, the resident physician miist watch the
delivered women, and begin the treatment at the very inset of the
disease.

22. Db. Dantac, in a second communication, reports the experieuce of
an intelligent midwife, a former pupil of bis, with regard to the famous
12me. arrondissemeiit, the average number of deaths of which com-
munity Dr. Tamier reports to be 1 out of 322 delivered women during
1866. At the beginning of 1834, a very disastrous epidemic prevailed
in this district, and daring 5 weeks in Febmary and March, out of 35
women, BO were taken sick with the fever, and from Iheao 20 women
19 died from puerperal fever, moat of them a few days after delivery.

The great diversity of opinions expressed in the Academy rendered
it a difficult task for the last orator, M. On^rard, to give a resnm<S
of the entire discussion. First of all, M. Gurfrard rejects the opinion
pronounced by some of the speakers, that tlie inner snrface of the
uterus, after dolircry, was akin to a wound after a surgical operation.
The act of placentar detachment is unconnected with any lesion of
continuity, and the secretion of the placentar surface is not pus, but
an albuminous fluid ; a purulent discharge from this place is only
observed in those cases where a superficial inflammation of the
utariuo tisane existed in the neigbboriiood of the insertion of the

Elaoenta. The ^eat variety of opinions in general may be caused
y the circumstance that some of the orators had very ample oc-
casion to study the disease, while to others only a comparatively
small field of observation was allowed. Among the former are Dcpaul,
Dubois and Danyau, all of whom agree as to the principal points
involved in the question. Finally, the varying characters of the dif-
ferent epidemics may party account for the diversity of opinions on
the nature of the fever. Depaul's, Dubois', and Danyau's views, are
comprised in the following theses i Women in childbed are exposed
to diflereqt diseases, but the name of " puerperal " disease belongs
only to those afiections which develop under the specific inflnence of
the puerperal state. The true nature of puerperal fever is character-

252

ized : 1. By the time of invasion (in the first 4 or 5 days, and gener-
ally in the 48th or 60th hour after delivery, very seldom after the 8th
day). 2. By the succession and quality of the symptoms. 3. By its
anatomical character, consisting of a specific alteration of the bipod,
with inclination to rapid formation of pus. 4. By its transmissibililj,
by infection, perhaps by contagion, and direct inoculation. Most of
the speakers considered the epidemic influence, and the over-crowded
state of lying-in hospitals, as the principal cause of the eruption of
the fever ; but these coincidences are often wanted, while the coone
and malignity of the disease are the same. Almost all agree as to
the curative trea'tement ; our art is powerless, and the right way has
yet to be detected. The principal remedies are the opium, the quinine,
and- the veratrum viride ; the latter, recommended, by Dr. Barker of
New York, has not been tested in Europe. The opium has been very
successfully employed by Dr. Faye of Christiania, in 1849, while in
other epidemics it seemed to have no influence whatevier. The use
of quinine, principally advocated by M. Beau, was useless in the
hands of others. Therefore Dopaul and Cruveilhier moved to abolish
the larger lying-in hospitals, and supplant them by smaller ones with
12, 16 or 20 beds. This procedure Dr. Danyau believed to be injor-
ious for the education of young physcians and midwives, and he there-
fore proposed to retain the hospitals existing, and modify their con-
struction.

The discussion of the New York Academy of Medicine opened in
1857, and closed this jear. It is void of that brilliancy which is pe-
culiar to French orations ; it is void of that vast amount of experienoe
collected for decenniums in French hospitals, and still, to say the
least, it is equally important. The orators were few in number, but
all that was said was well supported by a stringent logic and
a sound experience. The discussion has brought forward in bold
relief two remedies, which are at least worthy a further trial, and
this is a decided advantage over the results of the French discussion,
which has radically destroyed what little hope was left for one or the
other therapeutical means to battle against this scourge of humanity.

The subject of puerperal fever was brought up for discussion in
the New York Academy of Medicine by Dr. John W. Francis. He
admits its inflammatory character, and is not willing that this dis-
order should be restricted in its seat to inflammation of the peritoneal
lining, thus nosologically denominating the disorder "puerperal
peritonitis." Dr. Francis is satisfied of its contagious nature from
the authority of Gordon, and from what he has seca both abroad and
at home.

Dr. Joseph M. Smfth, after some preliminary remarks on the con-
tested points regarding puerperal fever, says, that in rejecting the
opinion that puerperal fever is a disease sui generis^ we must also
reject the idea of its propagation by a specific contagion. That the
disease is communicable there is no doubt ; but it is through the
agency of a poison generated in a mode totally difierent from that
peculiar to small-pox and measles. Prof. Smith then proceeded to
coneider the special etiology of puerperal fever. ^

The conclusions at which Prof. Smith arrived, are, that puerperal

263

fiBrer sometimes arises from the noxious air generated from the foul
discharges of puerperal women in crowded and ill-ventilated lying-in
kospitals ; sometimes from the emanations of patients laboring under
tjphiis fever, erysipelas, and gangrenous diseases ; sometimes from
the emanations from the human body dissected after death ; and
sometimes from the absorption of putrescent matters lodged in the
uterus and vagina after parturition. It would appear, also, from
this inquiry, that the miasms of typhus, erysipelas, and puerperal
fover are severally capable of producing any one, or all, of these dis-
eases ; and that they may attach themselves to the persons and
clothing of mid-wives and physicians, and thus be transported from
these sources, to the chambers of lying-in women. The more ordi-
naiy form of disease, induced b^ the febrific effluvia in question, is
typhus and its modification, typhoid fever ; while puerperal fever,
sod hospital erysipelas, are but varieties of that disease, taking their
forms from the peculiar predisposing conditions of system.

The following facts are important : 1. Let the physician take
care. 2. When it breaks out in a hospital, thorough resort to disin*
fecting agents and ventilation, and dispersion of patients is necessary.

Prof. Clark concurs with Drs. Francis and Smith in regard to the
oommunicability of puerperal fever. With regard to its connection
with typhus, it seems that there are no fixed relations between these
diseases. I am aware, he says^ that puerperal women have been
placed in beds near those who have had typhus fever, and have died
of puerperal fever ; but unless these cases are adduced in sufficient
number to balance the cases on the other side, they may be but coin-
cidents. No relation has been established lietween the typhus and
puerperal fevers, as far as the City Inspector's reports are concerned.
rrof. Clark here gave a statistical review of deaths from puerperal
disease and from typhus fever, from 1830 to 1853, from which it
appeared that the numbers somewhat increase together ; but the
proportions in which they increase and diminish, showed very few
analogies between the two diseases. The relation of puerperal fever
to erysipelas, at Bellcvue, has long been remarked. My impression
is that there is a relation between the two ; tliis is the prevailing
opinion there. A few days ago, when the puerperal fever broke out
there, it was ascertained that erysipelas was prevailing to some
extent in the surgical wards.

In looking over the City Inspectoi-'s report of deaths for fifty years,
it is found that from 1804 to 1830 the ratio of mortality from these
diseases is very variable ; the numbers are, however, too small
during this period to be of much value, but for the last twenty years,
when tlie number from each is considerably increased, it will be
remarked that they show a decided tendency to increase together,
and to diminish together, the ratio of mortality varying but little.

Hospital gangrene differs from erysipelas probably more in its
appearance and its results than in its nature. It is, perhaps,
erysipelas intensified, and somewhat modified in the tendency to
spread over the body. But as the two occur under the same circum-
stances, and as they certainly have close alliances, what has been
already said of one can hardly fail to be true of the other.

254

With regard to pathology. Dr. Clark feels compelled to with-
hold his assent to the doctrine that this is a /euer, and a fever only,
under any circumstances. He has not yet seen a single puerpenl
woman die of an acute febrile disease of short duration, in whom
there could not be found, on post-mortem examination, some Mitt
of an inflammatory character, while he admits that other writeis
have published observations of a different result. He thinks that m
every case where a full examination is made, one of the four lesicns
(peritonitis, phlebitis, lymphangitis, endometritis,) will be found.
Inflammation of the lymphatics is more common than inflammatkm
of the veins. It is very often met with, to a limited extent, in the
broad ligament, when the chief lesion is peritonitis. Another form
of disease is that which Gooch, Simpson, and Tyler Smith, reg^ard as
independent of anatomical lesion. He says, the view which I wish
to present of that class of cases is that they are probabj aU, in
reality, pyaemia, resulting from inflammation of the inner surface of
the uterus. In order that what I have to say on this point may be
better understood, we will consider one or two points in the anatomy
of the uterus after parturition.

The uterine sinuses remain open, or rather openable, for at least
ten days. Why do they not bleed ? I do not know that any one has
made an exposition of it ? If I see it correctly, these sinuses are
guarded by a valvular opening like that of the ileo-coBcal valve.
There are two folds, the longest is the innermost one ; through thb
inner fold there is a muscular flbre well marked, and, also, a smaller
muscular fibre running through the shorter lip ; these muscular
fibres are continuous with the muscular fibre of the body of the
uterus ; when the muscular fibre of the uterus is well contracted, the
shorter lip is drawn down on the inner one so that no blood escapes.
When the muscular tissue is relaxed, the mouths open in this way
(illustrated by two pieces of paper, the one overlapping the other,
like the two- parts of the ileo-coecal valve, and the ends approxt
mated) ; thus it is that bleeding occurs when the uterus is relaxed,
and hence the necessity of having the uterus contract to prevent
haemorrhage.

If the open body of one of these sinuses be lifted, a sort of sac will
be found one-sixteenth of an inch or so in depth ; and, looking to-
ward the wall of the organ, another little mouth, sometimes two or
more ; whether that has a muscular fibre I am unable to say.

Inflammation of the inner surface of the uterus is, also, inflamma-
tion of the valvular mouths of the uterine sinuses, since they are
really a part of this inner surface ; hence endometritis, as it seems
to me well to denominate it, is of necessity a limited phlebitis, and
inflammation of this inner surface of the uterus is of common occur-
rence, in one or other of its forms. Cruveilhier has described it as
attended by an exudation which is soft, vascular, and areolar, the
meshes of which are filled with blood clots. I have seen the exact
copy of what he represents in Plate VI., of Book 4 ; and can state
that the singular appearances there illustrated, are due to fibrin, pus,
and blood ; the first forming a velvety surface on the interior of the
uterus, which holds in its fibres the other two, and that there is no

255

proper Tascularity in this exudation ; it is nothing more than one of
the least frequent of the results of endometritis. The more common
results of the inflammation, are exudations of a creamy consistency,
varying in color from a pale pink, through a brick-dust to a brown-
ish red, or saneous hue, with or without a firmer fibrinous layer, in
contact with the uterine surface ; in rare instances the color is the
dark green, represented by Cruyeilhier.

When this endometritis exists with the symptoms of puerperal
fever, though p^itonitis be absent, and though pus be not found in
the lymphatics or veins of the uterus, yet we are not at liberty to in-
fer that the disease is a fever and nothing else. Here is a source of
purulent contamination. That pus is not found in the veins is not
proof that it does not exist in the circulation ; formed within the
mouths of these sinuses, it would be readily washed into the circula-
ting blood, and produce the symptoms of pycemia. Indeed, the proof
of such contamination I have seen in the deposit of pus within the
tissue of the liver.

Db. Reese remarked, that a law should be enacted to prevent per-
sons from attending on puerperal women, after attending cases of
erysipelas, hospital gangrene, or autopsies. He had never seen a
case which justified the view of this disease being contagious. He
had not found local lesions sufficient to account for its fatal results.

Dr. SiirrH said that Prof. Clark did not discnminate between
typhus in males and typhus in females ; if he had excluded the
typhus in males, perhaps the results would have been more equal.

Dr. Clark answers that, though he is unable to furnish statistical
accounts at present, he is satisfied that typhus fever takes its full
proportion of females, and in epidemics more females are lost, be-
cause females are more about the sick. He believes to have seen
the cases which Grooch, Simpson, and others describe as puerperal
fever, without lesions, and to have never failed to find the evidences
of endometritis. Puerperal fever is a purulent contamination of the
blood, in a manner already explained, and the patient dies, not of
endometritis, but of pyaemia. A febrile element cannot be excluded
from this disease, but it is accompanied by, if not dependent upon a
local lesion* Lately a form of puerperal fever was observed at
Bellevue Hospital which was not noticed on former occasions, the
nature of which has not been so thoroughly studied by the profession
as that of other forms. Its prominent lesion is inflammation of the
inner surface of the uterus, with evidences of general purulent con-
tamination ; and the disease is unusually protracted. The patients
have lived in several cases from ton to thirty days ; and the post-
moriem examinations have demonstrated the existence of secondary
purulent deposits, and pus on the inner surface of the uterus, and in
Its veins or lymphatics, This form of disease is more insidious in its
approach ; is often devoid of the symptoms that mark the outset of
the ordinary attacka^of puerperal fever, and is more allied to typhoid
fever. The minutes of ten cases, illustrating the foregoing remarks,
are given by Dr. Claris .In most of these cases, all the symptoms
on which reliance usually is placed in the diagnosis of puerperal
fever were absent at the commencement. No chill, no headache, no

256

pain in abdomen, no rapid rise in the pulse ; in fine, no well marked
period of invasion. The disease was marked by its gradual progress.
In the first narrated case, the characteristic point was the recurrence
of the chill, and the long perspiration that follows the chill, or of free
perspiration without chills. The solitary glands of tho intestines
were swollen, filled with a milky fluid, and stood out on the 8ur£ftoe
of the mucous membrane, in certain parts, like pustules, as they oAen
do in smallpox and cholera. Dr. Clark remarks, that he had been in-
duced lately to attach importance to this lesion and its connections
with pysamia, having met with it frequently during the epidemic
here described ; and in some cases of purulent infection unconnected
with the puerperal state. Thus the analogies of this casc^ all ally it
to common purulent phlebitis. Such it undoubtedly would have
been considered, had it occurred in any other than the puerperal
state, or even in this state, perhaps, if it had occurred alone. But
its associates are no less important than the disease itself. It
occun'e<l at the end of a series of eleven cases, four of which had the
peritoneal inflammatory lesions, and six appeared to suffer mainly from
uterine phlebitis and pysemia. Nine of the other ten causes occurred
between the second and the twelfth of April, Whether this form of
pldebitis should be considered a form of puerperal fever, may admit
of discussion, but it certainly appears in an epidemic form.

Dr. Barker feels compelled to differ from Dr. Clark's views, having
been accustomed to regard the local lesions as being the relation of
an effect, instead of a cause. There is a proportionate relation
between the intensity of the symptoms and the amount of the local
lesion. Puerperal fever is a distinct essential disease, i^nd associeted
with it are most generally lesions of the peritoneum, or of the Teins
of the uterus, etc., while we may have peritonitis, or phlebitis, or any
other of the local inflammations, even in the puerperal women, and
not have puerperal fever. Puerperal fever is a cymotic disease,
having an essentiality altogether distinct from inflammation of any
tissue, or structure of the body, even in a puerperal woman. The
puerperal state, per se, cannot alter in any sense the laws which
govern inflammation. It undoubtedly does increase, under eertain
circumstances, the susceptibility to inflammatory action ; but it
may, and often does, produce a condition of the system directly
antagonistic to inflammation, and it is precisely in this latter condi-
tion that we find the most virulent, the most intractable forms of
puerperal fever. Puerperal fever has no anatomical character. The
structural lesions are inconstant in their seat and their amount.
These lesions are often not sufiicient to influence the progress of the
disease, or to explain tho cause of death. The most malignant form
of the disease offers the fewest and the least striking structural
lesions. The longer the disease continues, the more prominent and
the more manifest are the organic lesions. Does not this prove that
the lesions are consecutive or secondary ? Thai there is a primitive
source or odginal cause of vital depression, which sometimes
destroys life so rapidly that there is no time for the development of
these secondary morbid alterations ? The symptoms are not then
the result of these lesions, but the result of some specific agent^ some

257

morbid poison, which Bobsequently develops the antopsic lesions.
We may have inflammation, even to an intense degree, of any of the
organs in a puerperal woman, in which the principal lesions of puer-
peral fever are. found, and yet the disease will lack some of the
essential characteristics of puerperal fever. We may have f. i.
uterine phlebitis, and not have puerperal fever. There is a great
contrast between the two as regards the mode of attack, symptoms,
and treatment. The difference being that the one disease follows the
laws of ordinary inflammation, and that in the other the toxsemic
origin of the disease gives it quite a different character. These
differences were strikingly illustrated in the recent epidemic at
Bellevue Hospital. In the latter part of January, succeeding a period
of almost unparalleled cold, came that long spell of warm, damp,
close, foggy weather. This change had scarcely set in, when one
after another, as the women were delivered — these wards having
been previously perfectly healthy — they began to develop, one pelvic
cellulitis, another peritonitis, another metritis, all of the asthenic
type, and with an early tendency to gangrene or suppuration ; while
scarce one escaped without a threatening, at least, of those terrible
torments of nursing women, sore nipples or mammary abscess.
Indeed, so well established did this state of things become, that a
pulse of 120 and a flushed cheek were looked for as matters of course
on the morning after confinement, and the pleasant soft pulse and
cool skin of the physiological recovery were luxuries which the
attendant physicians dwelt long and lovingly upon, when, at long
intervals, they presented themselves. These cases, notwithstanding
that they bore the outward semblance of inflammations, were yet, in
their mode of progression, constitutional effects, and indications for
treatment, so different from the ordinary phlegmasise, as to lead Dr.
Barker to announce his belief in the specific character of these dis-
eases ; that the quasi-inflammatory processes taken on by these
organs were, in reality, the results of the action of a poison infused
into them through the blood, and stirring up its peculiar excitement
wherever it found the proper amount of combined irritation and
exhaustion to insure it a nidus ; just as the typhoid poison awakens
its deceptive pseudo-inflammations in the brain, the lungs, the intes-
tines. '' Treat these cnses," said he, " as idiopathic inflammations, and
you must inevitably kill your patients.'' Most of these cases were
treated successfully, by early local derivation or depletion, followed,
or even accompanied, by profuse general stimulation. Three, how-
ever, terminated fatally ; two by suppuration into the pelvic cavity,
and purulent absorption, in one of which a large number of abscesses,
from the size of a walnut down, were found in the lungs ; and one
by gangrene of the cervix, extending to the mucous membrane of the
body, and involving to a slight extent the posterior walls.

The next point to wl^ch Dr. B. called attention, was that the le-
sions themselves differ materially from those having an inflamma-
tory origin. Prof. Murphy has so clearly pointed out these distinc-
tions that no apology is necessary for quoting them :

" In perUomtia, all the arterial capillaries are highly injected:
hence the intestines are streaked with bright red lines of capillaries

958

that encircle them. In puerperal fwer^ the venous capillariea predom-
inate ; hence the livid hue of the intestines, and the dusky red oohr
of the patches and streaks on their surface. InpmJUmUis^ tlie Ijnph
which is poured out is adhesive, uniting the dififerent parts like glue:
if removed from the surface of tlie intestine on which it is deposited,
the strings of this lymph are broken across, and the surface is rough;
the quantity of serum poured out is not great, and, being lodged in
the cavity of the pelvis, may at first escape observation. /» jnur-
peral fever ^ that which we call lymph is not adhesive: it is omch
more abundant than adhesive lymph, covering the fundus of tbe
uterus, the intestines, tlie liver, the diaphragm ; it is found also in
the pleura ; its color varies from a dusky brown to a pale yelbw ;
it may be peeled off the liver, the intestines, or the uterus, quite
easily; the surface from which it is taken is smooth, and that of the
intestines is a dark rod color. The quantity of serum ia equally
profuse ; and this substance being dissolved in it, gives H a lactes-
cent appearance like pus ^ hence, it is called scnhpumlent fluid.
Thus, when the abdomim is opened, a large quantity of tliis fluid
always escapes. It will be objected that tliis sero-purulent flud is ^
also met with in peritonUis, This is perfectly true : but it ia neces-
sary to note the stage of the inflammation in which it is observed.
I have never met with it unless in the second stage of the attack.
When a patient died in the first stage, there was none of it* I con-
clude, therefore, that in the former instance (the secoud stage) such
effusions only occurred when the constitution was sinking under the
attack ; but in the latter, when death ick)k place from a difiwent
cause, the effusions noticed were the true products of inflammation.
In puerperal fever, the greater the intensity of the seisure the lees
the chance of meeting anything like lymph. In the most intense
forms no effusion at all may take place. In a degree less intense, a
large quantity of scrum, colored brown by blood, is found in the
pentoneum and throughout the tissues : the lymph poured out is of
the same color, having no adhesion to the surface on which it lies,
as if the fibrin of disorganized blood had been deposited thera In
the next degree, the same kind of lymph or fibrin is found, of s
yellow color, with a quantity of sero-purulent fluid. And lastly, io
those cases in which the constitution for a time struggles success-
fully against the fever, some adhesive lymph will be met with, mixed
up with a larger quantity of what I have just described."

The next argument which he adduces in proof of the doctrine that
puerperal fever is a zymotic disease, and not a local phlegmasia, is
that simple iijiflammatory diseases are not communicable from one
patient to anoUier, through the medium of a third party. It may be
objected that this argument assumes that puerperal fever ia thus
communicable, which is not proven, and is one of the points now
under discussion. He says, " With all due deference to those present
who may differ from me, if any such there b^, I must be allowed to
say, that I think no one fact in medicine is better established than
this. The question of contagion is not one of abstract reasoning, but
one of facts ; and, as to tbe facts, a few amounting to positive de-
monstration, must be conclusive. Negative testimony ia utterly

269

worthleu in settling snch a qnestion. I shnnld almost feci that I
the intelligence of those present by entering into an argii-
nt on this point at the present day. Prof Oliver Wendell Holmes,
in his essay on the Contagiousness of Puerperal Fever, has brought
an array of facts which must, I think, be conirincing to every unprc-
indieed mind. For myself, I wonld say with. Dr. Binndell that, 'I
Bad rather those I esteemed the most shonld be delivered unaided in
a stable, by the manger^ide, than that they should receive the best
help, in the fairest apartment, but exposed'^to the vapors of this piti-
ksa disease.' I would heartily concur with the emphatic declaration
of Dr. Holmes that, 'if, on this point, there is any voluntary blind-
aeaa, any interested oversight, any culpable negligence, even in isuch
a matter, and the facts shall reach the public ear, the pestilence car-
rier of the lying-in chamlier must look to Qod for pardon, for man
will never forgive him.' Now, then, if this aiseasc is thus
oommnnicable, is there any other local phlegmasia which is thus
commnnicable f It may be objected that dysentery is sometimes
contagions ; I think I have myself been through an epidemic of
dysentery which was evidently contagious ; but I should answer,
first, that it remains to be proved that this form of dysentery is
limply a local phlegmasia; and, second, that there is no evidence
that a healthy person can communicate this disease from one person
to another.

** My next argument is, that the prophylaxis of puerperal fever is
not the ij^rophylaxis of local inflammation. In the large hospital of
Vienna, from 1840 to 1846, one in every ten mothers delivered
periabed, chiefly from puerperal fever. In May, 1847, Dr. Semclweiss
prevented stndents from touching parts at the autopsies, and direct-
ed all of them to wash their hands in a solution of chlorine before
and after every vaginal examination ; and the mortality from this
time so far diminished that, in 1848, not above one in seventy-four
mothers died. ' Does not this fact prove the toxsemic origin of the
disease in these cases ; and that the local lesions are secondary, re-
active, and have less pathological value than the change which pre-
cedes it ? It may be olycctod, that the views which have been ad-
vanced as to the pathology of puerperal fever entirely ignore the
existence of an epidemic influence ; and that, the epidemic influence
may give a specific character to the local phlegmasia. Fron\ Syden-
ham we have learned the phrase ' type of the season,' and another
phraae has come into use, meaning nearly the same thing, viz.,
'epidemic constitution.' Now, what is meant by these terms f
Clearly they must refer to certain atmosphenc or telluric influences,
which modify the susceptibility of the system to disease, or which
increase the virulence 6f * the poison which develops disease. Tliat
this influence really exists, acting in both ways, I think there can be
no donbt It sometimjps produces its influence wholly on the system,
diminishing the vital resistance to disease, and rendering inflamma-
tory action asthenic in its type ; or the opposite result may be pro-
duced. So, also, it may increase the virulence of the poison which
gives rise to the zymotic diseases. Puerperal fever is most notably
susceptible to an epidemic influence.

260

'* I have thus given my roasons for believing that puerperal fever ia
an essentiality, that it ia a zymotic disease, resulting from the ab-
sorption of a specific poison, and that its anatomical lesions are
secondary."

There is no specific therapeutics for puerperal fever. The sooner
this idea is dismissed from the mind, the more probable is it that the
ixeatment adopted will have a rational and philosophical basis. The
method of treatment must vary according to the condition of the
system ; according to the virulence of the epidemic or special
poison ; and according to the intensity and severity of its aecondaiy
lesions. The indications are : To diminaiefrom the sj^eiem, aa mticA
as ia possible, the morbid poison. This is accomplished by means of
depletion and the other evacuants. Unfortunately this indicatioii,
owing to the peculiar character of this disease, can rarely be fulfilled,
except to a limited degree. At the present day, the adyocates of
venesection are few in number. It proved to be the most effioient
remedy in the epidemics met with by Grordon, Hey, Armstrong, and
in one seen by Gooch. Venesection should never be resorted to
simply because the case is one of puerperal fever, but becaose the
svmptoms indicate that depletion is necessary. The same principles
snould govern us in resorting to purgatives, emetics, diuretics, eta
The second indication is : To control the vital distufiancee resuUing
from reaction These are principally vascular excitement and nervous
irritation. We have in the materia medica an agents lately brought
prominently before the. profession, which acts specificaUy as an
arterial sedative, without depressing the vital powers. This is
veratrum viride. Dr. Tully, of New Haven, first brought its medicin-
al properties to public knowledge. By it the pulse can be brought
under voluntary control. Dr. Barker has used it for several years in
puerperal fever, and he asserts that in no disease he saw its value
more strikingly exhibited. It is an agent which requires care in its
use, and in those cases where its full efforts are required, the patient
must be kept under careful medical watching and be seen at short
intervals. Unfortunate results wero never remarked from its use,
but very severe temporary depression.

''A case occurred at the hospital at the time of an epidemic, pre-
senting a combination of symptoms, which all familiar with the dis-
ease would pronounce truly alarming. By ihe verat. virid., the pulse
was brought down from one hundred and forty to sixty per minute ;
and it was never permitted to rise above eighty. The quantity
administered varied according to the condition of the patient^ two,
three, or four drops being found sufficient to control the vascular ex-
citement. In many other puerperal cases I have seen equally striking
results. I will briefly mention one which I saw in consultation with
Dr. Sayre, the teutix day after confinement. She was a primapara,
and her convalescence seemed perfectly normal until the sixth day,
when she began to exhibit some appearance 5f mental disturbance.
She was especially anxious in regard to her religious condition.
Gradually a high state of nervous excitement was developed with
insomnia, and when seen by myself she had been decidedly maniacal
for more than twenty-four hours. Her respiration was short and

261

hnrriecl, her palse very rapid, her conntenanoo anxioas and frighten-
ed ; she was incessantly talking*, and starting - with apprehension
from the slightest movement in the room. No physical exploration
could be obtained, but there were no local symptoms indicating
pelvic trouble. She sat np in bed and moved from one part to
another with great rapidity. The vorat. virid. was now given, and
by its influence the pulse was brought down below seventy per
minate, the respiration became slower, the mind tranquil, and she
was enabled to sleep. I am informed by Dr. Sayre that, in the course
of a few days, there was developed in the pelvic cavity an extensive
abscess, which pointed externally, near the sacrum. Her convalesr
oence was somewhat prolonged, but she eventually recovered."

There is a vast difference in the power of the herb grown at the
South, compared with that grown at the North. Seven drops is a
large dose of the tincture prepared at the South.

The opium treatment is moat successful in "puerperal fever with
peritoneal lesion." It is astonishing to see to what extent patients
will tolerate opium where the peritoneal lesion predominates ; but it
is only in this form of fever that this great tolerance exists. There
18 one point to which attention roust be called, and that is a test
whether the action of this drug is proving beneficial or not. If opium
be pushed to incipient narcotism, a gradual decrease in the frequency
of the respiration results. Now, the opium treatment is acting bene-
ficially, when, in connection with the reduction of the frequency of the
respiration, there is a corresponding decrease in thr* frequency of the
pulse ; but if with incipient narcotism the respiration grows slower
and slower, without a corresponding decrease in the pulne, the opium
treatment is to be abandoned at once. Dr. B. said : " In one case
that occurred at Belle vue Hospital some two years since, the opium
had been pushed to such an extent that galvanism had been resorted
to to make her breathe. When I saw her the respirations were 10
and 11 per minute, while the pulse was above 140 per minute.
Seeing this slow* respiration with the frequent pulse, I suggested
that no more opium should be administered, as I thought its con-
tinued use would overwhelm the vital powers. The veratnim viride
was then given, and in a few hours the pulse came down below 80.
This patient eventually recovered. I will state, then, as my convic-
tion, that in that class of cases where the peritoneal lesion predomi-
nates, the opium treatment has proved successful to an extent which
no other has." In many cases, to control the vital disturbances
resnlting from reJiction, it will be necessary to use a variety of
agents to accomplish this end. Venesection, veratrum viride, opium
in full doses, camphor, etc. Two cases in illustration of this are re-
corded by Dr. Barker.

Third, — 7b combat the local secondary lemons tchich may be dt^velop-
ed by local depletion, counter-irritation, fomentations, chlorinated in-
jections, etc. Another indication is, to gutUain the vital potoern of the
tystem ; in other words, keep the patient alive. There is a certain
class of cases where the system seems to be overwhelmed, and yet
life will be preserved by the heroic use of stimulant and good nutri-
tion. Many patients no doubt are permitted to die from the neglect

262

of these resources. After a patient has lived for fortj-eight hoim^
tlicre is constant encouragement for effort, and that the danger is» la
a certain sense, diminished in proportion to the duration of the di»
ease.

Dr. Clabk said he had expressed his ooncurrenoe in the Tiews cf
those who believe the disease to be contagious ; in his belief tlie di^
case is composed of two elements — a fever and an inflammation. la
this respect it resembles the epidemic dyseutory, the epidemic etjA
pelas, or small pox. In the epidemic erysipelas which prevailed in New
England, and in the Western States, from seventeen to ten years sM
these two elements were as clearly distinct, in the time of their da-
velopment, as they are in small pox — a febrile movement preceded
the grave inflammatory lesion. This same erysipelatous disease
assumed, in lying-in women and those in the puerperal states tht
form of puerperal fever. He believed that the puerperal disease itf
never fatal but by the aid of its inflammatory element He believed
that the cases reported without lesion of any kind were no exoeptloD
to the general rule, and that they were re^sJIy marked by inflmmtafr
tion, but that the inflammation was one that had escaped detection ;
that it was an endometritis, and that the inflammation affecting ths
inner surface of the uterus involved the open or valvular months of
the uterine veins, and might produce purulent contamination of Urn
system, while no pus was found in the veins themselves after death.
The evidence of this was in the inflammatory exudation on the inaida
surface of the uterus ; the redness of the uterine structure^ penetrafr
ing a minute distance from within outward ; the symptoms of
pyemia and the discovery of pus in distant organs. In objection to
Dr. Barker's remark, tliat the most malignant forms of puerperal
fever were void of any local lesions, Dr. Clark reports a number of
cases of very short duration (from 33 to 48 hours) having oocnrred
in Bellevue Hospital in 1840. In all these short cases there was evi<
dence of inflammatory lesion of the peritoneum ; in all but one there
was a morbid exudation on tho inner surface of the uterus, and in
this one the inner surface of the organ had not been particularly in-
spected by those who made the dissection.

From the researches of Dr. Sedillot, it appears that injection of
serum of ill-conditioned pus into the veins of dogs, was followed bj
rapid death, without any formation of metastatic abscesses. The
import of these experiments, and tlieir relation to the disease in
question, is evident, especially when it is remembered that the
uterine cavity is open to Uie ready access of air ; that when inflam-
mation has been recognized on its inner surface, it has often been of
a character most likely to furnish a septic ag^nt ; and that the veins
of the uterus are, after parturition, so arranged as to receive such
septic agent, healthy or degenerated pus, in an augmenting, and,
consequently, accumulative stream. Dr. Clark, after giving the
history of opium treatment in ordinary peritonitis, remarks, that the
confidence in the opium treatment of puerperal fever, with peritoneal
complication, is in no degree shaken by accumulating experience,
but is rather increased ; while its usefulness in that form of the dis-
ease whidb is attended by purulent infection, has not been demon-

26S

ftrated, at least as an exclusive mcUiod. With regard to the mode
of administering opium, Dr. Clark refers to a letter written in 1829,
by Dr. F. O. King, and directed to Dr. V. Mott, in which the dose
mentioned is from 70 to 100 drops of laudanam, given repeatedly at
short intervals, till the full influence of the drug is developed.

With regard to treatment, Dr. Barker said : " The value of vera-
tmm yiride in reducing vascular excitement has in this disease been
confirmed by many observers in this city and my own additional ex-
perience. It will most surely reduce the quickened pulse of inflam-
mation and irritation. Its use is not incompatible with that of
■timnlants. Experience has abundantly demonstrated the truth of
this apparent paradox. One patient who recovered took, every hour
for two days, one ounce of brandy and from three to ten drops of the
tine, veratnim viride, the quantity of the latter being determined by
the frequency of the pulse, which was never allowed to rise above
80 per minute, although it sometimes fell down to 40. In another
case the veratrum viride did not seem to produce any effect on the
palae, which remained steadily above 130, until the condition of the
patient was such that I decided to give brandy. After the flrst
ounce was given, it fell to 108 ; after the second, to 86. Continuing
the brandy, the veratrum viride was suspended for a few hours, and
the poise again rose to 130. After this it was curious to note the
(act, that if either agent was suspended the pulse would rapidly in-
crease in frequency, while under the combined influence of the two it
was kept below 80 per minute. I have little to add to what has
already been said on the use of opium in puerperal feiRr. In all
cases It should be given to the extent of entirely subduing the pain.
When tlic peritoneal lesion predominates, it is the principal agent on
which we must rely, and the quantity in which it is to be adminis-
tered is only to be determined by the effect which it produces.

"To combat the local secondary lesions, a great variety of means
haye been proposed, which will often tax the resources of the medical
attendant to the utmost. I have already spoken of the value of
opium in the peritoneal lesion. The tympanitis is often the most
striking and distressing s^-mptom, and I regret to say that I know
of no treatment by which we can always be sure of relieving it. I
lely, however, mostly on the use of turpentine, internally and ender-
matically. In some cases I have seen good results from the use of the
•acetate of lead, and in others I have seen all means fail. In those
cases where the secondary lesions are developed in the uterus, its
veins, or its lymphatics, I have seen no advantage from leeching or
blistering. The exposure of the abdomen to the air more than coun-
terbalances the proolematical advantages resulting from the former,
while the latter only adds to the nervous irritation already existing.
In these cases, the only local treatment I make use of is chlorinated
vaginal injections, repeated several times a day, and hot linseed
meal poultices kept constantly applied over the hypogastrinm.

" Finally, the vital powers of the system must be sustained. I
believe more patients die from the neglect of this point than from
any other error of treatment in this disease. The patient is often
~ by a contest between the doctor and the disease, both con-

264

tributing to exhaust ihe vital powers. In very many cases remedies
are utterly powerless in combating the disease, and the province of
the physician is to keep the patient alive nntil the disease is ex-
hausted. This can only be done by proper nutrition, and the pre-
vention of waste and the restoration of nerve power by the use of
alcoholic stimulants. I will not enlarge upon this point ; but I stfll
believe that when a patient with puerperal fever has lived for for^
eight hours, there is constant encouragement for effort, and that the
danger is in a certain sense diminished in proportion to the duration
of the disease. I will only allude to two points of practice whidi
seem to me of some importance. The first I have already menttoned,
the value of .a mercurial laxative when the patient has been 8uppor^
ed for some days by the liberal use of beef-tea and alcoholic stimo-
lants until the stomach loses the power of taking care of what is pat
into it, apparently from obstruction of the portal circulation and
congestion of the capillary circulation of the mucous membrane of
the alimentary canal.

'^ There is another class of cases where the stomach seems to give
out all at once from another cause which I will not undertake to ex-
plain. Everything is rejected in a few minutes after it is swallowed,
with a painful feeling of burning and excoriation. Now, if thfs con-
dition IS not changed the patient will soon die, as she can no longer
be sustained. I have in several instances been able to persuade the
stomach to resume its functions by adding to each table-spoonful of
beef-tea one drop of nitro-muriatic acid, the proportion of the mixtnie
being one^art of the nitric and two of the hydrochloric acid.''

Dr. Auber*s work contains a critical review of the discassion in
the Paris Academy of Medicine, and is intended to prove the existp
encc : Ist, of a peculiar puerperal state with consecutive, specifi<^
puerperal phenomena ; 2d, of a real (Idgitime) puerperal fever,
originating from the absorption of the lochia and milk ; 3d, of an
epidemic puerperal fever ; and 4th, of a puerperal typhus, being an
occasional result of putrid miasmas, developed in rooms overcrowded
with women in childbed.

Dr. Tarkier's book on puerperal fever is one of the most important
articles on this subject, written in France. He first treats of the
pathological anatomy, based upon a large number of post-mortem
examinations. He found the blood changed in all cases examined :
the alterations were those indicated by Dr. Yogel. In speaking or
uterine phlebitis, he says that according to his experience the so
called metastatic abscesses were only exceptional coincidences with
phlebitis. Virchow is of a different opinion, and very likely Dr. T,
has taken cases of lymphangitis for phlebitis. By a microscopical
examination the puriform liquid in the fallopian tubes was found to
be of a two-fold nature, one consisting of regular pus globules, one
of a transparent liquid with an abundant quantity of epithelial cells.
The liver is very often found in a state of fatty degeneration, which
is due not to puerperal fever, but to the physiological condition of
the puerperal state. The importance of symptoms with regard to
the hard string, representing the inflamed fallopian tubes, and
which Behicr considers as an unfailing sign of approaching puer-

265

peral fever, is admitted, still he does not consider this lesion as a
prodrome, and much less as the first period of the fever. The first
diill was never remarked as far as c\fg;ht days after delivery ; as a
general rule it sets in immediately after confinement. In p^enuino
paerperal fever there is only one or two initial chills, while its
neqnent repetition is rather an indication of purulent or putrid
infection.

COUBSE, DURATION.

Out of a number of 6t cases —

DMinSShouu I

" 89 " » 1

« 2 dmya 4

•* 3 •* 9

« 4 " 19

" 5 " 15

" 6 •« 10

« 7 «• 6

•* « " I

•• 9 «« 2

« 10 " OP more!.,!!!........!!..............*...

In the epidemic of 1856, which lasted from the beginning of April
to May 10th, when the Matcrnitd was closed, 64 women died of puer-
peral fever, during which lime 347 women were delivered. The
hospital was reOpened on June 2l8t, and during the month of Sep-
tember another epidemic began to rage, so that 27 deaths were re-
corded out of 266 confinements. At the end of October the disease
had entirely disappeared.

EHatoay, — ^With regard to the influence of the season upon the
origin of the fever, Dr. Lasserre has reported the distribution of the
disease during 12 years. He found

5 tjUdnaiai in Janaary.

6 « " February.

3 " " March.

1 " " April.

1 •* •* June.

S " •' July.

t " " August

1 « " October.

1 " " November.

8 « " December.

In the same space of time, the six cold months furnished 868
deaths of 18,108 confinements; the six warm months 465 deaths of
15,956 confinements.

After Dr. Lasserrc's and Dr. Tarnier's researches, it appears that
(he mortality is less among women who have been living for some
time inside the hospital walls, while those who entered shortly be-
fore delivery arc much more severely taken with the disease, and so
are the primiparous women. The generally adopted view that a
deadfoBtus in the uterus had an influence upon the development of
the disease, has been refuted by Dr. Dubois. Out of 89 still-born
childien in 1856, 6 only were born of women who afterwards died of
paerperal fever.

266

In diflcussing tho qnestion of contagion, Dr. Tarnier does not hesi-
tate to pronounce in the affirmative. During 1856 there were

At the Matemittf— 2,287 confloeneots tad 132 deathi.
At the Cliniqae— 630 conflnemeDts and 61 deaths.

Daring the closure of these hospitals, a portion of the pregnant.
women were received at the h6pital Cochin, and soon the same mop
tality was established, viz. : 16 deaths out of 206 coniineroent^
while in the city only 14 deaths were . noted down oiU of -S^ttS
women. The author himself had occasion to treat one of the nurses is
the Maternity during her monthly courses, for a disease which rese mb led
exactly puerperal fever. She died in three days, and the peritonenm
was found to contain a large quantity of purulent scmm ; the womb
appeared perfectly healthy. Another nurae was taken, while she had
her courses, with similar and very alarming symptoms, but she
finally recovered. A similar fact has been reported by Dr. Depanl
(Union M^icale, 1855, Mo. 26), and Drs. Dubois, Danyau, Yoillemier
have seen the same. Moreover, at the time when the disease was si
its hight an unusually large number of new-bom children died, ▼iz.t
18 out of 302 ; tliis was from April 1st to May 10th, a peroentage
four times larger than that of the entire year; and most of the
children who died, were born from mothers not taken with the fever.
The question whether a physician is liable to propagate the fever pes*
sonally, from one person to another, Dr. Tarnier is inclined to aa*
swer in the affirmative. To prove this he alludes to the many obaaf*
vations brought forward in the discussion of the Paris Academj.of
Medicine, by Drs. Danyau and Dubois ; he says : " If puerperal, lever
was only an epidemic disease, it would spread with an equal fbroe
outside as well as inside the hospitals, but it has been demonstrated
that this is not the case. Tho puerperal poison does not only infect
women in the puerperal state, but also non-pregnant^ quite yonng
women, and new-born children.''

As a prophylactic remedy, Dr. Tarnier proposes to have the hoih
pitals constructed so that only one woman is received in a nx>m
during confinement, to remain there for fourteen days ; this room to
be well aired and cleaned afterwards, and left unoccupied for 14 more
days. Moreover, the pregnant women ought to be received in the
hospital at least 14 days before delivery, in order to get acclimatised
to the hospital air, e:cperience having shown, that women reoeiYed
shortly before their confinement are more prone to catch the ferrer
than those who have been there for a grater length of time. With
regard to treatment Dr. Tarnier is in favor of administering an
cmetico-cathartic, in those cases where bilious symptoms are present.
The use of mercuiy he thinks, is of no avail, as he himself has never
succeeded in producing salivation. In epidemics of a very serious
character, the administration of quinine has had not the least m-
fluence. Dr. Dclpech has applied the bichromate of potash, and two
vervbad cases were cured. Still the remedy has been tried -too
little to allow of a final decision.

As to the nature of the disease, two principal objections can be
raised against those who advocate its local genesis. Fhrst, it is im«

267

poMdble darin]^ a well-marked epidemic to make a distinction be-
tween puerperal peritonitis, pleuritis, phlebitis, or lymphangitis, while
on the other hand a great number of observations are known where
the moat scnitiDOus examination was at a loss to detect the slightest
traoe of local disease. The epidemic and contagious character of

Crpenil fever, are a sufficient proof that it is a general and not a
1 disease. Dr. Tamier remarks that^ metro-peritonitis, uterine
Slebitis and angioleucitis, purulent and putrid infection, are acci-
■ta to which puerperal women are at times subjected ; but in this
oaw they represent peculiar diseases for themselves, which can be
distinguished from puerperal fever. The puerperal fever, according to
Sr. Tamier, is due to a poison, a morbid fermentation, which may
tike ita origin spontaneously in the organism, under the influence of
eartain unknown conditions, which at times forms or enters into the
qFitem by an epidemic influence, which at times is propagated
llNHn ime woman to another, by tlie di&rent modes of contagion.
The diacasea which puerperal fever resembles in many points, are
Ihe ^iaootio pneumonia and army-typhus. The thesis is concluded
by a number of very interesting observations.

Jte. MoBFHT considers puerperal fever as the consequence of a
poiaont affecting the blood, which has a disposition to ozudations
SDon the serous membranes. The fibrin of the blood already present
im a larger proportion, is altered in its cliemical conatitution ; hence,
tha profuse exudations of a diseased fibrin. It is not adhesive, but
dBcavs in a pultaceons mass ; the veins are filled with dissolved,
pwrolent fibrin. The poison proper to puerperal fever seems to have
aaoppoaite efiect to that of typhus fever ; the former increases, the
latter diminishes the quantity of fibrin. The character of the dis-
ease is modified by the quantity of poison received in the organism.
With regard to treatment, it must be remarked, that the use of
VSGaouanha saved many patients in some epidemics. Dr. M . pro-
poses to try chloroform as a specific remedy against the disease,
with a view to destroy the poisoning clement in uie blood.
^ Da. PiDovz remarks that puerperal fever comprises a series of affco-
tiena of a varying form and localisation, the climax of which was
npmented in the puerperal typhus. This typhus is almost ex-
doaively observed in overcrowded wards, and the only reliable
taatment for it is a thorough alteration in the construction of the
^|fiiig«-in hospitals.

Db. SncpsoN advocates the possibility of transmission of puerperal
fever from one person to anotlier l>y the attending physician, and
even believes that a typhus patient can produce puerjK^ral fever in a
pMrperal woman by his exhalations.

I^ BamER, a pupil of Trousseau, considers phlebitis and purulent
absorption as the principal cause of puerperal fever. It is no disease

Eiliar to women in childbed, but has been observed in persons
g neither pregnant nor in the puerperal state.
DiL SuBMAT believes that the extensive production of pus in puer-
peral fever, was owing to a general suppurative or inflammatory
lispoaition. The pathological condition produced by this profuse
Bnppnration does not produce a specific disease, but only a peculiar

268

form of disease, which is the representation of the general inflaah
matory stateT

Dr. Broohik defends M. Boaillaud's theories, who does not belieTe
in a specific paerperal fever. The fever is of an inflammatory or of
a typhoid nature, which depends from its sporadic or epidemic cha^
acter. With regard to treatment, Dr. B. insists upon checking tibe
progress of the disease by early attendance, and proposes to nave
the actual state of our lying-in hospitals thoroughly altered.

Dr. Cros advocates the use of calomel and mercurial ointment for
the treatment of puerperal fever ; 120 or 140 grmm. to be applied
for the space of three days.

Dr. Lkgroux is essentialist, inasmuch as he recognizes an tmknowa
general cause, which invades the organism, and thus produces tlie
disease. This cause shows a different intensity, and a changing dll^
acter in the different epidemics. The presence of the puerperal state
is indispensable for this cause, to deyelop its effect upon the i^tem.
Besides this epidemic influence, C(5lds or other injuries are apt to prch
duce severe puerperal diseases, in which case the purulent or putrid
infection takes the place of the epidemic influence. Both sporadic
and epidemic puerperal fever present a series of symptoms different
in one and in the otlier instance, while they assume the same chara<^
ter, and exhibit the same anatomical lesion at a more advanced
state. The disease becomes contagious under certain conditions, but
this is not a characteristic symptom of the fever. The treatment has
to be adapted to, and modified after the peculiarities proper to every
single case. As soon as a violent chill appears, first of all an emetio
has to be administered, in ordei^ to produce sweat, contraction of tlia
womb, and a retardation of the pulse. If, after this the fever co»
tinues, quinine ought to be given in large doses.

The epidemic alluded to by Frof, VxTchoiw, extended from the ftJl
of 1856 up to February, 1858, making eighteen months altogether.
The fever was at its hight in both winters, confirming a fact men-
tioned already in 1847 by Dr. V., that the disease is more prevalent
in winter than at any other season, thus contrasting with the so-
called traumatic fever, which is more prevalent in summer time. In
almost every case, the post-mortem discovered some localised affec-
tion. One of the most surprising features, was the frequent presence
of recent endocarditis, with undoubted symptoms of puerperal fever
during life. The affection, in most cases, had involved the mitral
valve. In some of these it could be stated, that particles from the
diseased valve had been removed, swept away with the current of
blood, and deposited in distant localities, thus obstructing capil-
laries, and causing local iuflammations, phenomena which hitherto
have always been called metastatic and pysemic deposits. The par-
ticles from the mitral were recognized in these embolic deposits by
treatment with a solution of caustic potassa, by which fresh fibrinons
concretions are partially dissolved, while the fragments from the
heart underwent no change. In these cases, the uterus was found
perfectly healthy, and the symptoms of puerperal fever started ex-
clusively from this affection of the heart. The author met with four
cases of this kind, in one of which the sudden death was caused by a

260

lalacia of the entire heart. Ho therefore considera this endocarditis
if a puerperal character, and thinks the condition of the heart ought
» be more generally considered in cases of so-called metastatic affec-
tions, especiallj if the state of the abdomen docs not sufficiently ex-
plain either the violence of the disease, or the frequency of the pulse.
At the time when the epidemic wus at its hight, most of the cases
ware of a peritoneal character, among which the greatest number
was free from metastases. The nature of this peritoneal inflamma-
tion showed two distinct forms ; one was a mere superficial periton-
itis with partly plastic, partly purulent exudation ; the other, more
dangerous, was of a diphtheritic character, the effusion of which spread
to the deeper layers of cellular tissue, which afterwards degenerated,
thus presenting a mixture of detritus and pus. This is tlie same
diplitberitic process, which, in so many instances, seizes tlie inner
poraon of the womb.

In one case the uterus itself was the seat of inflammation, which
resulted in gangrene. Of more common occurrence was ovaritis,
nprescnting also two different forms, viz., a superficial inflamma-
tion, resulting in abscess of one or more follicles, which, by ruptur-
iogi gave rise to violent peritonitis ; or a diffuse inflammation of the
parenchyma, Icfliding to considerable enlargement and malacia of the
ovary.

At other times, phlebitis prevailed, generally connected with
Bietaatases, which find a natural explanation, if considered as cmbol-
iaa. Inflammation of the lymphatics was scarcely ever followed by
metastases, which fiinds its natural explanation in the fact that the
greater number of lymphatics take their course through the lymphatic
glands, in whicli larger particles may be retained, and may produce
lymphangitis, but not vascular thrombosis. These latter affections
are generally connected with rupture of the perineum or vagina, or
lacerations of the cervix uteri, and are often complicated with gan-
grenous destructions of the cellular tissue in the pelvis and fossa
iliaca.

DtL Lehmann's article is a report on puerperal fever representing
the views of the Obstetric Society of Amsterdam. It appears that
the physicians of Holland consider puerperal fever as a primitive
disease of the blood, produced by tlie influence of a miasma, which
secondarily affects different local diseases. Both fever and local
lesions have one common source, viz., the primary alteration of the
blood. In some epidemics the fever prevails, in others the inflam-
mations. The alteration of the blood may be primary, t. e., originate
in the blood itself, or secondary, by resorption of septic particlea
With regard to prophylactic treatment, the secale takes the
first place in those very numerous cases where the uterus had
not been sufficiently contracted after every labor of considerable du-
ration, and whenever the afterpains are unusually strong, morphium
ought to be administered. In no disease the "principUs obsta" must
be more strictly observed. The general treatment consists of febri-
fuges (quinine, digitalis, aconite), antizymotic (mercury, nitrate of
silver, arsenic), and antipysemic remedies (chlor., kreosot, mineral
acids); the local treatment embraces poultices, bleeding, opium
enemata, and vaginal injections.

270

Dr. O'Rbiu.t'b article is intended to reconcile the diverging iden
on puerperal fever, by identifying it with erysipelas.

From an analysis of Paor. Pkluzari's lectores, it appears that ke
considers puerperal fever to be essentially nothing oat a punilelk
infection. Professors Vannoni and BufiSatnini, seem to be <^ the saae
opinion. The different forms of the disease are explained by the de-
ferent locality from which the infection takes place, and tlie diSr
ent quality of pus introduced into the system.' Moreover, the diftF
ent constitutions of the women taken, impress a diffisrent charaeldr
upon the course of the disease.

As predisposing causes, thirteen conditions are considered, wluek
may favor purulent absorption. Among these, absorptions of pn
by the fallopian tubes, and its promotion through this channel firott
the uterus to the peritoneal cavity, seems to be Dr. PelliaarriB fat^ofsl
idea, believing that puerperal peritonitis was in most of cases t
secondary stage of local disease.

The work of Dr. Braun on ummio convulsions is divided into Isa
chapters, of which the first two are devoted to an acconnt of the
symptoms and pathogeny. Eclampsia puerperalis is defined to be as
acute affection of the motor function of the nervous system, charao-
terised by insensibility, tonic and clonic spasms, and* occnrs oHy as
an accessory phenomenon of another disease, generally of Brightfi
disease in an acute form, .which under certain circumstances, sorted-
ing its toxaemic effecte on the nutrition of the brain and whole ner-
vous system, produces those fearful accidents. The eclampsia gravi-
darum, according to Dr. Braun, is commonly due to that form of
blood-poisoning which results from the retention and decompomttOA
of urea in the blood, or the retention of the excremential, extractive
matter of the urine. Another form of eclampsia, presenting some-
what different symptoms resulte from the defective elimination ef
carbonic acid, bile, and other matters which in a state of health aie
freely and constantly separated from the blood. There is also a
phlegm asial variety of eclampsia, known as the cerebral or apoplec-
tic, and originating from meningitis, encephalitis intermeninreal
apoplexy, thrombosis of the longitudinal sinuses, and hjrpei-^mia-ef
the brain, spinal cord or medulla oblongata. Eclamptic attacks are
sometimes very closely simulated by hysterical convulsions. Sudden
death from hemorrhage is often accompanied with eclamptic phenomena.
Conditions similar to eclampsia are occasionally nroduced by mineral,
animal , and vegetable poisons, and the inhalation of carbonic acid,
and carbonic oxide gasos. Dr. Braun, after analysing the numerous
views entertained as to the cause of eclampsia, arrives at the. con-
clusion that the eclamptic convulsions of women during pregnan^
must be considered to be identical with the fits of adults in general,
that are produced by urs^mia in the course of acute Bright's disease.
This doctrine, which he regards as '' an axiom in theory as well as in
practice," he announced in 1851, about the same time liiat Frerichs
published his well known essay on this subject. But from this con-
fession of Dr. Braun it would be wrong to deduct, that he considered
Bright's disease as the only cause of genuine eclampsia. When
spewing of the different forms of eclampsia he himself acknowl-

, 271

edges a phlcgmaeic, cerebral or apoplectic variety. All he endeavors
to prove is the frequent connection of eclampsia wi(h Bright's dis-
ease of the kidneys. Concerning the concomitant oedema, be says :
Only those edemata of pregnant women which exist contemporane-
ous! v with albumen, fibnn cylindres, and fatty degenerated scales of
Bellini's epithelium in the urine, have a connection with ursemic
eclampsia. The oedema of the lower extremities, ascites and hy-
dramnios, which are not complicated with albuminous urine contain-
ing fibrin cylindres, are not followed by ursBmic eclampsia in preg-
nancy or labor. The affection of the kidneys with disease cannot
with certainty be inferred from the appearance of dropsy, as distinct
causes may, at the same time, or one after the other, produce drop-
sies. With regard to the cause of ursemic convulsions Dr. Braun
adopts the theory of Frerichs, who attributes ursemic intoxication
not to urea but to the presence of carbonate of ammonia in the blood,
which he supposes to be formed from the urea by the action of some
ferment. He assures to have detected this salt in the blood, and ex-
halations in all cases in which the symptoms of ursemia were de-
veloped. The researclies of eminent writers upon this subject, such
as Litzmann, have shown sufficiently that carbonate ammonia is not
absolutely necessary for starting uraemic convulsions. Very recently
Dr. Hammond, Assistant Surgeon IT. S. Army, in his article ** on the
injection of ui-ea and other substances into the blood *' ( The North
American Med.-Chir. Review, Vol. 1, No. 2, March, 1858), has under-
taken some experiments, which are decidedly opposed to the views
advanced by Frerichs. From these experiments he concludes : 1.
That urea (simple and combined with vesical mucus), carbonate of
ammonia, and sulphate of potash, when injected into the blood-
vessels .of sound animals, do not cause death. 2. That nitrate of pot-
ash, when thus introduced, is speedily fatal. ■ 3. That death ensues
from the injection of any of the foregoing substances into the circu-
lation of animals whose kidneys have been previously extirpated.
4. That in neither case does urea, when introduced directly into the
circulation, undergo conversion into carbonate of ammonia. Judg-
ing from these experiments, Dr. Hammond thinks that Frerichs's
theory of ursemic intoxication is erroneous. In neither of the cases in
which urea was injected into the circulation was any ammonia detected
in the breath, or vomited matters. Without pret^ding to question
the accuracy of Frerichs's statement, he is of the opinion that the
presence of carbonate of ammonia was accidental. It thus appears,
from these conflicting statements, that the pathogenesis of this im-
portant disease is yet far from being satisfactorily established. The
third and fourth chapters of the work before us treat of the connec-
tion of labor-pains with eclampsia, and the influence of the latter
upon the life of the foatus. Dr. Braun thinks that the pains should
be regarded as the effect ratlier than the cause of eclampsia ; and he
asserts positively that fits cannot be produced at will, nor even
aggravated by exciting pains and increasing their strength. The
great danger to the life oi the foetus our author refers chiefly to the
presence of carbonate of ammonia in the foetal blood. Chapters five
and six are taken up with the consideration of the etiology and path-

272^

blogical anatomy of ursBmic eclampsia. The following chapters
treat of diagnosis, prognosis, and treatment of eclampsia and
Bright's disease. Altogether, Dr. Braun's work will fully repay
an attentive perusal. We conclude this short analysis by quoting
the words of the reviewer of the North American Medica-Chirurgiod
Review : " Upon the whole, this work is the most complete and eru-
dite essay upon the subject of which it treats, that we are acquainted
with, and we only regret that our limited space prevents us from
more fully laying before our readers the peculiar views of its author.'

Dr. Pirrie's paper, read before the Belfast Medical Society, k
essentially nothing but a reproduction and endorsement of Dr.
Braun's views on puerperal convulsions.

Dr. Isham's article on puerperal convulsions is one of the most
scientific and instructive articles we have met with. It discusses
the influence of diseases of the kidneys upon the production of
eclampsia in a way which clearly shows that the author is weD
acquainted with the latest progress in science. Added, are some new
and important observations.

In a paper read before the Berlin Obstetric Society, Dr. LnzMAim
expresses his opinion that future times would establish the fact that
eclampsia ought to be considered as a symptom of ursBmia with very
few exceptions. Still, eclampsia is not the only form of ursemic in*
toxication. Other symptoms of this affection are, amaurosis, coma,
mania and typhoid fever. The most general cause of ursdmia in
cases of this kind is Bright's disease of the kidneys, t. e., an exudation
of an albuminous and fibrinous fluid into the urinary ducts, in conse-
quencc of which the excretion of urea and other ingredients of urine
is checked. It most commonly takes its origin during the latter
months of pregnancy, owing to a stasis of the venous blood- in the
kidneys. The urine taken from women thus affected shows a con-
siderable decrease of urea, and very often of lithic acid. It often
happens that the progress of the disease, as detected by the micro-
scope, does not correspond with the symptoms during life, and the
reliction of the system seems to depend more upon the extension than
upon the intensity of the affection. If a considerable portion of both
kidneys is affected with the first stage of the disease, the effect upon
the constitution of the blood is greater than if a smaller portion is in
a more advanced stage. In the former instance, the excretion ot
urea must be more restricted than in the latter one. This is exem-
plified by tlie history of a case, where, with a seemingly far advanced
degeneration of the kidneys, the excretion of urea was not diminish-
ed, and, consequently, no uraemic symptoms occurred.

The second case reported was one of congestion of the kidneys, in
which severe uraemic symptoms set in, while only very slight traces
of albumen could be detected in the urine. But a chemical analysis
proved a considerable decrease of urea during the several attacks ;
and when the patient began to recover, a larger quantity of urea
could be detected in the urine. The child which was born with a
cyanotic tint, died twelve hours after birth. A chemical analysis
proved the presence of a considerable quantity of urea in his blood.

Dr. Fesch gives the history of a case of eclampsia, from which he

278

oondndeB that T^neBection is not usefal in all cases of puerperal
ooDTiilaions ; in this instance at least blood-letting seemed to do more
harm than good, as it was followed not only by a severe collapse, but
ilao by an increased intensity of the single fits. Moreover, the arti-
ficial termination of delivery seemed to have not the least influence
towards checking the convulsions. Dr. P. proposes the internal use
of chloroform in similar cases, as its application in this instance was
doubtless of great benefit.

The case of Dr. Wegscheider is interesting, inasmuch as it goes to
show, that the convulsions may set in independently of labor-pains —
a fact often disbelieved, and by eminent authors (Kiwisch). In this
instance labor-pains were observed only 48 hours after the first con-
vnlBionB ; tliey lasted for six hours, during which time not one fit
was observed.

Dr. Paget reports a case of eclampsia, in which the accouchement
forctS was successfully performed ; as soon as the child was bom,
the eclamptic attacks ceased spontaneously. The author is in favor
of early operation in cases of puerperal convulsions.

Dr. Uahville reports the case of a woman who was taken with
eclamptic attacks in the fifth month of pregnancy. The patient was
bled repeatedly for four days, when she began to recover. On the
fifth day a dead foetus was born. Although the legs were remarkably
(Bdematous and the urine albuminous, Dr. 0. does not believe that
thia was a case of Bright's disease, but ho attributes it to some un-
known occasional influence in connection with the peculiar condition
of the blood of pregnant women, overtaxed, as it is, with fibrin.
— ^Fibrin is just now, with our French brethren, the materia peccans
for anything that happens to a pregnant woman. — £. N.

In the cases of puerperal convulsions communicated by Dr. Dale,
the women had considerable serous effusion into the cellular tissue,
and in the fatal one, as proved by the post-mortem, into all the vis-
ceral cavities. In these cases, therefore, it is probable that the con-
▼olaions were produced by the united operation of effusion at the
base of the brain and the poisoned state of the blood. As regards
the treatment adopted, the author thinks that bleeding saved the
lives of the two patients who recovered. In the fatal case the
patient ought to have been bled more freely ; and it is probable she
also would have been saved if the feeble pulse (perhaps masked by
the Gsdema) had been disregarded.

Dr. Welunoton reports seven cases of puerperal convulsions, and
remarks, that of all the remedies used — ^^'enesection, leeches, cathar-
tics, anti-spasmodics, rubefacients, etc. — the inhalation of chloroform
or ether seemed the most efficacious. In two cases it controlled the
oonYnlsions, while in the others Dr. W. thinks it did ^ood.

Dr. Chapicak gives a few statistics from English books, and pro-
ceeds to report nine cases of eclampsia of his own. In reading aU
his remarks on the disease in question, we arc impressed with the
antediluvian character of this article. Not a word is mentioned of
the great discoveries of our times. The author seems to be perfectly
ignorant of the connection of morbus Brightii and eclampsia. lie re-
jects the use of chloroform in eclampsia, because the two cases in

274 ■

which chloroform was given, died. In one of the6e cases (5) it was
administered at a time when the case had advanced to sach a
hopeless condition, that Dr. Chapman had to *'call in" a third doctor
''to help him oiit." The other case (9^ seems to have nothing at all
to do with eclampsia. We -recomniend Dr. C. to read Dr. Brao&'s
treatise on eclampsia parturientium.

Dr. MoREAU recommends the use of elastic stockings (Bourgeaurd's)
incases of phlegmasia alba dolens. He has tried and found them
very useful in a considerable number of cases. They are preferable
to the common roller-dressing, because the pressure, thus performed,
is less energetic and still more efficient.

Dr. Atthill reports a case of mania in a lately confined woman,
where very large doses of morphia failed to produce sleep or rest
He therefore chloroformed the patient, and placed a grain of muriate
of morphia on her tongue, continued the inhalation of chloroform for
half an hour, and then gradually withdrew it. By this management
the desired effect was procured, she continued to sleep and recovered
her senses perfectlj'.

Dr. Lebert has already directed attention to a form of chlorosis,
peculiar to women in child-bed. He reports another interesting case
of death from this cause, where no anatomical lesions whatever
could be detected post-mortem, -r

The object of Dr. Coulson's article on secondary affections of the
joints in puerperal women, is to show that this disease is connected
with pyaemia. In the large majority of cases, purulent phlebitis of
the parts originally affected has been observed after death. This
holds good especially for cases which occur in connection with puer-
peral fever. The careful observations of M. Tonel!(§, at the Lying-in-
Hospital in Paris, place the fact beyond doubt, and show' that, al-
though these secondary joint-affections, and the general symptoms
which accompany them, never take place without having been pre-
ceded by primary suppuration, purulent phlebitis, and primary sup-
puration of the cellular tissue do not necessarily give rise to them.
The pus-poisoning and secondary deposits are an occasional, but not
a constant effect of the phlebitis and primary abscesses. Thus in
two hundred and twenty-two post-mortem examinations of patients
who died from puerperal fever, M. Tonelld found suppuration of the
veins or lymphatics of the uterus in one hundred and thirty-four
cases ; yet of these, ten cases only furnished examples of secondi^rj
articular disease. In many cases where pus has not been found in
the uterine veins or lymphatics, it has been found in other tissues ;
and the very few cases related where no pus was found, show either
that the post-mortem examinations were imperfectly conducted, or
that the temporary secretion of pus might have been fairly inferred
from the symptoms during life. The presence of vitiated and putrid
secretions in the uterus does not account for the disease. It is not
produced by retention of the placenta after abortion. It does not
occur (unless phlebitis exists) in the form of puerperal fever, which
is characterized by putrescence and softening of the uterus. It is not
produced by the ingestion of putrid animal substances into the
stomach. The disease occasionally occurs in females without any of

275

Che accompanying cirenmstances of the puerperal state. Yet in its
coarse, symptoms, and termination, it does not differ from the form
which occasionally accompanies puerperal fever ; the only modifica-
tions being those which arise from the presence or absence of the
puerperal fever itself. The author does not deny the pernicious in-
fluence of vitiated secretions, while he maintains that all obseiva-
tion and analogy establish the doctrine, that, unless these secretions
excite purulent phlebitis, or give rise to primary dcpo<)its of pus in
■ome of the tissues, they are not followed by the train of symptoms
known under the name of pyaemia.

X. APPENDAGES OP THE FCETUS, EXTRA-
UTERINE AND MULTIPLE PREGNANCY.

I. Duhamel, Robin and Mattel, on Hydrops of the Chorial Tiifts, —
Gaz. des U5p. U ; 84.

8. McCaw, J. B., a Case of Uterine Hydatids. — Virginia Jour. XI. 5.

November.

•

3. Maurice, on a Case of Uterine Hydatids, SaintrEtienne: Thealier,
ain^. 8. pp. 10. 1858.

4. Mayer, Bemoval of a Mole from the Uterus by Injections of Warm
IFater.— WUrtemb. Corr. Bl. 16.

5. Bead, W., on the Influence of the Placenta upon the Development of
the Uterus during Pregnancy. — Americ. Jour. April. — New York
Jour. Nov.

6. Tfcc Physiology and Treatment of Placenta Prosvia. By R. Barnes,
M.D. London, Churchill. 8. pp. 220.

7. Lee, R., Clinical Reports of Twenty-one Cases of Uterine Hcemor-
rhage from Placental Presentation, — Med. Tim. and Gaz. 426.
Aug. 28.

8. Cnrray, R. 0., Case of Placenta Prcema, etc. Nashville Recorder.
I. 1. Sept.

9. Grant, J. H., a Case of Placenta Prosvia. — Charleston Jour.
March.

10. Spiegelberg, 0., Cases of Placenta Prosvia. — Mon.-Scbrift f. Ge-
burtflk. Feb.

II. Byrne, E. D., a Case of Placenta Prosvia. — Med. Tim. and Gaz.
May, 22.

12. Rhoads, a Case of Placenta Proevia. — Americ. Jour. April.

18. Marshall Weir, Beport of a Case of Placenta Prosvia^ in which
Taming axis Successfully Resorted to in Extreme Exhaustion. —
Lancet. II. 4. Oct.

14. Garland, E. C, Report of a Case of Placenta Prosvia^ in vMch
Turning was Succdisfxdly Resorted to, Chloroform Oiven with Ad-
vantage, and the Child Resttscitated by the "Ready MethodP — Lancet.
IL 6. Nov.

276

15. Removed of the Placenta in the Early Months of Pregnancy,hii
Evulsion. (Discussion of the Obstetric Section of the New York
Academy of Medicine ) — Amer. Monthly. X. 4. Oct.

16. Gibb, 0. C, Removal of the Placenta in the Early Months (f Preg-
nancy by Evulsion. — Ibid. X. 6. Dec.

17. Dubois, P., on Morbid Adherence of the Placenta. — Gaz. des
H6p. 65.

18. VuUyamez, Application of the Forceps, Retention and Adherence
of the Placenta. — Povjerfvl injections of Water Successfully ApfM.
—Ibid. May, 20.

19. Geoffray (de Montreuil), on Injections of Cold Water into the
Veins of the Cord in Cases of Adherent Placenta. — Ibid. 76.

20. Smith, J. D., Adherent Placenta; the Use of Chloroform, — Ogle-
thorpe Jour. I. 4. Oct

21. Hancox, H., on Adhesion of the Placenta. — ^Brit. Jour. July 11

22. Jones, J. W., on Adhesion of the Placenta. — Atlanta Jour. March.

23. Houel. on Adhesion of the Placenta and Membranes toith Portiom
of the Foetus. — Gaz. de Paris. 3.

24. Perroud, a Fcetus urith Double Placenta. — Gaz. de Lyon, 15.

25. Lo^an, A., of Leavenworth Cy., Kansas, Case of Abortion at fitae
Months^ with a Remarkable Disposition of the Placentaj and the Mem-
branes of the Ovum ; with Some Remxirks thereon. — Cincinnati Ob-
server. I. 9. Sept.

26. Thomas, Gaillard T., on Prolapsus of the Funis. (Paper read be-
fore the New York Academy of Medicine). — New York Jour. <rf
Med. IV. 2. March.

27. Mendenhall, G., a Case of Prolapsus of the Umbilical Cord, Compti'
eating Labor. — Cincinnati Observer. I. 10. Oct.

28. Harris, R. P., Case of Fallopian Pregnancy, Resulting in Rupture
of the Cyst and Terminating in Death. — Americ. Jour. 1^V%,
January.

29. Johnston, Cr., Case of Extra-uterine Pregnancy; Fcetus Extracted
per Anum, Four Years and Six Weeks cfter the Completion (f Na-
tural Term. — Americ. Jour. April.

30. Younpf, W., of Aurora, 111., a Case of Extraction of the Bones <^a
Fcetus from the Peritoneal Cavity. — Chicago Jour. I. 8. Aug.

31. Lattey, P., Case of Extra-Uterine Pregnancy. — Med. Tim. and
Gaz. 428. Sept 11.

32. Levy, Extra-Uterine Oestation^ with Perforation into the Bladder, —
Schmidt's Jahrb. No. 11.

83. Harrison, G., of Macon, Ga., Medico-Legal Notes of a Ca&e of Esc-
tra- Uterine Pregnancy. — Southern Jour. XIV. 10. Oct.

34. Extra-Uterine Pregnancy; its Differential Diagnosis from Peri-
Uterine Hematocele. (Discussion of the Soc. Anatom.) — Gaz. Hebd.
V. 26. * .

35. Schultze, B., Twin-Birth with Five Extremities Presenting. — ^Mo-
natflchrift f. Geburtsk. May.

277

MLDaval, B., en a (kae cf Delivery wiik Twins, — ^Rev. Thdr. du Midi.
Xn. June.

87. Ck)ldberg, on a Bemarkable Case of Tmn-Birth. — Oesterr. Zcit-
Bchrift f. prakt. Heilk. IV. 39. Sept.

88. Webb, W., Birth of Triplets; Adhesion of the Placenta; Eecovery

r Mother; Death of the Children on the 2nd and Zd Day. — Lancet,
May.

39. Marx, on a Case of Birth of Triplets; Diagnosis before Delivery;
Three Living Children, — Jour, de Bord. — ^Mon. des llop. VI. 129.

Altboagb Dr. Tbomas's plan of managing the funis in cases of pro-
lapsas has been taught for years past by Dr. Bloxam, in his lectures
at the Grosvenor Place School of London, it w as not known to the
profession at large. Therefore Dr. Thomas's re-invention and publi-
cation of the proceeding, deserves the gratitude of all obstetricians.
It is a procedure which has already saved many lives, which would
have been lost, if it had not been for the application of Dr. Thomas's

Elan. The writer of this himself has treated lately a case of pro-
ipsed funis of the worst kind, viz.: connected with a cross presenta-
tion, — by placing the patient k la vache. The cord was retained
perfectly, and the child some time afterwards extracted alive. Of
course wc cannot expect that this proceeding will work so admirably
in every case, but if only the life of one child should have been saved
by the method in question, this would be sufficient cause of gratitude
towards its inventor.

Dr. McCaw reports a case of uterine hydatids and says : "It is
difficult to say, whether we should believe in the theory laid down
by most of pathological anatomists, that these hydatids were inde-
pendent organisms of law vitality, parasites of the body," etc., (sic 1 1)
Dr. Read's interesting paper was read before the Boston Society for
Medical Improvement, and is intended to clear up some dark points of
the theory of the development of the uterus in cases of placenta praevia.
The qnestion as yet unsettled is, whetljer irrespective of the position of
the placenta upon the uterine walls, the fundus always begins to ex-

iiand before any other portion of the uterus. The arguments brought
brward in its favor by Doherti, Jacqucmier, Murphy, Cazeaux, Ingle-
by, Ramsbotham, Lee, Blundell, J. Churchill, Meigs, Moreau, and
many others, are reported and duly criticised. Besides the weak-
ness of the evidence upon which these authors founded their theory,
it cannot account for all the phenomena which occur in placenta
praevia. Why do some females who have the placenta attached to
the proper neck of the uterus go their full term, while the majority
of those who are in the like situation do not go so long ? To give a
satisfactory and sufficient explanation of these hitherto unexplained
phenomena. Dr. Read proposes the following theory : the attachment
of the placenta to any portion of the uterus causes a development at
that place, which proceeds, joart passu, till the limits of growth in the
placenta having been reached, the enlargement is continued and kept
up by the pressure constantly exerted on the uterine walls by the
growing contents till the time of parturition. In this way, the fact
that very often, in complete insertion of the placenta, hemorrhage

278

docs not occur until the full term has been reached, findn a suflBcient
explanation. For by the time that the placenta has passed the
period of its most rapid growth, the foetal mass has already begun to
exert its effect upon the uterine walls to enlarge them ; the added
strength which the thick, firm disc of the placenta gives to the ceryi*
cal portion to resist this distension, is enough to prevent its being
felt in that direction. It applies also to partial presentations of the
placenta of ever}* degree, from that in which the os is almost entirely
covered to that in which the edge only of the placenta is at its mar-
gin, the latter instance having a marked tendency to early bleeding.
For just in proportion to the amount of the neck of the uterus covered
by the placenta is it protected from the distending process to whidi
it is exposed during the latter periods of pregnancy, and in jost such
proportion will the hemorrhage appear late or early. Those cases,
also, where the placenta is on the cervix, in the immediate vicinity
of the OS, but at the same time not overlapping it, instances which do
not manifest a hemorrhagic tendency, as was to be expected, aie
perfectly accounted for by the same reasoning.

Dr. Barnes' lectures on placenta praevia were delivered in 185T,
before the Medical Society of London. He gives a very philosophical
view of the nature of placenta prsBvia ; and while he repudiates
any attempt to establish dogmatically a new method of treatment^ he
calls in question the propriety of employing empirically the remedial
measures now generally practiced. Dr. Barnes' treatment of the
affection is eclectic, each case being treated according to the peciir
liar features it may present.

Dr. Curret reports a case of central location of the placeota.
After the os was somewhat dilated. Dr. Currey at the time of a severe
pain, pressed his finger firmly against the placenta, and gradually
worked it through the spongy mass till he had reached the mcmr
branous surface. The penetration of this gave a free passage to the
waters ; now the head could be felt presenting ; grasping the abdo-
men firmly with the left hand, and making pressure upon it^ he
found the head descend at the return of a pain, and begin to engage
in the expanded mouth. But the placenta was also pushed forward
with it, to the great fear of Dr. C. (?) He now administered a full
dose of Select powder of ergot ; a pain soon came on, but as it ex-
pelled the child, it continued to expel the placenta also, so that one
half of it fully was now protruded into the vagina. Another strong
pain passed the child beyond the placenta, and soon expelled it.

In concluding, Dr. C. says : " My whole course consisted simply in
endeavoring to check the haemorrhage, by cold applications and re-
cumbent position, until the favorable time for the laceration of the
placenta, through which I hoped and was gratified in seeing the
child safely pass." From this it seems that Dr. C. wanted the child's
head to pass through the artificial opening in the placenta, and adds^
he was gratified in seeing it pass. This latter remark is contradic-
tory to the account of the birth as stated above, whereby it appears
th^t the child passed beneath the placenta, leaving it in the vagina
after it was born, and this is tlie only course possible. How can Dr.
C. imagine that a child's head would pass through a small hole

279

made by the finger in the placenta, unless the latter was in nrinsnally
strong marginal connection with the womb by false adhesions ?
How can anyone suppose that such a broad surface as a child's head
ia, would pass through this small artificial opening ? The head will
alwaya sooner push the placenta before it, and finally pass by it, just
aa it happened in this instance. Moreover, this method of perforata
iDg the placenta, is not a new one, as Dr. 0. seems to suppose.
Ltvreif Merriman, . Oooch, and LHwenhardt, proposed to make an
opening in the placenta, to dilatate it, in order to enable the opcra-
tor'a hand to enter through this hole, to turn the child, and extract
it afterwards. Even this by far more reasonable proposition, has
not been found worth while to be tried by the profession, from rea-
■ons too obvious to discuss.

Dr. SnEGBLBERG reports several cases of placenta pnevia, and
cautions not to rely too much on plugging the vagina in cases of
severe hsBmorrhage from placenta prsevia, this applying more par-
ticularly to the caoutchouc bladder-plug (co1peur3*ntcr). In some of
the cases reported, the blood passed by the plug, or collected above
it in that large space of the laquear vaginae which remained between
the plug and the uterus.

The discussion of the Obstetric Section of the New York Academy
of Medicine on removal of the placenta in cases of abortion, was

Xned by Dr. Gardner with the remark, that in cases of retained
Denta, after a miscarriage, he introduced a small pair of polypus-

reepa, and withdrew the afterbirth. In the progress of the discus-
sion, the use of instruments in similar instances, was generally
rejected, because ergot, the tampon, or the operator's hand, were con-
aidered as remedies answering all purposes. Dr. Barker's method,
which has been successfully applied by the writer of this many
timea, is the following : a compressed sponge of the proper size is
introduced into the cervix, in order to stop the bleeding, and excite
uterine action, so that the ovum, or placenta, is completely detached.
In conjunction with this, an enema of the oil of turpentine (with
starch) is thrown into tic rectum, and retained as long as possible,
repeating it as soon as it comes away. The turpentine in this way
acta as a hemostatic and an oxytocic.

Dr. Gibbs reports two cases in which only part of the ovum had
been detached, while the remaining portions caused a violent
bttmorrhage. All the styptic remedies had been tried in vain, and
as the portion retained in the uterus could not be reached with the
finger, Dr. Carey's decidual separator was introduced into the womb,
and the membranes removed, whereupon the hsemorrhago stopped im-
mediately. Both cases are full of interest, and a fit supplement to
the discussion in the Academy just mentioned.

Dr. Dubois remarks that the adherence of the placenta was per-
fiect or imperfect ; that in the former instance, the after-birth is
■imply retained, while partial adherence is followed by heemorrhage,
because the utero-placentar circulation goes on undisturbed, and the
tendency of the blood rushing towards the entire placenta is un-
checked, from which place the blood escapes freely out of the opened
blood-vessels. The time allowed to wait for the expulsion of the

280

placenta by the author is one or one hoar and a half, after the birth
of the child.

Dr. Logan's article on a case of abortion, etc., is the choicest piece
of Betf-mystificaiion on record, bearing full evidence of the fact, that
Kansas is greatly in want of literary and scientific immigration. Dr.
Logan attended a five month's abortion case, and after removing the
ovum, he " found something he had never seen before, the placenta
and the greater part of the chord presenting the curious anomaly of
being entirely external, separate, and distinct from the membranous
enclosure of the child. The cord was given off about its centre, and
after proceeding a distance of sixteen inches, it entered the chorion
and amnion by a distinct perforation. The decidua vera not only
lined the placenta, but presented the appearance of a cellular mem-
brane, with the fleshy particles of the placenta deposited within its
mesches, as if it were the sole agent in its formation." Now from
this description, it is as clear as daylight, that the doctor, while re>
moving the ovum, had severed the foBtal from the uterine portions of
the placenta, as it may easily happen with a four or five month's ovum.
" This is but a single case," says our author, ** but the fact is here ;
a placenta has been in one case perfectly and apparently, naturally
formed, without any possible communication with, or influence from
the chorion." '' Regarding the decidua as an exudation of coagulable
lymph" (I) Dr. Logan proceeds to revive Hunter's dead theory of
placental formation.

Dr. Thomas laid before the New York Academy a plan of treatment
for prolapsed funis which he had proposed in a course of lectures on
obstetrics, delivered in the University Medical College of this dtj
two years ago, and which he has since taught, but had waited for
clinical evidence before bringing it before the profession. The causes
of the great persistence of this accident, said he (whatever may have
originally produced it), may be stated as these : Ist, the slippery
nature of the funis ; and 2nd, the inclined direction of the uterine
axis, which being in a line running from the umbilicus, or a little
above it^ to the coccyx, favors very much the tendency of the slippery
part to roll outwards. These conditions he 'had thought might not
only be overcome, but might themselves be rendered serviceable in
effecting reduction, by inverting the uterine axis by placing the
woman on her hands and knees, in the posture employed by surgeons
in operating on the uterus and vagina. He had now tried this
method in two cases, and reported as follows :

The first was a robust L'ish woman, a multipara, who was sitting
by her bed when the waters broke, and brought down a loop of the
cord. It had been returned to the uterus repeatedly by the phy-
sician in attendance, and the porte cordon recommended by Dr.
Ramsbotham was used to retain it. At each successive pain, how-
ever, it again prolapsed, and when he saw the case it was suffering
from pressure by the descending head. He repeated the attempts
which had been made by returning the cord, but, like them, his were
unavailing. Placing the woman on her knees, with her face and
chest resting upon the bed, he now proceeded to return the cord,
when he discovered that without his aid it had retreated — and the
labor proceeded without difficulty — a living child being soon bom.

281

To the second case he was called before the waters had broken,
and in the unruptured bag he detected the cord in large amount. As
the 08 was fully dilated he ruptured the bag, and instantly the cord
descended, and appeared to fill the vagina. Pushing it up beyond
the head in an interval, he now waited to see whether it could be
retained there during the next pain, but a large loop was at once
forced down, and this occurred two or three times as the result of
this attempt. The woman was now placed in position, and although
the cord did not, as in the first case, reduce itself, no part of it once
poshed up returned, and the labor safely concluded.

In both these cases the woman was allowed to choose her position
after the head had fully descended, and occupied the pelvic cavity.

The author, in concluding, expressed his regrets that the plan pro-
posed should not have been more fully supported by clinical facts,
and stated as his reasons for bringing it forward in its present con-
ditiony the conviction which he felt that the simplicity of the method
would at once recommend it for trial, and his desire cordially to
inyite the profession to test it, and give it its proper stand, whether
of credit or of discredit, among the means at present at our command
in treating this class of cases.

The rules of treatment pointed out were these :

1. If the cord is detected before the waters have broken, let no
msDoal assistance be offered, but place the woman at once in posi-
tion, and trust to this for its return to the uterus.

S. Should the waters have flowed away, and left the cord below
the head, place the woman in position, and push it up with the hand
if practicable, or with a porte cordon, consisting of a gum elastic
catheter, with a tape passed through it, if not so —

8. Let no manipulations be commenced until the woman be placed
in position.

Dr. Mendekhall reports a case of prolapsus of the umbilical cord,
head presenting, which was successfully treated by Dr. Thomas'
method.

Dr. Levy remarks, that the number of cases recorded in our litera-
ture as so-called vesical pregnancy, is very limited. The first instance
of this kind was observed by Dr. Ebersbach, in 1714 (Ephemer. naiur,
cur, cent. 6 oba, 20). Meissner ( Frauenkrankheiten Bd. 3j mentions
only 6 more cases, and Levieux {Bullet, des sciences mid., 1822)
reports some instances where particles of foetal bones had entered
into the composition of vesical stones in the form of nuclei.

Dr. Levy's patient was 54 years old, and had given birth to 3 chil-
dren. When 37 years old, she again thought she was in the family
way. Between the 2nd and 3rd month she began to flood consider-
ably without any ostensible cause, and she was of opinion that she
had miscarried. After the lapse of one month the bleeding discon-
tinued, and the menses did not come back any more. The woman
began to grow very stout, the mammas increased considerably in
size, and when she was gone about half of her time, as she thought,
she fancied that she felt the quickening. Altogether, her condition
was favorable ; nothing out of the way was observed with regard to
the abdomen ; the breasts contained milk, and. the feet were some-

282

what oedematous. When she calculated to be at her full term, she
suddenly experienced a movement in the lower abdomen, just so as
if the foetus had turned round ; this was accompanied by a severe
chill, which repeated several times. A few days afterwards energetic
labor-pains set in, which, however, soon stopped entirely, when i
short hemorrhage occurred. The attending midwife declared to have
felt something like the shape of a presenting head, but all was not
right. Instead of uterine contractions, a violent pain was now felt
in the lowest part of the stomach, right above the symphysis pubii.
This painful sensation went away gradually, while the abdominal
tumor grew smaller and harder ; the menses reappeared, and the
patient recovered so entirely that she began to resume her ordinary
occupations.

Early in 1854, i. e., 15 years afterwards, the patient was takoi
with symptoms of biliousness, with pains in the pubic region, com-
bined with constant inclination to pass water. Notwithstanding all
this her general health remained in pretty fair condition, and it was
only towards the end of December that the urine began to appear
thick and milky, with a disagreeable smell, till at last it became
purifonh. The sensation of bearing down now increased consider-
ably, when, without the least difficulty, a portion of a foetal bone
was passed through the urethra. From this time to April, 1855,
three more pieces were discharged in the same way. The patient
was now very pale and lean, still comparatively healthy. Up to
February 1, 1856, fifteen large and numerous smaller bones were
passed, the urine had a very foetid smell, and contained besides a
good deal of pus, a considerable quantity of minute bony particles.
At last the strength of the patient gave away, and she died on May
29, 1856.

Post-mortem examination. — No trace of peritonitis. After the in-
testines were removed, a hard, uneven tumor, covered with a serons
membrane, was detected ; it was coherent with the spinal column,
and attached to the rectum. This tumor was of the size of a child's
head, was situated exactly behind the symphysis pubis, and contain-
ed smaller and larger osseous plates. The uterus, of noi:mal size, was
pushed towards the left side. The extra-uterine sac, which contain-
ed the greatest portions of the bones, was located towards the right
side, between uterus and rectum. In front it communicated freely
with the bladder and backwards into the rectum. The bladder was
filled with numerous foetal bones, of different sizes, the larger ones
being incrusted to a considerable extent, while the walls of the
bladder were considerably hypertrophied.

The author, in ventilating the question, whether, under similar cir-
cumstances, an operation should be resorted to, remarks, that the
high operation for stone had been performed for the said purpose, bat
always with unfavorable result, and he, therefore, proposes to try
urethrotomy as a less dangerous operation. The very interesting
article is concluded with a short analysis of Dr. Josephi's case of
vesical pregnancy, published in a thesis on extra-uterine pregpiancy,
Kostock, 1803. In this instance cystotomia alta was performed, bat
the patient died 3 days after the operation.

283

The remarkable feature in Dr. Harrison's ease of extra-uterine
jfegnancy, was the presence of two ligaments attached to the pla-
lenta, independent of the cord ; one about six inches long, connect-
ing with the transverse colon ; the other about four, connecting with
the body, just above the point of the ileum.

The parts presenting after the rupture of the membranes in Dr.
Dutal's case were, nates and hand of one foetus ; elbow and foot of
the other. Our author applied the forceps to the nates and delivered
the child without difficulty, whereupon he seized the foot of the other
'child and extracted it without difiSculty. Both children were born
alive and continued in good health.

In the case publislicd by Dr. Goldberg, a woman was delivered
satarally of a healthy child, when ten minutes afterwards a second
apparently five months' foetus was extracted. It had the appearance
of an alcohol preparation ; it was compressed from both sides, thus
representing only the silhouette of a foetus.

XI. REMEDIES.

1. Lee, R., History of a Case in which Death was Quickly Produced by
the inhalation of Two Drachms of Chloroform in the First Stage of
Natural Labor.— Ucd. Tim. and Gaz. 436. Nov., 6.

2. Rigby, E., on the Use of Chloroform in Natural Labor. — Ibid. 429.
Sept. 18,

8. Williamson, W., Chloroform in Midwifery.^lhid. 432. Oct. 9.

4. Cotting, B. E., of Roxbury, the Extent to which Anassthetic Agents

should be Used in Midwifery.
6. Debussaux, A. N., on the Employment of Chloroform in Cases of

Hysteria^ Thesis (in French). Strassbourg, Bergen-Levrault. 4.

6. Afflick, J. G., Observations on the Use of Ergot as a Hoemostaiic and
Abortive. — Transactions of the Belmont Med. Soc.

t. Fauvel, Peculiar Effect of Ergot during Labor. — Rev. Mdd. July 15.

8. Hcslop, T. P., Suggestions relative to the Employment of Tincture
cf the Sesquichtorid of Iron in Puerperal Peritonitis^ Iritis and
Allied Disorders. — Dubl. Jour. LI. August.

9. Bonfils, on the Use of Opium and Turpentine in Puerperal Fever. —
Gaz. des H6p. 11. '

10. Vedder, J. H., Veratrum Viride in Cases of Puerperal Fever. —
Americ. Monthly. January.

11. Clarke, A. B., of Holyoke, Mass., on the Treatment of Puerperal
Mania by Veratrum Viride. — Brit. Jour. LIX. 12. Oct.

12. Gros, L., on the Use of Pepsine in Cases of Vomiiua Oravidarum.
Bull. deThdr. Feb.

13. Dezou, Vomilus Oravidarum, Treated by Cold Water. — Rev. de
Th^r. 9.

14. Darscb, E., Yarrow (Achillea Millefolium). — Peninsular Jour. L
t. Oct

284

15. Ronzier-Joly, A., on the Suppression of the Lochial Discharge in
Puerperal Disease; a Simple Remedy to EeHstablish U. — Bull, de Thdr.
LV. 8.

16. Beauvais, Uva Ursi as an Obstetrical Agent, — Bull, de Th^r.
Jan. 30.

It. Fenner, E. D., Remedy for Dysmenorrkcea and Consequent Sterili-
ty. — New Orleans Med. JNews. July.

18. Barker, 0. W., of Omega, Texas, Remedy for Dysmenorrhosa, —
Ibid. Nov.

19. Menill, A. P., of Memphis, Tenn., Dysmenorrkcea Cured by Strom-
monium, — Ibid. Oct.

20. Lobach, Semen Cardui Marxce and Cardui Benedicti in Cases of
Uterine Hemorrhage. — Jour, de Brox. June.

21. Williams, H. L., Fort Wine Enemaia as a Substitute far Trans-
fusion of Blood. — Brit. Jour. Sept. 4.

22. Bonafond, on the Application of Solid Caustics in Diseases (f the
Womb — Bull, de Thdr. LIV. May.

23. Aran, Laudanum Dressings in Painful Affections of the Uterus. —
Ibid. LIII.

24. Tilt, E. J., on the Right Use of Sedatives in Diseases of the Womb,
and in Morbid Menstruation. — Lancet. July.

25. Parks, L., on the Use of Potassa com Calce in Uterine Disease. —
Boston Jour. LIX. 9.

26. Joachim, W., on the Use of Belladonna in Neuralgia Uteri, —
Ungar. Zeitschrift. IX. 9.

21. Aran, F., on Aloes Enemaia in Uterine Catarrh. — Bull, de Th^r,
LIV. March.

28. Gaby, E., on the Use of Sous-Nitrate of Bismuth in the Ihreatment
of Leucorrhoea. — Ibid. Sept.

29. Lecointe, Tanninglycerol in Vaginitis. — Ibid. June.

30. Bernard, M. Ch., on the Treatment of Chronic Engorgement by the
Ointment of Chlorjodide of Mercury. — Gaz. Hebd. May, 21. N.
Amer. Review. Sept.

31. Storer, H. F., Caustic Potash as an Application to the Interior of
the Uterus. — Boston Jour. LIX. 11. Oct.

32. Aveling, J. H., Gentian I\mts in Partial Occlusion of the Uterine
Neck. — Med. Tim. and Gaz. June, 26.

33. Hartmann, on Successful TreatTnent of Pruritus Vulvce by a Strong
Decoction of HeUeborus Albus, Locally Applied. — Annal. de
Roulers. 21.

34. Imbert-Goubeyre, on the Use of Arsenic in Pruritus Vulvas. —
Annal. de Flaudre. 21.

35. Mac^, on the Use of Mineral Waters in Female Diseases (in
French). Mort^limar, Bourron, 8. pp. 8.

36. Basret, on the Use of Cold Water in Chlorosis. — L*Union. 39.

37. Villemin, A., Vichy-Water in Chronic Diseases of the Womb. —
Gaz. de Paris. 10.

285

88. Bmck, A. T., on the Use of DriJtmrg Springs in Diseases of Preg-
nant Women, — Mon.-Schrift f. Geburtsk. XL April.

89. Fleckles, on the Use of Carlsbad-Waters in Diseases of the Womb.
— Schmidt's Jahrb. June.

Dr. Lee was fortunate enough to ferret out at last a case, where
the administration of chlorofrom during labor was followed by sud-
den death. The htLfband of the patient had administered about two
drachms of chloroform, when she threw herself violently back, gave
a g^p or two, a slight gurgle was heard in her throat, and respira-
tion and the pulse instantly ceased. This fact was communicated to
the author by Dr. John Campbell of Langs. No post-mortem exam-
ination was made. — ^We leave it to the judgment of our readers if
they will be inclined to take this case as one of death from chloro-
form. The circumstances connected with the management of the
chloroform, the small dose administered, the source from which the
eommnnication emanates, the want of a post-mortem examination are
all circumstances, which must be taken into consideration so as to
gaide our judgment. But even suppose this and some few other
women had really died from the use of chloroform ? What does this
prove against the remedy? Nothing but the often repeated advice,
to be cautious with this drug. If we hear of but very few cases of
death from chloroform among women in labor, this is owing to the
fact that the number of parturient women to whom chloroform is
g^ven, is comparatively small, when compared with the number of
persons chloroformed under other circumstances. — E. N.

Dr. RiGBY is of opinion, that chloroform, when judiciously admin-
istered, has a more favorable influence as regards the patient's re-
covery after a severe labor, than when it has not been used.

Dr. WiLUAMSON looks upon chloroform as so^eat a boon in (almost
all) midwifery cases, that he would no more think of attending a pa-
tient in labor without having chloroform beside him, than he would
think of not having a catheter in his pocket.

Dr. CoTTiNO prefers ether to chloroform, because he thinks it to be
less dangerous for the life of the patient. The conclusions to which
he comes from its administration in several hundred cases of labor,
are as follows :

1. In ordinary cases of midwifery, while ether may be allowed in
moderation, when importunately demanded by the patient, it is quite
as well in the long run, to say the least, to let normal, uncomplicated
labors proceed uninterfered with. 2. In painful, laborious, or com-
plicated labors, and in cases of great tenderness or great rigidity of
the organs, of extraordinary susceptibility to pain, and where there
is great nervous irritation, or undue apprehension of danger, ether,
if favorably received, should be used to the extent of overcoming the
abnormal condition and suffering. 3. In cases requiring manual or
instrumental interference, ether should be used to the same extent,
and upon the same general principles as in other operations. 4. In
puerperal convulsions especially in those having the characteristics
of uromic eclampsia, ether should be given as soon as there are in*

286

dications of an approaching fit, and be continned if seemingly effica-
cious, until the paroxysm has subsided, and quiet sleep is induced ;
or until other medicine, if desirable, can be swallowed — care being
taken to allow a sufficiently large quantity of pure air, and not to
continue the ether if coma supervene.

According to the experience of Dr. Affuck, not only does the
ergot act well as a haemostatic previously to delivery, but it pos-
sesses also "a supreme power in the control of post-parturient hem-
orrhages." Whenever the system becomes fully imbued with the ergot,
his observations confirm him in the opinion, that there is little to be
dreaded from the occurrence of bleeding. He thinks that its dangers
to the life of the child are less, than is generally believed by the pro-
fession.

Dr. Heslop having seen good results from the administration of
sesquichlor. of iron in epidemic diphteritic affections of the month
and throat, and being dissatisfied with the discussion of the Paris
Academy of Medicine on puerperal fever, for not having agreed upon
a prescription for the cure of said affection he proposes to try the tinct
of sesquichlor id of iron, and the local application of dilut. muriatic
acid in puerperal peritonitis. "So far as Dr. H. knows, obstetricians
have never made an ocular examination of the walls of the vagina
in puerperal fevers." The writer begs leave to inform Dr. H. that ob-
stetricians are in the habit of inspecting the vagina, and most thor-
oughly too. Moreover, the writer can inform Dr. H. that obstetricians
do "treat the vagina with as little ceremony as the fauces," applying
solid caustics, acids, and camphorized ether to the frequently enor-
mous ulcerations, in cases of puerperal fever. For puerperal fever
in general, we have not, and will never have a panacea, but there is
a species of the fever, viz. : the diphteritic form, seizing almost ex-
clusively upon the mucous membranes of the system, in which the
use of perchloride of iron may be reasonably tried.

Dr. Bonfils reports that Dr. Trousseau had treated several cases
of puerperal peritonitis, oophoritis, etc., by large doses of opium (6
to 10 cgrm. in a day), injections with the oil of turpentine (oil of
turpent. 10 to 30 grm ; 1 yolk of cggy water 100 grm., with some
mucilage, twice a day), and the oil administered by the mouth in
capsules (6 grm. a day).

Dr. Gros reports seven cases, partially from his own experience,
partially from that of other practitioners, where the administration
of pepsine cured the vomiting of pregnant women, in some instances
where all other remedies had failed to make the slightest impression
on the disease. Far from advising its application as a general rule,
Dr. G. recommends it for all those cases where the stomach has par-
ticipated actually in the morbid condition, be it by an alteration of
the secretory activity, or in consequence of its being constantly
called into unnatural activity.

Dr. Dezou recommends in cases of obstinate vomiting to apply a
wet towel upon the epigastrium, to be changed every five minutes
until the cure is completed.

Dr. Darsch reports some cases of successful application of the herb
of Millefoliam for promoting the menstrual flux.

287

Dr. Ronzibr-Jolt recommends the same remedy for reifstablisliing
the lochial discharge iu cases of suppression in puerperal diseases.

Dr. Bouyais has successfully applied the folia uvae ursi in cases
of atonic labor pains, and in hemorrhages from this same cause.

Dr. Fenner states that he has used for some years in the treatment
of dysmenorrhcBa with great success the following mixture, original-
ly recommended by Dr. Falk of London :

Bw — Gum. Guaiac, $i. ; Balsam. Canadens, $viii.; 01. Sassafras,
5ii.; Merc. Corros. Sublimit, 9i.; Spir. Vin. Rectif., Jviii.

"Dissolve the guaiac and balsam in one-half the spirit, and the
corrosive sublimate in the other. Let the guajac and balsam digest
for several days ; then pour off the clear liquor, mix with the subli-
mate, and add the oil. Dose. — Ten or twenty drops night and mom-
iog in a glass of wine or water, pro re nata"

This was called by Dr. Falk "Tinctura antacrida." Dr. Fenner
says that he usually directs the patient to begin a day or two before
the expected period, and take twenty-five drops in a infusion of sage
0^ sweetened water, night and morning, until the discharge is estab-
lished ; then cease till the next period. In obstinate cases, the medi-
cine should be commenced a week or ten days before the period ;
and if the pain appears, the medicine should be taken every four or
six hours till relieved. Dr. Fenner has known immediate relief to
be given by a single dose taken in the paroxysm. In very violent
cases, in which the pain was excruciating, causing shrieks or even
violent convulsions, he has successfully applied the following : — R.
— Spirit, camphor, 5iii.; chloroform, 5ii.; tinct. opii., 5i. M. S. — A
teaspoonful in sweetened water once an hour till relieved.

Dr. Barker proposes the following remedy for dysmonorrhooa : —
R. — Gumm. guajac, Ji.; Potass Nitr., 3i.; Flor. Sulphur, 5i. To
bo well ground in a mortar and put into one pint of brandy or good
whiskey, and after standing a few days, to be taken twice a day one
tablespoonful. For retention aTid suppression of the menstrua the
following is recommended : — R. — 01. Terebinth, Ji.; 01. Sassafras,
Jss.; Spir. Vini. rectif, Jviii. M. S. — To be taken iu tea, in doses of

Si.

Da Merrill has successfully applied the extract of Strammo-
nium in a case of intractable dysmcnorrhcBa. He advises to begin
with one grain doses every third hour, ten days before the expected
time, and to diminish the dose in case of beginning narcotism.

Dr. Lobach recommends a remedy (before the Med.-Physiol. Soc.
of WUrzburg) which had been almost forgotten, if it was not for the
apostles of Rademacher, who make use of the semen cardui in cases
of abdominal plethora and its consequences. Dr. L.'s experience
goes to prove that it is a sure remedy iu uterine hemorrhage, even
when all other means have failed, but mostly in the flooding from
a stasis in the circulation of the venre portarum. The dose is from
2 to 13 drops of the tincture every half or third hour.

Dr. Wiluams recommends enemata of port wine in case of post-
partum hemorrhage, and records a case in which he resorted to it
successfully. The patient was in the most alarming state of prostra-
tion, pulseless at the wrist, with cold extremities, Ike. Dr. W. com-

288

menced by administering four ounces of port wine with twenty drope
of tincture of opium. The patient speedily manifested signs of im-
provement. In half an hour be repeated the enema with marked ad-
vantage, and the patient was soon out of danger.

The local application of sedatives, though very extensively in use
as a local remedy in the various forms of pain in other localities of
the system, is not sufficiently followed in the treatment of diseases
of women. Dr. Tilt, therefore, proposes to show in this article, what
good results may be obtained by application of narcotics to the fe*
male organs. In treating neuralgic affections of the womb, ovaries,
abdomen, etc., the. source of the disease, often lying in a slight ulcera-
tion has to be removed first, and afterwards, or combined with surg^
cal treatment, the local use of anesthetics is followed by very satis-
factory results. The use of sedatives in such cases paves the way to
a more rapid cure, especially when several remedies are combined.
For this purpose, Dr. Tilt orders a camphorated liniment, to four
ounces of which he adds half an ounce of laudanum, and two drachms
of tincture of aconite. Tliis has to be rubbed carefully for five min-
utes on the lower part of the abdomen, or on the sacral region.
Upon this, a wadding poultice has to be applied and kept in place by
a piece of oil-silk, sufficiently larire to wrap round the loins and fold
over in front. Should this be ineffectual, sedatives by the rectum are
prescribed. Such measures are generally found successful ; but some-
times the patient will not 01; cannot retain the medicated fluid, and
narcoting supjiositories are objected to, or else the neuralgia may be
too severe to yield to the treatment. In a case of this kind^ Dr. Tilt
placed one grain of acetate of morphine in a little cotton wool, folded
it up, tied a piece of twine round it, and carefully applied it close to
the neck of the womb. This was withdrawn by pulling at the piece
of twine, at the end of twenty-four hours. Three days afterwards
two grains of morphine salt were applied in the same way ; and four
days afterwards three grains. This medication had a really wonder-
ful influence upon the neuralgic disease, so that the lady affected,
who for months had been confined to bed, was now able to sit up-
right for several hours, and was not overfatigued by a two houiV
drive, and in a few weeks she was able to leave for the seaside.
This treatment was always found successful in cases of uterine neu-
ralgia. The cotton-w;ool charged with morphine, may be applied
without using the speculum. If the forefinger of the right haix^ be
introduced into the vagina, along this finger the left hand can easily
glide the forceps armed with the cotton- wool, until the neck of the
womb is reached. When possible, this application is renewed every
second day. Dr. Aran has extensively followed the same idea ; his
plan is to let fall one or two drachms of laudanum into the vagina
per speculum, fixing the fluid in the vicinity of the womb by a table-
spoonful of powdered starch.

Dr. Parks's article was prepared with the intention to prove that
the application of potassa c. calce outside and inside the cervix, if
made with circumspection, need not do injury. Added, is a table
showing the character and result of 37 cases in which this treatment
was applied. The average number, to a case, of applications to, and

289

insertions within cervix uteri, of caustic potash, with or without
lime, was 4 ; the average number, to a case of applications to the exte-
rior of the cervix uteri of potassa cam calce, was 3^^. In one case
the lesion was not satisfactorily made out. There was one case of
abrasion alone ; one of simple congestion ; and one of probable uterine
catarrh. In all the rest (34) there was more or less of hypertrophy
or engorgement ; in the removal of which lesions, the potash seemed
to be most often useful. Only in one case (8) an injury is reported,
perhaps depending from the application of this caustic, viz : inflam-
matory symptoms, with subsequent discharge of pus per rectum ; in
all the rest no injury is recorded. The treatment which Dr. Parks
endeavors to sustain, is the making of one or more issues on the
neck of the womb, the aggregate area of which issues is never to ex-
ceed the space which can be covered by a three-cent piece ; bearing
in mind that the diameter of the issue is usually about twice that of
the cylinder of caustic. The contact of the caustic with the lining
tissae, is usually continued from half a minute to a minute. The pot-
ash is always neutralized with vinegar before withdrawing the spe-
cnlum. The potassa cum calce cylinders used by Dr. P., are those
of Bennet, made by Sq«ier of London.

In conclusion, a belief is expressed that, in hypertrophy apd en-
gorgement of long standing, the potash treatment is more effectual
and rapid than the milder caustics.

Dr. Aran strongly advocates the use of aloe injections for the cure
of uterine catarrh. lie administers every day or every other, ac-
cording to the effect produced, first an erema of mere tepid water,
and then one of the following composition : Aloes, castile soap aa.
gr. t5 ad. gr. 150, boiling water Jiii.

Dr. Gaby recommends the bismnthum nitricum : 1. For simple vul-
vitis of small girls. 2. For vaginal leucorrhea. 3. For a form of
whites, generally embracing vagina, vulva and urethra, which in
most cases is of a specific nature. The powder is to be applied in
substance over the affected parts, and with the aid of the speculum,
when the disease is in the deeper portions of the vagina. Dr. G.
strongly recommends this remedy as a very eflBcient one.
• Dr. Lecointe recommends to apply a tampon of cotton, covered
with equal parts of glycerine and tannin to the vagina per speculum,
in cases of vaginitis. After the first applications, the discharge gen-
erally increases considerably, and disappears soon afterwards.

The formula of chloroiodide of mercury used by Dr. Bernard for the
treatment of uterine infarct is the following : — Take one part of iodine
and two parts of calomel ; reduce the calomel to a coarse powder,
and introduce it into a matrass, heat it gently while stirring it, until
it commences to sublimate, then add iodine in small portions, and the
combination takes place. For application to the uterus, from 50 to
f 5 centigrammes of this salt are mixed with 60 grammes of fat M.
Rochard recommended the use of this ointment only in cases of sim-
ple and subacute engorgement showing a tendency to become chron-
ic. It has been applied in the following manner : — The neck of the
uterus brought completely into view by means of a trivalve specu-
lum, is cleared of the mucous covering it, with charpie or wadding,

290

or with a taimpon soaked in glycerine, and applied the day before to
the cervix. On the other hand a moderately thick pledget of charpie
of a little larger dimensions than the cervix, is prepared, and its
centre covered by a thin layer of the ointment, so that its borders
remaining dry may defend the vaginal mucous membrane from coft-
tact with the remedy which would otherwise occasion inflammatioD.
Then the pledget is carried up to the neck, cither with the dressing
forceps or by means of a wooden tube, one extremity of which is pro-
portionate in dimensions to the cervix uteri, and in which slides a
stopper which applies the pledget exactly to the organ. This done
the vagina is filled with balls of wadding, and the speculum is with-
drawn. Care has to be taken not to cram the vagina, as it would
occasion unnecessary inconvenience and pain to the patient.

Six or seven hours after the application of the ointment, the differ^
cut parts of the dressing are removed and the cervix is laid bare,
which, on examination with the speculum, is always found covered
with an albuminous exudation. From a number of five observations
reported by M. Bernard, we take the following as a sample : Case
IV. — Old engorgement, which had disappeared after injections of
carbonic acid, but has returned in the last two months. Cervix
round, smooth, but hard, not voluminous, and directed backward.
Applications on the 7th and 21st of September and 9th of October.
On this day the engorgement was much diminished, also the redness
and anteversion. On the 18th the patient went out, feeling very
well. In all the cases reported the amelioration was obvious and
rapid. It is well to know that the application of the ointment pro-
duces, for some hours afterwards, more or less acute pain, which
lasts from twelve to fourteen hours with intensity'. The whitish ex-
udation, which was mentioned above, is generally formed at the end
of five, six, or seven hours. The process of elimination, the cicatri-
zation of the wound consecutive to the separation of the eschar, and
the resolution of the concomitant inflammatory tumefaction requires
about eight to ten days. It is, therefore, advisable generally to
observe this interval between two applications.

Dr. Bruck remarks, that the Driburg Springs were generally well
born by patients, even if they arc subject to organic diseases or.
great irritability of the respiratory organs, owing to the small per-
centage of iron (0.85 grains in 16 ounces), and the unusually laree
amount of carbonic acid. This is the reason why women, even in the
first months of pregnancy, may safely undergo a treatment with
Driburg waters in cases of far advanced anaemia, while it was generally
believed that a thorough mineral (iron) water treatment would
invariably induce abortus. Dr. Bruck, at least, has successfillly
treated pregnant women with Driburg waters, and has seen that
they had a good influence upon the foetus. A lady, 30 years of age,
was delivered of a microcephalic child 10 years ago. In her second
pregnancy she bathed at Driburg, and gave birth to a strong, well-
formed child. The third and fifth child were microcephali ; at both
these times she did not use Drit>urg. During the fourth gestation
she bathed at Driburg, and had a perfectly healthy child.

Dr. Fleckles has applied the thermal waters of Carlsbad ^Bohemia)

291

successfally in functional derangements, hypertrophies, and fibroid
tumors of the womb. Disturbances of the menstrual flux are bene-
fited by the use of these waters, when they depend from uterine
hypertrophy', combined with abdominal plethora. Fluor albus is
cured by the use of this water, when it is caused by a disturbed
state of health, be it of a scrofulous, gouty, or of a hemorrhoidal
nature. Ovarian tumors lessen in size after a protracted use of the
water. Disorders coincident with the change of lifQ find a ready
relief in Carlsbad.

[The writer can only endorse Dr. Fleckles' praise of this therapeu-
tical agent for the cure of uterine disease. The water imported from
Grermany in stone bottles is almost as efficient as that taken fresh
from tlie spring. I am constantly in the habit of prescribing it for
patients affected with chronic metritis and hypertrophy, and I know
of no remedy which is more certain to remove uterine congestion,
especially in those numerous cases which are combined with a torpid
action of the liver. — E. N.]

XII. OBSTETRICAL OPERATIONS.

1. Meissner, F. L., Staiistics of Operative Midvnfery. — Monatschrifl f.
Geburtsk. IX. pp. 19—72.

2. Meissner, F. L., Obstetric Resources of an Accoucheur in those cases
of Contracted Pelvis, where a Full Grown Child can not be Bom,
unless Diminished in Size (a historical sketch of the different ob-
stetrical operations). — Monatschrift f. Geburtsk. April and May.

3. Rousseau-Pommeret, G., on the Obstetrical Operations in Cases of
Considerable Contraction of the Pelvis. Thesis. Paris : Rignoiix.
In 4.

4. Mayer, L., Jun., the Indications for Induction cf Abortion, — ^Monat-
schrift f. Geburtsk. Feb.

5. Induced Abortion, on Account of Extreme Narrowness of the Pdvis.
Prize Essay of the Med. Faculty of Tubingen. Abridged and Pub-
lished by F. Rattenmann, M.I)., formerly Assistant Physician at
the Lying-in Hospital at Tubingen. Philadelphia: R. Stein. 8vo.
pp. 51.

6. Lee, R., on Induction (f Labor before the Seventh Month of Preg-
nancy, — Med. Tim. and Gaz. May, 8.

7. Kirby, E. A., Induction of Premature Labor in a Dwarf . — Lancet
II. 2. July.

8. Bullen, H. St, Induction <f Premature Labor in Drformity of the
Pelvis, — Lancet. May.

9. Hausmann, Case of Induction of Premature Labor after CoherCB
Method, — Monatschrift f. Geburtsk. May.

10. CoBsfeld, Two Cases of Induction of Premature Labor tfter CohevUs
Method. — Med. Yereinszeitung, No. 9.

292

11. Credd, Three Cases of Induction of Premature Labor cfher CohevCs
Method. — Monatschrift f. Geburtsk. February.

12. Riedel, Six Cases of Induction cf Premature Labor after Cohen^s
Method. — Monatschrift f. Geburtsk. January.

13. Birnbaum, My Experience with Regard to7ntra-Uterine Injections
for Inducing Premature Labor. — Deutsche Klinik. 34.

14. German, on Indu^ction of Premature Labor. — Monatshcrifb f. Ge-
burtsk. Oct! Dec, etc. (Not complete.)

15. Lumpe, Four Cases of Induction of Premature Labor. — ^Wien.
Wochenschrift. No. 1.

16. StoUz, 071 Induction cf Premature Labor. — Gaz. de StraBbourg. 8.

17. Braun, C, on Induction of Premature Confinement by Means of
Out-Strings Introduced into the Uterus. — ^Wien. Wochenschrift.
Nov. 13.

18. Gardner, A. K., an Obstetric History of one Woman. — ^Maine Re-
port. I. 7. Dec.

19. Smith, Andr., Cephalic Version in Arm Presentation. — Lancet. II.
5. Nov.

20. Figg, E. G., on Delivery of the Child by Turning as a General
Bute in Labor. — Med. Tim. and Gaz. 437. Nov. 13.

21. Barker, Fordycc B., on the Comparative Use of Ergot and Forceps
in Labor. — Americ. Monthly. X. 1. July.

22. Barker, F. B., on Forceps and Turning (Proceedings of the Ob-
stetric Section of the New York Academy of Medicine.) — ^Ibid. X.
4. Oct.

23. Spiegelberg, 0., Remarks on Forceps and Turning in Arm Pre-
sentation. — Monatschrift f. Geburtsk. May.

24. Elliot, G. T., Description of a new Midwifery Forceps^ having a
Sliding Pivot to Prevent Compression of the Fostal Head. (With
Cases). — New York Jour. V. 2. Sept.

25. Gross, Dilatation of the Vagina by the knife; Forceps Operation. —
Wtirtemberg. Corr.-Bl. 31.

26. Lee, R., History of a Forceps Case. — Med. Tim. and Gaz. 429.
Sept. 18.

27. Schultze, B., Indications for Kephalotripsis. — Med. Centr.-Ztg. 50,
51. — Med.-Chir. Mon.-IIefte. Sept.

28. Krieger, Case of Keptalotripsis. — Med. Centr.-Ztg. 38.

29. Richard, Th., Kephcdotripsis by the Hand with the Aid of Perfora-
tor and Crotchet. — Monatschrift f. Geburtsk. May.

30. North, N. L., of Brooklyn, N. Y., Difficult Labor; {Hydrocephalic)
Monster; Craniotomy without Instruments. — Buffalo Jour. HI. 14.
August.

31. Lee, R., History of a Case of Craniotomy. — ^Med. Tim. and Gaz.
431. Oct 2.

32. Ben Ezri, of Columbia, S. C, Gleanings from the History rf the
CiBsariAn Operation. — Oglethorpe Jour. I. 4. Oct.

293

83. Pagenstechcr, C, Four Ddiveries in Cases of far Advanced Con-
traction of the Pelvis, — Monatschrift f. Geburtsk. XII. 1. Aug.

34. Frericks, T. S., and Groesbeck, J. A,, on Some Cases of Cassarian
Operation with Happy EesuU for Mother and Child, — Nederl.
Tijdschr. II. Jan.

35. Duclos, CcBsarian Operation with Happy Besult for Mother and
Child,— RcY. Mdd.— Gaz. dcs Hop. 35.

36. Alonso, F., Ccesarian Operation in a Case of IntrorUterine Preg-
nancy of 22 Months Duration, with Happy BesvU. — El Siglo Med.
July.

37. Hawkins, J., Caesarian Section with Happy BesuUfor Mother and
ChUd,—Ued, Tim. and Gaz. May, 8.

38. Mcrtens of Neviges, Two Ccesarian Operations with Happy Besult
for the Mother, — Org. f. d. ges. Heilk. VI. 1. p. 31.

39. Chevillon, Gastrotomy and Becovery in a Case of Extra-Uterine
Pregnancy of Six Years^ Duration. — L'Union de la Gironde. Feb.

40. Dombrc, on Ccesarian Section, — Gaz. des H6p. 69.

41. Greenhalgh, Ccenarian Section for Extensive Disease of the Bones,
— Med. Tim. and Gaz. May, 1.

42. Pischcn, on Ccesarian Section, — Rev. Mdd. March, 31.

43. Owens, F. R., Casarian Section Performed after Death of the
Mother. — Recovery of the Child. — N. Carol. Jour. I. 1. August.

44. Mordret, on Death q/Her Ccesarian Operation. — Rev. M^. May, 15.

Dr. Meissner's report relates to 3,811 women, who gave birth to
8,980 children, as 136 were twins, and 2 triplet births. These 3,811
labors called for operative interference in 3,025 instances, dynamic
aid being required in 924 of these to effect a change of position. Out of
851 cases of turning, only 222 did prove completely successful for both
mother and child. In 104 cases the child was born dead ; in 2 cases
the mother died from delivery, and in 2 after this had taken place.
Dr. Meissner prefers turning by one foot, as all German obstetricians
do, unless there is some indication for hastening the delivery. This
rule is of especial importance when multiple birth is expected, so
as to avoid getting hold of two feet of separate children. In one of
the author's cases of triplets, all the children presented crosswise,
and six lower extremities were felt. All the children were safely de-
livered by operating upon one foot at a time. Cephalic version is
preferred by some practitioners, as giving the child the best chance ;
but it can only be tried when hastening the delivery is not an
object. The author resorted to it in 6 cases. In 4 of the 351 cases,
turning was performed by external manipulation, and in 3 by spon-
taneous version, the buttocks being forced by the presenting
shoulder into the pelvis, and all the children being born dead. Of
1,853 cases of forceps operation, in 1,750 the head was the present-
ing part, and in 113 the forceps were used for its delivery in other
presentations. Of the 1,754 children 99 were born dead, but many
of these children had died during pregnancy, and were in advanced
putrification on delivery. In 10 instances the child was hydro-

294 ^^^H

cephftlio ; in 3 the mothor was already dead ; there were ^^S^^r
Bpiua bifida ; t deaths took place from prolapsed funis, and S from
the arm and head being tightly wedged in together. In 1 iiiBtaiicefi
the mother had euETercd from repeated conTulsive paroxysms. In
other cases the application of the forceps had been repeatedly
attempted by preceding practitioners, or the passage was narrowed
by the presence of tumors. Extraction was performed in 247 cases,
and became necessary when in breech, knee, or foot presentation,
the child's life was threatened by cessation of pain, faulty position,
or prolapsus of funis. Only 1*5 of the children were bora living ;

13 had died through pressure on the funis, before the author's
arrival ; 18 wore in a state of putrifaction ; 10 were already born
except the head ; 8 were immature, and in 5 others there was hydro-
cephalus, or other forms of dropsy. In 43 instances extraction had
lo he performed on account of ceesation of pain after turning. Per-
foration has been performed by the author 32 times, and he has
always followed the maxim, of never ]iroceeding to the operation
until assured of the child's deatli ; and it has several times happened
to him to see living children born in cases which have been left for
days together to the powers of nature, and which in previous labors
had been delivered by perforation. Premature labor was induced 20
times, and never before the 36th week. Accouchement forcd was
performed 56 times. By this term the author understands the whole
scries of operations (as artificial dilatation of the os uteri, bursting
the membranes, turning, extraction, or removal of the placenta)
which may be required for delivery when the further continuance of
pregtfancy is dangerous to mother and child. It is especially called
for in certain cases of eclampsia, placenta prsevia, and obstinate
vomiting. Two instances are enumerated of opening the adherent
OS by the knife, and eight cases of its forcible dilatation. In thirty-
three of these cases both mother and children did well, although, as
the dilatation was usually undertaken for placenta prasvia, most of
the latter were born some weeks too soon. As the majority of cases
(31) were examples of placenta preevia, in which hemorrhage had
continued long liefore the patients were seen by the author, it is not
surprising that ten of the mothers died. Of the 6 Cfesarian opera-
tions, 5 were performed on mothers being already dead, tlie children
being saved in none. In the case of operation upon the living sijh-
.ject, both mother and child lived. The general results were as fol-
lows : Of the mothers, 41 were lost — 25 during and 16 after de-
livery. Of the former 25, 11 wore already lifeless when seen ; of tiie

14 others, 1 died from rupture of the omenltim with internal hieniDi^
rhage, 10 from placenta praevia, necessitating forced deliverj', 3 from
nervous shock after favorable labor, and 1 iVum hemorrhage. Of the
16 mothers who died after delivery, 1 died from cancer of the
stomach, 1 from pneumonia, 3 after repeated attacks of eclampsia, 1
from putrescence of the uterus, 1 from typhus, 4 from puerperal
fever following operative procedures, 1 from paralysis of the lungs,
3 from the consequences of lose of blood, and 1 bftcr several hours'
operative attempts by a country practitioner. Of the children, 390
were born dead, as already stated, under the various operations.

296

Xesides these, 36 died within fourteen days after birth — 4 from
debility, from too early birth, 6 from atelectasis pulmonum, 2 from
'trismus, 1 from fissure of the cranium after a forceps operation, 1
irom chronic hydrocephalus, and 2 from want of breast-milk. The
author remarks that, as a general rule, forceps operations are found
to be most frequent in cold, changeable weather, which induces
rheumatic affections of the uterus, not only rendering dilatation of
the OS very painful, but delaying its accomplishment for days.
When adhesion has taken place repeatedly at the same place, in con-
sequence of an indurated condition of a portion of the uterine wall,
we should, after the termination of the puerperal condition, endeavor
to induce absorption by mercurial or iodine medicines, or by the use
of alkaline mineral waters.

Every reader will be surprised at the great number of operations
performed and the large amount of fatal cases. But this is readily
accounted for by the fact, that scrofulous and rhachitic diseases are
Qimaually common among the inhabitants of Saxony, by the fact,
that Dr. Meissncr, the obstetricf veteran, is the very man who is
called in consultation whenever a case has come to the worst ; by
the faqt, that German practitioners in geucral have to attend more
often to pathological than normal confinements — the latter being
left to the care of our well-trained and trustworthy midwifes, who
are forced by State law to call in a physician as soon as a confine-
ment shows the slightest deviation from the natural course.

Dr. L. Mater, m a paper read before the Berlin Obstetrical
Society, on induction of abortion, considers this operation justifiable
under the following conditions — 1. Extreme contraction of the pelvis.
2. Very narrow constriction of the vagina. Some of the members of
^be Society remarked, that a vagina, contracted even to the utmost
denee, was very often softened and easily dilatable during labor.
8. Large tumors of the rectum and of the vagina. 4. Retroversion
of the pregnant uterus, if the reduction cannot be effected.

Dr. Kattenmann has very properly, we think, deemed it important
to reproduce his thesis on artificial induction of abortion, in an
English version. The little book is intended to discuss the question,
whether induced abortion in case of extreme narrowness of the pel-
vie, is to be received as one of the legitimate obstetrical operations.
In order to prove under what circumstances induced abortion is
a justifiable operation in a medical point of view. Dr. R. first consid-
ers the extreme limits of the dimensions of the pelvis, which will not
even admit of the escaping of an immature foetus, and in which the
operation in question is the only means left, to save the mother from
almost certain death, viz.: Caesarian operation ; he then proceeds to
give an account of the dangers connected with Caesarian section
and of the statistics of its fatality ; nor does he omit to glance at
the proposed craniotomy of the child, and to consider the dangers to
which the mother is exposed in the different attempts of saving the
child. The knowledge of the exact degree of pelvic contraction is of
course not a sufficient guide to decide whether the child may be de-
livered by craniotomy with safety to the mother, or whether the ex-
treme means, as the Caesarian operation, or induction of abortion,
are called for ; the final settlement of this question depends too much

upon the aize of the foetus. Although craniotomy has been p
with perfect success to the mother, in pelvea with antero-posterior
coutraction up to IJ" and 1" lOsborn, Wigand, Michaelia), a pelris
of leas than 3J" diameter, will, as a general rule, not allow eiren a
dead and perforated foetus to pass, without fatally injaring the
mother. In tlieee cases the unestion arises, shall we pnt the mfllher
to all the hazards of a Ceesarian operation, or ought we to sacrifice
one life in order to save another. A perusal of the statistical records
with regard to Ceesarian section, from 1750 to 1854, shows the fol-
lowing results : Of 801, upon whom this operation was performed.
507 died, and 294 were saved ; while not a single woman escaped
of those who underwent this operation in one of the large hospitals
of London, Paris or Vienna. The statistics of mortality would be
greatly increased if all those cases could be taken into account which
have not been published, as the greater number of Ctesarian opera-
tions which are kept secret, have resulted fatally (Naegele, lunonli,
Wilde). It further appears from the results recorded in literature,
that perforation and kep halo trips is are operations which endanger
the life of the mother to a considerable extent, and therefore the onij
way to safely deliver a woman with a pelvis, which makes all obstetric
operations impossible, with the exception of the Caesarian section, is
the induction of abortion. When speaking of the comparative value
of Craniotomy and Coasarian section, and mentioning that with a di-
ameter of 2^" craniotomy is more dangerous than the Ctesarian
operation. Dr. Rattenmann says : "To get easily and pleasantly out
of this difficulty, we have only to follow the advice of Kilian (Vol. U.
p. 280), which is to desert the mother, meaning to let both mother
and child perish without intei'fei'ing. The words of Kilian are:
' When the accoucheur has exhausted all allowable means of persua-
sion, it is his duty to leave the mother, who refuses to submit to the
Csesarian section, without doing anything further.'" — In this state-
ment the meaning and words of Prof. Kilian are misrcprcseitted.
The exact English version of Kilian's words runs as follows : " It ia
the duty (of every accoucheur) to leave this woman (who refuses lo
have Cmsarian section performed) when ho has exhausted all means
of persuasion, and to leave her to her own mercy, until she has come
la another corvdiision, prompted perhaps by the advice of her nitnufrr,
etc., or UTiiil the /inal death of tlie ckUd imperatively dettunuls perfora-
tion and extraction." (See : Die Operative Geburtshlilfe, Vol. ii., p.
737. Ed 1849.) The meaning of these words differs much from
that given by Dr. Rattenmann, and it does not deserve derision.
Kilian does not leave the woman " without doing anything furtber,"
but he leaves her to consult with her relatives and friends before de-
livering herself up to an operation, which, with laymen, is synonymoos
with death. Thus he resorts tu every means to avoid craniotanv,
which in those cases where the pelvis is contracted to such a degree
that Cmsarian section is thought of, must be considered the most dis-
gusting and most dangerous operation in midwifery. — G. N.

The chief indication for inducing abortion is the refusal of the
raolher to allow the Csesarian operation to be performed ia case she
should go to the full term.

Dr. Rattenmann asks : " Why should we hesitate to destroy tl»

297

cbfld, where our object must be to preserve the life of the mother,
ajid why Bhould we yt respect her just claims 7" From the cases
reported where abortion had been induced for diseases thrcateuing
the life of the mother, it appears that this operation was performed
'^rith perfect safety to the mother. When the shortest diameter of
the pelvis is less than 2 or 2J", abortion is indicated, and is justi-
fiable, when the pregnancy has not yet reached the seventh month.
Ab a gnide in practice, two tables are inserted upon page 33, repre-
senting the transverse diameter of the foDtal heads at diiferent stages
of development from the 10th to the 40th week. Rejecting the ob-
jections raised to the operation, Dr. Rattenmann proceeds to discuss
the different methods of inducing labor (rupturing the membranes ;
dilatation by sponge-teats ; plugging of the vagina ; injections into
the vagina or uterus ; galvanism ; medicines). After having
enumerated the medical reasons for inducing abortion, the author
considers the operation from a theological point of view. The fifth
commandment says: ''ne occidas;" but taking into consideration
the dangers incident to the Caesarian section, the same injunction
^)plie8 to the latter operation, and as the performance of hysteroto-
my is not considered a sin, no objection can be made to induction of
abortion. In discussing the legal bearings of the question, Dr. Rat-
tenmann strictly adheres to the rules laid down by Naegele, which
are based upon the right of self-preservation. In applying the laws
of self-defense to the induction of abortion, the author argues in this
way : " In a case where abortion is positively indicated, two not
eqnal rights are opposed to one another, but a weaker right comes in
contact with a stronger. The life of the mother, namely, appears
a real life, that of the foetus only a possible one. For as the foetus
has not yet obtained that conformation and development to enable it
to sustain life independently, we can only look upon it as a possible
life, which in law, cannot, by any means, be considered of equal
Talae with the real life of the mother." And further the author says :
"The mother at the period when abortion may still be induced suc-
cessfully, is actually under duress, on account of the great fatality of
the CsBsarian section. We must therefore, if the natural develop-
ment of the foetus proceeds unintcruptedly, look upon the mother as
threatened by certain death ; and as the mother is possessed of the
natural right of self-preservation, of which she can only avail herself
at the expense of the life of the foetus, wo must consider the mother
as under duress, and allow her the exercise of the right of self-preser-
vation, to the fullest extent, in the induction of abortion. The cir-
cumstance that the physician is not himself under duress can be no
motive to exclude his active assistance ; for he is only the means
and the tool of which the mother makes use to realize her right ; the
mother is the actually acting person ; she causes the abortion, the
physician, properly speaking, is only the medium, by which the
mother strives to preserve her own life, and thus exercises her right."
Therefore, Dr. Rattenmann, thinks himself justified in recommend-
ing induction of abortion : (a) Whenever the mother refuses to sub-
mit to the Caesarian section ; (b) when embryotomy is not practicable,
with a narrowness of the pelvis of less than 2^"

298

Dr. Lkk reports a case where labor was induced before the fifttm
month of pregnancy in a woman with oste^palacia of the pelru
bones, in order to avoid Csesarian operation.

Dr. Cohen's method of inducing premature confinement, seems
become the favored method among German obstetricians, it has
performed this year almost exclusively of every other naetl
hitherto in use for the same purpose.

Dr. Hausmanx published a successful execution of Cohen's method ^
A few hours after the first injection labor pains set in ; twenty-fou^-
hours afterwards the orifice was fully dilated ; two injections were
made, and sixty-three hours after the first injection the membranes
ruptured, and soon a living child was born.

Dr. Crede reports three cases in which he lately induced prema-
ture confinement for contraction of the pelvis, by injecting warn
water into the uterus. In all the cases, only one injection of front
eight to ten ounces of lukewarm water was required. The time from
the first injection up to the expulsion of the child, was respectivelj
sixteen, seventeen and one-haJf, and twenty-three hours. Two chu-
dren were born alive ; one was dead in consequence of prolapse of
the umbilical cord. The women scarcely had any sensation of un-
easiness when the water was injected.

Dr. Kiedel gives an account of his six cases of induction of prema-
ture labor, by intra-utcrine injections. The fact, that four of these'
children were stillborn, is accounted for by their malposition and
consequent turning, thus exculpating the method from any blame.
The time of labor from the first injection was respectively five, six,
eleven, forty, forty-four, and sixty-three and one-half hours. Thii
makes an average time of twenty-eight and one-half hours. The
author insists upon the necessity of retaining the injected water for
some length of time in the uterus.

Dr. Birnbaum used this same method in seven instances, partially
combined with other methods, partially alone. Not one operation
was followed by evil consequences. Of seven children, five were
born alive ; of which number, one died soon afterwards, two died
during the operation of turning and extraction. No death oconrred
which might have been attributed to the method. The time between
the injection and the beginning of the first labor pains was respective-
ly one half hour, two, five, seventeen, seventy-two hours, and the time
of actual labor respectively, one, three, six, ten, six, ten hours.
Therefore, the efiect of this method is sure and prompt, and demands
only in very rare instances a combination.

Dr. Stoltz reports the case of a woman who was prematurely
delivered by injections of warm water into the vagina, with a com-
mon enema-syringe. After the eighth injection, labor was fairly es-
tablished. Dr. Stoltz seems to prefer this method to others.

Dr. Braun, in considering the different methods for inducing prem-
ature confinement, proposes a new one, or rather a modification of
Krause's method. Instead of an elastic catheter. Dr. Braun makes
use of a gut-string, which he introduces into the cavity of the womb,
between the walls of the uterus and the chorion, to remain there
until expelled by the advancing labor. The principal reason why

299

Dr. Brann prefers a string, is the fact that the membranes bad been
ruptured in some instances, especially when the stiff English catheter,
with inflexible mandrin, had been used for the purpose. This accident^
happened at the moment, when the mandrin was withdrawn, while it
was not observed when an elastic, French catheter was applied with
flexible mandrin. In order to make the use of strings even safer, Dr.
Braun proposes to have the point of the strings dipped into hot
water to the length of about half an inch, by which process they be-
come very pliable and inoflfensive. Dr. Braun resorted to this
method of intra-uterine cathetcrism in twelve instances. The re-
sults were as follows : eleven children were born alive ; five still-
born ; eight mothers recovered entirely ; four died from diseases
uncounected with the puerperal state (one pneumonia, one tuber-
culosis, two Bright's disease). Gut-strings were used five times,
flexible French catheters four times, and in no instance the mem-
branes were ruptured ; the English catheters, having a very small
amount of elasticity, were used three times, and in every single in- •
stance, the membranes were ruptured. The shortest time of labor
after the introduction of a gut-string was five hours, the longest term
one day. Added, is the history of the above-named twelve opera-
tions. As a a sample, we will reproduce

Case VI. Fistula vesico-vaginalis and pregnancy ; induction of
premature labor, by means of a gut-string for contraction of pelvis ;
recovery of the mother.

Johanna H., thirty years of age, was delivered thirteen years ago
of a premature dead child. At the full term of her second pregnancy,
craniotomy was performed on her for contracted pelvis of 3-3 1"
antero-posterior diameter, as the forceps had failed to deliver her ; a
vesico- vaginal fistula was established after this operation. The fis-
tular opening had been reduced to a very limited extent* by suture,
when the patient became pregnant for the third time. Her last
menstrual courses appeared towards the end of October, 1857, and
the first quickening was remarked in February, 1858.

On May 17, 1858, premature labor was induced by introducing a
gut-string 10" long and 2'" thick, between the uterine wall and the
chorion, as high up as 8", to remain there. Two hours afterwards
labor pains set in, which twenty-two hours later expelled the string,
and effected the birth of a stillborn child (of 4 pounds weight and
17" length), in a cranial presentation. The mother recovered
promptly.

In case V. it was impossible to push a gut-string through the os
uteri, " as it was narrowed by cicatrices," and thrf membranes were
ruptured on purpose by an English catheter.

Dr. Gardnkb reports the history of a woman who had been de-
livered three times by craniotomy for contracted pelvis. In the
seventh month of her fourth pregnancy, premature labor was induced
by the douche inserted into the mouth of the uterus.

Dr. Andrew SMrra reports a case where cephalic version was suc-
cessfully resorted to in an arm presentation. Dr. Smith prefers it to
turning by the feet, on account of the large amount of infantile mor-

300

tality in footling cases. He recommends it for all cases in which the
safety of the mother does not call for speedy delivery.

By a comparison of the respective advantages and disadvantage
of the operations of turning and forceps, in cases of protracted labor,
where the head is floating above the brim. Dr. Figg advocates Simp-
son's method of turning, instead of delivery with the forceps. In i
P. S., the author says : — " Since writing the above observations some
months ago, I have attended sixty labors, three of which alone have
been conducted as head presentations. Of the remainder, two^were
breach presentations, and the other fifty-five were conducted accord-
ing to the principles advocated In the above communication, m:
the children were all delivered by turning." It seems that our Lord
made a mistake when he ordered the children to be bom calvirit
praevia, and Dr. Figg is called to correct this error. — E. N.

The article of Dr. Barker on the comparative use of ergot and fo^
ceps is, as all his articles are, replete with literary and practicil
knowledge, and written with a great deal of sound judgment He
confines the use of ergot only to very few cases, viz., to cases of
inertia uteri, in the last stage of labor, at a time when delivery ii
expected to be finished before an hour. In the first stage of labor it
ought to bo applied only in cases of partial presentation of the
placenta, for the purpose of controlling the hemorrhage. With regard
to post-partum hemorrhage, the author recommends this dmg for
those cases which occur in plethoric women, with flushed skin, thirati
and bounding pulse, while in those cases where the countenance is
sunk, the lips blanched, the skin cold, the pulse gone, the opium wiU
act like magic. As a remedy for retention of urine after labor, erg^t
in doses of twenty drops of the tincture, repeated every half hour,
is of greatest importance. After stating the difierent indications for
the application of forceps. Dr. Barker says : — "In conclusion, I most
state my conviction, that the more enlarged is the clinical experience^
and the more accurate the observation, the more rarely will the ergot
be used before delivery ; and furthermore, that the fear of delay in
labor will be greater than the apprehension from the use of forceps."

Dr. Barker gives the history of a case, where turning was substi-
tuted for the application of the long forceps, in order to save the life
of the child. The danger consisted in the cord being wound three
times around the childs neck, pulsating very feebly. If the cord
should happen to be very short, not only would the life of the child
be imminently jeopardized, but that of the mother, also, from forci-
ble detachment of the placenta. The child was still-born, but resusci-
tated. ,

Dr. Elliot describes a new forceps with a pivot, which can be
moved upwards and downwards, thus keeping the blades at a dis-
tance from another, so as to avoid undue pressure upon the foetal
head. This sliding pivot is a happy modification of Mendt^s appara-
tus. — E. N. The usefulness of the instrument is illustrated by a
large number of cases. In order to render the forceps applicable in
a great variety of cases, especially when the head is floating above
the pelvic brim, and when even the os is undilated, the instrument is
slender and long, with only a slight ^pelvic curve. It is 15^ inches

301

lonr ; extreme width between blades 2^^ inches ; length of blades
6j inches ; the widiii of the fenestra only ^g of an inch. The blades
are very thin, the handles long and powenul.

Dr. Les records a case, where it could not be ascertained whether
the child was alive or dead, and he therefore proposes to inquire into
the comparative temperature of dead and living children, in order to
ascertain whether this way might not become of usefulness for diag-

Dr. ScHVLTZE remarks, that the limits of a justifiable operation with
the craniotomy-forceps, for removing a full-grown child, are 2 J" or«
f antero-post. diameter of the brim. Below two inches the extrac-
tion of a fnll-grown child never ought to be attempted. The non-
aitendance to this rule has destroyed many mothers. Dr. Schultze
cavtioDS against the proposition of turning the child, in cases of con-
liderable obstruction, to avoid craniotomy, because after the opera-
tion of tuminff has been performed, it is often necessary to apply the
perforator to uie head remaining in the uterus, beneath the shoulders — ■
a feat very difficult to perform. We heartily subscribe the author's
Teto from oar own experience ; we have been led to act once on this
principle, for the first and last time, proclaiming, with Dr. Dubois,
" On ne m' y prendra plus 1 " — E. N. It is equally wrong to deliver
afnll-gp'own child through a pelvis of less than 2|" shortest diameter.
Between 2}" and 2" shortest diameter, it is impossible to produce a
living child on the natural way — the CsBsarian operation alone gives
a chance of saving mother and child. But the life of the child has to
be sacrificed, as soon as its integrity has become dubious, by
previous attempts to operations or other circumstances. By Csesarian
operation we arc justified to endanger the life of the mother for/
saving the life of the child ; but to put a mother's life at stake for a
chfld of questionable vitality, is an act of inhumanity. But in pelvic
contractions of 2|" shortest diameter and upwards, the rules to be
followed are different. Here it is where to the forceps ought to be
given a full and fair trial, and the perforator must be kept behind,
until the former way is abandoned as insufficient. If, however, the
child is notoriously dead, we must abstain entirely from the use of
the forceps, considering that an easy kephalotripsis gives a better
chance to the mother than a difficult forceps of»eration.

Dr. Lee reports another case, where he perforated and extracted
the head of a child, which rested upon the perineum. In concluding
the article he says : It might now I think be considered as an
aphorism in midwifery, that the forceps is not applicable to dead
cnildren, nor in cases where the os uteri is not fully dilated, and the
head has not descended into the cavity of the pelvis and can be felt.
— The writer ventures to express his humble opinion, that a dead
child, with its head resting upon the perineum, is quicker delivered
by forceps than by the craniotome, and with the same safety and
comfort for the mother.

Dr. Ben Ezri's article on the history of Csesarian operation, is in-
tended to prove, from the Jewish Talmud, that this operation had
been in use as far back as 130 ante-christum. [This same opinion
has been advanced by Dr. Mannsfeld in his thesis : Ueber das Alter

302

des Baucb- und Geb^Lrmutterschnitts an Lebenden. Brannsdiweii^r
1824. 8. — E. N.] The words alluded to by Dr. Ben Kzri may be
found in the Mishna, Section VII. : "The male child bom by anop^
ration on the side of the mother, and one bom after it (twiiw),
neither of them is considered a first-born, in regard to inheritance or
to the redemption by the priest f and further, in Tractat Niddi,
Sec. V. : "A child born by means of an operation performed on the
side of the mother, the law does not compel the mother to observe
the prescribed days of impurity and purity." Prom these quotations
. the author concludes that no better proof was necessary tlian the
certainty with which the above passages express, not only a knowl-
edge of the Sectio Caesarea, but also that the operation was perform-
ed on living beings, and that their lives were preserved.

We have received this year an unusually large number of success-
ful Caesarian operations — 2 by Dr. Pagenstecher, 2 by Frerickb and
GiuESBECK, 1 by Dudos, 1 by AlonsOf 1 by Hawkins, 2 by Mertens,
and 1 by Ghevillon — the latter in a case of extra-uterine pregnancy.
The cases reported by Dr. Mertens go to show, what many obstetri-
cians can confirm by their own experience, that often the apparently
most unfavorable cases result in general satisfaction.

Case 1. — A primipara, 30 years of age, perceived the first labor
pains on November 25, 1856 ; but during the progress of labor the
head became so firmly incarcerated in the pelvis, that the enormous
caput succedaneum prevented a closer examination of the pelvic
diameters. It was impossible to apply the forceps, and when the
child was ascertained to be dead, his head was perforated and dimin-
ished, after which the accoucheur was able to perceive that Gsesarian
section was even now the only means left for delivering the woman.
This was performed in the linea alba. The patient recovered finally,
notwithstanding her taking cold three days after the operation, in
consequence of which an obstinate cough, with swelling and tender-
ness of the abdomen, set in. She left her bed after four weeks.

Case 2. — A multipara, who had been delivered two years previous-
ly by the CaBsarian operation, was taken sick on January 6, 1856.
The uterus was now situated in a sac formed by the abdominal wall,
and extended downwards to the middle of the thigh ; the cut ran
alongside the linea alba. The womb being very thin, the incision
touched the placenta, which was removed immediately with the
living child. The patient left her bed ten days after the operation,
in consequence of which she caught cold and was taken with inflam-
mation of the left ovary, after which an abscess formed and broke in
the vaginal region. The patient also recovered from this accident in
three weeks.

REPOKT

OS THK

PROGRESS OF INFANTILE PATHOLOGY IN 1858.

I. MANUALS, GENERAL PATHOLOGY, DIETETICS,

STATISTICS, ETC.

1. Hennig, K., Lehrbxtch der Krankheiien des Kindes in seinen ver-
schiedenen Aliersstvfen. Zwcite Auflage. Leipzig, 1858. pp. 476.
{Manual of the Diseases of Children in Different Ages.)

2. Condie, F., a Practical Treatise on the Diseases of Children. Fifth
Edition. Philadelphia, 1858. pp. 702.

3. Meigs, J. F., M.D., a Practical TreMise on the Diseases of Children.
Third Edition. Philadelphia, 1858. pp.724.

4. Tanner, T. 11., a Practical Treatise on the Diseases of Infancy and
Childhood. I^ndon, 1858. pp. 408.

5. Hajr, Fr., Politzer, L, M., Schuller, M., Jahrbuch fur Kinderheil-
kunde und Physische Erziehumj. 1857,1858. 1.1—4. 11.1—2.
f Annual for Infantile Pathology and Physical Education. Six num-
bers.)

6. Behrend, Fr. J., und Ilildebrand, A., Journal fur Kinderkrankheiten.
1858. 1 — 12. (Journal for Diseases of Children. Six bimonthly
numbers.)

7. Mayr, Fr., on Examination and Semiotics of Sick Children. — Jalir-
buch f. Kind. 11. 1.

8. Gumming, W. H., on a Substitute for Human Milk. — Am. Monthly.
March.

9. Gumming, Wm. H., on Natural and Artificial Lactation. — Am.
Jour. July.

10. Politzer, L. M., on Scientific Dietetics and Physical Education of
Children. — Jahrb. f. Kind. 8, 4.

11 Routh, C. H. F., on Vegetable Substitutes for Human i/i/it,— Med.
Tim. and Gaz. Aug. 21, 28.

12. Routh, C. H. F., on the Mortality of Infants in Foundling Hospitals,
and Oenerally as Influenced by the Absence of Breast-Milk. — Brit.
Med. Jour. Feb. 6, 13, 20.

13. Aravaca y Forrest, Practical Considerations on Lying-in Women
and Newborn Infants. — II Siglo Med. 228.

304

14. Caron, A., Hygiene for Nevuborn In/ants, Considered in Relation to
their Physical and Moral Devdopment, — Gaz. des H6p. 142. 144.

15. Chabrely, B., on Hygiene of Irfarjfs in their Earliest Age, — Jour, de
Bord. Nov.

16. Patron, August, De roWai^emen/ mafemeZ. Paris. Thtee. pp.34.
(On Maternal Lactation,)

17. Besser, Leopold, Den Deie/sc/ien Muttem und Vaternein Buchiaher
dan Werden und Wachsen ihrer Kinder als Schlussel zu deren Oem-
derer Erziehung, Frankfurt a. M., 1858. pp.344. (A Bock fw
Qerman Mothers and Fathers, on the Formation and Chrowth (f
Children, being a Key to their Sound Fducaiion,)

18. Gauneau, J., Education Physique et Morale des NouveaurNis, Sum
de r Importance de PAllaitement pour la Mere, Paris, 1858. pp. 106.
(On Physical and Moral Education of Nevabom Children, vjiU^m
Appendix on the Importance of Nursing to the Mother,)

19. Hufeland, Chr. W., Outer Bath an Mutter fiber die Wtchtigslen
Punlcte der Physischen Erziehung der Kinder in den Ersten JfUvren.
Nehst einem Unterrichte fur Junge Eheleute, die Vorsorge fur Unge"
borne betreffend, I^eipzig, 1858. pp. 257. (Advice to Mothers on
the most Important Points in the Physical Education of Children in
the First Years of Life, With instructions to young couples an Uie
care of the Utibom.)

20. Plath, Wilhelm, Briefe eines Arztes an eine Junge Mutter. Ham-
burg, 1858. pp. 308. (Letters of a Physician to a Young Mother.)

21. Ddclat, G., Hygiene des Enfants Nouveau-Nds. Paris, 1858-1859.
pp. 316. {Hygiene of new-horn children,)

22. Sclireber, D. G. M., Kallipaedie, oder Erziehung zur ScJiMieii, etc,,
Mit 72 Abbildungen. Leipzig, 1858. pp. 309. {KaUipaedia, or
Development of Human Beauty by Education, etc,)

23. SchOpf-Merei, A., and Whitehead, J., Second Report on the Hos-
pital for Diseases of Children at Manchester, — Jour. f. Kinderkr.
9, 10.

24. The Murder of the Innocents, — Lancet. May.

25. London Hospital, Returns of Patients under Seven Years of Age
in the Children's Ward during the Year 1857. — Lancet. ApriL

26. Helflft, on the Mortality during the First Year of lAfe, of Childrm
Born Alive at Berlin, — Monatsbl. f. med. Statistik. 2.

27. Kaedell, C, Contributions to the Statistics of Neujbom Children
at Berlin, — Ibid. 9.

28. Huaemann, Th., Contributions to the Medical Statistics of the Prin-
cipality of Lippe.- -I bid. 1 .

29. Scherzer, C, Medical Notes, — ^Wiener Zeitschrift. 45.

30. Moore, W., Contributions to Infantile Pathology, — Dubl. Hosp.
Gaz. Aug. 15 — Journal f. Kinderkr:

31. Stendelj H. and Giirtuer, 0., Second Report on the JatrogymnasHc
Institution at Stuttgart. — Journal f. Kinderkr. 1, 2.

305

32. Hauner, Report on the Eleventh Year of the Dispensary Connected
with the Children's Hospital at Munich. — Ibid. 7, 8.

33. Faye, F. C, The Children's Hospital at Christiania in the years
1855-1857.— Ibid. 7, 8.

34. Lttscher, Jahresl)ericht des Franz Joseph Kinderspitals in Frag,
vom Jahre 1857. (Annual Beport on the Francis Joseph CkildrejCs
Hospital of Frague^for the year 1857.)

35. The Hospital for Sick ChUdren.—Brit Rev. Jan. *

36. Reports of Continental Children's Hospitals. — Edin. Med. Jour.
March.

37. Hermhilfe zn Wildbad, Filial der Kinderheilanstalt zu Ludwigs-
burg, zur Verpfiegung Badebedarftiger Kinder; der 4. Summer da-
selbst. Ludwig-Bburg". pp. 20. (Herrenhilfe at Wildbad^ Branch of
the Children's Hospital at Ludwigsburg; for the Purpose of IbJting
Care of Children Needing Baths; the Wi Summer.)

38. Dissauer, The Children's Hospital at Oraz. — Jahrb. f. Kind. 4.

39. Foundling and Medical Ifiditulions for Children at Vienna, —
Ibid.

40. Schreber, M., on the Therapeutical Use <f Sun-Baths^ particularly
in certain Chronic Diseases cf the Infantile Age. — Ibid. 3.

41. Schuller, on the Abuse of Syr. Diacod. in Diseases of Infants. —
Wiener Zeitschrift. 50.

42. Joachim, W., on the Use of the Laudanum in Diseases of Infants.
— Ungar. Zeitschr. 32.

43. Pollard, Th., Use of Opium in Children.. — Atlanta Jour. Nov.

44. Meigs, J. F., on Semiotics and the Examination of Sick Children.
— Jour. f. Kinderkr. 2.

45. Folitzer, L., Critical Beview of some Opinions on IrfantUe Fatho-
logy and Therapeutics. — Wien. Med. Wochcnschrift. 47. Oesterr.
Zeitschr. f. Prakt. Heilk. 46.

46. Schauenstein and SpJCth, on the Transition of Medicines from the
Circulation of Pregnant and Nursing Women into Milk, Amniotic
Liquor and Foetus. — Jahrbuch f. Kinderkr. II. 1.

47. Ploss, H., on the Causes of Sexual Difference in Infants. — Monat-
Bchrift f. Gebiirtsk. May. Pamphlet.

48. Jacobi, A., Beport on the Progress of Infantile Pathology arui
Tlierapeutics. — N. Y. Jour. Jan., March, May, July, Nov.

49. Jacobi, a Critical Examination of all the Recent Works rdaUng to
Infantile Pathology and Therapeutics. — N. Y. Jojir. Nov.

50. Thomson, J. B., on the Comparative Influence of the Mde and
Female Parent upon the Progeny.— Ed. Med. Jonr. Dec.

51. Edgren, Swallounng Needles. — Jour. f. Kinderkr. 8, 4.

52. Silvester, H. A., a Contribution to thfi Science of Teratology. —
Med.-chir. Trans. XIII.

53. Kuhn, on the Origin (/ Monstres per dgfecium.— BolL do I'Ac.
XXllL Sept.

306

54. Joseph, on Dovbie ifaj^mafum. -^Abhand. d. schles. Gee.
XXXV.

55. De Oarzia, A., CorUributions to the History o^ Ifii^aniui^unw.— EI
Siglo Med. 255.

56. Schmidt, J. B., Congenital JtfalformaHons among 889 btrftt in the
Glinique of Frof, Scanzoni, — Scanz. Beitr. III.

91, Schultze, B., Cases of Mialfornu^ions. — Schmidt's Jahrb. Not.

58. Martini, on Surgical TreatmenJt of Congenital Maiyarmalkm;
Atresia ani ; Obliteratio llei ; jSpina Bifida. — Ibid.

59. Budd, Ch. A., a Case of UnusuaUy Large Devdopmeni of the Ammi
Fijstiis. — ^Am. Monthly. March.

60. Ramis and Breslan, a rare Case ofDouUe Ma^ormaHon Xifkofy
ma. — ^Bayer. iirztl. Intellig.

61. Geoffrey St. Hilaire, Monster; JTipAo^lymtf.— Gas. Hebdom. 4.

62. Girard, on a Monster, Xiphodyme. — ^Un. MM. 186.

68. Johtison, S. P., a Curious Monstrosity. — ^Yirg. Med. Jour. Nov.

64. Jackson, J. B. S., Two Foetuses United, Face to Face, from the
Umbilicus to the Upper Third <f the Sternum, — ^Bost Med. Jour.
May, 14.

Of the manuals of Dr. Hennig, Prof. Condix, and Frof.'M|BiQ8 new edi-
tions have been published ; the introductory chapter to the work of
the last writer, on clinical examination of children, has been trans-
lated into the German language, and printed in the " Joum.fitr Kir^
derkrankheiten.^ It is of a similar scientific value, and practical im-
portance to that exhibited by Dr. Mayr, of Vienna^ in his article on
examination of sick infants, in which the semiotical signs taken
from forehead and physiognomy are treated of. We regret to stale
that a new manual on diseases of children, has also appealed and
swelled the number of those already in existence ; we legfrot it^ be-
cause an inclination to collect, destroys or lessens the tenden^ to
produce. We may confidently assert that the larger the number of
manuals issued, the greater the dearth of new facts and real scientific
discoveries ; at all events, it is true, that a small monograph or a
short, but original article in a medical journal, is to be vauiea higher
than a large manual destitute of new facts and the most recent dis-
coveries like that of Dr. Tankeb. We regret that it is oar duty to
notice a book, which does not at all meet tiie demands of the time in
and for which it has been written. We the more regret it^ because
we have completely to disagree with a highly favorable report in the
Edinbur^ Jour. ^ Medicine (Aug.), the reports and reviews of
which we have always been accustomed to hold in gpreat esteem.
We feel, however, very willing to acknowledge everything that is
praiseworthy, and therefore we heartilv, with the Edin. Jour., give
vr. T. credit for limiting excessive bloodletting in infantile diseases ;
but we deny him the originality in these views which the Edin. Jour.
claims for Dr. T., and which Dr. T. claims for himself. The same re-
marks which the Edin. Jour, is at the pains of reprinting, may be
Cound JBst as well expressed ui any good manual on diseases of chil«

807

dren, mnd mnch better, we think, in Dr. John B. Beck's JSSnoys an In-
fant Therapeutics (New York, 1855, pp. 82-100).

A oommendable feature of the work is the large nnmber of sub-
jects treated of, as but very few of the many manuals on diseases of
children are complete. This deficiency is a great defect in a book
designed to give full information on any subject tliat may occur in
practice, and is not only found in our own American manuals, by
Mei^, Dcwoes, and Bedford, but in those also by West, and even
Silliet and Barthez ; this latter work should rather be considered a
collection of most excellent monographs, than as a complete manual.
Wbfle thus acknowledging the completeness of Dr. Tanner's book its
regards the range of subjects considered, we have to confess that
there is scarcely one article in the whole collection a^eeing with the
results of modem science in general, and of paadiatncs in particular.
We shall cite only a few examples, from which our readers may draw
their own conclusions. Atelectasis pulmonum (p. 808) has no other
cause attributed to it by the author than bronchitis. In his opinion,
plenrisy in children (p. 805) is most frequently produced by the ex-
tension of the inflammatory action in pneumonia, while it may be
considered as certain, that the most obstinate and fatal cases of
pleurisy very frequently are not even combined with pneumonia.
Again our author asserts that laryngitis, pneumonia, and pleurisy
are not unfrequent, while bronchitis and croup are perhaps, of all the
severe afiections of childhood, those which are most commonly met
with, when, in fact every practitioner is accustomed to meet with
many cases of bronchitis and pneumonia to a single case, except
dnringr a severe epidemic, of genuine croup. And it is well known
that pieurisy and pneumonia do not rank equally as to the frequency
of their occurrence. In the opinion of Dr. T. again, "Croup is most
oommon perhaps during the second year of life,'' (p. 282), and where
be is enumerating (p. 284) the indications and centra-indications of
trmdieotomy, he savs : ''The practice of auscultation in the second
and third stages, yields information as to the amount of air entering
the lungs, and the extension or not of the inflammation to the bron-
diial tubes and lungs.'' These assertions are by no means true, not
even ^>pToximatively. The first one may readily be refuted by sta-
tistics which constantlv prove, that (primary and secondary croup
taken together) croup is less frequent in the first two years of life,
than in the period from two to five years. Further, whoever has at-
tentively observed the stages of croup, is well conversant with the
fact^ that in almost all cases it is more than difficult, even impossi-
ble^ to learn the state of the lungs, because no pulmonary sound can
be perceived on account of the overwhelming noise in the larynx.
Wnat^ ftgftin, are we to say of the symptomatological accuracy of a
writer, who calls (p. 228) " a continued contagious fever, accompanied
by an eruption, and frequently attended with inflammation of the
nincous membrane of the n^spiratory organs," the distinguishing char-
acter of measles ? Or what of his nomenclature, when wiUi him
(p. 230), "simple or infantile, or remittent, or more correctly, typhoid
fever" are synonyms? What estimate shall we place upon the sci-
entific attainments of an author who, in a book written for the infer-

808

mation of others, has only the following to say on typhus in children:
"Typhus is, I6eZieue, contagious?" or of his knowledge of pathology,
who ventures to call infantile intermittent fever " a rare disease in
children under five years of age?^ or of his physiological learning,
when amongst the four general effects of abstractitm of blood from
the system the first is said to be the diminution of the quantity of
blood, and another, the weakening of the heart's action 7

Wc must add, that we can but find fault with a sentence like the
following (p. 304): ''Either the inflammation terminates in resoln*
tion and complete recovery, or the roughened surfaces become adhe-
rent, or they are separated by the effusion of serum, and a kiud of
dropsy results, known as hydrothorax" — in which the terms are as
badly selected as the pathology is incomplete or false. Moreover, we
desire to state, that the general opinion expressed on diseases of
childhood is not fully according to truth. For example, the author
states (p. 20), that, ''tlie maladies of this time of life are severe and
insidious in their natpre, soon give rise to organic change, and run
their course with a rapidity not seen in the adult." This is true, bat
the contrary is equally true ; that the maladies of childhood, severe
and insidious though tliey appear to be, do not give rise tu organic
change, but yield readily to health and cheerfulness. .Such is the
action of the nervous system, and the rapidity of metamorphosis in
the organism of children, tliat sometimes an extremely doubtful prog-
nosis is refuted by an unexpectedly speedy recovery, and vice vena.
A practitioner yielding to the impression communicated by the above
quotation from Dr. Tanner's work, would be liable to many mistakes
in his estimation of the importance of apparently dangerous symp-
toms.

We have not space to extend our criticism, and will merely add
t^at the author has, by no means, given to individual subjects the
space and consideration which they deserve. Wc have spoken of
atelectasis pulmtmum , so prominent a feature in the invcHtigations
and studies of European writers, which is dispatched in a few lines.
Tuberculosis occupies only two pa^^es ; scrofula only three and a
half; syphilis only one and a half, \vhile the symptomatology of this
latter important disease is mure defective and inaccurate than almost
anything in the whole book. Finally, we have to state, that the*ex-
tracts given above are taken at random ; they are not a few points
selected after a careful reading, but they were generally found on
the first page wherever we happened to open thp volume.

After the Journal fur Kinderkrankheitenf Journal for InfaniUe Dis-
eases), edited by Drs. Fr. Behrend, and A. Hildebrand, and published
at Erlangen, had been existing for thirteen years. Dr. Kraus, of Vi«
enna, undertook to publish, also in twelve yearly numl)ors, the Oes-
terreickische Zeitschri/lfur Kinderheilkunde (Axistrian Journal for In-
fantile Fathology). \Vnen he was, by his private business, no longer
able to attend to its publication, it ceased to appear after two years
had elapsed. Sept, 1857. Drs. Fr. Mayr, L. M.Politzor, and M. Schul-
ler, have since stepped in to fill the void, with the Annual for Infan-
tile Fathology and Physical JSducation, six numbers of which have
since appeared. Wlule no other country, has a single journal

309

for the specialty in qaestion, Germany can boast of two jonmals de-
voted to infantile pathology, both of which have alike able contribu-
tors, and a large number of friends and readers. The contents of the
Annual are composed of original contribations, miscellanies from
general medical literature, and critical reviews. The first are most
valuable. As instances, we name Prof. Claris essay on the pathology
and therapeutics of some of the most important disease of the infan-
tile intestinum crassum ; Dr. Vogel's contributions to the physical
ezplc^ation of the lungs in young infants ; Dr. Mayr's articles on the
examination and semiotics of sick children ; Dr. Herman ZeissPs
essay on congenital syphilis of new-born infants and nurslings ; Dr.
Bokai's article on retropharyngeal abscesses in children ; Dr. Politzer's
treatise on scientific dietetics and physical education ; and Drs. Frie-
dinger's, Mayr*s, and ZeissVa essay on syphilides of the infantile age.
The care and industry given to each of the six nnmbers which have
hitherto appeared, has been the very same from the beginning to the
end. The editors cannot but win by their labors the thanks of the
profession and a good reputation for themselves.

Dr. CniMiNo's articles " on a substitute for human milk," and "on
natural and artificial lactation," are as able as they are earnest. A
few of his statements will be deemed sufficient to prove this asser-
tion I An infant three months old will take from forty-eight to
sixty-four fluid ounces daily, in six or eight half-pint doses. During
the first 3'ear, therefore, he will take from 1000 to 1300 ponnds, in
which the weight of butter is 2T pounds, casein 18.5, sugar 97.5,
water 1157, salts 2.1 pounds ; of these latter, 12 ounces are phos-
phate of lime. It thus appears, that during the first year, the child
receives from 110 to 143 pounds of dry solids. He may thus readily
gain 15 or 20 pounds in weight, implying less than three pounds of
dry solids, and yet have a large residue to be expended in the pro-
duction of heat, and in the activity of an energetic vitality. A child
thus nourished, can make teeth and bone without difficulty. A
woman in fully nourishing her child, must furnish as much milk in
proportion to her weight as a good cow ; a woman weighing 130
pounds, will give daily 4 pounds of milk, containing about 5 ounces
of dry solids ; the cow weighing six times as much, will give 6 times
as much, containing 30 ounces of the same. In an ordinary parturi-
tion, a woman loses not more than 20 pounds, containing less than
3 pounds of dry solids ; this amount furnished in nine months, is at
the rate of 4 pounds a year. Many women fail to furnish fully even
this small amount ; the infant at birth being small and meagre,
looking like a starveling. If unable to furnish this small amount,
how can a mother be expected to furnish 30 times as much f

Cow*s milk
coDtaina.

Batter, 38^
Casein, 40.75
Sogar, 53.97
Water, 86<.e9

Haman mUk
eootaliB.

Batter, 2a76

CMein, 14.34

Sogar, 75.02

Water, 889.88

It is thus evident, that by no mode of dilution, can ordinary cow's
milk be made a substitute for human. There will be in every case
an excess of casein, or a deficiency of butter. As long as the but-
ter is to the casein as 100 to 115, instead of 100 to 70, so long must

• 310

dilution fail to adapt it to the wants of the child. But if this ori(^
nal proportion oomd be changed to that existing in human milk, ive
might have hope of success. If we leave at rest for four or fin
hours ordinary cow's milk, and then remove and examine the upp^
third, we find in it 50 per cent more butter than it at first containel
In round numbers, its butter is no longer to its casein as 100 to 105,
but as 150 to 105, or as 100 to 10. If then, by dilution of this milk,
we reduce tixe butter to 20.76, we have 14.34 of casein, as in hnmaa
milk. Another mode of obtaining the same result, is by using the
latter half of the milk furnished by the cow. The former half coik-
tams 22.18 of butter to 41.63 of casein, while tlie latter half has 54
of butter to 38 of casein ; here again the right proportion exists.
The actual composition of this latter half, is butter 54, casein 88,
sugar 53, water 855. By adding sugar 142, and water 1458, wa
have butter 54, casein 38, sugar 195, and water 2818, or in pro-
portion butter 20.17, casein 14.61, sugar 75, and water 889.62 ; the
difierence from human milk is unworUiy of notice.

To imitate colostrum, we must, during the first month of the
child's life, use milk, containing from 75 to 80 thousandth of butter,
or from 94 to 107 per cent more than the ordinary milk of the cow.
This rich milk may be obtained, by taking the upper eighth instead
of the upper third of milk left to repose for four or five hours. It
may be also obtained by using the last tenth of the milk famished
by the cow.

hHc

1 from 3 to 10 dmyv old.

Milk 1000.

Water 2643

Sugar S4S

10 to SO ««

2500

u 225

1 month old.

«i

2250

«« 204

2 montliB old.

1830

" 174

1500

•^ 144

1250

** 124

1000

«* 104

875

II 94

750

u 34

675

« 73

625

« 73

«l

550

" OT

500

.« 63

In general, it is better to begin with milk more diluted than the
age and development would seem to indicate, and then gradually in*
crease its strength. It is better that the food should be insufficient
than that it should be indigestible. A child ten days old will take
about 32 ounces daily in eight four-ounce doses ; the doses will xor
crease in size and somewhat diminish in number, so that at 8 months
seven eightounce doses are usuallv taken. The milk should be
given at regular intervals ; the child should be trained to pass six
or eight hours at night without feeding. The temperature should
be from 100^ to 104° ; ten or fifteen minutes ought to be given to
each dose. This food thus administered, may well be styled artifidii
hunuin milk.

Dr. Poluzsb tries to find a scientific basis of infantile dietetics, by in-
vestigating into the peculiarities of the metamorphosis of the sub-
stances of the infantile Qgrganism, and the proportion of gain and

311

loss, by exploring the exact nature and faculties of the digestive
organs, and of the food most in use for children. In his opinion,
metamorphosis of substance in the infantile organism, is particularly
modified by the incompleteness of the body, and the chemical and
physical difference produced thereby of infantile organs in propor-
tion to those of adults. The osseous system, muscles, and skin, are
most apt to show such a difference. There is another species of
glue— cartilaginous glue — and less lime in the infantile bones than
in those of adults, but more chloret sodii, this haying a greater
affinity to the glue of cartilages ; infantile muscles contain more
albumen, less fibrin, and assimilate from the blood a larger amount
of salts of potassa and magnesia than of lime ; this forming no larger
part of the muscles, until a more powerful respiration, and a greater
amount of oxygen in the blood favors the formation of fibrin. The
skin, too, contams more albumen than in adults. Respiration is ac-
celerated and less energetic, sleep of longer duration ; according to
the results of physiological science^ therefore, less carbonic acid is
exhaled, less urea excreted. Motions of the body are but few, men-
tal activity inconsiderable. In the circulation, there are also some
peculiarities, the heart being less powerful, and the "aspiring"
effect of feebler inspirations on the veinous blood less consider-
able. Nor has the relative inactivity of infantile muscles much effect
on general metamorphosis. Milk undoubtedly changes the ratio
of its elements according to the period of nursing, but not at all in
such a degree as albuminous, fatty, and saline elements are changed
in the food of adults. Finally, digestion, resorption, the size and in-
fluence of the liver, are of peculi:ir importance m the infantile organ-
ism. The practical consequences of the foregoing facts are easily
understood ; the assimilation of food will have more than only to re-
store the loss ; it ought to be as digestible as its amount sufficient ;
proteinates ought to outweigh fats ; lime, potassa, phosphates, are
required in laree quantities, and the food ought to be equable and
appropriate to tne age.

The further expositions of the author contain a full review of the
physiology of the digestive organs, as applied to the infantile age.
The organs of mastication, the stomach, intestines, liver, spleen, and
pancreas, are treated of ; the digestive power of the infantile saliva,
gastric, pancreatic and intestinal juice, and of the bile, further the
digestion of amylacea and carbonhvdrates, of proteinates, of fats, and
finally, the process of resorption of the digested masses, are scientif-
ically examined. Thus tne physiological knowledge of infantile
digestion, we dare say, is matenally improved by the accurate and
ingenious essay of the author.

Dr. Routh arrives at the following conclusions as to the diet of chil-
dren : — I. The analogy of comparative anatomy of a child's alimen-
tary canal, imjicates that its food should be animal. 2. The child
should not be weaned, if it can be avoided, before the 8th month. At
this period it may be allowed to give vegetable food, but animal is
better. 3. The vegetable aliment selected should contain chloride of
potassium and phosphoric acid among its mineral ingredients, and a
due proportion of plastic as compared with calorifiant matters ;

312

excess of starch being very di£Bcult of diffestion. 4. K pap be
given, it should be made wiUi milk, so as to include fat and chloride
of potassium in the compound, and not given in large quantities ;
above all, it should not be made with white, town-made bread, which
contains alum, and is nothing better than a slow poison. He ex-
presses the opinion that, amongst the vegpetablc substances, that
which comes closest to milk in its composition is, without doubt,
lentil powder, or, as it is called for the purpose of obtaining a better
sale, Revaleuta Arabica, containing both phosphoric acid m abondr
ance, and chloride of potassium ; it also includes casein, the same
principle which is found in milk in its constituent parts. Moreover,
its nutritive matter is to its calorifiant matters in the proportioD of 1
to 2^, milk being in that of 1 to 2.

Dr. Patron gives but a compilation of what is generally known on
nursing, its utility to mother and child, its troubles and difficulties,
its duration, on weaning, and on the diet of the newly-^born.

Generally, the majority of books on dietetics of infants do not form
a part of tlie library of medical practitioners, who usually have
neither time nor inclination to read whatever is written for the
public. Now, we do not contend that all the numerous books pub-
lished on this subject ought to be read by the profession, for the
purpose of increasing their medical knowledge; for an exact. ac-
quaintance with physiological facts enables the medical man to draw
his conclusions for himself. But there is a good reason why every
physician should read as many popular books on infantile dietetics
as possible. It is only natural that the public should, in their selec-
tion of books written on a medical subject, mostly depend upon the
judgment of their medical advisers ; in this case, the physician is
placed in the most favorable and agreeable position ; he haito not then
to cure diseases, but to prevent them ; not to act as doctor, but
as medical friend and protector. Every educated physician has no
difficulty in deciding what kind, and what amount of instruction may
be safely recommended in the individual case ; but the very fact,
that the kind of instruction has to vary with education, position in
life, and talent, should induce physicians to read as many popular
works on dietetics as possible. What is most important is, that no
works be selected in which anything is given not based upon incon-
teatable scientific results ; as nothing is more apt to confuse the
mind than discussions on scientific subjects not wholly decided upon.
Whatever, then, is laid before the unprofessional public ought to be
perfectly clear and intelligible. Therefore, everything relating to
pathological changes, and the cure of diseases, should not be * a
part of the work we refer to ; when they are given, they are more
than unnecessary, they are positively injurious, because subjects
requiring years, to be thoroughly comprehended by the student and
physician, will certainly not be readily understood by the popular
mind. These preliminary observations are rendered necessary for
the purpose of applying a uniform standard to the works under con-
sideration.

Dr. Besser has, after having obtained a good reputation, a few
years ago, by a small pamphlet on the importance of the first days of

813

infantile life for the education of infants, come before the public
with a book, which cannot fail to place tl»e author in the first rank
among popular writers. His purpose is not only to give a number
of remarks and prescriptions on physical and mental education of
children, but to make parents understand why they are given. Ilis
expositions of generation, embryology, pregnancy, and parturition,
belong to the best we have ever seen published for the use of the

Eublic at large. This book is more deserving of being translated
>r tlio benefit of our country, than any with which we are ac-
quainted.

Dr. Gauneac's book treats of the usual subjects of a work of this
character : such as food, air, temperature, light, exercise, bathing,
dress^ dentition, weaning, etc. Good though a part of the articles
bCt and although we do not desire to detract in tlie least from their
Talae, it is impossible for us to agree witii the author in all his
premises. Among the opinions and doctrines which we could not
approve, are the following : Digestion is said to be more active
during sleep, while physiology is teaching the contrary. The in-
fant ought to take the breast, according to our author, every hour,
or at least every two hours during the first four or five days, ** as long
M the milk fever lasts, and weaning never ought to take place, in
common cases, before 16 or 18 teeth are cut, at 22 or 24 months of
age ; and in no case to be allowed before the age of 13 or 14
montliB." We can no more subscribe to this than to Dr. G.'s asser-
tien, that generally cerebral symptoms and mania occurring during
the puerperium, indurations of the breast, degenerating into cancer,
■terility, leucorrhooa, etc., arc the consequences of mothers nut
nursing their infants themselves ; the author not even undertaking
to ahow a physiological or pathological connection, as betwecii cause
and effect. Finally, sentences like the following do not read well in
a medical work : *'At the same time that physical and moral strength
are being developed, the organs, too, develop themselves" (p. 73).
The anther does not appear to be entirely convinced of his own
" oonvictions," because there is a striking contradiction between tlie
following important sentences : ** The moral education of the infant
bejpns with its birth " (p. 41), and " the infant cannot have habits at
this early age, its life being too active ; every day new sensations
are impressed upon its brain, and the preceding ones are forgotten "
(p. 65). Nevertheless, there are some good views, especially in tlie
^apter on moral education, which we sincerely wish every mother
to Know, and the perusal of which has given us a great deal of
pleasure.

Dr. Plato's book contains simple and unassuming expositions on
the dietetics of pregnancy and infancy, presented in an easy, simple,
and modest manner. The method is somewhat different from that
generally followed, the author preferring to expound the matter in a
series of fifty-five letters addressed to a newly married lady. Al-
though not all of his opinions and directions may be agreed upon —
the author thinks dentition facilitated by some accompanying erup-
tion, considers the removal of crusta lactea to be absolutely danger-
ous, directs cold in convulsions to be principally applied to the fore-

314

head, etc. — ^we cannot but highly recommend as well the abandance
of matter contamed in this little book, as the manner in which it hu
been written.

Of Prof. Hufkulnd's " Advice to Mothers," the eighth edition hu
appeared.

Dr. Hauschild is not a physician, bnt a well educated physiologist
and, moreover* an enthusiastic friend of the subject he is writing on.
His bool^ is written on the principle, that the cure of sick children is
naturally the physician's business, but that the care of healthy dut
drcn and the prevention of diseases is a duty belonging to physicians,
parents, and teachers, in an equal manner. The work being imb-
lished for the use of parents and teachers principally, no new facts
are developed, no physiological theories examined or illustrated:
only well establish^ truths are exposed in a clear, simple way, ana
in such a manner as cojafers honor on the author for his anatomical
and physiological learning, and for his knowledge of the scientific
horizont of tlie public. Some of his views, for instance, on the patho-
logical importance of dentition, and of worms in the intestinal canal,
give t<^stimony of such a ripe physiological and pathological jnd^
ment, as we but too often look for in vain, even in physicians. We
have no doubt that if many voices like Dr. Hauschild's will be able
to make themselves heard and understood, the knowledge of infan*
tile dietetics will make a rapid progress among the public, and
anthropology applied to the infantile organism will be estunated as a
popular study m all the classes of the people.

Db. Declat's work treats of the foetus after the seventh month of
pregnancy and the infant at the breast ; the author considering the
period of weaning to be but the commencing, for the infant, of a truly
independent existence', the infant being a part of the maternal organ-
ism, as long as it depends on the mother for its food. In seven
chapters the author treats of the mother before her confinement, of
the infant and the selection of a nurse ; of the birth of the infant ;
of nursing ; of general rules ; of weaning ; of the most frequent in-
dispositions, diseases and accidents daring the period of nursing and
after weaning, and of vaccination. He emphatically states that his
book purports to be but a guide in the hands of motlicrs, to the end
of preventing diseases and saving life ; nevertheless he thinks proper
to enlighten " his professional brethren only," with his views on the
diagnosis and treatment of croup, which is a disease the author, we
are sure, will hardly have observed at the early age in question. The
diagnosis of croup is rendered xertain, in the author's opinion, by
merely inspecting the fauces, ps^do-croup showing scarcely a slight
redness of the mucous membrane, and croup exhibiting false menh
branes. This is untrue even in France, where diphtheritic croup is
most frequent ; tlie author himself reporting a case where no false
membranes were seen in the fauces. His treatment consists of the
frequent administration of emetics (tart. em. with ipec.), and of
bicarb, sod. or chlor. pot; and if the disease will progress, respira-
tion become more sibilant, and aphonia ensue, of performing trache-
otomy. He objects to cauterization of the fauces and larynx, for a
pretty curious reason ; not proving, but stating as his " conviction,"

315

that it will a^ffravate the disease, produce "a terrible inflammation,"
and often kill at once. The copter on indispositions, diseases
and accidents of infants and mothers contains only a few other subjects
besides croup, viz.: diarrhoea, excoriations of tlie nipple, bums, cuts,
falls and muguet. Finally, to wind up with our general opinion on this
new book on dietetics of infants, we dare say that we have never
had the opportunity to read a more eloquent and enthusiastic eulo-
gium on tiie Queen of Spain, to whom the work is dedicated, " wise
and vast genius in governing nations," and her " womanly loving
heart, which derives m>m her inspiration the true rays of divinity,
the tenderness and care for her diildren," and on her being " Queen
both by blood and by love f but that the book fulfills but incom-
pletely the promises pronounced in the introduction, contains nothing
new, and omits a great deal.

Dr. ScHRKBKR is well known to the European profession as a writer
on both the general pathology and the dietetics, particularly gym-
nastical exercises of children. His new book is a complete review
of all the means, both phvsical and psychical, by which the infant
may be educated from birth to the adult a^ ; by which its body will
be strengthened, its understanding enlightened, its knowledge in-
creased, Its temper corrected, and manners and habits formed. The
aathor is well aware that education will have to vary in everv single
case, every individual's natural disposition and faculties dififering
from those of another ; but that the rates of education are the same
for everv human bein^, and have to be applied to individual cases.
We feel a gpneat satisfaction in meeting at last a physician writing
on infaiitile matters, who is at the same time a good psychologist
and pedagogue ; as it is but too true, that writers on psychical and
moral education of children have seldom been physiologists, while
physicians who tried to teach dietetics and bodily development, have
seblom directed their attention to psychology. Dr. Schreber's book
is divided into four principal parts, the first of which treats of the
first year of life, the " sucking age f the second, of the period from
the second to the seventh year, ** playing age ;" the third, of the
period from the eighth to the sixteenth year, the " learning a^ f
the last period comprehends from the seventeenth to the twentieUi
year. Each of the corresponding treatises comprehends the author's
views and remarks on ana rules for both bodily and mental develop-
ment ; and the chapters on food, air, baths, sleep, motion, gymnastic
exeroises, dressing, attitude, habits, cultivation of single parts of the
bo4y ; further, those on playing, on the relations of the child to its
niurse, to other children, to parents, teachers, and strangers, and on
coltivation of the character, belong, we dare say, to the best we have
ev«r known to be laid down in a ^^ok, proving the author to be both
a learned and a thinking gentleman. The diction is, in the average,
dear and plain, but some parts of the book, by their theoretical rea-
soning ana by a diction tasting somewhat of passed by periods of
German philosophy, will undoubtedly be fully appreciated and re-
lished but by welt-educated readers. Thus the author's work will be
more found in the hands of the better classes, of reasoning parents

316

and teachers, than of the large majority of the people, who want to
be instructed easily, plainly, quickly, and cheaply.

Schttpf Merei's and Whitehead's report treats of 1,548 sick children
attended during 21 months ; its most interesting featnre arc the
notes on the patients' motliers, residences and alimentation. On 122
children, of from 9 months to 3 years of age, whose nutrition and
bodily development was accurately recorded, the following facts
were obtained :

The bodilj derelopment wu

I. — 120 cbildrea were nursed by their good. middling. iMid.

mothers alone, without any artiflcial In 71 (60 p.c.) 81 (25 p.c) 18 (14} px.)

food, for 9 months or longer.
XL — 68 were nursed by their mothers firom

6 to 9 months exclusively, and were 35 ^51 ^^^ ^ ^^ ^^^ 15 ^^ p^)

afterwards partiftUj fed with milk and .

bread, etc.
Ill- — 216 were not exclusively nursed by

their mothers, but had artificial food HO (51 pA) 54 (26 px.) 52 (24 p^e.)

intermixed fh>m a yerv early date.

Of 1,548 sick children, 249 were suffering from troubles of the
digestive functions, 116 from atrophy, 256 from weakness, T4 from
rachitis, that is to say, 696 suffered in consequence of vicious
alimentation ; 93 died of this number. Of the whole number of
1,545, 117 died : 12 of them were from 8 to 14 years old ; 105 under
3 years ; 96 under 2 years ; 4T under a year ; 29 under 6 months.

Of 186 sick children under 6 months, died 29 j iti ^ ^
** 195 " from 6 to 12 " " 18 \ ^^* **• ^

" 345 " " 1—2 years, " 49 141 p. c

" 220 " " 2—3 " « 9 4} p c.

« 602 " " 3—13 " «• 12 2 p. c

1,545 117 7}p.c.

Two papers, read by Dr. Routh before the Medical Society of Lon-
don, furnish the following statistics : The mortality amongst young
children during one year, in Manchester, amounted to 55.4 p. c; the
corresponding figures for London being 40.2, for Leeds 52, and for
Birmingham 50 p. c. in the same year.

In 1857, there died in London 363 children from "want of breast-
milk.;'' and in seven years (from 1848 to '54) the number of deaths
in all England due to this cause, increased from 393 to 842. Amongst
the main causes of the large number of deaths occurring among
young children, Dr. Houth counts the injurious excess to which wet-
nurses are employed, even such as are by no means able to nurse,
and the bad quality of the milk, the sale of which ought to bo regu-
lated by the law.

The returns of youn^ patients of the London Hospital are of no
statistical importance, because the 214 cases are only those of acci-
dent and diseases of the more urgent character.

317

The proportion of children dying under 1 year, to the whole num-
ber of toe population of Berlin, according to Dr. Helfff, was in

1849 1: 166.16

1862 1 : 139.62

1856 1: 140.72

Of the children who died in the first year, 3.11 per cent, died within
die first twenty-four hours ; 23.75 from the second day to the end of
the first month ; 12.01 in the second month ; 10.03 in the third ; 9.47
in the fourth ; 6.91 in the fifth ; 6.87 in the sixth ; 5.87 in the sev-
enth ; 5.33 in the eighth ; 4.48 in tlie ninth ; 4.18 in the tenth ; 4.05
in the eleventh ; 4.00 in the twelfth. Hence, the probability of life is
increasing monthly, even daily. As a general rule, August was the
most pernicious month at every age.

Dr. RfDELL reports some statistical facts on the new-born children
of Berlin, taken from the records of the years 1846-1855. The pro-
portion of males to females is 1.0772 : 1. Of 23 new bom boys, 1
18 still-bom ; of 25 girls, 1 ; of new-born infants in general, 1 is still-
bom out of 25. The temperature appears to have & great influence
upon the sex of infants. The higher the average yearly temperature
at the time of conception, the larger is the proportion of males to fe-
males. Conception in Spring is more favorable to the female sex,
conception in Fall to the male. Temperature, finally, is not only of
some influence upon tlie sex, but on the chances of living after birth
also ; a high average temperature at the time of conception (not of
birth), appearing to augment such chances.

Dr. Husemann's accurate statistics are of great value. He shows,
that of newly born children, in the principality of Lippe, from 3.3 to
4.27 per cent, die in the first six weeks after birth. Of the children,
born alive, 15.54 per cent, will die under two years of age (in Bcl-
einm 29 per cent, according to Quctelet's reports) ; of the whole num-
ber of deaths 21.6 per cent, occur at this age. It is to be noticed as
a remarkable fact at once, that this rate uf morta^ ty has been about
equal for the last seventy years. Of the whole number of deaths
9.1 per cent, occur from 2 to 5 years of age ; 5.12 per cent, from 5 to
10 years. This proportion was much more unfavorable in the periods
of 1788-1807 (7.5 per cent ), and of 1808-1822 (5.7 per cent.), be-
fore and after the first introduction of vaccination. Of the whole
number of deaths, 5 per cent, occur at the age of from 10 to 20
years.

Dr. ScHF.BZER states, that the mortality of children in China, is at
least as high as in Europe, perhaps even larger. Variola and tetanus,
dysentery and cholera, are trequeut and very dangerous. Many cases
of intermittent fever came under observation in the age of from 8
to 20 years.

According to the Report of the Hospital for sick children, Ormoud'
Street, 1857 ; of the whole number of children of the better classes
in England, from 25 to 30 per cent, die in the first ten years of life,
of the lower classes from 30 to 40 per cent., and as many as 60 or 70
per cent, under peculiar epidemical influences. Mortality among
children at London, is but 2 per cent, less than fifty years ago. Of
60,000 deaths in London, 21,000 die under 10 years of age ; in the

318

eight largest cities of Scotland, of the whole nnmber of deaths 46^
per cent, occur in the first five years of life. In Ireland, 18 per
cent, of the deaths occured under five years of age, less in the coun-
try (in some counties 14 per cent, only), more in the cities ; thus in
Oalway, 20 ; in Dublin, 20.2 ; Kilkenny, 20.8 ; Waterford, 21.5 ; Lim-
erick, 22.1 ; Belfast, 32.7 ; Cork, 28.6 ; and Drogheda, 25.5 per cent
In France, of 100 newly bom diildren, 20 males and U females will
die in the first year, that is to say, a fifth part of the mates, and a
sixth of the females. In some of the Snglish colonies, the rate cS
mortality is highly unfavorable ; during the summer, at Melbourne,
there are scarcely more births than deaths, in the course of six
months, in 1858, the number of deaths was even twice as larg^ as <tf
births ; in 1857 there Were TO deaths in children under a year, to 100
newly bom children.

Some of the facts observed by Dr. HAimxit are exceedingly inter-
esting. For the months of September and October, 1850, a similar
weather and a like temperature prevailed ; nevertheless bronchial afieo-
tions were numerous, and very much so, in the course of October
only. The temperature of October, 185T, was very much like that
in 1856, but bronchial afi*ections were very rare occurrenoes. Hoop-
in cough was influenced, in 1857, neither by season nor by tempera-
ture ; ^phoid fever occurred in the same mon^ly number during the
whole year, December excepted, where no case occurred. In Feb*
ruary and^March, without any particular changes in the atmosphere
being observed, inflammations of the parotis were very frequent.
Acute exanthems occurred in every month ; and infantile cholera and
slight dysenteries were observed as well in December as July. Dr.
Hauner's therapeutical remarks are accurate, but naturally do not
contain much that is new. Hooping cough was treated more suo-
cessfiilly, than by any other class of remedies, by narcotics, morph.,
aq. lauroc, extr. bellad., and in later stages by chin., lich. island.
Diseases of the liver were sometimes found in j>ost-mortem examina-
tions, where they were very little thought of ; fat-and nutmeg-liver
were the most frequent anomalies found, particularly in rachitical
children suffering from dyspepsia and intestinal catarrhs. Dysuria ,
was met with several times ; in the majority of cases, the cause ori-'
ginated from the influence of cold, some of superabundance of uric
acid. Incontinence of urine was observed in a boy of five years !
the disease depended on weakness of the neck of the bladder, and
was successfully treated by appropriate diet and posture, local ap-
plication of cold, and cold hip baths. Diphtherite of the vagina was
observed in a healthy girl of 14 years ; local application of nitr. arg.,
and the administration of the chlorate pot. proved successful. Fluor
albus was observed in four little patients, who were cured by a gen-
'eral antiscrophulous treatment, baths of chamomile flowers (chamom.
vulg.), and application of Ooulard's water. A case of tuberculous
inflammation of the petrous bone ended fatally, by tubercular disease
of the brain. Rachitis will in almost every case be cured by cod-
liver oil ; iron, so highly recommended by some writers of Vienna,
proved proportionately unsuccessful.

Pbof. lAacHXEB^s, of Prague, report on the Children's Hospital and

319

Dispensary, is of but little scientific interest. Among 971 patients
of the Hospital, the mortality was but 10 per cent, in . spite of epi-
demics of measles and scarlet fever.

The report on the Children's Hospital in Great Ormond Street, Lon-
don, which was founded by Dr. West, is painfully interesting. The
iiiimber of beds in 1857 were 31, though the number of 1 00 beds was
originally contemplated. The funds were nearly exhausted.

jiie reports on Continental Children's Hospitals, are uninteresting ;
at they do not contain anything except some meagre notices on the
Hoepitals of Berlin, Frankfort, and Prague.

The Children's Hospital of Graz (Austria), has had, in the twelve
years of its existence, 1,803 patients, of whom 1,377 were dismissed
oared, and 286 (13 per cent.) died. A large number of patients
suffered from scrofpla and rhachitism (260V catarrhal affections of
the respiratory organs and intestines, and inflammatory diseases of
tbe lungs. Cases of oroun were, in 12 years, 8 ; acute hydrocephalus
5, of which one was saved.

The Foundling Hospital of Vienna received, in 1856, 9,228 infants,
of whom 2,105 fell sick ; 55 per cent, with acute, 45 per cent, with
chronic diseases. The mortality among the patients was 60 per
cent. The percentage of diseases of the several systems is the fol-
lowing: Diseases of tbe nervous system, 2 percent.; sensory or-
gans, 23 ; mouth and fauces, 5.5 ; circulatory and respiratory organs,
13 ; chylo(^potic system, 20.5 ; urogenital organs, 0.5 ; skin, 6.5 ;
nutrition and blood, 21 ; external diseases, 9 per cent. Besides,
thefe were 6 cases' of variola, 1 of measles, 1 of scarlatina, 2 of
liooping cough.

Tliere are two Hospitals and 5 Dispensaries for sick children at
Vienna. The main statistics are given in the following statements :

320

a
o
o

M 5

r S-

►

•a

CO O CO g g

««l fe«

lO M Ci lO C4 •<«

o» fc* »H

tf> M

•

•q iq

e4 f-t f^ 1-1

►

o
a

»q •q

CO "«• i-l

<o o lo o e

C4 r-i ,^ C4 f-4

s S: :s S

r^ C« »H •*

^•«g« l"S3

I I

r- S2 «

O W rH

•q

•

9-i

M (o eo M|

1^
I

00
00

o
f-l

eo c4

• •

n
o>

«o

tq tq

r-i c4 K- e4

i-i »^

04 esi

00 lO *A ^4
C4 •^

§ e.

6g a

OL M

-a -a

t & -•

•g

"S s s S

5^ i a

O d OD

d
d

321

Dr. Schreber exposes cliildren suffering from scrofula, atrophy, bad
ffen^ral devolopment without a distinct organic disease, anemia,
flabby and pale skin, torpid tumors, osseous swellings, etc., to the
sun, one, two, three times a day, keeping the child, the head covered,
from ten to thirty minutes (no longer, for fear of erythema) in a room,
undressed (full bath) or half dressed (half bath). He expects the
sunbeams to enliven the peripheric nerves both generally and locally.

Dr. Pollard advocates the use of opium in cautious doses, as he
considers the objections to its administration in diseases of infants
unwarrantably magnified by some writers. Generally, opium is
much dreaded in diseases of infants, for its dangerous efibctid on the
cerebrum and meninges. We think that it must be dreaded when
given without strict indications, but will easily be tolerate4 whenever
it is not applied unscientifically or wantonly.

Dr. PouTZER has expressed, before a Medical Society at Vienna, his
views on several important points concerning infantile pathology, of
which we select the following : High rate of mortality is no physio-
logical consequence of infantile nature, but is proauced by accidental
obnoxious incidents. On the contrary, things are even more favor-
able in infancy, the Causes of diseases increasing in number and
severity with advancing years, and the frequency of 80-c€dled infan-
tile diseases being greatly overrated. Typhus, pneumonia, and mor-
billi give proof of the readiness of recovery in children ; but diarrhoea
is very dangerous. Diseases from teething and worms do not exist
Emetics and purgatives are much misused, so are leeches ; opium re-
quires great care and caution. Constitutional diseases ought to be
treated in early age, and never overlooked indifferently ; iron is espe-
cially indicated in the chronic form of rachitis ; acute rachitis is fre-
quently mistaken for some other trouble. Suppression of chronic
exantiiems is by no means dangerous ; diaphoresis never ought to be
resorted to for the purpose of reproducing an exanthem that has dis-
appeared.

Dr. Schauekstein's and Dr. Sp^th's careful examinations have re-
sulted in the following facts, viz., rhubarb was found in the breast-
milk, sulphate of potassa was not. Iodine was proved to be present,
after having been/ taken by pregnant and nursing women, in the
meconium of the foetus, in the urine, milk, and amniotic liquor during
pregnancy. The chemical signs of mercury were not discovered witi^
any degree of certainty.

Dr. Ploss, after reviewing former opinions on the subject, tries to
arriye at a result from a great number of exact statistical reports.
The principal conclusion he draws, and found very rarely refuted, is
this, that the sex of the children bom during a year is in a strict
proportion to the dearth and consumption of bread and meat. The
number of males will always increase with the scarcity and dearth of
bread and meat, while in those years where these victuals are
copious, the number of males is less. Such is Dr. Ploss' con-
clusion, arrived at, not only by statistical comparisons of different
nations or districts, but of the same localities or populations in differ-
ent years. It is to be kept in mind, however, that at all events the

number of newly-born males is always and everywhere absolutely

322

larger than of females, and that, therefore, the above stated conclu-
sions must not be considered but in regard to the relative number of
females and males.

Mr. Thomsox arrives at the conclusions : 1. That in the lower
animals, and in man also, the influence of the male is greater than
that of the female parent, in the transmission of the skin texture to
the progeny. 2. That the exceptional cases (probably more in man
than in the lower animals) lead us to look for some primary or
secondary law presiding over the physiology of generation.

Db. Edoren reports two cases of children swallowing needles
without unfortunate consequence^. A boy, three years old, swalr
lowed a needle two and one-half or three inches in length, which
a month later penetrated the skin, near the sternum, from beneath
the pectoral muscle. A boy of four years of age, swallowed a large
pin with a big head, the head going down first. On the third day
after, there was pain in the right side, about the region of the pylo-
rus and duodenum^ On the eighth day, the head was removed from
the anus, only an inch of the pin being in connection with it

Mb. Silvsstbb draws, from a large number of cases observed by him,
a series of conclusions, of which the following are the most import-
ant : 1. The deformity appears to be the result of, first, the malforma-
tion of the germ; secondly, the subsequent deformation of the
embryo and foetus, by causes operating on its development : and,
thirdly, by certain compensations and vital accommodations having
a conservative tendency. 2. The arrest of development relU^ on
various parts of the body, and particularly on such parts as have
either a casual or a natural connection with the original malforma-
tion. 3. A law of compensation prevails during the growth 'of
monsters, consisting in a tendency to render the parts as nearly nor-
mal as possible, and to make up by excessive formation for the defec-
tive development of an adjoining part. 4. The several parts of the
body arc formed and developed independently of each other. 5. The
muscles are directed to fixed points of attachment, and in the most
nearly regular way possible under altered circumstances. When a
bony insertion is unattainable, they unite together by their tendons ;
there is a vital accommodation to the exigency of the case. 6. The
absence of the usual bony attachment, or the want of a firm point of
insertion, exerts a material influence upon the development of a
muscle. 7. The absence, or defective state of an organ, relicts nn-
favorably upon the formation of the nerves and vessels which supply
it, even at a distance. 8. The deformity in the arm does not conform
to the rule laid down by Rokitansky : " When the radius is wanting,
the thumb and forefinger, with so much of the carpus as belongs to
them, are wanting too.''

Among the congenital malformations observed in the cliniqne of
jRtq^. 8(xmzoni were : 1. Fractures of the bones of all the four ex-
tremities. The ri^ht forearm was fractured just above the carpal
joint, the left a little higher, either of the femora above the condyli,
the left leg* above the ankle. The arms were kept bandaged, the
lower extraaities were left to nature. A cure was effected within
eight weeks, i Absence of the soft palate, and coherence of the

323

last two toes of the left foot. 3. Supernumerary thumbs. 4. Cases
of atresia ani, both epidermoid and membranous. 5. Insufficiency of
the bicuspidal and tricuspidal valves, which was diagnosticated be-
fore birth, by Prof. Scanzoni.

Db. Marhni gives a review of the recent progresses of the surgical
treatment of congenital malformations, such as imperforate anus,
obliterated ileum, and spina bifida. None of his facts and extracts
belong to the year 1858. Such is also the case with the cases col-
lected by Dr. Schultze.

Dr. Budd describes a foetus, perforated and extracted by means of
the crotchet, twenty-three and one-half inches long, and weighing a
trifle over twelve pounds. The measures of the cranium are of little
moment, as the bones were broken and cerebral substance evacu-
ated.

Drs. Ramis and Breslau report the case of a woman of thirty-nine
vears, who had borne three children ; the youngest one, one and one-
half years old. The fourth pregnancy took a regular course, being
troubled by neither bodily nor mental affections. She brought, with-
out artificial means, a xiphodymc, with two heads, two thoraxes, four
hnmeri, four arms. The two xiphoid processes cohered closely.
Tbere were only one abdomen, two lower extremities, one umbilicus,
one set of female genital organs. The monster was born at matu-
rity, lived eight days, cither half like an independent being. Never-
theless the organs of nutrition appeared to be in connection with
each other. Death ensued on the eighth day, one dying about
fifteen minutes after the other, as is usual in monsters of this descrip-
tion.

Dr. Johnsox has observed the case of a child bom at maturilrj^,
and living for half an hour, who was large and perfectly well-
formed from the attachment of the cord upwards. " From the navel
downwards, there was a gradual tapering. There were no geni-
Ui organs, no anus, and no well marked pelvic bones. At the
junction of the sacrum, with the lumbar vertebrae, there was an in-
termption of the spinal column. A small circular scab covered this
opening in the spine, and, we suppose, closed the termination of the
rectum. All the bones of the le^s were present except the patellae.
There was no lino of demarcation between the legs, both being
enclosed in the same cuticle, and one single set of muscles. To this
doable leg, there was attached a single club foot, with ten perfect
toes."

Dr. Jacksok reports, from the practice of Dr. D. J. Perley, of Old
Town, Me., the case of two foetuses united, face to face, from the
umbilicus to the upper third of the sternum, living until about ten
minutes after birth. There was but one placenta, and but one funis,
until it arrived within about two inches of the foetal abdomens, when
it divided, and a branch went to supply each of the children. The
following organs were found in eacn foetus, and they were well
formed : the spleen, two kidneys, with their renal capsules, the blad-
der, and the testicles ; all four of the latter being in the abdomen.
Penis of each larg^ Yesiculae seminales of each well developed.
Pancreas of one, "felt, but not dissected." The heart was single, but

324

formed by a fusion of two, and contained in a single pericardium.
Its transverse diameter was much greater than the longitudinal.
Between the two right auricles tliere was nothing like a septum ; the
left auricles also opened freely into the right. The great vessels
naturally offered many anomalies as to size and course. There
were two livers, the whole mass being small for the two foetuses.
They were intimately fused by their upper edges or extremities, and
each had its gall-bladder ; in each the umbilicar vein entered the
convexity, and each had its suspensory ligament. The diaphragm
formed a large arch. There were two distinct pleural cavities, two
sets of lungs, two tracheas, larynxes, thyroid and thymus glands.
Weight of the two foetuses five pounds ten ounces ; length fifteen
and three-fourth inches. No hernia at insertion of cord.

II. DYSCRASIC AND TOXAEMIC DISEASES.

1. Gabriel, Case of IntermiUends Larvata BthebdomadaricL — Jour. f.
Kinderkr. 1, 2.

2. Heidenhain, on Intermittent Fever. — Virch. Arch. XIV. 5, 6.

3. Craig, J. W., Cerebro-spinal Meningitis: Brain Fever. — Buff. Med.
Jour. July,

4. Avrard, on Pernicious Intermittent Fever in Children, — Gaz. d.
n6p. 70.

5. Jones, C. Hansfield, Malarvoid Intermittent Fever in Children. —
Brit. Med. Jour. July 31.

6. Joseph, Case of Intermittens. — ^Virch. Arch. XV. 1, 2.

*l. Mall, J., Typhus, xoiih Secondary Croupous Inflammation of the Be-
spiratory, Intestinal and Vaginal Mucous Membranes. — ^Allg. Wicn.
Med. Zcitschr. 22.

8. Lebcrt, Neio Investigations on the Pathological Anatomy of Abdomi'
nal Typhus. — Prag. Viert. 1.

9. Bazin, Er., Lemons Thioriques et Cliniques sur la Scrqfule, Conei-
dirie en Elle-memc et dayis ses Rapports avcc la Syphilis, la Dartre el
V Arthritis. Paris, pp. 262. — (Theoretical and Clinical Lectures on
Scrofula, Considered in Itself and in its BelaJtions to Syphilis, 2btfer,
and Gout.)

10. Peloly, G. F., Qu'est ce que la, Scrofulef Paris. Thfese. pp. 83.
—( What is Scrofulal)

11. Faye, F. C, The Children's Hospital at Christiania in the years
1855-185T.— Journ. f. Kinderkr. 11, 12.

12. Mass^, Z., Trois Maladies Riputies Incurable, JS^lepsie, Dariret
et Scrofule. Paris. IV. ed. pp. 251. — ^ Three diseases Reputed In-
curable, Epilepsy, Tetter, and Scrofula.)

13. Ilauncr, Report on the Eleventh Year of the IXq)€nsary Conneded
with the Children's Hospital at Munich, — Jour! f. Kinderkr. 7, 8.

325

14. Hauner, Therapeutic Notices from the Children's Hospital at
Miimch.--J ahrh. f. Kind. II. 2.

15. Leriche, de VEmploi de Nouvelles Formvles Jodiques comme Sue-
cedan^es de VHuile de Foie de morue dans la Scrofide, et de VJodure
de Potassium dans les Affections Syphilitiques. — (On the Use of
Formulas of Iodine Instead of Cod4iver Oil in Scrofula^ and of
Iodide of Potassium in Syphilitic Affections.) •

1 6. Lcbert, Observation of Scrofula Healed by lodcAed Alimentation. —
Un. M^. 124.

17. Engert, on Tuberculosis and Scrofula in the Infantile Age, — Joum.
f. Kinderkr. 5, 6.

18. Rollet, Hereditary Transmission of the Tuberculous Diathesis. —
Gaz. M^d. de Lyon. 10.

19. Hutchinson, Cancer of the Testicle in a Child. — Med. T. and Gaz.
May.

20. Diday, P., Exposition Critique et Pratique des Nouvelles Doc-
trines sur la Syphilis, Suivie dune Etude sur de Nouveaux Moyens
Priservatifes des Maladies Viniriennes. Paris, pp. 560. (Critical
and Practical Exposition of the New Doctrine on SyphiliSy vrith In-
vestigations on New Preservatives against Venereal Di^^ases.J

21. De Mdric, V., Third Lettsomian Lecture on Hereditary Syphilis. —
Lane. Dec.

22. Parker, L., Lectures on Infantile Syphilis. — Lane. Aug., N. Y.
Jour, of Med. Sept.

23. Knoblauch, Aerztlicher Bericht uber die Leistungen des Rochus-
spitales zu Frankfurt a. M., im Jahre 1857. (Medical Report on the
Results of the Rochus Hospital at Frankfort^ in the year 1857.^

24. Friedinger, Mayr and Zeissl, on Syphilitic Eruptions in the In-
fantile u4^e.— -Jahrb. f. Kind. II. 1.

25. Congenital Syphilis in an Infant a few Weeks old. — Lane. Oct.

26. Thiry, on Hereditary Syphilis and Syphilitic Induration of the
Liver. — Presse M^. Belg. 22.

27. Hutchinson, J., Death from Hereditary Syphilis. — Lane. Aug.

28. Hutchinson, J., Report on the Effects of Infantile Syphilis in Mar-
ring the Development of the Teeth. — Trans. Path. Soc. IX. p. 449.

29. Friedinger, Ooae of Hereditary Syphilis. — Jahrb. f. Kind. II. I.

30. Sigmund, C, Notices on SyphilizatUm as Performed by Dr. Sperino.
7a. d. Ges. d. A. z. Wien. 46.

31. Thompson, on Diphtherite. — Brit. Med. Jour. 75.

32. Atcherley, on Epidemic Ulcerous Angina. — ^Brit. Med. Jour. 77.

33. Heslop, T., on Diphtherite and its Treatment. — Med. Times and
Gaz. 413.

34. Martin, Pseudo-Membranous Angina, Extraction of False Mem-
branes by Means of the Finger, Cauterization with Hydrochloric
Acid. — Joum. d. Ikfei. (Bmx.) May. .

35. Barthez, E., on Diphiiierite.—TJn. Mdd. 133.

326

36. Beale, L., The Structure of PBeudo-Mentbranea in 9ome Oases of
DiphJtheriie. — Arch, of Med. I. 3.

3t. Bouchut, on ike Treatment of Diphth. Angina. — Gaz. Hebd. 44.
G. H6p. 127.

88. Bouchut and Empis, on Albuminuria in Croup and Diphth.
Di8ea8e8.—Un. U6d. 132.

39. Bryden, W. A., on the Treatment of Diphtherite. — Brit. Med. Joor.
Nov. 6.

40. Cowdell, Ch., on Epidemic Croup of the Fau^ces. — ^Brit. Med. Jour.
Nov. 20 and 2T.

41. Duchd, on the Prophylaxis of Diphtheritic Angina. — Gaz. dea H6p.
125, 133.

42. Giraud-Teulon, Retrospect on Croupous Affections. — Gaz. de
Par. 46.

43. Mauguin, A., Des Eruptions qui Compliquent la Diphthirie et de
P Albuminuric Considdrie comme Symptbme de cette Mcdadie. — ^Paris,
Duboisson & Co. pp. 32. — (On the Eruptions Complicated wUh
Diphtherite^ and on Albuminuria Considered as a Symptom €f this
Disease.)— Uon. d. H6p. 130, 131.

44. Odriozoli^ on Epidemic Diphtheritic Angina at Lima. — ^Gaceta
Med. de Lima. Julio 15. — ^Amer. Jour. IV., 620.

46. S^ and Piogey, on Diphtherite, Croup and Tracheotomy. — Un.
Mdd. 154.

46. Semple, R. H., on Diphtherite. — ^Brit. Med. Jour. Nov. 5.

41. Wade, W. P., Observations of Diphtherite. — London, pp. 32.
Edinb. Med. Jour. Dec.

48. Ward, T. 0., Cases of Diphtherite.— TrhnB. Path. Soc. IX. 217.

49. Edrveian Society; Diphtherite. — Lancet. June, July, Sept.

50. Godfrey, B., Beports of Cases of Diphtherite or Malignant Sore
Throat. — Lane. Jan. — N. Y. Jour, of Med. March.

51. Henderson, J., a Case of Cynanche Maligna; Tracheotomy Per-
formed. — Edin. Med. Jour. Nov.

52. Brown, B. M., Beport of Two Cases of Diphtherite. — Lane. May.
N. Y. Jour. July.

53. Camps, the Lately Prevailing Diphtheritic Affections. — Lane.
May. — N. Y. Jour. July. — Brit. Med. Jour. March 20.

54. Registrar-General, on Diphtheria. — Quart. Ret. Reg.-Gen.
March.

55. Fourgeaud, V. J., DiphtheriUs : A Concise Eistorical and Critical
Essay f on the Late Epidemic Pseudo-Membranous Sore Throat cf
Calif omia (1856-67), vMh a Few Remarks lUu^strating the Diag-
nosis, Pathology and TreatTnent of the Disease. — Pac. Med. and Surg.
Jour. X. (Reprint. Pamphl.)

56. Blake, J., on Diphtherite. — Pac. Med. and Surg. Jour. VIII. IX.

57. Diptheritis, the Quinsey Malignant Sore-Throat Prevailing in
Albany, N. T. — ^Am. Monwly. Dec.

327

58. Fuller, a Fibrinous Cast of (he Pharynx, Injected by a PatierU of
Eleven Years Suffering from Diphtheriie, — Trans. Path. Soc. Ix.
S06.

69. Thompson, D., on Dyphtheria, or DiphtherUe. — Brit Med. Jour.
June 5.

60. Wilks, Diphtheria and its Connection wUh a Parasitic Vegetable
Fungus. — Med. Times and Oaz. Oct 2.

61. Laycock, on Diphtheria as caused by the Oidium Albicans. — ^Ibid.
May 27.

63. Hauner, Therapeutical Notices from the ChUdreris Hospital of
Jfunic^— Jahrb. f. Kind. II. 2.

68. Jaoobi, A., Report on the Progress of Infantile Pathology and Ther-
iq)euHcs. — N. Y. Jour, of Med. July.

64. Kingsford, Ch. D., on Diphtheria. — Lane. Nov.

65. Santesson, Case of Hydrophobia. — Joum. f. Kinderkr. 3, 4.

66. Bouchut, E., 'on Diphtheritis, Abtual Gauiery, and Amputaiion of
the TonsQs.'-Vn. U6d. 12t.

61. Vigla, Communications Relative to Pseudo-Membranous Pharyn-
giHs.—nn. U6d. 115.

68. Schwarz, P., on Solid Nitrate (f Silver in DiphtherUis. — Oest. Z.
f. prakt. Heilk. 32.

Dr. Gabriel reports the case of a boy of fourteen years of age, who
had been suffering, for the last two and a half years, from headache
and yomiting, every fourteenth day, which was always Tuesday; the
boy being entirely well the other thirteen days. He soon recovered
after taking chin, and ac. arsenicos.

Dr. Heidekhaik gives, in an elaborate article on intermittent fever
in general, his views and experience on what he calls convulsive in-
termittens, viz., such cases of intermittent fever in children as show
no other prominent symptoms except convulsions, instead of the
usual symptoms of fever. In the majority of cases only one side is
affected ; whenever both are, they are alternately. The attacks last
for 4, 6, 8 hours, without dangerous results, or with paretic weak-
ness or complete paralysis following. Sometimes in Heidenhain's
experience, tlie child died in the second attack — always in the third.
Deietth ensues with the symptoms and the pathological alterations of
hydrocephalic apoplexy ; the commencement of each attack resem-
bling very much hydrocephalic apoplexy, and ending in sweating,
with a large ^r slowly diminishing number of pulsations,* and high
temperature of the skin. The diagnosis is very difficult ; the pro-
dromi must be carefully weighed, and the epidemic genius considr
ered. But it must be remembered, also, that hydrocephalic
apoplexy is as common in Spring as inteimittent. Already, Golis has
spoken of an intermittent form of hydrocephalus ; thus this disease,
and tubercular meningitis, may be mistaken for intermittent fever.
Dr. H. reports the case of a girl of 9. months of age, who went
through a sudden attack of convulsions, returning about the same
hour on the third day ; the last attack appearing less severe than the

328

first. Death ensued after 8 days had elapsed, and the post-mortem
examination showed purulent arachnitis. During the convulsive
attack nothing should be done ; some good may be effected by cold
applied to the head ; leeches are always injurious.

Dr. Craig reports a series of cases occurring among adults and
children, of meningitic symptoms invading suddenly and abruptly,
with chills, followed by prostration, pain in the head and neck, and
vomiting. The diagnosis was much more certain by a periodicity of
the disease after it had existed for a few days. All of his cases,
which were 129, 12 of which proved fatal, occurred at a time when
there was a prevalence of miasmatic diseases, such as intermittents
and remittents, of a persistence and severity before unknown. The
whole course of the disease, and the success of the treatment by
large doses of quinin(5 and stimulants, proved the miasmatic origin
of the disease. Death occurred in 5 cases within 36 hours ; in 8
within 1 week ; in 1 in the 5th week ; in 1 in the 8th ; in 2 after
several months. The post-mortem examinations " revealed a softened
condition of the base of the brain and upper portion of the spinal
cord, with a very copious effusion of limpid fluid in the ventricles —
in one case amounting to 8, in the other to 12 ounces." Evidently,
all these cases of Dr. Craig do not deserve the name of " cerebro-
spinal meningitis," as given by the author, but are cases of intermit-
tent fever like those of Dr. Heidenhain.

Thus Dr. AvRARD rightly answers the question put by Bouchut,
Is pernicious intermittent fever ever met with in infantile age?
affirmatively ; in declaring at the same time the diagnosis to be more
difficult than in adults. Troubles of dentition or meningeal affections
often give rise to mistakes. Two cases are given as illustrations.

Dr. Jones describes a morbid condition met with in children, not
entirely corresponding with what is called remittent fever in adults.
The children have been gradually losing health for several days or
weeks ; they are languid, drooping, emaciating, and, without appe-
tite, more or less thirsty. The night is the time of most disorder ;
there is considerable cerebral disturbance ; in some cases, also,
copious perspiration. The children may be apyretic during the
day, but becpme feverish at night. The bowels may be costive
or much relaxed. The tongue is clean in some, in others coated.
Quinine in large doses,«was found to be of decided curative efficacy.
Cod liver oil and steel wine ho also sometimes gave with advan-
tage. He is much inclined to consider these fevers as of malarious
character, and we do not perceive, indeed, why he should not, be-
cause, in the series of symptoms enumerated, the high nervous ex-
citability of the infantile age taken in account, there is nothing
that would not agree with the symptomatology of so frequently
indistinct malarious processes.

A rare ingeniousness is exhibited by Dr. Joseph, in discovering a
new variety of intermittent fever, viz., the " intermittent worm
fever." A boy of 2 J years evacuated a large number of oxyuria
vermicularis, after injections had been given ; for three weeks he did
not feel well, and finally had two severe attacks of daily intermit-
tent fever. Dr. Joseph administered santonine, but without success

329

as to the ejection of helminths. Finally, quinine was given, and the
boy recovered rapidly. This was a case of intermittent worm fever
in the opinion of the author, while we are surprised at his naivetd,
and see in the whole report nothing but a boy evacuating some in-
nocent helminths, and suffering afterwards from the prodromi, and,
finally, the attacks of intermittent fever.

Dr. Mall observed a case of abdonunal typhus in a girl of 6 years
of age, the complications of which are unusually interesting. On and
after the eighth day of . the disease, pseudo-membranes developed
themselves in the mucous membranes of the nose, and went down
into the lar^'nx, mouth, oosophagus, stomach, intestines, and vagina.
Local applications of borax and roborant remedies and diet formed
the principal part of the treatment. The child finally recovered.

Of all the cases of abdominal typhus recorded by Prof. Lebert, .
ten per cent, occurred in individuals under fifteen years of age. In
this early age intestinal afiections were little or not at all discovered.
^The examination of a girl of fifteen years, who died after the fourth
week of the disease, resulted in the following facts : Meninges and
brain contained a moderate amount of blood, the ventricles little se-
rom. Lungs were full of blood, otherwise normal ; in the heart,
black and fibrinous coagulations were found ; the liver was normal,
the spleen very much enlarged, seventeen centim. long, eight broad,
and three and a half thick ; it was soft and dark ; kidneys and mu-
cous membrane of the stomach normal ; mesenteric glands some-
what swelled ; the small intestines were nowhere ulcerated, Foyer's
glands slightly swelled, some small sugillations near the coocum ;
solitary glands normal. The mucous membrane of the large in-
testines were nowhere softened nor swelled, but generally very hy-
persemic. Another child, feeble and emaciated, left no pathological
sig^B. A third patient, already recovering, was affected with peri-
tonitis of the right side, and died twelve days afterwards. The fun-
dus of the gall-bladder was perforated and surrounded with a puru-
lent peritoneal exudation. In the dilated gall bladder there were
some ulcers of diphtheritic appearance, ductus choledochus was ob-
literated probably in consequence of ulcerous inflammation of the
dilated gall-bladder. In general, the results of Prof. Lebert agree
with those of Dr. Friedrich, who has proved alterations of the intes-
tines and pathological changes in general, to be by no means frequent
in abdominal typhus of the infantile age. Besides, it is well known,
that Drs. Rilliet and Barthez have found resolution of the swelled
elands of Peyer to be not an uncommon process even in a stage of
Sie disease where ulceration is going on actively.

Tlie subject of Dr. Bazix^s book has been treated of so many times
and BO variously, that the reader will necessarily expect some new
facts or views in opening another volume on the same subject. AVe
must confess that he will feel sadly disappointed. The author's dis-
coveries are no discoveries, his new facts are very old, his classifica-
tion is either prolix or confused, and his pathological views are very
antique indeed. The old doctrine of diatheses is confessedly only a
scape-goat of our ignorance, so much so, that every educated physi-
cian of the present time feels somewhat confused or unsatisfied in

330

merely pronouncing the word ; the author, however, is bo far from
feeling the necessity of limiting the use of the term of "duUAesit,"
that he invents some other diatheses besides those the unaatisfactoiy
state of modern pathology requires. According to him, a diathetit
is "an jACUte or chronic, feverish or unfeveris£^ continued or inte^
mittent, contagious or not contagious disease, characterized by the
formation of one, single, morbid product, which may have its seat
indiscriminately in all the organic systems.'' Thus there are purulent^
chondromatous, tuberculous, hemorriiagic^erous, saccharine, and cal-
culous, pseudo-membranous, gangrenous, adipose, fibrous, cancerous
diatheses (p. 10). Nothing can be more convenient than to hide onffM
self behind the screen of a Greek word with more sound in it than n^
telHgibility and pathological signification. One of the "discoveries"
of the author is that the lesions of the skin are no diseases, but symp-
toms of diseases ; that, therefore, the investigation of cutaneous
eruptions ought to be considered as a part of general semiotios.
Another discovery of the author's is, that cutaneous diseases are
affected either by external or by internal causes, and that parasitical
diseases belong to the first class ; that parasitical diseases have
been confounded with cutaneous afiections from internal causes up to
his, the doctor Bazin's time, but that, "God be praised for it," this
family is now at last established on a solid basis. As his third ior
portant discovery the doctor asserts, that cutaneous eruptions frcun
mternal causes are "either congenital or pathological." NsBvi and
ichthyosis belong to the "congenital" affections, the "pathological"
arc composed of the exanthems, and the whole number of diseases of
the skin called irapetigines by Frank. The usual name of these "ioh
pctiff ines " is tetter, according to the author ; for which four princir
pal diatheses can be found to exist, viz., scrofula, syphilis, herpetism,
and arthritis. Now tetter, when the consequence of only one dia-
thesis, is very easy to diagnosticate and to cure ; but it is often
the result of a number of diatheses combined, and then our author
declares it to be truly a terrible affair. Thus our readers perceive^
that the author not only turns his back upon even a trial of physiolo-
gical investigation, but hastens to return to the very worst ontdo-
gical period which medical science has long ago overcome. This
book is a useless play-work of classifications and sub-classifications,
without scientific foundation, without new facts. The only thing new,
is his return to ontology ; his manner of writing and explaining is
very discouraging. We venture to pronounce the opinion, i^at
nobody will ever read this book from the first to the last page,
except the author, without becoming either simply tired or thor-
oughly disgusted.

Dr. Peloly defends Piorry's opinion on the absence of a peculiar
diathesis in what is generally known by the collective name of scro-
fulous affections. We may say that the opinions of medical men of
modern times on this subject, are not very different from each other,
although they may appear to be so ; for it is evident, that a local
trouble affecting digestion and assimilation, will always infiuenoe
the formation and composition of blood, and that very often what
was but the consequence of a local affection, has been mistaken for

831

the origitMl wnw of later troubles of the Bystem. From tiiis point
of view we regard the Beemisg difference between the opinions of
Prof. Von Dlibcn and Faye. We think that both of lliem will readily
subscribe to the following notice on Mr. Duriau'a report on Prof. Pi-
orry'B lecture on scrofula,* published by ns in the N. Y. Jour, of Med..
Nov., 1858 :

" Inflammatory action becomes manifest by the stopping of san-
guineous or lymphatic circulation, by the coagulation of the liquid
contained in the vessels, and, finally, by the exudation of a plastic
lymph. After the inflammation has ceased, circulation may take
place again by means of the vessels, but the plastic product exuded
into the interstitial cellular tissue will not disappear in the same
manner. It will undergo a process of condensation, and leave an in-
duration of the ganglion, which by itself will, more or less, prevent
lymphatic circnlation, and give rise to a new pathological aflection
somewhere else in the organism. Thus, such an induration must not
be considered as the symptom of a specific diathesis. Now, these
indurations are very slow in their development, and especially does
suppuration take a very slow and tedious course. But this, atUiough
being a general fact wilb "scrofulous " individuals, is not a proof of
the existence of a peculiar diathesis ; for all such patients, suffering
from the influence generally admitted to be the cause of ''scrofula,"
as inappropriate food, bad air, etc., have a small heart, a small quan-
tity of blood, and exhibit a slow circulation ; and undoubtedly, ac-
cording to Msgendic, the circulation of the blood has a direct influ-
ence on lymphatic circulation. Therefore, in cases of this description,
reaction and absorption are less powerful. "Scrofula," then, is but
a defective development of organization, with the characters of anoe-
mia or hydrtemia, and consequently a disposition to indurations and
swellings of the ganglia. Moreover, Lebert was unable to detect
bored itariness of "scrofulous" symptoms in more than a third of his
cases — an assertion which diminishes a great deal the necessity, of
assuming a diathetic peculiarity. Neither the general disposition,
nor real local lesions must be classified as a specific disease. Even
the chemical alterations of the blood, that have been found, are to be
considered as a conseqneuce of local leatons and the general quality
of the blood, and not as a primary disease. Scrofula, then, is no
more a specific disease according to Piorry than according to Vel-
peau."

Of the book of Dr. Massif on epilepsy, tetter, and scrofula, the fonrth
edition has appeared. It is destined to enlighten the public on the
nature and cure of those obstinate diseases, and to prove, what
nobody ever denied, that not all the cases of epilepsy, tetter, or
scrofula are incurable.

Db. HArNBB, in all scrofulous affections, attended always to the
general disease ; taking scrofula to be always the consequence of
vicious alimentation. He never saw a local cure yielding successful
results. As to special and specific medicaments, he declares to have

332

never seen any effect of cod liver oil on scrofula and tnberculosis of
children ; but highly praises the administration of equal parts of
old claret and Heilbronn water, from four to eight teaspoonfulfl a
day.

Dr. Leriche puts his confidence in iodine. His method of adminis-
tering it, is to give a syrup of the seeds of sisymbrium officiuale witii
iodine. Besides, he likes to prescribe tincture of iodine to be taken
in claret. We should always prqfer to administer a medicament in
a simpler manner, and do not think that a practitioner will find it
very difficult in private practice to cure, without Dr. Leriche^B
recipes, 21 scrofulous patients out of 38, in the course of several
years. One case of cured scrofula has been reported by Dr. Lebcrt,
who refers to a young man of sixteen years, who had been suffering
from scrofula for six years past, and did not get well before having
had, for a while, his bread mixed with iodine.

Dr. ExGERT gives a report on the cases of scrofula and tnberculofliB
observed during the course of a year, in the Children's Hospital of
Munich. He counts such cases of scrofula only, where the diagnosis
cannot be doubted because of preceding diseases, hereditary in-
fluences, and evident scrofulous habitus. Rhacbitis, craniotabes,
idiotism, and struma are not counted in the number. Of 2,916 patients,
360 were scrofulous. In 10 others suffering from diseases of the
eyes and skin, the origin was dubious. There was no difference as to
sex, 178 boys, and 182 girls being affected. The majority of cases
occurred from the second to the eighth year of life ; 10 per cent, of
the whole number of cases belonging to the second, 28 per cent, to
the eighth year. The relative immunity from this class of diseases,
in the first period of life, Engert explains by the prevalence of in-
testinal diseases followed by atrophy and death, before constitntional
diseases have a chance to finish their slow course. Scrofula in the
360 cases referred to, showed itself in 10 per cent, as tubercular dis-
ease, in 20 as diseases of bones and joints, in 40 as ophthalmic dis-
eases, in 22 as cutaneous, and in 8 per cent, as affections of the mucooB
membranes. Hereditary influence appeared to act most unfavorably,
as cause of the disease ; so did moisture and darkness of the rooms;
food seemed to be of less dangerous influence. The treatment was
more a dietetic one, than by medicaments ; as iodine, the syrup of
the iodide of iron, and cod liver oil containing iodine.

Dr. Hutchinson records the case of a boy who exhibited the first
swelling of a testicle when a year and five months old. At the age
of 2 years 3 months the testicle was operated upon and a medullaiy
cancer of the size of a man's fist removed. The child was well for
8 months, when symptoms of pulmonary cancer developed them-
selves. He died eleven months after the operation had been per-
formed. Both of the lungs were infiltrated with medulary cancer. A
cancer of the size of a pea was found in the liver, but nowhere in
the other abdominal organs. Two aunts of the patient, sisters of
his father, had died from cancer of the mamma.

Dr. DmAY again, as in his " Essay on Syphilis of New-born Infants
and Nurslings" (Paris, 1854, pp. 439), discusses the important ques-
tions : by whom the infant can become infected, and whom it can

333

itself infect The infant may be infected by the father, although he
does not show actual symptoms of syphilis ; it may be infected by
the mother either in the moment of conception or during pregnancy ;
it may be infected by its nurse. Again, the foetus after having con-
tracted syphilis from the father, can infect the mother ; and the in-
fant suffering from hereditary syphilis can give the disease to any
body that approaches it, because the lesions of hereditary syphilis,
although showing the outside appearance and evolution of secondary
syphilis, are distinguished from common syphilis by thoir being as
contagious as primary accidents. The elucidation of these facts,
which beg^n gradually to be taken as such by tlie whole profession,
we principally owe to Dr. Diday.

IhL De Meric considers hereditary syphilis from two points of view —

1, the limitation of time as to the appearance of the symptoms ; and

2, the action of the infected foetus upon the healthy mother. Out of
forty-six cases of hereditary syphilis in children bom alive, only two
presented at birth distinct symptoms of syphilis ; two a few hourii
after birth, four a few days, live from ten to three weeks, ten from
six to thirteen weeks after birth. Thus there were 21 cases in which
the symptoms appeared before the child was thirteen weeks old. In
sOTen other cases the symptoms appeared at the age of three months,
fourteen months, twenty-one months ; two years and three months,
eigrht years, twelve years, fifteen years. As to scrofulous diseases
being the consequences of hereditary syphilis. Dr. De Mdric does not
feel entirely satisfied, nor does he allow of more than the possibility
sometimes proved, sometimes denied by facts, that the mother may
be infected by the syphilitic foetus.

The main points of a lecture delivered by Dr. Parker, arc tlic fol-
lowing : A father having symptoms of constitutional syphilis at the
.time of marriage, or at periods more or less remote before it, may
procreate a diseased infant, and the mother may never exhibit any
^mptoms of disease. The explanation of these cases appears to be,
that the ovulum is impregnated with diseased semen, and its product
is consequently diseased. The chances are in favor of the child
escaping, if the outbreak of disease has been very violent, i. e., if the
skin has been loaded with eruption, or again, if the patient has
been submitted to a prolonged and energetic treatment. The mother
sometimes retains her immunity, but in a number of cases does not ;
in such cases, tlie mother derives her disease from the foetus, a proof
whereof is the fact, that the symptoms of syphilis in the motlier very
frequently disappear after abortion or delivery, even without treat-
ment. Some even assert the mother to get diseased sometimes from
the seminal fluid alone. The mother may be the source of disease to
her foetus, or infant, in four ways : 1, she may be diseased before
conception ; 2, she may become diseased after she has conceived ; 3,
she may disease her infant in its passage through the vagina, or 4,
after birth. Where the fatlicr impregnates tlie foetus with diseased
semen, the infant, having been developed in the womb of a healthy
female, will usually be cured ; a cure is probable also in an infant,
whose parents were both healthy before its birth, but whose mother
was diseased afterwards, and communicated the disease to her

834

offspring. Where the infant is conceived and developed in the womb
of a mother diseased before conception, the prognosis is most tin-
favorable.

Dr. Knoblauch reports a case of hereditary syphilis oooorring in a
girl of two monUis, who, at and after the age of six wesks, waa
affected with syphilitic coryza, spots and pustules n^iidlj tana-
forming into ulcers. The copper color of syphilitic eruptions is not
always found, not even in adults ; in children, seldom anything ^
is observed except the usual redness of cong^tion and inflammatioD.
Dr. K. cured his patient, by the use of calomel, within for^ days.

Dr. White reports a case, in which parents, being syphilitic aboat
the time of their marriage, had 5 children in 6 years, all of whom
were syphilitic.

Drs. FiUEDiNOER, Matb, and Zeissl consider the principal forms of
syphilitic eruptions in infantile age to manifest themselves as — ^1,
maculated or squamous ; 2, papulous ; and 3, pustulous. The msou*
Jated form is usually found in the face, and consists rather of a deooku^
ation of the flabby and dry skin, than of a real eruption. Hie skin,
although very dry, looks rather fatty, particularly after the q>ot8
have turned either intensively pale or brownish, auid spread over
chin, cheeks, forehead, and, at a somewhat later period, over nates
and extremities. The spots, by their not disappearing when pressed
under the finger, proved to be of pigmentous nature. Sometimes
spots are found either on the maculated brownish surface or on the
hitherto healthy skin, which can be compared to roseola only : th^
seldom remain unaltered, but in the majority of cases rapidW cnange
into psoriasis, flat condylomes, or tubercles, or ulceration. The papu-
lous form is rarely independent of complications, but usually c<mi-
bined with the maculated form ; it is usually brownish, and consists
of small knots, either dispersed or in groups, mostly on the volar sides
of feet and hands ; it undergoes either inflammation (acne) or suppu-
ration. Dr. Friedinger observed a case, where but the inierior luJf
of the body was affected with this eruption ; the efflorescences were
distinctly separated from each other, but gradually enlarged so much
as to form uneven, infiltrated spots, but little elevated above the sur>
face of the healthy skin. The dry exudation turned into a thin scnif,
leaving the corium dry, and not bleeding like the corium in syphilitic
psoriasis. The pustulous form is, in Dr. ZeissPs opinion, less frequent
in newly-born infants than in adults ; in none of his cases the mother
was proved to have been syphilitic — in every one the father. This
form is cither developed in lUero (such infants will die before birth
or in the first eight or ten days of life^, or within eight days after
birth ; in such cases the little patients lived from twenty to twenty-
two days. The opinion of Cazenave and Dubois, who believe puru-
lent vesicles to be found on the volar sides of feet and hands, Dr.
Zeissl declares to be erroneous. Nor does this observer agree with
Cazenave's assertion, that ulcers will always follow the rupture of
purulent vesicles, Dr. Zeissl considering desiccation and peeling off of
the epidermis as a much more common occurrence ; this being the
more certain, the less strength and embonpoint is left to the patient
Loss of substance is perceived only on the sacrum anc^ calcanous.

335

wbfBge rliftgades are fonnd partly from infiltration of the ciftiB, partly
from rapination.

Dr. Thibt reports the case of a still-hom child, showing the
anomaly of the liver, which is considered hy Gubler as characteristic
of syphilis. The liyer was enlarged, hypersemic, and contained
nmnerons oval, whitish-yellow nuclei, of different sizes and fibro-
cartilaginoas hardness. The tissue consists of cells, more or less
elongated, without nerves nor vessels, that is to say, of fibro-plastic
tiarae in ^e first period of development. The parents had not been
closely examined for syphilis, but the mother had undergone three
aaccessive abortions before. Thiry considers the main characteristic
of this hepatic disorganization to consist in induration ;^the fibro-
plastic prcMduction, aluiough observed in every form of constitutional
■jphilis, differing only according to the variety of organs and tissues.

From a number of cases Mr. Hutchinson draws the conclusion,
that the period of the first dentition in infants affected with hercdita-
17 ayphiiis seems to be accelerated. In cases where information
oonld be obtained, 2 had their teeth at birth, 1 when a few weeks
oUt 2 about two months after birth, 2 about the usual time^ the re-
mainder very late. The teeth are generally small ; altho\igh the
alveolar arches are decidedly below the average size, there are in
most considerable spaces between the teeth ; they are more round
in form, resembling little pegs ; they are often worn from mastica-
tion, the enamel being very soft. In nearly every case there is a
deficiency in the superior alveolar arch, at the anterior portion, so
great in some patients, that the upper and lower incisors arc a con-
siderable distance from each other when the mouth is shut. The
eolor of the teeth is of a dirty translucent shade.

The same author reports a death from hereditary syphilis after
a mmith's illness, with disease of the heart. The pericardium was
distended with coagulated blood, the source of which was not ascer-
tained. The father and mother had primary syphilis two months
before the birth of the child.

Dr. Fbikdinqeb reports a case of hereditary syphilis, which was due
to the father only, the mother having never been affected by syphilis
neither before nor during pregnancy. Vaccination in the syphilitic
child proved successful, no anomaly being exhibited in the develop-
ment of the pustules. The use of vaccine matter taken from the
duld affected with latent syphilis, proved entirely unable to produce
any inconvenience in the vaccinated children. A successful cure of
hereditary syphilis can be effected by means of mercury, but not
without the child being nourished by breast-milk.

Syphilization has been resorted to in hereditarv syphilis first by
Prof. Boeck, of Ghristiania, afterwards by Prof. Sperino. The ma-
jority of cases exhibited the papulous form. The more imminent the
danger appears to be from this grave disease, the more highly this
method of treatment, in Prof Sperino's opinion, is indicated.

Dr. OoDFRKY reports four cases of diphtherite, and believes the order,
in which its symptoms generally occur, to be this : Shivering ; in-
tense depression ; dryness and tingling of the throat, nares and
ears ; external swelling of the glands ; a whitish spot on the

336

mucous membrane of the tonsil, gradual deepening in color as the
disease progresses ; dysphagia and dyspncea ; dilated pupil ; im-
pending asphyxia, and death. The disease appears to Dr. God-
frey to be confined to the mucous membrane, neither touching the
muscular nor grandular structure. The glandular enlargement is
due to sympathetic irritation. Its diagnostic difference from scarlet
fever consists in : 1. The absccnce of all fever ; 2. absence of all
rash ; 3. papillae of the tongue not enlarged ; 4. no desquamation
of the cuticle after the disease passes off. In cynanchc tonsillaris
the abscess forms within the tonsil, and bursts its way out, but in
diphthcrite, the morbid change commences .on the surface of the mu-
cous merrtbrane, and is confined solely to that covering. The ex-
treme and rapid depression is only equalled by the depression of ma-
lignant scarlet fever, or the collapse of Asiatic Cholera. Each patient
that' died appeared to sink from exhaustion and partial asphyxia. The
main point in the treatment is to support the patient's powers, by
stimulants and tonics ; and to check the inroad of the disease by tlie
application of the strong mineral acids. Tracheotomy is unsafe, be-
cause tl^e depression of the patient's powers is far greater than the
dyspncea, and the depression, while appearing before the dyspncBa,
cannot result from the blood' being improperly a^'rated. Dilatation
of the pupils existed as a marked symptom in every case. Dr. Grod-
frey believes the tincture of sesquichloride of iron the best remedy.

A large number of notices on diphthcritis contained in the £ng^
lish journals, are not deserving of any particular attention. The
disease being unknown in England, the practitioners of that coun-
try think every trifle known everywhere except in England, worthy
of being printed. Amongst them are the specimen of " the tonsils
and other parts from a case of diphthcrite," exhibited by Dr. Ogier
Ward in the Pathological Society of London : the discussions in the
Harveian Society of London as reported in tnc Lancet, which never
led to a result, each of the members expressing his opinion and
keeping it, and no unanimity as to its local or general character
being arrived at ; the cases recorded by Dr. Godfrey ; those of Dr.
Fuller and Dr. Greenhow, and the two cases reported by Mr. Browne,
of deaths by diphtlieritic dissolution of the blood, which he re-
. gards as a new disease, though allied in some of its character to
malignant " scarletfever." • Rapid deaths by diphthcritis seem to be
of a very rare occurrence in Great Britain, which is an interesting fact
as to nosography. Thus, after all, an English physician may be
excused for never having seen the disease in question, but not for the
total want of knowledge of its existence. For there is scarcely a
manual on the diseases of children on the continents of Europe and
America, and in England too, that would not state the fact^ that
some cases of diphthcritis faucium have such an asthenic, adynamic
type, and accompany such a general depression of every vital
function as to cause death in a short time, without apnoea or any
visible material change in the organic structure of the body, except
the diphtheritic exudation on tlie fauces. Such cases are to be con-
sidered as proofs of a rapid dissolution of the blood, similar in its
effect to the typhous. The like want of knowledge of their own

837

and fbreigni literature has been shown by tbe Hedfeal Society of
London, iniere Dr. Caxps read a pi^per on the same subject

Tbe only continental work known to tbe English writers appears
to be Brekmneau, Des InflammoHons Sp^cia!e$ du TIku Muqueux^ el
em Partictdier de la IHphthSrite, Paris, 1826, while the Manuals of
Vermm, Miiliet and Batihet, Bouchui, Bednar, Sennig, SchnUzer etnd
Wb^^ Oole^, Wed, ChurthiXl, Edaneon and Manmiu^ eren Under*
woed, Oondie, Meigs, etc., may be found to contain many remarks on
the same subject. Even a good paper written by Dr. HemtUm, for
Bd. Med. Jonr., Vol. II., p. 285, is unsnown to his own countrymen.

Mr. Hkndemon states, that diphthertic affections, after having been
anite unknown in Aberdeenshhre, have assumed the form of an epi-
oamic. The history of his case corresponds with what is generauy
known of diphtheritis. Tracheotomy was performed, but proved nn-
svccessful, as is generally the case in true diphtheritic afibctions with
a thorough decomposition of the blood. At all events, by means of
the operation, " life was prolonged, and suffering was arrested.''

According to Dr. Fakr's report, diphtheria proved very fatal in
Norfolk, Suffolk, Essex, and Staffordshire. Four hundred cases have
been attended at Bradwcll, in Essex, where eight died out of twenty-
one. ^Diphtheria is,'' in Dr. Parr's opinion, "like Asiatic cholera,
probably a more intense form of an old disease."

Mr. Gamps draws the following conclusions from the facts he col-
lected : 1. A disease very analogous to, if not identical with that
described by Bretonneau as diphtherite, had existed in England for
■OBie years. 2. This disease was mainly of an asthenic, adynamic
type : and characterized in the severer cases by the formation of
j^astac pseudo«membranou8 exudations. 8. It was primarily pharyn-
geal as to its seat, and not laryngeal, ergo secondarily, and by com-
pUoation ; thus differing anatomicallv f\rom croup. 4. Its difference
Irom stomatitis was a difference of decree or intensity, rather than
a dUFerence of kind ; and one chief pomt of difference from the ma-
lignant sore throat, consequent upon scarlatina, consisted in the tdn*
doioy to the fbrmation of plastic pseudo-membranous exudations.
5. In many instances tliis disease possessed the characters of an epi-
demic. 0. The treatment should be both topical and general ; tne
topical consisting of applications of nitrate of silver, or chlorine, or
l^diochloric acid ; the general comprising the administration of
chlorate of potassa, with chlorine, or a combmation of cinchona bark,
or its alkaloids ; and in the severer cases, calomel in repeated doses,
se as to produce ptyalism. In the early stages emetics have proved
neefuL * The vital powers must be well sustained by wine, stout,
beef tea, and other mv?gorating means.

Tbe Reqistrar^Oeneral, while reporting on the existence of epidemic
diphtheria in France, avails himself of the occasion to urge the im-
portance of fresh air, and especially the removal of the sewer gases
mto the atmosphere in a direct manner, through pipes running up,
and at least as high as the chimneys.

Mr. Hbslop recommends, in diphtheria, the administration to an'
adult, of about twenty-five minims of the London tincture of sesqui-
chloride of iron every two, three, or four hours, conjoined with a few

3S8

drops of dilute hydrochloric acid. He also applies daily, sometimes
twice a day, by means of sponges, a solution of hydrochloric add,
and always enjoins the regular use of weaker gargles of the same
acid. Stimulants, beef-tea, milk, jellies, constitute the dietetic part
of the treatment.

The discussion of the Albakt GorNTT Medical SociErr resulted in
recommending emetics, to cleanse the stomach and fauces of vitiated
secretions, gargles of diluted vinegar, and the mineral acids and
tonics very early in the disease to counteract the tendency to the
typhoid condition. Chlorates of potassa and soda were only men-
tioned in reference to their use as gargles ; their internal use wan not
discussed.

In Mr. FouRGBAiVs opinion, diphthcritis is merely a local affection.
He is opposed, therefore, to Mr. Blake, who considers, with the ma-
jority of modern writers, the main thing to bo the diphtheritic fever,
and all the sometimes severe and sudden symptoms pointing to dis-
solution of the blood. If diphtheritis was only a local process, the
accompanying fever, the general debility, and miasmatic expansion,
could not be well explained. Fourgcaud's opinion in this re-
spect, as well as his therapeutical treatment show him to be well ac-
quainted with the older literature, but entirely ignorant of the results
of late years. While fully agreeing with his expositions on the
application of muriatic acid and nitrate of silver, while further fully
admitting the danger of performing tracheotomy in secondary
croup, we entirely disagree on the antiphlogistic, local and general,
treatment recommended by the author ; for we have no doubt, that
the general debility and dissolution of the blood wHl not be pre-
vented or cured by antiphlogistics and purgatives, and that local
bleeding in cases of tumefaction of the throat, and the submaxillary
glands, will do good in only very few cases. A tonic, restaurant^
stimulant general treatment (together with the almost specific anti-
diphtheritic remedy, chlorate of potassa), and stimulant embroca-
ti(5ns to tbe neck, have proved more useful and appropriate. The
author not being acquainted with the use of chlorate of potassa
piH)ves by this very fact, tliat he ir not acquainted with the results
of scientific researches and experiments of the last three or four
years.

Mr. TnoMPsoK is inclined to adhere to the opinion, that dipbtherite
may be a modification of scarlet fever. "The following are the rea-
sons for considering so : 1. Dipbtherite prevailed in this neighbor-
hood as a contagious epidemic at the same time as well marked scar-
let fever, and chiefly among children. 2. In the same honse the
father and mother had well marked scarlet fever severely, withoat
any ulceration or deposit on the tliroat ; while the three children had
all the marked symptoms of dipbtherite, without much feverishneaa
and no rash, though attended by the same premonitory symptomt ;
the cases occurring at the same time. 3. In many instances, caaea
of apparently pure dipbtherite were, after some days, attended by a
rash, that seldom remained more than a few hours. 4. The disease
in most instances commenced with all the s^^mptoms of fever, its du-
ration being similar to that of scarlet 5. In cases of apparently

839

pore scftriet ferer, the throat became, after a few days, coYered with
a diphtheritic deposit. 6. The sequel» of the two diiBeaaes nearly
resembled eadi other. Albaminoas arine, with casts, being present
in eight cases of diphtherite ; and anasarca proving fatal from con-
▼nlsions in one."

Dr. Skkplv is mach opposed to the assumption of an identity of scar-
let fever and diphtheritis. The onset in the cases he observed, was
/very insidious ; the diphtheritic membrane had often reached the air-
passages before advice was songht. Death ensued from asphyxia,
ont in many more cases from exhaustion.

The principal fact Mr. Wade lays stress upon, is the presence of
albumen in the urine as a common symptom ; then he goes to show
that neither the false membrane, nor the fatal croup, ought to havo
induced Bretonneau to consider diphtheritis a new disease, and
pathologically different from scarlatina. As to the initial fever, he
rightly observes, that the stage of reaction bears no relation in in-
tensi^ to the stage of depression (or rigors) : that the initial fever,
though frequently slight, bears no relation whatever to the amount
or extent of the exudation on the fauces. Sometimes Mr. Wade has
found a certain diminution of the general symptoms, with the first
appearance of the exudation. Mycelium and Oidium albicans, as
found in the exudate membrane, by Dr. Laycock and Mr. Jauncey,
he did not find ; but in one case he saw the leptothrix, which, how-
ever, is common in various forms of disease. As to albuminuria in
diphtheritis, the author thinks too much of its importance and dan-
gerousness ; it being indeed a very common symptom in the first
stage of diphtheritis. Mr. Mangin has proved, moreover, that albu-
minuria, wherever found, accompanies the first stage of diphtheritis,
while in scarlet fever, it is seen with or after desquamation. Bo-
sides, according to his experience, albumen is found in almost all
tiie cases of diphtheritis, and always in large quantities, while it is
not seen in the majority of cases of scarlatina, and never in a large

Saantity. Cutaneous eruptions may be found from several causes.
ither they take their origin from a former disposition, or are like
theerythems observed in cases of virulent or miasmatic poisoning,
or the skin is simply congested by the general fever, such erup-
tions, then, in Mr. Mangin's opinion, are never peculiar symptoms of
diphtheritis.

Da Latcook compares diphtheria and muguet, and endeavora to
show that either of these diseases is due to the presence of a para-
sitic fungus on the surface of the mouth, fauces, and other mucous
structures. The sporules and mycelium of the oidium albicans,
which are, besides m diphtheria, found also in muguet, act as an irri-
tant, inducing increased formation of epithelial scales and effusion
Off mucous exudation coi-puscles, or plasma ; intermingled with
these, are the sporules, and the mycelium of the microscopic fungus ;
the whole constituting a pellicle. l%is fungus, however, appears
not to be limited to one form of disease. Dr. Laycock has had a
ease of syphilitic disease of the fauces and phar^x, in which the
pellicle containing the oidium was noted, and which seems to have
mtroduced it into the clinical wards. Whenever there is an epi-

340

demic of scarlatina, the presence or absence of the fungus, in each
individnal case, will decide on its cliaracter, whether diphtheritic or
not. The condition of the intestinal and bronchal mncous membranes
Bccm to be not very favorable to the formation of the mycelium, or a
pellicle ; still inflammation, and even ulceration of these surface^
will occur as the result of the irritative action of the parasite. In
diphtheritic croup there is no mycelium, either because the weather
is cooler when it prevails, or because tlio mucous membrane of the
larynx and trachea, being cooler generally, from the transit of air, is
less favorable to the development of the mycelium. The fungus,
however, may fix upon any suitable portion of the skin, thigh, labia,
malleoli, and angles of the eyes and mouth. The diagnosis from
ordinary aphtha is not difficult ; this latter disease is vesicular, and
the white specks or patches are ulcers, while in diphtheria they are
pellicular, and not ulcerous. The redness, too, is much deeper in
diphtheria, and tliere is no oidium in aphtha. The indications m the
treatment are given by the constitutional condition, which is always
low and asthenic tonics, stimulants, antiseptics j and by the local
afTcctions, in which tlie remedies called parasiticides are the best ;
biborate of soda, clilorate of potassa, bichloride of mercuiy, any
metallic salt ; particularly perhaps, chlorides, alkaline gargles and
applications, nitrate of silver. Diphtheria, as due to the oidium
albicans, is infectious and contagious.

Mr. Wilxs endeavors to show tliat a vegetable fungus may spring
up on the buccal mucous surface in various cases of diseases, but
requiring, probably, some previously morbid condition for a nidus ;
but that the pellicle in diptheria is always composed of a vegetable
parasitic fungus.

TIic result of Dr. IIauner's observations on diphtheritis are laid
down in the following, viz.: Diph thorite generally, and diphtheritic
an<^ina and laryngitis particularly, arc originally observed in feeble
children and such as have been sufiering from preceding (mostly ex-
anthematic) diseases. It is contagious and infectious ; may kill
either by intoxication, or exhaustion, or secondary affection of the
larynx, trachea, or bronchi ; and will never be cured by antiphlogis-
tic trr^atmcht, but only by roborants and local treatment. Dr. Hauner
applied in all his cases the solid caustic to the tonsils and fauces,
sometimes using a strong solution of it, and always sufficiently to
form a line of demarcation between the diseased and the healthy
parts. The internal treatment consisted of chlorate of potassa, Sm>
or i. daily, quinine, and a roborant diet. Aromatic baths proved
useful.

Mr. KiNOSFORD publishes a very judicious essay on diphtheria, divi-
ding it into a mild form, viz., diphtheritic sore-throat, and a severe
one, viz., genuine diphtheria. This latter is highly dangerous. No
antiphlogistic remedies must be adopted ; it should be borne in mind
that the fever is the result of a poison analogous in type to adynamio
erysipelas. The pharynx should be sponged every 8 hours witk *
solution of lunar caustic ; a most liberal allowance of wine and
nutritious diet must be instituted from the first, and the following
draught : chlorate of potassa, 10-30 gr^ ns ; tinct of sefiquichloride

841

of iron, 10*30 minims ; syrnp, 1 drachm ; water, T drachms ; ^ven
every one, two, or three hours. The more intense the inflammatory
■jmptoms, the oftener should the draught be administered ; nonrish-
ment also should be given in intervals. Cases in which deglutition
is impossible, or voluntary efforts at swallowing are resisted, reouire
dysters of beef tea and port wine every two hours in older children,
combined with quinine. At the same time the topical application of
the nitrate of silver must be persevered in. ; no mercury must be
given except as a cathartic at the onset of tte disease ; no blistering
and external stimulants applied, they being worse tiian useless.
Tracheotomy, if entertained, should be entertained immediately after
the croupous symptoms have become established, and not deferred i^s
a dernier reseort ; the author does not say whether he ever saw a suc-
ceasful case of tracheotomy in diphtheria. When tiie affection of the
throat assumes the malignant or putrid type, a gargle ought to be add-
ed, consisting of one drachm of liquor cnloricte of lime and 8 ounces
of water. A very serious complication, in severe forms of diphtheria,
is paralysis of the muscles of the neck, of the pharynx, and of the
larjmx ; such cases require change of air, and those remedies which
are calculated to improve the general health ; the nervine tonics are
especially indicated.

Prof. BoncHUT, of Paris, has done to his utmost during the year to un-
dermine what reputation he has obtained by former labors. In his
Q|>iiiion the false membranes will be best removed b^ emetics, or by
cauteries, of which he would prefer the hydrochloric acid to nitric
acidy nitrate of silver to the actual cautery. He generally applies
glycerine, which is expected by him to dissolve false membranes,
when not too hard. Of internal remedies he is, rightly, afraid of
mercury ; but he sins as much as those who recommend mercury, by
•praising divided doses of antimony. Of chlorate of potassa, he
declares to have seen no effect whatever. So far, all may be rieht ;
bnt» finally, ho g^s as far as to praise the excision of the tonsils as
an infallible remedy in cases of diphtheritic membranes.

Br. Babon recommends carbonate of soda or the Vichy waters.

A case of hydrophobia observed by Prof. Samtbssok, of Stodcholm,
occBrrcd in a girl eiffht and a half years old. The disease showed
itself on the forty-nfth day after the child had been bitten, and
resulted in death after two days' intense suffering. Post-mortem ex-
amination eighteen hours later : considerable ri^or in the maxillar
joints, the joints of the lower and particularly the upper extremities
being somewhat more flexible. When the external integnmente were
beinff incised, there was a smell of chloroform, which the child had
inhated before death. The inner side of the galea, corresponding
with the spot where the child was bitten, had its blood-vessels pretty
much injected witli blood ; also the cranium was, in the correspond-
ing part, somewhat exfoliated. The cerebral membranes were nor-
mal, the venous vessels of the arachnoidc, particularly on the basis,
abnormally filled with blood. The cerebral substance was normal, a
little hypersdmic ; the lateral ventricles contained some clear serum;
the choroid plexus of the right lateral ventricle was somewhat
extended by serum. When the thorax was being opened, the lungs

342

did not collapse ; after an incision was made, a large quantity of
dark fluid blood effused , the ri^ht lung adhered to the thoracical
pleura by old adhesions ; its middle lobe was almost entirely cdl-
lapscd ; the bronchia, in this part, were dilated and filled up with a
purulent liquid. On the outside of one of them was a calcareous con-
crement of the size of one half of a pea. The mucous membrane of
the larynx was pale, of the trachea red, and everywhere below the
bifurcation, in all tlie bronchia, highly congested. The left lung
showed interlobular emphysema. The heart was normal and con-
tained liquid blood and fibrinous coagulations. The mucous mem-
brane of the fauces was not particularly injected ; the tonsils were
swollen ; when incised, a purulent fluid escaped. The superior sur-
face of the tongue was pale and covered with some mucus ; the
inferior surface showed no blisters of any kind or size. There were
some erosions on the mucous membrane of the stomach, particularly
near the pylorus. The intestines and spl^n were normal, liver and
kidneys normal, but hypers&mic.

ni. ORGANS OF DIGESTION,

1. Neudtirfer, Contribution to the Operation of Hare-L^, — Oest. Z. f.
prakt. Heilk. 32.

2. Duke, Allen, New Operation for Hare-Lip. — Lancet. Feb. — ^N. T,
Jour, of Med. July.

3. Guersant, on Hare-Lip Operations. — Gaz. d. H6p. Nor. 24. — ^Med.*
Chir. Rev. July.

4. Volkmann, Case of Sudden Death after an Operation of Hare-Lip.
Monatschr. f Geb. May. — N. Y. Jour, of MecL July.

5. Tamcle, J., on SpIU Palate.— AUg. Wien. Med. Z. 45.

6. Butcher, on the Proceedings Employed in the Operation of HoBr^
Lip. — Jour, do Mdd. Chir. Pharm.

T. Morrogh, Case of Congenital Hypertrophy if the l\mgue, and Am-
putation. — Med. and Surg. Rep. Jan. — N. V. Jour, of Med.

8. Roussc, J. M., Ulcerous and Pultaceous CHngimtis. — ^Mon. d. H6p.
126.

9. Guillot, N., TreatmeyU of Muguet.—Rev. Thdr.

10. Delvaux, Ulcerous Gingivitis of Children. — Jour, de Med« Chir.
Pharm. April.

11. Seux, Beport on the Contagiousness of Muguet and on the **Oailar-
idty " in Children. — ^Bull. des Trav. de la Soc. Imp. de Mars. 8.

12. Gubler, A., Investigations on the Origin and Deveifopmeni of
Oidium Albicans, the Fungus of Muguet. — Mdm. de I'Ac. do MM.
XXII.

13. Moore, W., Spontaneous SdivaHon, Cured by Chlorate (f Pota8$BL
— Dubl. Hosp. Gaz. Aug. 15.

14. Corse, Case of Oangrcena Oris, in Summary of the IVans. of (k»
coU. of Phys. of Phil. — ^Am. Jour, of Med. Sc. July.

843

15. Montcpomery, J. E., Cancrum Ovia. — Nashv.'Jour. Med. and Snrg.

Id. Bryant, F., Fibrous Tumour Devdoped toiihin the Lower Jaw
Surrounding the Dented Nerve, — ^Trans. Path. Soc. Lond. IX.

IT. Mag^tot, E., J^ude sur le Divdoppevnent et la Structure des Dents
Sumaines, Accompagnde de Deux Planches Gi*aT^8. Paris, pp.
112. (Esaay on the Development and Structure (f Human Teeih).

18. Bokai, on Setropharyngeal Abscess in Children, — Jahrb. f. Kind.

19. Yirchow, R., Case (f Hydrops Ascites in a Neuiom ChUd, — ^Mon.-
Schrift f. Geb. March.— N. Y. Jour, of Med. July.

SO. Thompson, H., Large [Hydatid in the Liver, — ^Trans. Path. So<l.
Oond. IX. p. 994.

81. Lnschka, H., on a Large Fibro-Plastic Tumor in the Liver of an
Infant Four WMbs old,—Yirch, Arch. XV. 1, 8,

SS. Morris, J. C, Congenital Malposition of the Liver, In- TVans. CoU,
Fhys, PhU, — ^Amer. Jour. April.

23. Meyer, 6., on the Presence of Sugar in the Liver, in Diseases, —
Molesch. Untcrs. IV. 2. p. 179.

24. Charcot, Rupture (/the Spleen in a JVb^u^.— Oaz. d. H6p.. 144.—
Oaas. d. Par. 46.

25. Sibley, S. S., Extensive Tubercular Disease <f the Spleen in a
Child Sujff^ering from Purpura. — Trans. Path. Soc. Lond. IX. p.
425. Lancet. Sept

26. Hauner, Report on the Eleventh Year of the Dispensary of the
ChUdren^s Hospital at Munich, — Journ. f. Kinderkr. 7, 8.

2t. Death from (hSer-Feeding, — Lancet. Jan.

28. Wallace, S. W., Ldter to the Chicago Medical Journal, — Chic.
Med.. Jour. May.

29. Royal Free Hospital, — Lancet. Dec.

80. Maschka, Report on Forensic Examinatians. — ^Prag. Viert I.

81. Schuppert, M., Three Cases (f Congenital Deficiency of ike Intesti-
nal Canal, — N. 0. Med. News and Hosp. Gaz. April.

82. Willshire and Cooper Forster, Fistula of the Colon and Navel.
Operation. — Med. Times. 899.

88. Results if Therapeutical Experiments Made on Pepsins. — Jahrb.
f. Kind. I. 8.

84. Wade, W. F., on Lientery in Children — ^Brit. Med, Jour. Nov. 30.

86. Guerdau, A., Die Diarrhoea Ablactatorum, Rrechruhr und Oastro-
malacie der Kinder, nebfit deren Specijischer HeUmethode^ ErkXdrt
durch R, yirchou/s Entdeckung der Leuk&mie des Rlutes. 11. Auf-
lage. Heilbronn, 1869. pp. 81. — (On Diarrhcea Ablactatorum, In-
fantUe Cholera aud Ghstromalctcia and their SJMtdJIo Remedies. Ex-
plained by R. Virchoufs Discovery of Leukaemia,)

86. Hexamer, A. C, ZHe Kinder-Cholera oder Sommer-Complaint in
den Vereinigten Staaten, ihre Natur, Verlwtung und rechUeitige Er^

844

bennung. New York. pp. *l*l.^Gholera tn/onlum or Summet Com-
plaint in the United Stciea ; its Nature^ Prevention^ and Early Diag-
noeisj

87. Ghelson, B. A., on /^ TreaJfmeni <f OhoHera IitfaniMm. —"^kg.
Jqur. July,

38. Oholion, B. A., Addenda to the Bemarka an Cholera Irifimtum. —
Ibii Aug. .,

89. BeidfiNrO., Cholera J^aHtunL-^Utd. and Surg. Bep. Sept.

40. Smith, J. L., Beport of the Post-mortem Appearances in Sleixn
Oases ^ Oholfira /q^n^uoL-r-N. Y. Jonr^o^ Hea July.

41. Schuller, biarrhoea in ike First Tear </ Z«|^.-rJahrU f. Kind.

42. Weisse, J. W., Raw Be^ in the Diarrhoea JVaetab^rtm. — Joorn.
£ Eindark. i. 2.. . ^

48. Bicordeau, J. 0., De tJEntkite Gkoltmforme thrvensM chts PVn.
fynt Nouveaurni dan^ les Quime Premiers Jours de la Naismne^
Paris, p. 5*r.— /On ChoUriform Snteritis Ooparinff in Ir^nis Act-.
ing the First Fortnight after Birth,)

44. Moore, W., Sugar I^reatment in Sepsis and ZHar^Ac^a ^ Ohildfen
— ^Dubl. Bjoap. Gaz. Aue. 15.

45. Lederer, Infantile marasmus^ a BesuU of Chronio. JhtesUnd
Diseases, — Wien. Med. Woch. 16, 11. -

46. ip^fltto^er, <m Dystrqpkia qf CAt^ran.— ^ounx. f. Elinderk. ^ t>^

4*r. Ferrand, Obstruction of the Intestine in an Infant; Admnistntitm
of the MeialUa Mereury and figuisiet's .fiecotxry^-^oiUB.

d. Bord. Oct

48. Gaboret, Invagination of the Colon in a CkUd^ Bqjlaoed by L$ P^*
lettier's Method. — BeT« de th^r. m^. chir. 18.

49. Jacobi, A., Invagination of the Colon Descendenf^ in^ an Ifjfyuii,
with Bepeated Hemorrhage in the Colon Transversum.'y'S^ Y. Jofir,
of Med. May.

60. Mertens, A., Perforation of the Verm'^orm Process. '^Joxmx.t
Kindeik. 8^ 4.

51. Elliot, Q. T., Obstetrical and Medical casesi—^. Y. Jour, of Med.
Nov.

52. Glar, Catarrh and FoUictdar Ulceration of the Iniestinum CroBSum.
-^ahrb. f. Kind. I; 8]

68. Clar, Colitis Crouposa. — Ibid. 4.

54. Clar, Dysentert/.—lhid.

55. Clar, Constipation. — Ibid.

66. Cofistwation for (hree months completely removed, in CZim'calJBe*
cords.— Xancet. Oct

6T. FOrater, on Meoonkm. — ^Wien. Med. WocIl A2.

58. Debout, on Congenital UmbUiad JEHsmia. — Bollk de I'Ao. Edge.
1861-1858. L 4.

69. MeeHngs of the *'SociM de Chirurgie.^ On CongeniUL Inguinal
Hernia.— Vn. U6d. 61.

846

60. ExtracUfrwn the Beoords cf the BotUm 8<HAeity far Medicd hnr
provement. — BoBt, Med. Jour.

61. L^tand, A., on Exomphalus in Negro Infants. — Schweiz. Hon. 5.

62. Transactions of the Obstetrical Society at Berlin. — ^Monatschr. f*
(Jeb. May.

63. Jones, B. L., a Bandage for Treating Umbilical Hernia and for
Dressing the Umbilicus of a Newly-Bom Infant. — Oglethorpe Ined.
Jonr. Dec.

64. Ravothy Case of Hamiotofmy in an /n/aii<.-^Monat8ohrift t Oeb.
Sept.

65. Otia, G. A., Strangulated Bemia in Children, — ^Virg. Jour. March.

66. Boaer, The Theory ofBerm/oe Again,— Atc\x f. Phja. HeOk. 1.

6t. Richard, k.,onihe Beneficial I^eds cf the Bmphyment of BdUh
donna in IneonOnence of Fecal Matters, Existing Alone, or Compli-
cated with JEnuresis, in Children. — ^BnlL g^. de th^r. Aug. 15.

68. Berciouz, Bdladonna in Enuresis and Invoturdary Evacuation cf
Fecal Matters in Children.—O^LZ. Hebdom. 25, 28, 30.

69. Clar, Paralysis (fihe Sjpincter iini.— Jahrb. f. Kind. I. 4.

10. Magnus, on Fi^dapee cf the Bedum Cured by Local Applioation
cf Strychnia to the Frclapaed Intestine. — Ugeakrift for Lssger,
XXXIII. 11.

11. Hofanos, Fedunculated Polypus from ihe jRMicm.— Trans. Patli.
Soa Lond. EL p. 212.

12. Barwell, R., on a Case cf hnperfortOe Anus, vcHh a Peculiar De-
formity. — Lancet. Oct.

13. Berend, Atresia BecH. — ^Mon. d. Hdp. XL

14. Cwics of Imperforate Ajiue. — ^Brit. Med Jonr. 28.

15. SenfUeben, Beports en Prof. Langenbec^s Surgioal Oinigue at
Berlin.-^J>. Klin. 8.

16. Bryant, A., Ifnperfbrate Anus. — ^Virg. Joor. ApriL

11. Krieger, Some Bemarks on Atresia Ani and Uterus Bicomis. —
Monatschr. f. 6eb. Sept

18. Davies, R., Proposed Modificaiion (fAe Operation for bnperforate
Anus. — Ed. Med. Jour. March. — ^N. i . Jour, of Med. Jnly.

19. £lin,ifa{rorma<toA^aeiZ0C<tMi^^ IX.
p. 205.

80. Jones, J.» The Effects y CathBOiios in 'Imperfim^ Jhusl— N. O.
Med. and Snrg. Jour. Jan.

81. Meyer, "B., Die Wu rm k raiMcUen des Menschenmii Versudhen an
Ubenden Thieren. — ^Zweite Anflage. Lefpeig. pp. 181. — (On the
Worm Diseases if Man, with E x per i me nts on Limng Animde )

82. Paasch, Tcenia Solium in a CkUd. — Jonm. f. Slinderkr. S, 4.

83. Dies, Ascarides m the UMilicus.—Wv^rtemh. Corr.-BL 12.

84. Ramskill, £. J. &, on the Use if BatOera Tmotoria in Taenia and
other Intestmal IFbrmSj— Laneel Jidy.

346

85. Moore, W., Cases iUxistraiing the Value cf " EaoMda'" as an AsMt
mintic. — Dubl. Hosp. Gaz. May, 1.

86. Leared, A., on the Use cf Kamala as an AntheiminUc. — ^Lanoei
July.

87. Peacock, Imperfect Sesultafrom Kameda, — Med. Times and Qaz.
Nov. 6.

88. Schultz, C. H , Nitrate of Silver against EdmirUhs in the BectunL--
D. Klin. 15

89. Walter, G., Contrilmtions to the Anatomy and Physiology of
Oxyuris OrncAa, — Z. f. wiss. Zool. VIII. 2. — GUnsb. Zeitscbr. IL

Dr. Neud5rfer, after mentioning the well-known fact that the cici-
trice, after the operation for hare-lip, does not keep pace with Hbs
growth of the upper lip, recommends transyera^l mciBiona throngli
the wound in order to elongate the cicatrice to the full length of ue
lip. Diefifenbach is well known to have, for the like parpoM^ aepft-
rated the margin of the lip from the alveolar process.

AixEN Duke operated on four children, whose ages varied from six
weeks to five months, in the following manner : '^ The edges p«jed«
not in the usual way, but by an oblique incision from before bad[-
wards, slightly concave, and the reflecting bands of macons mem-
brane, freely divided, are to be brought neaUy together hj two or
more sutures, each armed by two curved needles, which ars to he
introduced immediately under the skin, carried completely throodli
the remaining thickness of the lip, and firmly tied inienuMy. To
facilitate the removal of the two upper ones, the ends of the sutnies
should be brought out at the angle of the mouth, and secured exte^
nally by adhesive plaster, strips of which are to be applied the more
firmly to bring and retain in contact the skin. The sutures may be
safely removed in the course of a few days. Should there be a
fissure of the jaw, and any portion unnaturally project, it should not^
as is usually recommended, be entirely cut ofi*, but partially seveiedy
the edges pared on both sides, and neatly adjusted by sutures, in
order to fill up the vacancy, and preserve the natural rotundity of
the forepart of the jaw, previously to operating on the soft parts.''

Prof GuERSANT declares the result of operating for simple or double
hare-lip, at any age, to be almost always favorable, of operating fcnr
complicated hare-Tip only exceptionally successful ; but almost always
unsuccessful whenever a oomplication supervenes in the Shape cX
disease of the skin or some other part. He usually does not operate
until 6 weeks or 2 months after birth, some newly4)om infants hav-
ing died after the operation, being unable to take food. Moreover, a
considerable number of children die within the first 2 months, even
without having undergone any operation ; the loss of blood, too, in
the operation for complicated hare-lip, is more than many chil<ben
bear. For some time past Prof. Guersant has employed separate
points of suture, having found that they less easily cut through the
lips of the wound than the twisted suture. As to the inability of
taking food. Prof Guersant appears to be somewhat mistaken ; at no
age privation of food is less mconvenient and dangerous than in the

347

newly-bom. Moreover, the process of suckling does not at all inter-
fere with the woond of the upper lip.

Prof. BuscH, in his book on ''3urgical Observations" (1854),
directed the attention of the profession to the fact, that infants,
accustomed to breathe while the mouth is closed, through the large
abnormal opening, keep the mouth closed also after the operation is
performed, and are subject sometimes to fits of suffocation. Such a
case is reported by Prof. Yolkman ; it resulted in the death of the
patient, a boy of one year of age. Dr. Gurlt has seen similar cases.

Dr. Tamble publishes some practical notes on and rules for the
operation of split palate.

A case of congenital hypertrophy of the tongue, and amputation of
the diseased parts, was reported by Dr. If obbogh, of New Brunswick,
N. J., and occurred in a girl, seven years old. At birth the hyper*
trophy was moderate, but it had increased more or less rapidly till
reaching its present dimensions ; the tongue was found protruding
two inches outside the jaws. It measured two inches across the
teeth, and was of a corresponding thickness. The papill» of the
protruded portion w.ere enlarged^ and the mucous membrane was
thickened and indurated. On the under surfape was a ragged, hard
ulcer, produced by the pressure of the teeth, ftese were pressed for-
ward considerably out of their natural position. The horizontal rami
of the inferior maxilla were curved downwards, so that^ when the
molar teeth came in contact, a space of about one inch remained
between the upper and lower incisors. By this the girl was able to
masticate and swallow without difficulty. After the example of Dr.
Harris, .of Philadelphia, who, after endeavoring to amputate in a
similar case by ligature, in 1829, performed the same operation in
1 835, by a double flap incision, checking the hemorrhage by ligature.
Dr. Morrogh operatea by removing a V shaped portion from the ante-
rior middle part of the tongue, and ligating the ranine artery.
Although copious hemorrhages followed, Uie patient went home well
on the sixth day after the operation.

Mr. MooRE i-eports the case of a boy, of 4| years, who had suffered
severely from spontaneous salivation for a month. No cause of this
salivation could be found ; there was no tumefaction of glands, no
affection of the tongue, no calomel taken. After taking tor awhile
chlor. pot. gr. jii., and tinci. catechu gtt viiL every two nours, he re-
covered.

Mr. RoussE savs, that in cases of ulcerous inflammation of the gum,
where antiscrophulous treatment seems to cure but with the loss of
the teeth and alveolar procesises, he has repeatedly seen a rapid cure
follow but 4 applications, by means of a brush, of perchlor. of
iron.

Muguet is said by ICr. Guiuat to be cured in a simple way, bv
rubbing off the deposits from the mucous membrane of the mouth
and slight cauterization of die diseased pvts with the solid lunar
caustic.

The principal facts of Dr. Gublib^s careful investigations are
the following : The concretions of pultaoeous appearance, known
by the name of muguet^ are constituted by a fungus, the oldium

648

(dbicans, which is developed from sporuln disseminated in the atmos-
phere, and deposed at the entrance of the or^ns of digestion.
Thus infection may be transmitted by the air, or the fungus spread
by direct transplantation from one mneous membrane of the montii
to another. But it will not always develop itself with eqiial readi-
ness, certain conditions being required, as diseases of the organs
of digei^tion in children, or tubercular phthisis, typhoid fever, or
angina in adults. In all these affections, the mucus of the lining
membrane of the mouth is sour instead of alkaline ; such, then, is iS
least one of the conditions on which the existence and development
of oidium albicans depends ; easy access of air, too, is required.
The fungus is mixed up with mucous concretions, particles of food
retained in the mouthy and the epithelium of the mucous membrana
This strange composition is only superficial, does not penetrate into
any tissues, and does not aflbct circulation. Thus the prodnction of
mug^et is a simple accident, and has no particular connection with
the affection it is found to be complicated with. After all the foie-
going remarks, it is of therapeutical importance, to avoid the neigh-
borhood and the contact of individuals attacked by the cryptogaiiie^
to remove the morbi4>}na88es by mechanical means, and to wash the
diseased parts with idltong alkaline solutions.

In the summary of the transactions of the College of Physicians of
Philadelphia, a light case of noma is recorded by Dr. Oqssk. lb.
MoirtGOifSRT reports the case of cancrum oris occurring in a girl of
from four to five years of age, which was almost entirely left to
itself, and naturally proved fatal.

The case of fibrous tumor, developed within the lower jaw of a
boy of nine years, related by Mr. Bryant, is remarkable for uie entire
absence of pain.

Dr. MAorroT is of the very rare class of Frenchmen, who confess
that a thing may be done or understood better elsewhere than in
France. While he found, in England and Germany, a large number
of treatises on the development and structure of teeth, he regrets to
say, that he has found but a small number of articles on the subject
in France, and these, too, under the influences of old and antiquated
doctrines, and with only a very incomplete knowledge of tiie results
obtained in foreign countries. For tnis reason, he quotes largely,
Owen, Nasmyth, J. HUller, Purkinje, Schwann, Kdlfiker, eta ne
considers the development of the dental substance during the em-
bryonic period ; in what he calls the period of actual development^
where the elements of dental structure are formed and dispose them-
selves ; and, finally, in the adult period, where the tooth is entirdy
constituted. The first part treats of the development and structure
of the dental follicle in all its parts, before the production of the hard
dental substance has commenced ; the second part comprehends the
development of the proper dental substance in the follicle ; and the
third oescribes the elements of the definitive structure of the teeth.
As to the original condition of dental structure, he mostly follows the
opinions of Raschkow {Meldemata circa dentium mommaltwn evclur
honem. YratislavisB 1885), and Huxley {On the Devdopmeni cf Ihe
Teeth, and on Oie Nature and Importance <f NatmytKe PereMtentCap-

S49

mfa, in Quart. Jour, of Hicr. Sc. April, 1853), only denying the exist-
enoe of tiio membrana prKformativa.

Hie Yeiy best essay on this important disease of the infantile a^e,
!• jet pnblishcd, is from Dr. Bokai. The main points of his yiQu-
able expositions are the following faf ts : Retropharyngeal abscesses
may be classified under three heads. Some are developed idio-
pathically, from an inflammation of the pharynx, and the surround-
ing cellular tissue, the inflammation taking its origin from either a
eatarrhal affection, or a metastatic process, under the influence of an
acote exanthem, typhus, pysemla, etc. Another class are secondary,
being produced by tlie suppuration of inflamed lymphatic glands of
the neck. The third class owe their origin to ^ suppuration of ber-
Tical YertebrsB, or their ligaments. The first class occurs in the ma-
jority of cases before, or at the time of the first dentition, this period
of life being most subject to idiopathic catarrhal inflammations.
The second class are more frequently found about the time of the
second dentition, which is most favorable to inflammations of the
Ivmphatic glands, as produced by scrofula. The third class belong, in
their nuyority, to the same age ; inflammation, tuberculous as well
as tFanmatic, being uncommon at an earlier period. The prognosis
in cases of the first class, is generally favorable, unless the incision
ci the abscess be neglected ; with the only exception of metastatic
abscesses, which are but symptoms of a more or less gi-ave affection
of the whole system ; in these cases, everything depends on the pos-
sibility or impossibility of a cure of the morbid crasis of the blood.
The cases of the second class are not unfavorable, although they be
only secondary, because there is always a hope that a rational treat-
ment of the general disease will be successful. The prognosis of the
third class is most unfavorable ; for there is only a momentary relief
after the abscess is opened, either artificially or spontaneously.
The treatment is to be modified according to individual cases. Idio-
pathic abscesses, when in their beginning, require a rational an-
tiphlogistic local application of cold, either externally, or by garg-
ling, with, or without alum ; local application of alum or nitrate of
'silver, leeches, scarifications of the pharynx. When the inflammap
tion cannot be kept from further development, warm poultices will
be jfoond preferable ; they may be omitted, and warm emollient
nigles given instead, where congestive cerebral symptoms prohibit
tiieir fuller application. Internal treatment is not of much use, ex-
cept in moderating the fever, cerebral symptoms, etc., especially the
tartaivemetic is not deserving of its general warm recommendations.
Wheie the symptoms are grave, and suffocation imminent, undoubt-
edly the safest and quickest remedy is incision, after which the ab-
scess is to be washed out by gargling or syringing. Metastatic
abscesses require incision only where the symptoms are verv gprave.
After it has been made, water would not be sufScient for cleansing
and healing the wounds, but stimulants, astringents, and roborants,
arc always required, such as ohioret calc, alum, nitr. arg., tann,
ac. ; also, the internal treatment has to be modifiied by the general
morbid affection, and bark, mineral acids, etc., will often be found
necessary. Secondary abscesses of the second class above-men-

360

tioned require the same local treatment as idiopathic ones. Where
an external abscess originating from glandnlar inflammation is dii§^
nosticated, it has to he incised from outside, in order to prevent^ if
possible, the formation of a retropharyngeal abscess. At all eventB,
the treatment after the incision of a retropharyngeal abscess of this
class will take the more time and care, the graver the general gUn-
dular disease, and the severer the dyscrasic dissolution of the Mood,
jod potassii, iod. ferri, and cod-liver oil, will often be re(|[nired. The
cases of the third class, offer a largpe number of indications, but ire
much less hopeful. Quiet position, application of cold, leeches, oint-
ments of mercury ayd iodine, calomel, nitr. potasssB, tart, em., iod.
potassii, iod. ferr., are indicated, and have been used and abuse!
The incision ought to be made as late as possible.

Prop. R. Yirchow reports the case of an infant, bom with ascites
and congenital peritonitis. The mother, about thirty years of age,
had six children, the first of whom is about twelve jeun dd, and
healthy ; but tiie last three died pretty soon after birth, «nd had,
each of them, the abdomen swelled by dropsical exudation.

Mr. Thoxpsok relates the case of a boy who had complained for
some months of abdominal pains, and had been suffering daring the
last six weeks preceeding his death, from epileptic fits recurring al-
most daily. The liver was divided into two portions by a large fib-
rous cyst in its substance, within this was an acephalo-cyst almost
filling the fibrous cyst, from which twenty-two ounces of albumin-
ous fluid were evacuated ; and one other smaller cynt, containing
about two or three ounces. In the fluid contents were nomeroui
echinococci, and booklets, seen under the microscope.

Prof. LusoHKA reports the case of a prematurely bom male Infant^
who suffered from loss of blood after the umbilicus had fallen off, and
aneemia, and evacuated blackish brown f»ces. The liver was of a
dirty greenish-yellow color, and very large. A fibroplastic tumor
was situated behind the gastro-hepatic ligament, originating, prob-
ably, from extravasation during fcBtal life, into- the parenchyma of
the liver. The parents were not syphilitic. This case of Prof. Lnschka,
is exceedingly interesting, because independent fibro-plastic tumors
(with the exception of fibroid masses in the syphilitic atrophy of the
liver in adults), have been found in but rare instances, and never in
children.

Mr. Morris made the examination of a woman of fifty years, who
died from granular degeneration of the kidneys ; the liver appeal^
perfectly normal in structure, but instead of occupying the concavity
of the diaphragm, it was lying on the right side, so that the left lobe
occupied the ordinary position of the right lobe, while the latter was
forced downwards and forwards.

Dr. Meter attended for a long time, a boy of six years, 'vriio at last
died from a phlegmonous inflammation of his right check, and cami-
fication of the inferior third of the left lung. The liver was carefully
examined and found to contain sugar in imcommon quantity.

Mr. SiBLET records the case of a boy of four years of age, who
died with the svmptoms of purpura and tubercular disease. Tnber-
cles were found in large numbers in all partQ of the lungs, on the

861

sorfaoe of fho peritonenm (rf the liver and spleen, which weighed
three and a half onnoea. The bronchial glands were converted into
masMfl of soft^ cheesy, yellow tubercle ; so were the glands in the
(^astro-hepatic omentum, bdt the mesenteric glands were simply
somewhat larger than usual.

Of 9,51 'T children treated in Dr. Hauner's dispensary, more than
1,000 Buffered from diseases of the organs of digestion, particularly
bam gastro-intestinal catarrh, in consequence always of a vitious
alimentation. Atrophy and death were no uncommon results. Of
100 deaths, as many as 134 were produced by atrophy.

In the London Lancet a case is reported, of what is called death
from oTer-feeding. A female child, nt. 8 months, who had been un-
well for several days, died pretty suddenly. It was ascertained that,
in addition to tiie breast-milk, three cups of arrow-root and some
milk and water had been given to the child, and death was attributed
to the fact of the stomach being unable to relieve itself of the mass.
— Verdid : " Died/rom natural causes.*^

Mr. Wallace observed the case of a new-bom infant, in which " the
stomach and intestines, except a portion of the rectum, were found
external to the abdomen, protruding through an opening about two
inchei long, by the side of the umbilicus." The infant died the fol-
lowing morning.

A penetrating wound of the abdomen, produced by a pair of scis-
flora, and protrusion of the bowels, has been observed by the phy-
sicians of the Royal Free Hospital, London, in a child of live years.
The result was fatal.

Dr. ICaschka reports the case of a child, in whom, after having been
alive for two or three days, the stomach was still in a vertical posi-
tion. Thus the position of the stomach can no lon^r be taken for a
certain sign of the life or death of a child, at the time of birth. An-
other case shows the diagnosis of lungs swimming in water, after
the diild lived, and such as have been inflated by putrefaction ; the
latter sinking in water after the vesicles have been opened and the
Inng^ slightly compressed. This same case even shows some other
particulars of great importance ; there were sugillations in the lungs,
whidi the autfaK>r says, have always been taken as a certain proof of
the diild's life, whereas, the child was not only dead, but had even
undergone putrefaction when born. (See, however, p. 164.)

Dra. WiLLsmRE's and Cooper Forster's case of fistula between colon
trans^rsum and umbilicus occurred in a boy of five years, who had
some three weeks before, an abscess between colon and the abdomi-
nal integuments. Faeces were excreted directly from the transverse
colon, through the fistula, only very little being ^evacuated through
the anus. Occlusion by a plastic operation was readily effected, only
a small aperture, scarcely large enough for a probe, remaining.

In one of the Children's Hospitals of Vienna, numerous experi-
ments have been made with pepsine. The mode of preparing this reme-
dy differs greatly. One of tne drugs experimented upon, consisted
mainly of the parenchyma of the ventricular glands, and contained a
larg^ quantity of mucus matter, mucine, which ^ives a tough mass
i^er being influenced by acetic acid. Besides, there were found in

352

it, remainders of plants, fungi, stony matter, and an egg of a hel-
minth, belonging to the stomachs of swine. Even in the reoentlj mide
preparations, Dr. Wkdl found fuAgi. Otlier kinds of pepsine oontoin
a great per centage of amylum, to preserve the dmg from potrefoo-
tion, and to have it always as an equal mass.

The reporter savs that the experiments do not prove, hitherto, vxj
healing effect of the pepsine, given pure and as powder^ in dyapepeit
of chiUren and its consecutive sufierings. Neither does ** pepsise
whey'' seem to be promising of much more effect ; the results oSi^
observations made on this preparation may be comprehended in the
following : 1. Older children (of from 3 to 6 years), and such as did
not keep in bed, tolerated pepsine whey pretty well, and relished it
somewhat ; their i4>petite appeared not to be diminished. Tounger
children, and such as were kept in their beds, threw it up again^ eren
when given in smaller doses. When such was the case, the diildrai
did not want to take it again. 3. Such of the whey as had a nsni-
fest nauseous taste after the preparation, was usuaHy brooght up
again. 3. Convalescence appeared not to be aided, in any rematka-
ble degree, by the use of pepsiiie whey. 4. It was generally kss
relished and tolerated with more difficulty, than cow-milk. 6. Sodi
a healing effect, as is sometimes seen and usually expected from
drinking whey, in bronchial catarrh, particularly in the ;^ogre ss of
tuberculosis, could not be observed. 6. Nevertibelesa, if there ever
is an indication for the use of whey in diseases of diildren, the pep-
sine whey, prepared without the nauseous taste of the dmg, wul
likely be found more wholesome than the common serum iacHa.

Of Dr. Querdan's book on diarrhcBa and gastromalacia of children,
a second edition has appeared. The author expresses the same opin-
ions as in his first edition, on the reality of gastromalacia ajud on its
nature, considering it to be the consequence of a b^^ning leakssmia
(Yirchow, leukocytha&mia, Bennet), of a «etrogra<te metamorphosis
of the elements and proteinous substances. As specific remedies, he
again recommends acet. plumb, and chlor. oxydul. ferri, inahigfaly
unchcmical and injudicious composition. His anatomical knowMge
appears to be dubious, his pathology somewhat old-fashioned, ms
belief in the ignorance or credulity of his readers enormous, his dic-
tion neither accurate nor proper, and his natural calling certainly
not that of a medical writer.

The little book of Dr. Hexamer, who, we are sorry to state, has
since died in this city, is a clear and true exposition of what the
public ought to know on cholera infantum. The author does not at
all pretend to ofier a new book to the medical profession, bat expects
to find his readers in the public at large. We have considered it as
our duty to recommend the book to the public in a widely-read
paper, and we again state our conviction of its value, as a tribute to
the memory of the deceased.

Dr. Gholson's treatment of cholera infantum is not at all new, but
good things may be repeated more than once. He individualiaes, as
every rational physician ought to do, according to the stage «nd
gravity of the disease, and the strength and general health of the
patient In mild forms, sugar of IcmI; calomd, anodyne iiyections.

S53

and tannic acid ; in more advanced stageB, adstringenta poBsossing
tonic properties, as logwood, ratany, catechu; and a very cautious
use of mercury and narcotics, a^ indicated ; in cerebral affections,
with due regard also to some epidemic type, ansemia is to be con-
sidered as most dangerous, and to bo removed by quinine, stimu-
lants, etc.

He lays particular stress on the fact that, the disease being not at
all confined to the United States, in order to explain the universality
of occurrence, we must invoke the agency of those physiological
cfaangces which dispose so inevitably to certain diseases at certain
periMs of life. He further considers the simple uncomplicated folli-
cnlar affection as the normal type of tlio disease, and, therefore, he
recommends, in the early stages, minute alterative doses of sugar of
lead, calomel, and bicarbonate of soda. Real inflammation does not
belong to the usual and single symptomatology, and requires the
greatest caution when an antiphlogistic plan of treatment is resorted
to ; hydrocephaloid symptoms being a frequent consequence of inani-
tion.

Db. Bud's deductions are, that ** cholera infantum is simply an aton-
idty of the sympatlietic plexus or nervous centres, induced by the \
oppressive influence of a highly negative electrical atmosphere."

Dr. SviTH publishes 11 short reports of autopsies made on children
who died of cholera infantum, from which he draws the following
concliisions — 1. That the stomach, though so irritable in the disease,
and the liver, in the few instances in which it was examined, did not
present any notable alteration from the healthy state. 2. That in all
the cases there was well-marked intestinal inflammation. Two died
when only five days sick, and yet in both the descending colon pre-
sented the inflammatory lesion in a high degree. 3. That the inflam-
mation was not confined to the mucous follicles, but extended in
patches over the mucous, surface. 4. The portion of the intestinal
canal in which the inflammation was not intense, was in all the
patients the descending colon, and colitis was the only lesion in-
variably present. While fully acknowIedgii\g tlie scientific vdue of
Dr. Smith's observations, we would remind the author that, from the
resolts of post-mortem examinations like his, we are b^ no means
entitled to draw conclusions on the nature of cholera infantum in
general. A large number of undoubted cases of infantile cholera
yield not the least morbid traces in the corpse, as we have seen our-
selves in many instances, to say nothing on the difficulty to find the
anatomical basis of catarrhal affectious existing during life. But it
is true that about the time when Dr. Smith made his post-mortem ex-
aminations, we have repeatedly met with like pathological anomalies.

Dr. ScHULLER is of tne opinion that calomel, } grain ever^ third
hoar, is a remedy, where there is no fever, in the diarrhoea of mfants
under one year of age, who are or have been nourished by breast-
milk ; experience in hospitals, on children artificially fed, gave a
negative result. Calomel has the favorable effect, which has just
been stated, oul^ while the diarrhoea is beginning. If it has not
been successful in stopping diarrhoea within 24 or 48 hours, it is of

364

no use, and has to be discontinued. Vomiting, while calomel is
given, yields no contra-indication.

Seventeen years ago, Dr. J. F. Wsisse, physician of the Ghildrei^B
Hospital of St. Petersburgh, recommended for the first time raw beel^
scraped, as the best remedy against the diarrhosa setting in after
weaning. He repeats his recommendation as warmly now, a^ it has
been given in former years, referring' to his own experience and the
approval of a great many well-known observers. It is a remarkable
fact, and worthy of being communicated, that many of the children
cured by the use of raw beef, had subsequently tasnia solium, whidi
is not usually found at St. Petersburgh, but which, according to D.
von Siebold (On Nematodes and Cystid^ Lieipsic, 1854) is introduced
into the Russian capital by Podolian oxen.

This experience ought to make practitioners careful as to the use
of raw beef when unnecessary. We have been ourselves undar tlie
necessity of attending for tsBuia a child of from four to five years^
whom we prescribed the free use of raw beef some years ago.

Under the name of choleriform enteritis of the newly-bom infant,
Dr. RicoRDEAU describes a disease, easily diagnosticated from catarrhal
diarrhoea, cholera morbus, and dysentery, by the greenish or serous
diarrhoea, high fever, coolness of the skin, senile expression of the
face, retention of urine, and partial, seldom general, cyanosis. High
temperature, bad air, and unappropriate food are among the princij^
causes. In the first two weekis of life it is always a fatal disease^
neitlier emollients, nor antiphlogistics, nor local nor cutaneous revul*
sives, nor opiates, nor tonics and adstringents, nor absorbents being
of any use whatever. The nature of this disease Dr. Ricordeau con-
siders as merely inflammatory, sometimes stomach and the small in-
testines l>eing injected, sometimes normal, but the large intestines
showing always inflammatory alterations and swelling of the f<^
Holes.

Dr. Ledercr states that infantile marasmus is the consequence
of a groat number of organic diseases. The one consequent on
chronic intestinal complaints must be distinguished from thai f^-
lowing on tubercular degenerations of the mesenteric glands,
etc. The cause of enteric atrophia is either a simple chronic in-
ternal catarrh, or follicular catarrh, or enteritis cbolerifOTmis
^cholera infantum), or, in a vorr few cases, dysentery, of which in-
fants in early age usually die in an early stage. Sxtreme emacia*
tiou, diarrhoea, pain, and sleeplessness, are the jMst common symp-
ton\s, lvside« most craving thirst and hunger, jlieae are of a diag^
ttostio importance, being not found in the other kinds of marasmus :
neveitheles$v the stomach and intestines are not sufficiently powerftu
to digest. AbseiKV of fever is characteristic, so much so, that fever-
ishiiei$» is usually a prodxv^me to cerebral or other OMnpIications, <tf
which the most conmh>n are : cerebral or pufanonaiy stasis, otonhosa,
tumef^'tioiis of the glands^ ahs«.vsse&. fsniBclea. and hooping cough.
Milk is not ahR^-^ tolerated, and is seldom so in large cities. Dr.
lANlerer tlK« pnHKnrs to give beef tea* without ^Mce, but widi some
siKgar ; sottetuues; wher^ diarrbc»a is |pceK9at» with riee water. Yeal
soup gettecaUT cattK« or aggravates danhoM ; lo does vesL Raw

• 355

beef is di^tible in the first stage of the disease only ; carrots are
rather injurioas. Baths, mixed with milk, beeC tea, and embroca-
tions, wiu fats, have a good efiect. Diarrhosa requires the nse of
nitrate of silver, nux vom., and tannic acid. Whenever pain and
sleeplessness are injuring the strength and the favorable course of
recovery, a cautious use of opiuw ought to be resorted to.

Dr. KurrKBR, of Dresden, publishes some valuable reiparks on what
he prefers to call dystrophia of infants, (xcnuine dystrophy, paedo-
dystrophia, psedatrophia, is the low state of nutrition and the gen-
eral exhaustion, which arc caused by insufficiencv of food, cither as to
ouantity — simple dystrophy— or as to quality — dyspeptic dystropliy.
This genuine dystrophy diifere much from the cases of emaciation
and exhaustion which are merely symptomatic, and the secondary
consequences of some local affection of the digestive or respiratory
Gleans, or of syphilitic or tuberculous, etc., dyscrasics ; in dyspeptic
^atrophy the author recommends, as a tonic and stomachic, from
eight to ten drops of Malaga, Hungarian, or Port wine, to be taken
three or four times a day.

In cases of diarrhoea of children, combined with putrid decomposi-
tion, Drs. F. J. Behrend and Sieber, of Berlin, have administered large
doses of Sugar,- with good success (Journ. f. Kinderkr. 1857. 1, 2).
The sugar is expected to develop, in the digestive organs, its anti-
septic nutritious, and fat-forming qualities. Mr. Moore, of Dublin,
reports a very successful case of this kind in a boy of sixteen
months. The doses of sugar were about two teaspoonfuls every
two hours.

Mr. Cabaret availed himself of Le Pelletier's method to replace
a long piece of the colon prolapsed through the anus, with complete
success, by pushing the whole prolapse at once upwards by means of
an elastic sound. The patient, a feeble boy of two years, recovered.

Dr. A. MsRFENs, publlishes four cases of perforation of the vermi-
form process, all them resulting in the death of the patients. They
occnrred in males of 9, 18, 4, and 5 years of age. The ccBcum took
little or no 4)art in the disease, just the reverse of what Copland re-
ports to have occured in his cas^ (Diet of Pract, Med, Art, ccecumj,
llie majority of cases reported in the medical journals occur m
yomi^ persons. The usual result of foreign bodies lodging in the
vermiform process, is death, in consequence of a very dangerous
reaction following, which fact proves by itself, that the process has
a function of its own. The author is inclined to attribute to it a
fnnction analogous to that of the pancreas ; it is said to complete
the ccecal digestion in a similar manner, as the pancreas completes
the duodenal one. He believes that he has found, on the ccBcal part,
bundles of circular fibres, constituting as it were an orbicular
muscle.

Dr. G. T. Eluot, publishes the case of a boy of 11 years of age
who died of peritonitis with perforation of the appendix vermiformis.
A foreign body removed from the vermiform process was found by
Dr. Alonzo Clark to be formed by six distinct layers, which like those
of the tomea, were susceptible of further division ; these inclosed a
nucleus, somewhat larger then a mustard seed, forn^ of condensed

36C •

fecal matter, and the refuse of food. The layer immediately enyelop-
iDg this nudeas displayed under the microscope very numerous
fragments of the pericarp of wheat, with spirial vessels of the rasp-
berry seed, and the spines from that or the strawberry seed, ha^
den^ by calcareous matter which efferresced and disappeared under
the mineral acids. The other layer/were similarly composed of con-
densed fecal matter, hardened by the calcareous deposit, and the
outer shell was roughened with slightly projecting, uneven eleva-
tions with whitish spots. Under the scalpel, the whole gave a gra-
ting sensation ; and on exposure to the air soon lost even its former
comparative flexibility; and on section, looked not unlike a calculus.
Db. Elliot, at the same time avails himself of the occasion to ze-
commend the use of qpium in peritonitis of children in a similar
manner as it is administered to adults.

Fbof. Clab, of Gratz, publishes several essays on the pathology
and therapeutics of some of the most important diseases of the m-
fantile intestinum crassum, of which the following is an extract :
Catarrhal diarrhoea, during dentition, especially where some cerebral
or pulmonic affections are present, ought not to be suppressed as
long as a derivation is desirable, and ti^e child does not suffer from
impaired nutrition. If such is the case, or a catarrhal diarrhoea is
continuing, without symptoms of difficult dentition, injections of
salep, starch, alum, tannic acid, with a small quantity of opium,
are indicated, together with the internal use of ipecac, tinct., cat,
ratanh. Injections, sometimes emollient, sometimes astringent, have
also to be employed in the protracted catarrhal affections of the ini
crassum, in ansemic, scrofulous, rachitic children ; most fnccossful
are injections of solutions o( tannic acid or nitrate of silver. In
general it may be stated, that Prof. Clar lays more stress on the im-
portance of injections in infantile diseases than has ever been done.
His desire to publish his experience, and to recommend such a simple
mode of. administering medicaments in diseases of the lower intes-
tines, cannot be too much praised. Children with follicular ulcerar
tion range from some months to some years of age ; they are anaemic
and atrophied, their hands and feet infiltrated with serum, as well
as their cerebrum, the repeated cedema of which is a usual cause of
death. There is bronchial and pulmonary catarrh, sometimes the
lungs are oedematous, but in the majority of cases, full of air, and
bloodless ; the liver is somewhat enlarged, filled with serous blood,
the spleen pale and small, the mucous membrane of the stomach and
intestines covered with a tough and viscid mucus, and in some parts
of a grayish color ; on the mucous membrane there are the peculiar
solitary and blueish spots (almost similar to pale sugillations), which
show, in their centres, small ulcerations, with the follicle somewhat
excoriated, and of a looser tissue, sometimes even without a follicle
being present at all. The progress of this disease is, generally, this:
The first cause has been bad food, and insufficient care ; pulmonary
and bronchial catarrhs, of great obstinacy, impaired the sanguifica-
tion ; the catarrh and follicular ulceration of tne int. crassum accel-
erated tihe consumption of blood and strength, and, finally, the
cerebral or puhnonaiy cedema, or both, resulting from the gpreat

. 357

exhanstion, produced death by means of cerebral or pulmonary pa-
nJTsia.

On colitis crouposa, Prof. Clar, gives the following particulars:
Colitis crouposa must be suspected wherever a young and feeble
in&nt is suffering from a diarrhoea, which shows neither the
catarrhal nor the dyspeptic characters. The evacuations are mixed
^ with small points and stripes of blood and exudated matter, even
pseudo-membranes ; the pain is manifestly following the direction of
the* colon; urine is easily passed, although the symptoms may be
similar to those of cholera neonatorum. Moreover, it is to be kept
in mind, that a genuine dysenteric process, producing similar excre-
tiondy occurs but very seldom, if at all, in so early a period of life.
Whenever the colitis is idiopathic, and not the consequence of pysd-
mia, local treatment appears to be most successful. Injections of
cold water, or emollient liquids, with or without laudanum, and in
severe cases, from a quarter of to a grain of nitrate of silver, dis-
solved in two or three ounces of water, form the b,etter and principal
part of the medical treatment.

The same author describes three different classes of dysentery, of
which one may be, in some cases, only a preceding or consecutive
stage of others. There is, 1st, a light erythematous dysentery ; 2d,
a graver inflammatory affection of the mucous membrane ; and 3d, a

Save inflammation of the mucous membrane with simultaneous exu*
tion in the sub-mucous cellular tissue, and sometimes inflammation
of the muscular tissue and serous membrane. Dysentery, although
often occurring epidemically, is rarely observed in the fb^t year of
Ufe. Its characteristics are a peculiar excretion of viscid mucus,
and yellowish, reddish, bloody, chocolate-colored, even black and gan-
grenous, foetid masses ; tenesmus ; sensibility of the rectum ; high
color of the orificium ani ; collapse ; a peculiar expression of the phy-
siognomy, corresponding with the grave abdominal affection, and, in
a large number of cases, pain following the course of the colon as-
cendens, transversum and descendens. The erythematous form of
^^sentery is rarely observed before, usually after, the third year of
nfe ; its symptoms arc less severe, but not a few cases occur which
lead to rapid death, although the progress of the disease seems slight
and mild. Medicaments, introduced by both stomach and rectum,
must vary according to the individual case. Emollients and sedatives,
Bometimes narcotics, will do good in many mild cases. Injections of
nitrate of silver, injections of cold water, or of both of them alter-
nately, cold applied to the external surface of the abdomen, some-
times warm poultices, will be found to act successfully. Prof. Clar
does not seem to think much of calomel, but very much of antacids.
In no disease is it more necessary to individualize, than in dysenteric
affections ; for now the inflammatory, then the septic character will
be predominate ; sometimes mild dysentery will be accompanied by
the most excruciating attacks of colic ; in midsummer, congestion,
even metastatic inflammation of the liver, will go along with it ; and
again, rheumatic affections of the peritoneum may aggravate the
number of even slight symptoms of the disease.
It cannot too often be stated, that there is nothing more dangerous

358 .

to children than repeated laxatives. They operate once, but only to
leave the bowels more subject to constipation than ever. Prof. Clar
allows only very few indications for the use of purgatives. Some-
times stimulation is wanted, 1st, of the intestinal mucous membrane ;
2d, of the action of the intestinal muscular fibres. The first is ^
fected by injections of soap, sulph. magn., sulph. sod., chloret. sodii,
dissolved in water ; where any contra-indication forbids the injection
of salts, injections of sugar and water will be found useful. In. order
to stimulate the muscular fibres of the intest. crassum, he recom-
mends dec. tarax., dec. gramin., with an addition of tinct. colocynth,
tinct. rhei aq., tinct. rhei vin., tinct. aloes, or a mild inf rad. jalap, or
inf. fol. senn. Wherever, for the last few years, we have met with
obstinate constipation in young infants, we have generally succeeded
in giving speedy and full relief by ordering some sweet sugar-water
to be taken every day, besides the breast We are satisfied, that tiie
chief cause of constipation in nurslings is the insufficiency of sugar
in the breast-milk, the proportions of which are, naturally, not the
same with every mother. Wherever casein exceeds the proportion
of the other parts of the milk, it becomes indigestible by a relative
want of lactic acid in the contents of the stomach and intestines.

Dr. Brinton attended a boy of eleven years, whose bowels had not
been moved for three months , and whose abdomen was forty-three
inches in circumference. The rectum was scraped out, and enemata
of croton oil, caster oil, turpentine, and gruel, were administered
daily, until the abdominal measure came down to the natural circum-
ference of twenty-eight inches.

It has been a general belief, that the meconium consisted of bile,
and of the mucus and epithelia of the intestines. But it is certain,
according to Prof. Forster's investigations, that it mainly consists of
vernix caseosa and the colored matter of the bile. Its largest part
is obdurated pavement epithelium, like that of vernix caseosa ; vernix
and meconium are discernible only by the presence of coloring mat-
ter, and for a smaller amount of fat in the latter substance. Besides,
there is always hair in it from the surface of the body, as it is found in
vernix, even without a microscope. Stomach and intestines have no
pavement, but cylinder epithelium only ; in the mucous membrane of
the mouth and oesophagus hard squainous parts, like those in meco-
nium, are not found. The fat contained in the meconium takes its
origin from the general surface ; Cholesterine has probably been a
part of the bile. Thus the main part of meconium is vernix caseosa
which has been swallowed. Its water is rapidly resorbed, or ex-
creted by the kidneys. Perhaps some part of the fat is resorbed by
the follicular glands of the small intestines. The contents of the in-
testines have not been examined as yet, as to different ages of the
foetus. Acephali have no meconium ; formerly this fact was attributed
to the absence of bile in consequence of deficiency of the liver ; but
this malformation would account for the abscence of coloring matter
only.

The report on umbilical hernia, of Dr. Debout and a special com-
mittee to the Belgian Academy of Medicine, contains the following
particulars : The umbilical funis, in the commencement of embryonal

369

•

life is a divcrticle of the abdominal cavity which contains but a small
part of the digestive canal ; about the seventh or eighth week the in-
testinal rudiments hitherto situated in the funis, will enter the ab-
dominal cavity. Wherever this will not occur, the intestinal canal
contained in the diverticle will increase in size by the always rapid
growth of all the organs, and give rise to congenital umbilical her-
nia ; moreover, the Uver, connected with the umbilical portion by the
umbilical vein and drawn downwards, is very apt also to enter, par-
tially, the abnormously large aperture. Thus there are two different
kinds of congenital umbilical hernia, viz., such as contain a portion
of the intestinal canal exclusively, and such as contain a portion of
the intestinal canal and a part of the liver. This latter variety is
more favorable than the first one, the entrance into the abdommal
cavity being kept open, and the possibility being ^iven of the viscera
leaving their abnormal situation. In this case .the external integu-
ments of the sac, belonging to the umbilical funis, will fall off after
a somewhat longer period than is usual with a normal funis, only the
inner membrane remaining, which is connected with the muscles and
the peritoneum. This membrane will inflame and become covered
with membranous flocculi, will gradually contract, and after sponta-
neous reposition of the intestines will bring into contact the margins
of the umbilical aperture. At all events, the physician's only busi-
ness is to support the curative efforts of nature in a simple mechani-
cal manner. The other variety, in which only a portion of the intes-
tinal canal is contained in the hernia, and the ring contracted, is
most unfavorable. Not one case is known to have resulted in the
preservation of life to the infant. Nature certainly will make the
same efforts, the external membrane of the funis will dry off, the in-
ternal one will contract, but finally, no reposition being effected,
break. In all these cases Debout would recommend a surgical dila-
tation of the umbilical ring, to effect the reposition of the intestines.
Dr. Chapux communicates the case of congenital umbilical hernia,
measuring around the umbilical opening seven and a half inches,
around its largest part nine, and in its short diameter two and a half
inches. The hernia could only partially be reduced, but was not
strangulated. Only a moderate pressure was made upon it, under
which the hernia was gradually reduced, until, at the age of nineteen
months, there was only " at the navel a circular space an inch and a

auarter in diameter, formed of close wrinkles converging towards
be centre, where there is a prominence of the size of the end of a
thimble, and about a quarter of an inch high, with a mark like the
cicatrix of an old wound running through it The whole is covered
with natural-looking skin.''

Of quite another nature appears to be what Dr. Leotand calls um-
bilical hernia, and asserts to be produced by meteorismus, ascites,
obesity, and different abdominal tumors as well in children as in
adults. This hernia is apparently but a partial distension of the ab-
dominal walls, into which the intestines will protrude.

Dr. Ravoth spoke on umbilical hernia, in the Obstetrieal Society of
Berlin. He recommended the application of coUodium. Dr. Brandt
proposed a bandage of india-rubber, not to be applied too tightly.

360

Db. Mobel-Latallee reports to have examined thirty congenit
inguinal hcrniee. In two caaea only the testicle was found in the
hernial sac. Thererore two varieties of congenital hemiie will neces-
sarily be discriminated, the one in which the sac is independent of
the tunica vaginalis ; the other, in which the sac communicates with
it.

Dr. GLOQim thinks this latter & more frequent occurrence than
Br. Morel-Lav all (5 e, who found it in only two caaes among thirty. In
children affected with hernia at the time of birth, the inte^tiDe is ad-
joining, sometimes adhering, the testicle ; but wherever heruia does
not exist in tlie first weeks or montlis after birth, it is found in a sac
not communicating with the tunica vaginalis, the sac being fonned,
however, by the diverticulum testis of the peritoneum. In short,
both varieties of mngenital hernia originate in the testicular diver-
ticulum of the peritoneum, with this single diETerence, that the pMt
of the diverticle forming the hernial sac will communicate with the
tunica vaginalis, wherever the testicle descends early, and will not
communicate in all cases of the testicle descending at a later period.

Dr. Ravoth, after giving the anatomy and theory of congenital
heruia of the inguinal canal, points out the dififerential diagno-
sis between congenital hernia and congenital hydrocele. As to
hernia, a hereditary dispositinn can be found in many instances ;
continued screaming, or coughing, is usually known as the last
cause ; the majority of hydroceles are preceded by some extenial
local injuries ; hence, thetesicle is often sensitive and swollen. Her-
nia descends slowly from the abdomen downwards, hydrocele is ob-
served to slowly ascend. In hydrocele no colic is felt, as in
hernia. The hernial sac is easily perceived, by the touch, to protrude
into the abdominal cavity, at all events, whenever the diagnosis is
doubtful ; it is necessary to look for the continuation of the swelling
into the abdominal cavity, The intestine has a peculiar elasticity, the
tympanitic sound of percussion, the omentum will be diagnosed from
the tnmor fonned by hydrocele, The transparency of hydrocele is
diEQcult to perceive, and docs not always exist. Not a few instances
arc difficult to diagnosticate, becanse reposition of both hernia and
hydrocele is possible. But hernia usually is reduced suddenly, and
with a peculiar intestinal sound, while the reduction of hydrocele is
more gradual. After a hernia is reduced, the tumor presses on the
finger, but is successfully kept back, while hydrocele, after being re-
duced, will appear anew, from the lower part of the scrotum.

Dr. 0ns gives a compilation of forty cases of strangulated hernia
in children, the results of which he sums up by the following con-
clusions : 1. Strangulation seldom occurs in the heruia of childhood,
and only in the inguinal variety. 2. The taxis is more frequently
successful, in proportion, than in adults. Tlie auxiliary mcasTires
should be limited to chloroform, opium, the warm bath, and cold to
the tumor. 3, If it is impossible to reduce the bowel, the progress
of the symptoms is more rapid than in adults. If you temporize and
postpone in -children's cases, you will be too late, i. The mortally
after herniotomy in children is less than in adults. Where t"
operation is seasonably practiced, success is almost unifonn.

Where tl*^^^

361

The extrarperitoneal operation is preferable, when not counter-indi-
cated.

Db. Ravoth relates the case of a boy of fourteen months, in whom
he performed herniotomy two days after strangulation had com-
menced, when the scrotum was swelled already to the size of a fist.
There were but few symptoms other than local ones ; only in the last
twelve hours, the food which had been taken, was tlirown up again*
Chloroform was resorted to during the operation, and for every dress-
ingy which was repeated daily. Dr. Ravoth is fond of applying a
tniM as early as the hernia is seen. Hernice in children will descend
easily, enlarge the abdominal ring, produce colic, injure digestion
and nutrition, and the development of the testicles and spermatic
cords.

Prof. Roser states as a general assumption, that the common
umbilical hernisd of infants are produced by a merely local expansion
of the peritoneum and formation of a diverticle ; a dislocation of the
peritoneum being impossible, because there is no place where it ad-
neres so firmly to the external integuments as in the neighborhood
of the umbilicus. The prognosis, therefore, is favorable, as these
bemisB are produced by a visa tergo only. They heal spontaneously
in many instances, are freaucnt in infants, and rare in adults, witn
flie exception of fat old individuals. During the course of develop-
ment they undergo obliteration, in consequence of elasticity, or re-
sorption of what was hypertrophied. Such is not the case, in Prof.
Boeer's opinion, with external inguinal hernia, which is to be con-
sidered as an affection that either is, or could be congenital. It is a
mord frequent occurrence than is generally believed, to meet with
the vaginal process remaining open in its superior portion. Almost
all the children affected with inguinal hernisd, give evidence of this
fact. No less in the bodies of adults, there are hernial sacs met
with sometimes of such length and narrowness, that they must be
considered as vaginal processes of the peritoneum, the retrograde
development of which has been incomplete, and which, probably,
never contained any viscera.

Dr. Richard, induced by the effect of belladonna, in cases of incon-
tinence of urine, prescribed the same remedy to a boy suffering from
incontinence of fsdcal matters, and put a suppository coated with
belladonna into the rectum. Two days after the commencement of
this treatment, the child 'had no more involuntary evacuations. In
some other cases, too, the same treatment proved satisfactory.

Db. Bercioux, too, employs belladonna in cases of enuresis and in-
voluntary evacuations of feeces in children, where hitherto tonics
have usually been administered. He claims almost a specific effect
for this remedy, which was recommended more than twenty years
ag^, but has been forgotten since. He considers the cause of
involuntary evacuations to be muscular weakness, either of a local
or general nature, and insensibility of the organs. The children
suffering from these affections, are mostly pale, scrofulous, rachitical.
Tonics, iron, cold, cantharides, secale, are mostly unsuccessful ; herb,
and extr. bellad. aa. gr. 4» ^, 3, or 4 times a day, was generally suc-
cessful, even in inveterated cases.

• 1

362

Prof. Clar remarks that temporary or persistent paralysis of the
sphincter is usually observed in children of from eight to twelye
years of age, and occurs after exhausting diarrhoea of long standing,
after long and continued irritation by worms, and sometimes without
any manifest cause. The patients drop their excrements, solid or
liquid, while walking. The orificium ani shows a large opening.
Cold and copious injections ought to be given and often repeated,
and after an evacuation has been effected, a small injection of a solu-
tion of tann. ac. in water, with some tinct. nuc. vom. The same
treatment may be resorted to in paralysis of the sphincter, compli-
cated with prolapsus recti, after reposition has been performed.

Dr. Magnus reports the case of a girl of two years of age, sofferinff
from prolapsus of the rectum for two months, the intestine protrud-
ing after every passage for one and one-half inches ; reposition was
not difficult to perform, only the sphincter was loose and flaccid.
Mild laxatives, astringents, aromatics, and bandages were used in
vain. After ^ of a grain of the nitrate of strychnia was locally applied
in the prolapsed intestine for the first time, it went back by a sing^
touch with the finger. After the application had been made four
times, the prolapse did not re£lppear for some time. It did relippear
at a later period, but was entirely cured after, in the whole, j of a
grain of strychnia had been applied.

Dr. Berend reports, in the Annales de la SociiU midico-chirurgiede
de Bruges, 3 cases of atresia ani, on which he operated in one year.
1. Atresia ani, vagince, urethree. Child died in the night following
the operation. 2. Atresia ani, vaginae. Child died five days after
the operation. 3. Atresia recti. Operation in the usual place tried
without success. Then an artificial anus was formed. Child died
forty hours after the operation.

Dr. ScHUPPERT publishes the following cases of imperforate anus —
1. No indication of an anus, lower part of rectum forming an impei^
forate cord of half an inch in length. 2. Unnatural termination of
rectum in the bladder, with total absence of any indication of an
anus. 3. Total occlusion of anus, and entire want of rectum. Colon
transversura, terminating in the left kidney.

Dr. Bryant operated upon a child of 2 months of age, with cuta-
neous artresia ani, there being in the occluding membrane a natural
outlet so small as scarcely to be seen with the unassisted eye.

Dr. Elin met with a case of malformation of the rectum, in which
the anus was perfect, but both the lower and the upper part of the
rectum ended in a cul-densac.

Mr. Barwell reports a case of imperforate anus, operated unsnc-
cessfully upon, in which the anus was distinct externally, leading
into a cavity lined with mucous membrane, which ended, at the depth
of an inch, in a cul-de-sac. The intestines were wholly normal to the
spot where the sigmoid flexuf e should have begun, and here it turned
upon itself forwards, and ran up again in front of the descending
portion to the left lumbar region, tben ran across the abdomen in
front, and a little below the true transverse colon, descended on the
right side, and ended in a pouch in the right flank, with a pointed
caecal end in the pelvis, behind the bladder, about. half an i nh dis-
tant from the external oval porch and to its right side.

363

In St. Mary's Hospital, LondoD, Mr. Lans operated, for imperforate
anus, upon a child, who died 22 days after the operation. The rectum
opened into the vagina. The rectum and sigmoid flexure were
dilated into an immense reservoir, and capable of containing five

{»ints of fluid. The muscular coat was greatly hypertrophied. This
arge sac occupied the pelvis, the hypogastric, both iliac and part of
the umbilical regions, pushing upwards and nearly hiding the small
intestines, concealing the coBCum and the parts of the coecum in the
iliac fossa, pushing the liver up to the third intercostal space, and
altering the form of the kidneys.

Mr. Johnson operated successfully on a case in the London Hospi-
tal for sick children.

Dr. Senftleben reports 2 cases of imperforate anus, in order to
show the reason why so many infants, even after the operation has
apparently been successfully performed, die in a short time after-
wards. The reason is, that, in a large number of cases, imperforate
anus is not the only malformation, the kidneys, being usually mal-
formed at the same time.

Very good renrarks on atresia ani and uterus bicomis are those of
Dr. Kriegeb, with excellent and large citations from literature.

Dr. Hermann Friedberg ( Chirurgische Klinik, 1855, i. p. 165-224)
recommended the method of Amussat, viz., bringing down the gut
when an opening has been made in it, and stitchmg it to the outlet
in the perineum. The advantages are that there is a mucous mem-
brane lining the whole tract of the canal ; that the evacuations are
more easily accomplished ; that the natural tendencies in canals, not
80 provided, to gradually contract, is prevented ; that the irritation
and danger arising from the contact of effete matter with tissues not
intended for such contact is also obviated. Dr. Redfern Davus
thinks success more probable by often repeated, almost impercep-
tible tractions upon the gut, than by trying to bring it down at once.
Such is the modification he recommends. The idea has been taken
from a case operated upon in a similar way and successfully, which
has been described in tne Lancet of 1846.

Dr. Jones, of New Orleans, reports some unsuccessful cases of im-
perforate anus, with the object, in the first place, to demonstrate that
m obstructions of the bowels from malformations, as from other
causes, cathartics are both useless and injurious ; and in the second,
to establish not only the inadmissibility of all food in similar cases,
but this interesting fact also, that, under absolute diet, life may be
protracted for a number of days a^er birth, without the sudden and
alarming prostration we are generally led to anticipate. In proof
thereof he reports the case of two infants, who were bom each with
an imperforate anus, and to whom no food was given. One of them
died on the eighth day, the odier one on the thirteenth day, after
birth.

Dr. Paasch, of Berlin, publishes the ease of a child, 21 months old,
who suflered for six days, from the symptoms of what seemed to be
a severe intestinal catarrh, which were prescribed for. On the follow-
ing morning a complete tasnia, head and all, was removed vnth the
faeces.

364

According to Dr. Moobx's report, kameela (kameyla, kamala) is
the reddisli4)rowii powder which clothes the capsules of the Rottleria
tinctoria — one of the euphorbiaceae. Dr. MacKinnon considers it safe
as an anthelmintic, and more efficient than turpentine or kousso ; 8
drachms is the dose for a strong European, but for a person of more
feeble habit half this quantity ; this may be followed by a dose of
castor oil.

Dr. Leaked also considers kameela to be a very efficient remedy,
the effect being produced by a soluble resin, which may be given in
the form of pills, or a tincture of the drug may be used.

Mr. Ramskill publishes the case of a boy of 18 months, suffering
from tssnia, who took tincture of kamala, six minims, water, two
drachms, night and morning. He asserts that in most cases where
the head has been carefully looked for it has been found.

Dr. Peacock administered, to a boy of 5 years of age suffering from
tenia, 2 doses of kameela (one drachm each) on alternate nights,
and castor oil in the following mornings. After the second dose some
fragments of the lower part of a tsBnia was passed quite alive. The
medicines were repeated after a week, and again after two weeks.
Three hours after the last some portions of the tssnia came away, but
not the head nor any part near it. Peacock prefers the oil of male
fern to either kameela or kousso.

Dr. DiEZ reports the remarkable case of a girl of nine years, who
was affected with a fistula of the intestine, a typhous ulcer having
perforated and cohering with the abdominal wall. This fistula healea
after a fortnight, nitrate of silver having been applied daily. Nine
months afterwards the patient complained of pain in the umbilical
region, the umbilicus ruptured, and ten living ascarides came forth«
The opening closed for a month, ruptured a second time, and again
ascarides marched off. A complete cure was obtained afterwards.

Dr. ScHULTz gif es, to obtain a speedy and' radical evacuation of
oxyuris from the rectum, enemata of 4 ounces of water with from 10
to 15 grains of nitrate of silver. Complete success was obtained
after two or three injections.

IV. ORGANS OP CIRCULATION.

1. Gebhardt, C, Diseases of the Heart in Children.— D. Klin. 11.

2. Holmes, T., Secondary Abscess from Fycemia toOhin the WaUscf
the Heart.— Ttslus, Path. Soc. IX.

3. Leared, Case of Death from Anosmia, Fibrirums Clots in the Heart
—Ibid.

4. Treadgill, H., Letter to Ed. Nashv. Jour. — Nashv. Jour. Sept

5. Peacock, Th. B., on Malformations, etc., of the Human Heart. WUh
Original Cases. London, pp. 143, and 8 plates.

6. Williams, C. B. J., Congenital Deficiency (f the Sternum, Bendering
Visible the Movements of the Heart.— TrsLUB. Fskih. Soc. IX,

366

7. Hewitt, G., PenisterU Dudus Arteriosus. — ^Trans. Path. Soc. IX. —
Lancet Jan. — N. Y. Jour, of Med March.

8. Bochdalek, Description of a Highly BemarhMe Deviation of the
Pulmonary Veins in a Boy of Four Days^ who Died from Peritoni-
tis. — Prag. Viert 4.

9. Armitage, Rupture* of the Abdominal Aorta in a Child, — ^Trans.
Path. Soc. IX.

10. Stevens, N. C, Case of Hemorrhage in an Irfant. — ^Bost. Jonr. 20.

11. Behr, Fatal Injury to a Child in Utero by Bupture of Bloodvessels
and Extravasation, — Henke's Zeitschr., 47th Snppl.

12. Jacob, Hemorrhage of the Vulva with Discharges (f the Mammary
Glands and Milky S&cretions in a New-bom Child,— Gslz, d. H6p.

Aug. 19.

13. A very extensive Nobvus on the Chest of an Irfanl. — Lancet.
Jan.

14. More than a Hundred Noevi in the same Infant. — ^Lancet. March.

15. Valenta and WaUmann, Sanguineous Cavernous Tumor above the
Boot of the Nose in a Neio-bom Infant. — ^Zeitschr. d. Ges. d. Aerzte
z. Wicn. 14.

16. Shore, S., A Case of Nobvus Matemus. — ^Am. Med. Monthly. Sept.

17. Bryant, Th., Extensive Noevus, Involving the Whole (f the Bight
Leg, in Different Stages of Development. — Trans. Path. Soc. IX.

18. Medico-Chirurgical Society of Edinburgh. — ^Ed. Med. Jonr. July.

19. Walton, The Treatment ofNcevus by Injections with Tsmnic Acid.
— Med. Times and Gaz. July 12.

20. Quinlan, Case of Ncevus in the Lefl Cheek Cured by the Injection
of Tannic Acid. — ^Dublin Hosp. Gaz. Sept. 15.

21. Wood, J., Subcutaenous Ligature cf Extensive Naevi MatemL —
Med. Times and Gaz. July 81. — ^Lancet Oct.

22. Werner, Seven Cases in which Middddorpf's Chdvano-caustiG
Method ucas Employed, — Arch. f. Phy«. Heilk. 1.

28. Neugcbauer, L. A., Morphdogie der menschlichen Nabelschnur.
Mil 2 Tafeln Abbildungen. Breslan. pp. 80. — (Morphology of the
Human Umbilical Funis.)

24. Robin Ch., Betraction of the Umbilical Vessds.— Bull, de PAc. do
Mdd. XXII, XXIIL

25. Lucas, Strangulations ^ Newborn Childrenby the Umbilical Funis.
— Casper's Zeitschr. XIV. 1. — ^Prag. Viert 4.

i6. Newman, W., Curious Case of Tunns^ in which the Cord of one
ChUd was Encircled by a Knot on the Card of the other Child.-^Ed.
Med. Jour. July,

27. Jenkins, J. Foster, Beport on Sjpontaneous Umbilical Hemorrhage
of the Newly-Bom. — (Extr. from the Trans. Am. Med. Assoa PhiL
1858.)

28. Friedreich, J. B., on the Death <f Newborn Children by Loss of
Blood from the UmbOical J^ms.— Bltttter f. ger. Anthrop. III.

366

Diseases of the heart, in the first two years of life, are nsnally
deemed excessively rare. Amongst the number of cases reported 1^
West, Rilliet and Barthez, Bednar, and many others, there are only
a very few which occurred at this early age. There is no doubt,
that the diagnosis of organic alterations of the structure of the heart
in very young children is sometimes exceedingly difficult ; for the
impatience, troublesomeness, and screaming of the patients, the fire-
quency of the action of the heart, and the small size of the organ,
are very important obstacles. Besides, it must be held in view, that
many diagnostic signs are not of the same value in very young
children, and in adults. Thus West is of the opinion, that some
sounds heard in general anaemia, cannot be referred to the same
general cause in the infantile organism, but are to be attributed to
some pathological alteration in the structure. Furthermore, it ia to
be borne in mind, that there are many abnormities, which, because
they once lead to an early death, are heard only in infancy, and ag^
gravate an exact diagnosis because of their midtifarious origin. The
largeness of the foBtal apertures, the presence of extensive atelec-
tasis pulmonum, which will stop circulation in the pulmonary
arteries, and force the blood into the left heart, anomalies in im
origin and course of the great blood-vessels, are amongst their
number. Even the ictus cordis may be misunderstood, and the
results of percussion unavailing, because of local atelectasis, whidi
is also, sometimes, a frequent cause of mistakes in explaining the
facts found in post-mortem examinations. Sometimes the heart,
after the thorax is opened, is visible in an uncommonlv large circum-
ference, whenever the lungs are reduced to a smaller volume, is
filled with dark blood, and pericardium and thymus are remarkably
cyanotic, not because of a supposed disease of the heart, but for bo
other reason but atelectasis pulmonum. These facts are collected,
in a well-written article, by Dr. Gebhardt, and illustrated by a series
of cases: Nevertheless, in his opinion, diseases of the heart, in very
young children, are not rare at all. There are many instances rf
slight thickening of the auriculo-ventricular valves, small hem-
orrhages in the valvular tissue, small red fibrinous depositions on
the valves, and extensive genuine degenerations of the heart, with
hypertrophy and its consecutive symptoms. They are very frequent*
ly found in infants suffering from, and perishing by, constitutional
diseases, as rachitis, syphilis, etc. ; less so in well-developed infants,
who died from acute diseases.

Mr. T. Holmes reports the case of a male child of five years, who
suffered from extensive caries of the right calcaneus, superficial
abscesses in various parts of the body, and numerous abscesses in
the lungs. The pericardium contained a sero-purulent fiuid ; in the
wall of the left ventricle was a sloughy cavity filled with decomposed
blood, and opening into the pericardium below the auriculo-ventrico-
lar groove.

Dr. Leaked found, in a girl of 11 years, fatty degeneration of the
heart.

Dr. TREADOttL reports the case of a negro child, of about 6 years of
age, in whom the post-mortem examination revealed " a cartilaginous

867

development attached to the internal coat of the aorta near the heart
for three-foorths of an inch, ahnost filling up the entire cavity of the
aorta."

Several original observations on malformation of the heart, have
indaced Dr. Peacock to revise and extend a series of lectures, pub-
lished some years ago in the Medical Times and Gazette. The sub-
jects treated of in this essay embrace — 1. Misplaccmenta of the
heBrt 2. Deficiency of the pericardium. 3. Malformation dependent
on arrest of development at an early period of foetal life (defects in
the auricular and ventricular septa, contraction and obliteration of
orifice of the pulmonary artery, supernumerary septa). 4. Malfor-
mations preventing the heart undergoing the changes which should
ensue after birth (premature closure of the foetal passages, patency
of the foramen ovale and ductus arteriosus Botalfi). 5. Malforma-
tions which do not interfere with the functions of the heart, but
which may lay the foundation of disease in after life (irregularities
of the valves, etc.). 6. Malformations consisting in the irregular
development of the primary vessels (transposition of aorta and pulir
monary artery, descending aorta given off from the pulmonary
artery, etc.). 7. Mode of formation, symptoms and effects, diagnosis,
and medical management of malformations of the heart. Tlie whole
is a valuable contribution to the literature on malformations, particu-
larlv so from the original observations communicated. Besides, the
aathor proves^ himself to be well acquainted with the preceding lite-
rature on the . subject, quoting largely from English, American,
French, and Oerman books and journals. The latter are more defi-
cient than tlie others ; we miss particularly the monograph by Dr.
Hermann Friedberg on the same subject. (Die angebomen Kranh-
heiten des Herzens und der grossen Oe/'dsse des Menschen^ nehst Unter-
9iychvmgen vber den Blutumlauf des menschlichen Foetus, Von Dr.
Hermann Frikobero. Leipsic, 1844, pp. 170.)

Dr. Williams describes the case of Mr. Groux, of Hamburgh, who
is personally known to, and has been examined by a great number
of our readers, as he has traveled all over the world to exhibit his
congenital deficiency of the sternum.

l%e abnormity of persistent ductus arteriosus Botalli was observed
by Dr. HEwnr in a cnild of three months of age. The heart was only
about one-third of the size of a healthy heart from a child of the same
age. Foramen ovale open ; the ductus arteriosus perfectly pervious,
having at its junction with the aorta a diameter of three millimetres.

Prof. BocHDALEK, of Prague, describes a very extraordinary devia-
tion of the pulmonary veins, found in a boy who died from peritonitis
at the early age of four days. The child had always been cyanotic.
No ductus venosus Arantii was found, as in some cases recorded by
Soemmering and Otto ; which proves that this canal is not absolutely
necessary to foetal life, although there is, without it, no canal
through which blood from the vena portarum may be led directly
into the cava. Reports from literature, containing cases of Rams-
botham, G. Cooper, Hyrtl, Wilson, M. J. Weber, and E. F. Gurlt, are
added to illustrate the new case of the author.

Dr. Armitage records the case of a girl of 7( years, who had suffer-

868

cd from palpitations from her earliest infancy, exhibited extenaiTe
dullness in the precordial region, and a systolic bellowsHSOund, com-
plained a few days before death of severe aching pain in the legS|
principally knees and wrists, and died after an attack of convalsions.
The aorta was ruptured at its bifurcation, rather more of tiie left
iliac having yielded than of the right

Dr. Stevens publishes the case of an infant, bom by easy labor and
well developed, who had been well for the first two days, but died from
copious dejections of blood through the anus. The whole body was
anaemic, except the larger part of the ileum and all of the large in-
testine, which was found to be congested, of a dark red color, and
covered with coagulated blood.

Dr. BEmi reports the case of a new-bom infant^ in whom the
aponeurosis above the parietal bones and their pericranimn was
hypersemic ; on the right parietaj bone there was a thick, coagpilated
extravasation, 2} inches wide and 3 long ; on the left another, some-
what thinner, along the margin of the bone. ' No extravasation was
found on the basis cranii. No bones were hurt. The child was
feeble and prematurely bom. Dr. Behr then adds some remarks
on the possibility or probability of severe injuries to the foBtos in
utero from external causes. Such cases occur, rare though they be.
Concussion of the uterus, detachment of the placenta, concussion of
the foetal cerebrum, rupture of vessels and organs combined with
extravasation, are doubted by nobody. But some, lik^Prof. Caapefy
of Berlin, doubt the occurrence of fractures or impressions of the
bones from external causes.

Dr. Jacobi publishes the case of a puny girl, who was affected with
leucorrhoea on her second day, with heemorrhage on the third, to such
an amount, that two cubic centim. of blood were discharged in i4
hours. The mammae were slightly swelled, and yielded serous di»-
char^e similar to milk. Injections of aq. plumb, proved successfdl.

A large naBvus, which occupied the entire left mammary region of
a healthy infant, was observed at St. George's Hospital, London. It
was about five inches long, transversely, and three and a half from
above downwards, its greatest point of elevation being over half an
inch. It was congenital, had not increased much in size, and was
thick and rugojse in surface. It was treated by passing a number of
threads from above downwards, tying their ends so as to completely
strangulate portions of it, which was, however, permanently done by
passing long pins in its two directions, and winding a ligature
around the whole.

Another child had a nsBvus similarly treated. It was the size of a
crown-piece, and was situated on the calf of his left leg.

A case of a healthy boy of three weeks, related in the London Ixm-
cetf is remarkable for the large number of nadvi found. A few of the
marks had been noticed on the day of birth, but had increased in
size, and many others came out since. They were found to number
upwards of a hundred and fifty. The largest were about the size of
sixpences. The treatment consisted in applying a little of the com-
pound iodine ointment once or twice a day to me spots separately,
and in the course of a few weeks this appeared to be exerting a very
perceptible influence.

369

Drs. Yalinta and Walucann report a case of erectile tumor, an-

Sioma, which rose from the pia mater, and being enveloped by the
ara mater, penetrated through a fissure between the frontal, eth-
moid, and nasal bones. An erectile tumor of the pia mater, on the
surface of the left hemisphere, has been described by Rokitansky
(Bandbuch der Pathologiachen Anatomie, ii., p. 1^); but in general
SQch cases are very rare. Cases of cncephalocele on the same place
where our erectile tumor was found, have sometimes been reported.
Dr. Wallmann relates a case of hydromcningocele in the same locality,
which he found in an idiotic female of fifty years of age.

Dr. Shorb operated upon an erectile tumor on the nose, extend-
ing to a little above the superciliary ridge, below to within four lines
of the end of the nose, and laterally quite to the inner angle of either
eye, by passing a great number of hot needles rapidly through every
portion of the tumor.

Mr. Spence exhibited a drawing of congenital nsevus which had
undergone a spontaneous cure. The lad had been suffering from gum-
bile, which had given rise to abscess, and consolidation of the erec-
tile tissue of the nsevus had been the result. In other cases, Mr.
Spence is in the habit of employing the perchloride of iron as an
iiyection.

Dr. Walton reports a case of subcutaneous naavus at the root of
tbe nose in an infant eight months old,, who was treated with iodine
ointment and cold lotions without benefit. An aperture was made in
the base of the tumour with a narrow tendon knife which was moved
about with a view of breaking down some of the texture. A strong
solution of tannic acid was then gently injected till the naBvus was
well distended. Six weeks after the operation there was no appear-
ance of a tumor.

There is no risk of sloughing, an occurrence that is apt to ensue
when the muriated tincture of iron is used, and when it is due to the
free acid it contains.

Dr. QuiNLAN removed a neevus from the cheek of a girl of nine
months of age, by breaking up the tissue of the nsBvus by means of
a cataract-needle in three different places, and injecting a solution of
a drachm of tannic acid to an ounce of water.

Mr. Wood operated on a naevus successfully by passing a worsted
thread, dipped in iodine paint, superficially through the nsevoid
growth, by a blunt needle, in the direction of the lines of longitude
on a globe map, through two punctures of opposite points, the thread
being left in loops protruding at the punctures, A disk of flat wood,
of the size of the part operated upon, having two projecting points

2>posite the punctures, was then placed upon the tumor, the loops
ipped over the points, and the thread tightened. The effect was
speedy, and obliteration complete.

Among the seven cases, in which Prof. Middeldorpf 's galvano-caus-
tic apparatus was resorted to. Dr. Werner relates the case of a
healthy girl of nine months of age, whose lower lip was increased
to double size, on its right side, by a soft, compressible, not painful
sanguineous tumor. It was operated upon by the galvano-caustic
meuod, a copious loss of blood ensued but soon stopped. A scurf

370

formed, bat was detached after ten or twelve days ; granulation was
supported by external application of nitr. arg., but the tumor did not
diminish in size. Finally the excision had to be performed by means
of the knife.

Dr. Neuoebauer's pamphlet contains the literature and the author's
extensive new investigations on the formation of the umbilical funis,
and particularly on the relative position of its several constituent
parts. The circumvolutions of the umbilical arteries and veins take
a prominent part in these expositions, leading to entirely new results.
One of them is this, that neither the umbilical arteries are circum-
volved round the vein, nor sometimes the arteries round the vein,
and again the vein round the arteries, as was supposed to be the
case in some instances by Baudelocque, Yelpeau, and Weidmann ;
but that umbilical arteries and vein together, and without any change
in their mutual situation, follow the spiral line pharacterizing the
course of these vessels. Further, the pathological circumvolutions
of the funis round the foetus, and the real knots in the coarse of the
funis arc made the subject of interesting examinations. The new re-
sults, and the real scientific gain obtained by this little book are so
important, that we despair of doing the author justice and giving the
reader a full view in the few lines allotted to us. The book is not
only prominent by the common sense and clear reasoning of the au-
thor, but we have seldom had occasion to admire greater learning,
and more special knowledge of the literature on any given subject,
of all times, nations and languages.

Dr. Lucas considers the decision on the strangulation of a new-
born child by the umbilical funis to be very difficult. Some prob-
ability is given by an extraordinary length of the funis ; by its
strength, a normal funis, according to Ncgricr's experiments, being
sufficiently strong to suffi)cate a child ; by the presence of genuine
knots recognizable by the intumorrhoea in the next neighborhood, and
by the dilatation of the vein ; by a corresponding impression in the
neck ; by central insertion of the funis, marginal or velamental inser-
tion being more apt to effect death by bleeding.

Mr. Newman relates a curious case of twins, in which the cord of
one child was encircled by a knot on the cord of the other child.
One child was alive and healthy, the other livid and dead.

Dr. Jenkins gives a tabular analysis of 178 cases of spontaneous
umbilical hsemorrhage, showing the existence of two varieties of the
form of umbilical haemorrhage under discussion. First, and most
common, that depending on a depraved condition of the blood, the
spansemia resulting sometimes from jaundice, through malformation,
or deranged function of the liver, sometimes from an inherited
scrofulous or syphilitic taint, and, probably, not unfrequentljc from
privation and despondency in the mother during gestation, or during
the same period an excessive use of alkalies or diluent fluids.
Second. Independently of any dyscrasia of the blood, umbUical
haemorrhage seems to arise by reason of an unusual patency of the
umbilical vessels, in otherwise apparently healthy children. As a
predisposing cause of hsdmorrhage, may act any influence which
affects the normal plasticity or coagulability of the blood, as malfor-

371

mation of the liver resulting in jaundice, excessive drinking of diluent
fluids, inherited taint, excessive use of alkalies during pregni^ncy,
insufiScient food, diseased condition of the umbilical vessels, arteritis,
hereditary transmission of the hsemorrhagic predisposition, external
violence to the navel, and, perhaps, the mother's imagination or
emotions during pregnancy. Jaundice was present in more than
twenty-three per cent, of the tabulated (178) cases, purpura, in
some stage of the malady, in 20 J per cent. In more than 27 per
cent, the bleeding took place from the walls, or at the insertion of
the funis, before the completion of the physiological process of desic-
cation ; in nearly 27 per cent., it occurred on the day of the separa-
tion of the funis ; on an average in 102 cases, it commenced on the
8th day, viz., in the first week after birth in 56, during the second in
89, during the third wee*k in 7. In one case, bleeding was apparent
in 81 hours after birth ; in another, only at the termination of eight
wecKS. The average duration of the disease, in 82 fatal cases, was
8} days ; in one case, death ensued as early as 18 hours from the
beginning of haemorrhage, in one 88 days thereafter ; the fatal issue
may be attended by purpura, oedema, diarrhoea, muguet, or other signs
of exhaustion. As to pathological anatomy, a great frequency of hep-
atic malformation or derangement, and an equal frequency of pervious-
ness in some of the umbilical vessels, is prominent. Prognosis is
fearfully grave, 149 out of 178 cases proving fatal. The treatment
16 more simple than successful. Neither styptics, nor cauteries, nor
coDopression, are of any use ; the ligature ^ masse^ as recommended
by raul Dubois, being the only remedy. " Dr. Perry suggests that
the use of the mineral acids during pregnancy, by women whose
children have been affected with umbilical haemorrhage, might be
followed by favorable results."

Essays, articles, and literary notices on the question, whether the
ligature of the umbilical funis, when omitted, must or can produce
death, are very numerous indeed. There is no donbt that death by
loss of blood from the funis has occurred, but it depends on a num-
ber of conditions. Among them Prof. Frederick counts the follow-
ing : 1. The ligature of the funis may be too loose, completely
omitted, or rendered impossible by the funis having been torn or cut
into immediately in front of the navel-ring. 2. The umbilical vessels
may remain open for too long a period. 3. Respiration may not
have set in at all, or been interrupted. 4. A funis separated by a
cut has more tendency to bleed than when torn. 5. Equable surface
and structure, and absence of knots, gives more tendency than the
reverse. 6. Detachment of the funis from the placenta is somewhat
dangerous. 7. A greater disposition is given by an unfavorable
position of the child. 8. By high temperature. 9. By tightly dress-
ing. All these things may increase the possibility of loss of blood
from the funis ; but in every forensic case, the child must be proved
to have been alive, when found dead by what appears to be loss of
blood. Furthermore, a proof will always be necessary of the entire
absence of any other cause of bleeding, as wounds of the vessels,
precocious detachment of the placenta from the uterus, wound of the
placenta, rupture of the funis before birth ; in all these cases, there

372

are no symptoms of life ; or as rupture of the uterus, vicious sangui-
fication from diseases of the mother, vicious development of the
foetus, etc. Moreover, it must not be overlooked, that a funis may
bleed, although regularly tied, by the collapse of the tissue surround-
ing the vessels. No less the second twin may die from loss of blood,
wherever there is but one placenta, and the funis of the first-bom
child has not been tied twice.

V. ORGANS OP RESPIRATION.

1. Betz, on Snoring in very Young Children, — Memorab. a. d. Praxis, 5.

2. Voltolini, on the First RespiraJtory Movements of Infants. — ^D. Klin.
42.

3. Zeissing, on the Infliience of Be^ration upon the Life of Neibbom
Ir/ants,—Y\eTte\y f. ger. u. Off. Med. Vol. XIII. 2.

4. Williamson, T., The Condition of the Lungs not Invariably to be
Depended on, as a Proof that the Infant has been Bom Alive. — Ed.
Med. Jour. Feb.

6. Morris, J., Apnoea in Neujbom Children. — Med. Times and Gaz. Jan.

6. Heard, Imperfect Befpiration in an Infant. — Artificial Bemedy; Be-
covery. — N. 0. Med. News and Hosp. Gaz. Jan.

T. Ashenheim, L., Leaves from the Note-Book of a West Indian Prac-
tUioner. — Lancet. Sept.

8. Benson, J. W., Marshall HaJlVs Beady Method in Asphyxia of the
Newly-Born. — ^Chic. Med. Jour. May.

9. Woodworth, B. S., Marshall HaWs Beady Method in Asphyxia.-
Cinc. Lane, and Obs. Sept.

10. New Directions to Bestore the Apparently Drovmed^ on the Marshall
Hall Plan. Issued by the National Life-Boat InstUtition.

11. Silvester, Henry P., T?ie True Physiological Method of Bestoring
Persons Apparency Drowned or Dead, and of BesusciUUing Newborn
Children. — Pamphlet. London.

12. New Method of Besuscitaliiig Persons Apparently Drowned. — ^Dubl.
Hosp. Gaz. Aug. 1.

13. MoUer, Fissura Colli Congenita. — KOnigsb. Med. Jahrb. 1.

14. Behrend, Fr. J., on Chronic Hoarseness in Children^ its Cause and
Treatment. — Journ. f. Kinderkr. 9, 1 0.

15. Wilks, Ulcers of the Larynx in Typhoid Fever , Producing General
.Emphysema.— Trans. Path. Soc. Lond. IX. p. 34.

16. Kerli, Besearches and Experiences on Croup, Pseudo-Croup and
Millar's A8thma.~D. KHn. 6, 6, 7. ^

17. Hauner, on Dr. Luszinskifs Proceeding in the Treatment of Croup.
— Journ. f. Kinderkr. 3, 4.

18. Luszinsky, My Views and Experience on Croup and its Treaimeni-
A Bepiy to Dr. Hauner^a BemarJcs. — Journ. f. Kidderkr. 9, 10.

873

19. Coxe, E. J., Beport of Successful Treatmeni of a Case of Croup,
of a Severe Character, — ^Bost Med. Jour. Dec. 16.

20. Wasson, L. M., Fseudo-Membranous Croup, — Nashv. Med. Joxir.
Sept.

21. Barthez, M., On the Employment of Instillations of a Tepid and
Bather Concentrated Solution of Chlorate (f Soda into the Trachea
of Children qff^ectedmih Croup, — Bull. Q^n. de Th^r. May 30.

22.0 Missonx, on the ^Kellent Effect of Sulphate of Copper as an Emetic
in Croup, — Ibid. Dec.

23. Loiseau, Croup Cured by Cauterization of the Larynx, Performed
by Means of Catheterism. — Gaz. d. H6p. 80.

24. Mayer, E. R., Glycerine as a Local Application in Pseudo-Membra-
nous Croup, — Amer. Jour. April.

25. Shelton, J. D., on the Local Application of Belladonna with Mer-
curial Ointment in (he Treatment of Croup. — Ibid.

26. KortUm, A., Practical Bemarks on the Treatment of Croup, — ^D.
Klin. 20. ^

27. Pudon, Cold Water and Sulphate of Copper in Croup. — jiDum. f.
Kinderk. 1, 2.

28. Lorut, L. P., Du Croup et des Moyens de le Prix)enir, Paris,
pp. 24. (On Croup and its Prophylactics.)

29. Hdrveian Society. — Lancet April.

80. Thompson, H., ViUous Growth from the Vocal Cords, Causing
Death by Asphyxia. — Trans. Path. Soc. Lond. IX. p. 55. — Lancet.
Sept.

81. Roberts, B., Tubular Cast of the Trachea, at its Bifurcation. —
Trans. Path. Soc. IX. 52.

82. Hutchinson, Membrane Expectorated from the Trachea. — Lancet.
Oct

83. Vogt, A., Case of DiphtheriticLiJlammation of the TongUs and all
the Bespiratory Tubes. — Schweiz. Mon. f. pr. Med. 2.

84. Bouchut, A., New Symptom, of Croup, Serving as an Indication
for Tracheotomy. — Gaz. Mdd. de Paris. Aug. 7.

85. Rochester, Th. F., Tracheotomy im Pseudo-Membranous Croup, —
Buff. Med. Jour. July.

86. Passavant, Bemarks on Prof. Pitha^s Essay on Tracheotomy. —
Wiener Med. Woch. 28, 29.

87. GUntner, W., Explanation of Dr. PassavanVs Bemark^s on Prof.
Pitha^s Essay on Tracheotomy. — Ibid. 33.

38. Saxer, Tracheotomy for Croup, in Children. — Arch. f. phys.
HeUk. 1.

39. Petit, v., on the Indication of Tracheotomy in Croup, — Presse M^d.
Beige. 17.

40. Vogt, A., on Tracheotomy in Croup, — Schweiz. Mon. f. pr. Med.
4,5.

41. Blin, L., Du Croup etdela TracMotomie, pp. 8. (On Croup and
Tracheotomy,)

374

42. Gitersant, Practical Remarks on Tracheotomy, — Dubl. Hosp. Gaa.
May 15. Jour, of Pract. Med. and Surg.

43. Martini, on Tracheotomy. — Schmidt's Jahrb. 1.

44. The Importance of Group in Children, — Journ. f. Kinderk. 7, 8.

46. Cr^qxiy, M., Notice sur le Group et les Affections DiphtirUio, Ob-
seruies i V Hospital Sti Euginie, pendant l^Prenuer Seme^ra de
r Annie 1868. p. 67. (Notice on Group and miphiheritic Affections,
Observed in the Hospiial St. Euginie, during Inb First Months of Jhn
Year 1858.;

46. Middlesex Hospital. Impaction of a Grumb of Bread in the
Larynx <f an Infant; Threatened Suffocation; Tracheotomy. —
Lancet. Dec.

47. Buckingham, C. E., Gase of Membranous Group, Treated by 7\xiche'
otomy, — Best. Med. Jour. 20.

48. Extracts from the Records of the Boston Society for Medical Im-
provement. — Ibid. 16, 17.

49. Bird, W. V., on a Successful Gase of Tracheotomy in Group, —
Lancet. March.

50. Martyn, (7ase of Group. — Lancet. Sept.

51. Salzer, Three Gases of Tracheotomy in Group. — ^D. Klin. 42, 43.

52. Browning, C, Gase of Successful Tracheotomy in Group, Be-
covery. — Lancet. Sept. — Med. Tim. and Gaz. p. 419.

53. Fuller, N. W., Seven Gases of Tracheotomy. — ^Brit. and For. Med-
Chir. Rev. July.

54. Martin, Laryngotomy in a Little Oirl. — ^Presse Mdd. de Mars.

55. Klett, Successful Gase of Tracheotomy in Group. — ^Wttrt. Med.
Corr.-Bl. March.

56. Millard, A., De la Tracheotomie dans les Gas de Group. Observa-
tions Becueillies d VHbpital des Erf ants Malades, dans les Annies
1857 et 1858. (I. Semestre.) Th^se, Paris, pp. 245. (On Trache-
otomy in Gases of Group. Observations in the Hospvtat for Sick
Ghildren, in the years 1857 and 1858).

67. BesuUs of the Operation of Tvacheotomy in the Hospital for Side
GhUdren at Paris. — ^Bull. 6dn.'Vle Thdr. Aug.

58. Matthieu, New Instrument for Performing Tracheotomy. — Gaz.
Hebd. 17.

59. Bouchout, E., on Gatheterism of the Larynx, and on Tracheotomy
in Group; vrith Trousseau's Beport, and the Consequent Discussion.
— Bull, de PAcad. 1160,1180. Sept.; 99. Nov., Dez.— Gaz. Heb-
dom. 66-49.— Gaz. de Par. 45.— Bull, de Thdr. Nov., Dez.— Gaz.
des H6p. 131, 132, 139. — L'Union. 130-132, 137, 143. —Rev. de
Thdr. Mdd. Chir. 23.

60. Bouchut, E., on Amputation of the Tonsils in Diphtheritic Angina.
— Bull, de Thdr. Oct.

61. Cr^quy, Gatheterism of the Glottis, Venesection, Analysis if the
Bloodf and Pleuritic Exudajticnf in Group. — L'Uuion. 133,

876

62. Demarqnay,' Contnbutiona to Tracheotomy, — ^L'Union. 126.

63. Desaiilt, on the Introduction of Elastic Frobanga into the Larynx
(md Trachea. — Rev. d. Thdr. du Midi. Nov.

64. Girand-TeuloD, on Tracheotomy in Croup, — Gaz. de Par. 48, 49.
66. Hardy, Ch., on Tracheotomy. — ^BuU. de Th^r. Oct.

66. Klein, Successful Tracheotomy in a Case of Croup, — Gaz. de
Strassb. ^

67. Loisean, on Cathetensm of the Larynx and Tracheotomy, — Gaz.
Hebd. 43.

68. Mathien, Langenbeck's Tenaculum for Tracheotomy. — Bull, de
Th^r. Oct.

69. NeudOrfer, Ign., Canula for Bronchotomy. — Oest. Zeitschr. f.
praEl. Heilk. 46, 47.

70. Petfel and Baudin, Thirteen Cases of TraoJieotomy; seven success-
/u/.— Gaz. d. H6p. 142.

71. Roger, H., and Sde, G., Contributions to the Statistics of Tracheot-
omy in Croup, — Gaz. Hebd. 46, 48. — Bull, de Thdr. Nov. — Gaz.
de Paris. 45.

72. Trousseau, on the Larynx^ Tracheotomy and the Method ofLoiseau,
—Gaz. d. H6p. 124.

73. Trousseau, on some Indications of TracJieotomy as performed in
the different Stages of Croup in the Hospital for Sick Children. —
Bull. deThdr. Dec.

74. Bienfait, J. Contributions to the Treatment of Croup^ and on the
Usefulness of Hepar Sulphur. — Gaz. Hebd. 67.

76. Crdquy, C, on Crotp and Diphtheritic Affections in the Hospital
"St, Euginie " during the first half-year of 1858. Paris. Th5se.
pp. 67.— Gaz. d. H6p. 119.

76. V. Faber, on Croup, — ^WUrt. Corr. 36.

77. Marc d'Espine, Beclamation against the Statistics (f Croup as given
by Bouchout. — L'Union. 140.

78. Sales-Girons, Inhalation in Diphtheritic Angina and Croup. — Rev.
m^. Fran9. et Strang. July. 15.

79. See, Bouchout, etc., on Moirfality in Croup. — ^L'Union. 138, 139.

80. See, Barthez, Bouchut, on Tonsillotomy and Albuminuria in
Croup. — Gaz. d. H6p. 145. .

81. Villars, Cauterization in Croup through the nose. — Gaz. d. H6p.
136.

82. Sales-Girons, Cathitirisme des Bronches. — Rev. Mdd. Fran9. et
Strang. June. 15.

88. Sales-Girons, Nouvelle Thirapeutiqae Bespiratoire. — Ibid. May 31.

84. Assanes, G. A., Du Croup Comdd&i Frinoipalement au Point de
Vue du Diagnostic et du Traitement. Thfese. Paris, p. 45. {On
Croup, with a Particular View to Diagnostics and Trealrnent.)

86, Medical Society of the Seine Department. — Gaz. Hebd. 38, 39.

86. Demarquay, on Anassthesia Besulting from Asphyxia, — Ibid. 41.

876

87. Bouchut, Staiisiics of Croup. — ^Un. Mdd. 47.

88. Tubage du Larynx. — Mon. d. H6p. 113, 114.

89. Boi^chut, on the Caiheterism of the Glottis by Means of Forced
Dilatation of the Larynx for the Cure of Croup, — Gaz. Hebd. 38.

90. E-^g, on Croup and Tracheotomy. — Journ. f. Kinderk. 1, 2.

91. On the Mortality of Croup in Private Practice and in the HospUaU
of PariSf from 1826 to Sept. 15, 1858.-4Paper Read before the
"Acad, des Sciences." L'Union. Sept. 27.

92. Loiseau, Notice on Catheterism of the Glottis and Tacheotomy.—
Gaz. Hebd. 43.

93. Bouchut. E., and Empis G. S., Risumi of a Paper on Albuminuna
in Croup and Diphtheritic Diseases. — UUniou. 132.

94. Trousseau, Report on a new Method of Treating Croup by meani
of Catheterism of the Glottis. — Gaz. Hebd. 45.

95. Trousseau, on the Treatment Consequent upon jyacheotomy. — ^GasL
d. H5p. Aug. 19.

96. Medical Society of the Second District of Paris. — (On the size of
Canulas, etc.) — L'Union. 126.

97. Neuddrfer, J., on a new Canula for Performing Bronchotomy. —
Oest. Zeitsch. f. prakt. Heilk. 46, 47.

98. Hauncr, Some Remarks on Dr. Luszinsky's Views on Croup and
its Treatment. — Journ. f. Kinderk. 3, 4.

99. Samuelson, on the Epidemic of Croup, at Kihiig^^berg. — KOnigsb.
Med. Ann. 1.

100. Hauner, Report on the Eleventh Year of th^ Di^)ensary, Connected
with the Children's Hospital at Munich.— Journ. f. Kinderk. 7, 8.

101. Ziemssen, W., on the Fluctuations in the Frequency of Pneur
monia, and Especially on its Course in the Two Decennia 1836-1856.
— Prag. Viert. 2.

102. Guillot, N., Treatment of Pneumjonia in Young Children. — ^Presse
Mdd. Beige. 16.— Med. Chir. Monatsh. Oct

103. Hirsch, G., Catarrh-Expectorants. — Klinische Fragmente. IL
p. 22. 68.

104. Jacobi, A., on the Oxysulphuret of Antimony as an Expectorant
in* Inflammatory Diseases of the Infantile Respiratory Organs,-^
N. Y. Jour, of Med. Nov.

105. Mascjika, Medico-Forensic Decisions. — Henke's Zeitsch.

106. Hewitt, G., on Vesicular Emphysema of the Lungs in Early
Childhood; its Origin, Causes and Pathological Importance, etc.
Liverpool, pp. 22. (Rep. from Liv. Med. Chir. Jour.)

\Q*{ . Kx2^n, Pulsaling Empyema. — L'Union. 99.

108. Roe, Circumscribed Empyema. — Lancet, Oct.

109. Moore, W., Contributions to Infantile Therapeutics. — ^Dubl, Hosp.
Gaz. Aug. 15. — Journ. f. Kinderk. 9, 10.

110. Hirsch, 6., Thoracocentesis. — Klinische Fragmente. II. p. 123.

377

111. Dix, J., Deaikfrcm a Wound by a Needle. — ^Brit. Med. Jour. 93.
p. 847.

112. Eff^ect of Belladonna in Hooping Cough, — GUnsb. Zeitschrift.
I. 79. .

113. Ballard, Tuberculous Abscess of the Anterior Mediastinum^
Bursting into the Trachea, — Trans, rath. Soc. Lond. IX. p. 38. —
Lancet. ApriL

114. Miller, G. C, a Case of Spasmodic Asthma in a ChUd Five Years
old, — Med. and Surg. Rep. Sept

116. Plagge, Th., Intumescence of the Mass of Glands Adjoining the
VaguSf the Probable Cause of Asthma MiUari. — Memor. a. d. Prax.
IIL 7.

116. Hirsch, G., Asthma. — Klinische Pragmente. II. p. 156, 157.

117. Hartshome, H., Fatal Enlargement of the Thymus Oland with
Subfacent Tumour^ in Transactions of the College of Physicians of
Philaddphia. — ^Amer. Jour. April. — N. Y. Jour, of Med. July.

118. Priedleben, A., Die Physiologie der Thymusdruse in GesundheU
und Krankheit, vom Standpunkte EaperimenteUer Forschung und
Elinischer Erfahrung, Ein Beitrag zur Ld)ensgeschichte der Kind-
heit. Frankfurt a. M. pp. 336. ( The Physiology of the Thymus
Oland in Health and Disease, Viewed from Experimental Examina-
tions and Clinical Experience. A Contribution to the History of
Infantile Life.)

Dr. Bktz considers snoring, in very young infants, to be produced
by one or more of the following anatomical causes : Retropharyngeal
abscess, inflammatory swelling of the epiglottis and fauces, struma,
apnoea, dysphagia, convulsive symptoms, croup, laryngismus,
ang^a, tubercles of the bronchial glands, and polypous excrescences.
The direct cause, and the seat of snoring, is usually found in the
velum palatinum or epiglottis. The author relates the case of a
child some weeks old, in whom, at that age, the foetal condition of the
longs were overcome. The abnormities found about the upper end of
the respiratory organsL will be found to fully explain the obnoxious
symptom of snoring. The hard palate was high and rounded, isthmus
faacium narrow and round, velum palatinum nearly in contact with
the tongue, uvula short and small. Pharynx was narrow, tonsils
in close neighborhood to each other. Epiglottis can hardly be
reached by the finger. Whenever the mouth was opened widely,
the child did not snore. Nose appeared to be sunk, nasal cavities
were narrow in their whole length ; and the upper lip thickened.

Dr. Voltouni, induced by observations of slow birth of the
trunk, after the head had been born, expresses his opinion on the
theories of the cause of respiration. Rind, and after him Valentin
and M. Hall, considered the first respiratory movements of the infant .
to be produced by reflected action, the atmosphere coming in contact
with the cutaneous surface, that is to say, with the peripheric ends
of the spinal nerves and the trigeminus. This theory the author
deems unable to explain respiration in cases of vagitus uterinus,

378

where atmosphere is coming in contact with but a very small part of
the skin, but entering mouth, nostrils, and lungs. In his opinion,
the excitation of the ends of the vagus nerve produc^es the reflected
action of the respiratory muscles. Certainly it cannot be made an
objection to this opinion, that even after both of the vagi are cut, the
respiratory movements continue for a while ; it being a physiological
fact, that the action of nerves serving vegetative life, when once
instituted, does not cease suddenly. One fact cannot be doubted,
viz., that in all cases of asphyxia of adults, or new-bom infante,
every irritation is and may effectively be employed to produce res-
piratory action. Thus more causes than one may exist at the begin-
ning of respiration, but the normal one will always be the irritation
of the vagus.

The observations of Prof. Ritgen, and others, show infants to be
able to breathe, after the head is bom, with circumfiexed funis ; the
complete circulation may be prevented, and death produced by a
proportionate shortness of the funis before the rest of the body is
born. Dr. Williamson reports cases where the infants, while being
born, respired freely, but afterwards one or more loops of the cora
were found firmly encircling the throat. In some instances the dis-
engaging of the coil of the cord was, owing to its extreme shortness,
found impracticable ; for each succeeding contraction of the uterus
was found to tighten and constrict the umbilical ligature more and
more ; respiration ceased, and the face of the infant became black
and congested. The author has found deep indentations around the
neck of the child. In such a case, when left to itself, the infant
would, after having respired, have been born dead, with an indented
bluish groove encircling its neck. A postrmortcm examination, in a
case of alleged infanticide, would reveal all the indications usuallj
regarded as conclusive proof, that the child had been born alive.

In cases of incomplete respiration in new-bom children, Mr. Morris
resorts to mechanical means which he does not consider as new, but
at all events highly recommendable ; effecting rhythmical motion of
the thorax, by putting his thumbs on both sides along the vertebral
column, and spreading his fingers like a fan all over the ribs.

Dr. Heard, of Galveston, Texas, thinks proper to report a very
simple case of very simple atelectasis piUmonum in a new-born child.
On the second day, he ''felt satisfied that the lungs were at fault,"
and therefore he "determined to resort to artificial respiration.''
After six or seven respirations, he saw entire relief of all the
distressing symptoms. Finally the author learns " from Dr. Stokes*
work on the Chest, that there are some very sensible remarks by Dr.
Joerg on this subject," meaning a book published twenty-four years
ago on foetal lungs in the new-born child. We venture to say
that a chapter on atelectasis pulmonum can be found in any manual
on diseases of children, written in the last twenty years.

The same remark applies to Dr. Ashenheim who publishes a very
simple case of atelectasis pulmonum.

The new method which Mr. Silvester brings before the profession,
is effected by means of the same muscles as are employed by nature in
respiration. In ordinary deep inspiration we lift the ribs and ster-

879

num by the pectoral and other mascIcB vbicU pass between the chest
and the shoulders, and thus produce the threatened vacuum which in-
flates tbe luugs. Silvester lifts the ribs and stcruam by the pectoral
and other muscles, which pass from the shoulders to tbe parietes of
the thorax, by steadily extending the arms up by the side of the pa-
tient's head ; by elevating the ribs the cavity of the chest is enlarged,
a tendency to a vacuum is produced, and a rush of air immediately
takes place into the lungs. Expiration ia brought about by simpb
compri-ssion of the sidefi of the cheat by the patient's arms.

The advantages of Silvester's method, as compared with that of
Marshall Hall's, as stated by its author, are the following :

8n.TcsnB's mctsoii :
lospintioa naj be made to precede
eiidntlioQ, or rixwriii.Bt tbe wtU of
tbe operator.

Ma; be adopted vben the patient U in

uie irarm bath.
Contents of slumach not liable to pam

Both cidM or lbs Gbe«t are eqaall; in-

Blted.
A largvr amount of air binEpirid tban

bj any other method ; as proved by

Mucsuuj. Haij.'3 hetdod :
EipiralioD a made to precede iospinttioa

— tbe rereive of the natural order. la

atill-bom in&nla forced erpirstlon, at

firat (as they have nerer breathed), is,

of courw. imposQble.
The warm bath cannot be employed dur-
ing ita adoption.
Whea tlie patient ia turned lo the lace,

and prenure made, the content! of the

•tomach arc liable to pass into the(EtK>-

pbagui and trachea.
Ia thu anplnated posjtiua. the tongue is

apt to olwtmct iufplralioa by fulliag

back into (he throat.
Both ridea of the chest are not equally

inflated.
Tbe amouat of air respired is exceedingly

Hoall, the aXuoI capacity of tbe luogB

not being enlarged i as proved by ei-

perimeol*.

Dr. Beurend publishes Rome cases of his own, and three others de-
scribed by Drs. Peacock, Bbmxeit, and BiitsErT, in Lond. Med. Times,
Jan., of chronic hoarseness in children. Some of these cases lasted
for months, eveu for years. This hoarseness is an affection similar in
its symptoms as in its treatment to the Clergymen's sore throat, but
the cause seems to be over-exertion and cold combined.

Dr. WiLKS reports the case of a lad of twelve years of age, who
died in the course of a typhoid fever, from general emphysema pro-
duced by a sloughing ulcer in the larynx. At the back part of thia
organ, at the junction of the vocal cords, wae a hollow space the
si:fe of a large pea. On the left side, a probe passed through this
cavity into a space between the trachea and cesophagua ; in this
was some purulent mucus, proving the communication which bad ex-
isted during life. The air had thus penetrated into the posterior
mediastinum, and thus by the thoracic walls to other parts of the

Db. Hadner reports an extraonlinary frequency of diseases of the
respiratory organs in spite of a beautiful weather, especially in
October, 1 851. The majority of cases were those of a febrile catarrh of
the briiuchia, with a very troublesome nightly cough, lasting for ser-
eral days, and ending with copious expet^oration. Hooping cougb

380

was most effectually removed by belladonna, small doses of morphine,
laurel water, and at a late period of the disease, chin, and lich.
island.

In a very elaborate and careful essay, Dr. Ziehssen comes to the
following results on pneumonia in children : Mortality from pneu-
monia of the infantile age, exhibits larger fluctuations than in adults.
Pneumonia in children and in adults, need not always coincide as to
the number of cases and mortality. Infantile pneumonia is some-
times epidemic, without particular influence on adults ; and pneu-
monia may be frequent in adults, without affecting children very
much. In Hamburgh, in 1 84 1, the mortality amongst children, from
pneumonia, amounted to 22 per cent, more than the average, whereas,
in the same year, the mortality amongst adults, from the same dis-
ease, was 17 per cent, below the average. The fluctuations in the mo^
tality from pneumonia in adults, exhibit some parallelism in different
localities of the same climate, but the fluctuations of infantile pneu-
monia do not correspond at all. Copenhagen and Hamburgh are
cities of nearly the same climate, site, and social standing, but the
excessive rate of mortality from infantile pneumonia at Copenhagen
in the years 1844 and 1847, does not find its equal at Hamburgh,
and again, the fearful epidemics of infantile pneumonia in Hamburg
of the years 1841 and 18^43, are absolutely isolated. Thus, the occur-
rence of infantile pneumonia in territorial limits can hardly be
accounted for by modifications of known atmospheric influences, but
has to be considered from a similar view to that of contagious dis-
eases, measles, scarlatina, etc., in general.

Dr. Guillot publishes the treatment of pneumonia in nurslings, as
practiced in the hospital "Necker^at Paris. No general or local
blood-letting is resorted to, except from six to eight cups in very
robust children. Emetics of ipec. and tart. em. are freely adminis-
tered, sometimes dry cupping is resorted to. Vesicatories are ob-
jected to. Excessive thirst is soothed by breast-milk or sugar-water,
During convalescence, the thorax is covered with adhesive plasty
until the cough has completely disappeared . We fully agree with Da.
VoGEL, that the worst complication of pneumonia in nurslings is diarr-
hoea, which is often increased by ipecac ; tartar emetic, in the dose of
iV grain, which is administered by Guillot, is, perhaps, not injurious,
but certainly of no use. Besides, we would say that it is not a good
practice to allow breast-milk for removing thirst, because food ou^it
to be diminished in acute febrile diseases, and not increased, as
would be done by giving the regular food, where not hunger, but
thirst only, is present. And a large amount of sugar-wat«r is also
objectionable, because of the sugar having a great tendency to
produce diarrhoea. Water will not only be found sufficient, but cer-
tainly be found best. ^

Prof. Hirsch recommends the oxysulphuret of antimony in catarrhal
affections, where the inflammatory stage has passed by, or has never
been present. He administers this remedy as soon as the least
mucus or serous secretion is perceived, as well as in pneumonia,
after the inflammatory orgasm has subsided.

Db. Maschka, among a number of other forensic cases, reports that

381

of a woman charged with willfully suffocating her child. The child
was proved to have died from pneumonia of both lungs.

Dr. Hswrrr says, that the emphysema of the lungs most undoubtedly
plays a very important part in most of the diseases of the respiratory
organs in children, that it adds much to their fatal tendency ; that
it has probably no small- influence in hastening the fatal event in
some diseases in which its existence is hardly suspected, and that
many adults who are supposed to have been entirely cured of the
respiratory diseases pf their infancy and childliood, are not seldom
suffering severely fi'om the emphysema contracted at that early
period of life. No part of the lung-surface ig free from the liability
to be affected with emphysema, yet it is rare to meet with it in its
primary and simplest form at the extreme borders of the lobes ; these
latter parts being, in children, the particular seat for apneumatosis.
Emphysema is not often confined to one lobe. Apneumatosis is never
unaccompanied by emphysema ; and if large portions of the surface of
the lobe present the one lesion, it is the rule that adjacent portions
of the tissue are affected with the other. Solidification of the lung
tissue, due to the presence of tubercle or true pulmonary inflamma-
tion, appears also, though in a less degree and less constantly, to
entail with it an emphysematous change in the vesicles of neighbor-
ing lobules. The individual air-cells are not much enlarged in size ;
the average measure of normal air-cells is about ^ih of an inch in
diameter ; emphysematous ones of -^oth or ^V^h inch in diameter are
very rare occurrences. Emphysema is produced as a secondary con-
sequence by whatever reduces the bulk of th^ lung at any one point.
Atelectasis is a frequent cause of emphysema ; so are bronchitic
affections, particularly in the first two years ; the reason why emphy-
sema produced by atelectasis is slight in degree is, that the shape
and size of the thorax is, in the newly bom infant, from the first reg-
ulated by the degree of expansion of the lung tissue. The first
effect ,of bronchitis or catarrh in an infant is obstruction to the en-
try of the air ; this obstruction increasing, certain portions of the
lung become apneumatic, the adjoining healthy lobules taking a
compensating action, but by so doing, themselves become diseased
— emphysematous. This acute form most commonly attacks the
upper lobes of the lungs ; most extensively so below the clavicles.
Whenever it is present to a considerable degree, the " expiratory"
type of respiration is intensified, the respirations are eminently
shallow in character, the cough is short, stifled, and weak ; and
coincidcntly with these, the physical signs of emphysema at the
apices, and of collapse at the lower portions of the lungs may be sat-
isfactorily made out. Chronic emphysema produces a great liability
to frequent attacks of bronchitis ; the rapidity with which severe
dyspnoea supervenes on an apparently slight attack of bronchitis is,
in ordinary cases, a good test of the presence of emphysema. Its

Shysical signs are well known, and there are no new particulars in
ir. H.'s remarks.

Dr. Aran operated upon a case of empyema, in a girl of twelve years
of age, which was situated on the diaphragm and the right lateral
snrface of the pericardiom. This aingalar sitaation was the reason

. 382

of some peculiar symptoms before the performance of thoracocente-
sis, the tumor pulsating isochronously with the pulse of the hearty
and expanding during expiration, decreasing during inspiration.

Dr. Roe describes a circumscribed empyema occupying the left
mammary region of a child of nine years of age. A trocar and canih
la were introduced, and ten ounces of puriform fluid drawn off. Mr.
MooRE relates the case of a double empyema, with malposition of the
heart and sternum.

Prof. HiRscH reports the case of a girl of teij years of age, who,
after having been affected with severe attacks of inflammatory rheu-
matism, suffered from a large number of pyaemic abscesses, and was
finally submitted to thoracocentesis. She fully recovered, but after
some years was observed gradually to sink from pulmonary tubercu-
losis.

Mr. Dix reports the following pathological curiosity which oociu^
red in a child of eight months. A common needle, three inches
in length, and broken through the eye, entered the right side of the
chest between the cartilages of the 8th and 9th ribs, passing below
the free edge of the lung without wounding it. At tbis part it pene-
trated the convexity of the diaphragm and traversed the upper po^
tion of the right lobe of the liver, and again finding its way into the
chest, it transfixed the lower lobe of the lung, and its point was at
last arrested by the spinal column. There had been no bleeding what-
ever, but the lung was completely collapsed and compressed by the
escape of air into the pleural cavity.

Mr. Ballard attended a child aged five months and a half, who had
been suffering from symptoms of croup, and died rather suddenly.
In the anterior mediastinum there was a mass of tuberculous glands,
and an abscess the size of a pigeon's egg^ containing softened tuber-
culous matter, which communicated with the trachea through its an-
terior wall, by a ragged opening half an inch in length, the mucous
membrane around and above for some distance being much ulcerated.
The larynx and the tracheal mucous membrane below it, for the space
of more than an inch, appeared quite healthy. The pharynx con-
tained a good deal of purulent fluid, such as was found in the cavity
of the abscess. Both lungs were entirely studded with masses of
tubercles ; the pleurae of the right side being, adherent The right
side of the heart was distended with dark, semi-coagulated blood.

Prof. HiRscH makes some remarks on paralytic laryngostenosis
produced by swelled or tuberculous lymphatic glands compressing
the nerves of the vocal cords. The attacks of suffocation will return
many times, and always last longer than in inflammatory or spas-
modic affections ; but the patients, are, as it were, used to it, and do
not suffer from it. In some cases the treatment wiUi iodine and cod-
liver oil proved successful. Of a like nature, as to the disease in
question, are the remarks of Dr. Plagge.

The same author directs attention to the difference between spasm
of the glottis and laryngitis stridula, which he prononnces to
be a catarrh of the glottis with spasm and oedema. Therefore, its
attacks last longer, sometimes a day or more, than those of spasm
of the glottis^ but are not so frequent ; although children are met

383

^ih, from, time to time, suffering repeatedly from this affection.
Children, who are said to have suffered from croup ten times or more,
will almost always be found to have been affected with laryngitis
stridula.

Dr. Habtshorne believes to have seen an enlargement of the thy-
mus gland, proving fatal in a child five months old ; it had always
appeared to be healthy and well developed, and presented no symp-
toms of disease to attract attention up to the moment of death. It
was suckled by its mother at two o'clock of the morning of its de-
cease, when it went to sleep as usual. At about seven A. M. it was
found dead, lying on its back, with blood about the nostrils, and the
jugular veins distended. Examination of the body displayed no pe-
cuTiarity, except the morbid alteration of the gland, and the results
of its pressure upon other parts. The heart was forced down close
upon the diaphragm. The vena cava descendens contained an unu-
sual quantity of blood. The thymus was very much enlarged, and
below the proper gland, but connected with it, and inclosed in a con-
tinuous enveloping membrane, was a mass whose appearance and
consistence resembled those of fatty structure, and which, when
shrunk under the influence of alcohol, had three inches in perpen-
dicular length, two inches in width transversely, and seven-eighths
of an inch in antero-posterior thickness.

In order to enable our readers to judge themselves of the value of
Dr. Fribdleben's book, we give in the following some aphorisms con-
taining the principle results obtained by the author :

1. The thymus is a gland without any excretory duct ; it consists
of an aggregate of closed follicles.

2. Its blood-vessels are of moderate size ; thus tlieir amount of
blood is also moderate.

8. The nerves contained in its substance belong to its blood-ves-
sels.

4. It exhibits a secretion, consisting of a transparent, clear, inter-
cellular liquid, and numerous round nuclei intermixed with some
cells.

5. The nuclei are transferred, unaltered, into the venous circulation.

6. The follicles of the thymus are subject to an unremitting decom-
position and reconstruction ; the so-called concentric corpuscles de-
scribed in the microscopic anatomy of the thymus, are follicles under-
going their morphotic decomposition.

1. The thymus is growing in size, without interruption, from its
first embryonic formation up to the years of puberty ; but its relative
growtli, after birth, is less than the average development of the rest
of the body ; the more so, the greater the age.

8. After the years of puberty have been reached, the thymus either
remains stationary in its growth, or undergoes a gradual diminution
of its volume ; the diminution of size is rapidly increasing in adult
age.

9. In old age the thymus is rarely met with ; wherever it is found
it consists of an adipose intercellular tissue, preserving the shape of
the thymus.

10. Years advancing, the secretion of the thymus decreases.

kUb

384

11. The normal diminution of the thymus consists in a process of
fatty degeneration, taking its origin from the wasting of its vaso-
motory nerves. Thus obsolescence of its arteries and dilatation and
varicosity of its veins are effected. Metamorphosis becomes slow,
and the morphotic elements of its secretion are decomposed or under-
go fatty degeneration ; only the action of ihe lymphatic vessels re-
main intact, and enables resorption of the tissue to go on.

12. The thymus may be wanting in the foetus and in infants of
normal development.

13. The chemical elements of the thymus are water, albumten, glu-
ten, sugar, lactic acid, pigmentous matter, fat and salts, and perhaps
hypoxanthin besides. Ammonia, leucin, acetic acid, and succinic
acids do not take part in the formation of the thymus.

14. In early age, albumen, sugar, salts are prevalent ; in later
years, glutin, lactic acid, and fat.

15. The salts principally are phosphates of earths in young indi-
viduals, of alkaline nature in older ones.

16. The general nutrition of the individual determines the volume
of the thymus and the amount and nature of its secretion ; the scarcer
food and the more prevalent hydrates of carbon, in proportion to azo-
tic substances, the less the secretion of the thymus or the more pre-
valent the per centage of fat and water.

It. Want of nourishment and diseases going along with troubles
of digestion and assimilation produce a collapse of the tissue of ihe
thymus. The secretion formed is rapidly resorbed and the chemical
composition is soon altered.

18. The pathological disturbance having been removed, the tbymus
again takes its former functions, increases in size and continues its
growth ; only when the interruption lasted for a long time, the tissue
may be collapsed and resorbed to such an extent as to produce per-
petual partial obliteration.

19. The nerves of the thymus do not suffer from the atrophy of the
organ brought about by general diseases ; thus this atrophy is, in its
histological and physiological nature, essentially different from the
process of normal involution.

20. The thymus exhibits, while in its physiological condition, a
slight turgcscence during assimilation, depending on secretion being
more copious ; there is no turgescence in the thymus depending on
the circulation of the blood being stopped.

21. The size of the thymus is subject to numerous individual changes
in every age.

22. Metamorphosis of matter in the thymus is like that of the
other organs.

23. The growth of the spleen is increasing, in advanced years, in
the proportion of the diminution of the size of the thymus.

24. The thymus is more active during digestion and assimilation,
the spleen in the intervals.

25. The thymus is found in all classes of the vertebrates and obeys
the same laws in its growth. It will decrease quickest in the ani-
mals whose growth is the most rapid.

26. Its histological and chemical nature differs entirely from the
fat-gland of the winter-sleepers.

385

27. Diseases of the respiratory organs do not affect the volume and
secretion of the thymus, except by injuring digestion and assimila-
tion.

28. The thymus exhibits abundance of growth wherever general
growth becomes extravagant. After this period of extravagance of
growth has[passed by, the thymus is somewhat inactive ; thus its ac-
tion is always in proportion to the general metaiQorphosis.

29. The thymus may be extirpated without injuring the well-being
of the animal. •

80. Animals deprived of their thymus take a larger quantity of ali-
ments than before the extirpation ; there is no tendency in such ani-
mals to devour heterogeneous substances.

31. The growth of the body is larger in animals, whose thymus is
extirpated, than in normal ones ; but it is less than ought to be ex-
pected from the immense amount of food swallowed.

82. Extirpation of the thymus has no particular effect on the volume
of the liver. In the normal animals, during the first two months of
life, the growth of the liver is proportionately smaller than that of
the body in general ; afterwards, for a short period, larger, and
then again smaller. The like is oljserved in animals whose thymus
has been extirpated.

88. Extirpation of the thymus has a manifest effect on the spleen ;
the growth of which is less in proportion to the body in general,
after the operation has been performed. The growth of the spleen in
animals operated upon is, in the first weeks of life, larger by 6 per
cent, than in animals whose thymus is untouched. But as early as
after the eighth week, the growth of the spleen in animals operated
upon is less, by 26 per cent, than in normal development.

34. Sanguification in animals whose thymus is extirpated, is accel-
erated ; their blood contains more albumen and water ; the number
of the uncolored blood-cells is greater, of the colored ones less ; se-
cretion of albuminates increased, of carbonic acid diminished ; ex-
cretion of water greater by means of perspiration, less by secretion
of urine.

85. The growth and chemical constitution of bones is influenced
by ihe extirpation of the thymus. This influence depends on the
state of osseous development at the period of the performance of
extirpation.

86. Such being the main results of a series of physiological re-
searches, it may be taken as a fact, that the thymus is an organ
furthering f during the period of growth, nutrition and sanguification^
and theformation and development of tissues.

8T. Diseases of the thymus gland are proportionately rare occur-
rences. Hypersemia and apoplexy have been met with in new-born
infants, who had died from the use of violent means during the par-
turition, and have been found also in somewhat older infants. Also
tuberculosis has been occasionally obsei*ved in the thymus. But oc-
currences of this kind are by no means so frequent as former authors
have believed them to be.

88. The majority of cases considered hitherto to be diseases of the

386

thymus, either did not occur in the thymus at all, or have wrongly
been taken as such ; the thymus being not at all diseased.

39. There are no characteristic symptoms belonging to diseases of
the thymus. Only one case of suppuration of the thymus has been
made public ; no peculiar symptoms could be distinguished during
life.

40. A great number of cases of alleged hypertrophy of the thymus
have been reported ; nevertheless, real hypertrophy is a very rare
occurrence. The majority of cases of so-called hypertrophy are over-
rated, the physiological size and weight of the thymus not being
sufficiently known. /

41. Undoubtedly not one case is hitherto known of hypertrophy of
the thymus producing pathological symptoms dependent on its ex-
cessive volume.

42. Neither in its normal, nor in its hypertrophied condition, is the
thymus able ever to become an obstacle to respiration and circula-
tion, or to exert a pressure on the respiratory nerves, or to injure
cerebral circulation and the innervation of the muscles of the glottis,
or to produce a periodical turgescence in its substance by stoppage
of the circulation. Thus the thymus is unable as well in its normal
as in its hypertrophied condition, to produce laryngismus stridulus.
There is no asthma thymicum. Thus, the name of thymic asthma is
but of a historical interest ; it was founded on erroneous ideas on
the nature of the disease, on erroneous interpretation of anatomical
results, and on insufficient knowledge of the physiological nature of
the thymus gland.

All the preceding theses on this subject have been proved by ex-
tensive anatomical and physiological researches, and an ingenious
sifting of the ancient and modern literature on the subject. We are
not surprised when the author says that this work took him a decen-
nium. It is not only one of the most important recent books in the
whole bulk of medical literature, but as a contribution to infantile
pathology, we rank it foremost among all the monographs that have
appeared for a long time past. It belongs to the class of books
which, although the author may never again touch a pen, makes him
an authority at once, and leaves his name to the history of medical
science.

Dk. Hauner, when refuting some theses published by Dr. Luszinsky,
gives the following aphorisms, embracing the contents of a work
soon to appear : 1. Qenuine (laryngeal) croup is a disease peculiar
to infantile age ; its cause is to be looked for in the organization
(stage of development) of the infantile larynx. 2. Anatomy and
physiology will probably elucidate its nature. 3. There is no proof
that croup is produced by a peculiar orasis (abnomal plasticity) of
the blood. 4. Genuine croup always commences in the larynx, and
many times migrates downwards, but in no case upwards. 5. A
Pseudo-membrane, large or small, is a characteristic of croup. 6.
Diphtheritic croup differs much from laryngeal croup, and usually is
the consequence of, or connected with, a peculiar crasis of the blood,
which is known also in other organs. 7. Thus diphtheritic croup is
almost always secondary, and is essentially not very much different

387

from croup following acute cxanthcms. 8. Diphtheritic croup usually
commeuccs in the fauces, on the uvula, tonsils, etc., migrating down-
wards ; very seldom it commences in the larynx and trachea. 9.
The symptoms of a violent laryngeal catarrh are very similar to
those of genuine or diphtheritic croup ; but there is never a false
membrane in catarrh. 10. Such cases are very often considered to
be, and are described as croup. 11. There is no specific remedy
against genuine croup ; therapeutics have to undergo modifications
according to the individual case. 12. In the average of cases,
emetics, cold, mercury, blood-letting, will do good. 13. In certain
cases of laryngeal and tracheal croup, the operation is indicated.

14. Diphtheritic croup requires cauterization, emetica, alkalies,
tonics ; in no case calomel, bloodletting, vesicatories, or purgatives.

15. In diphtheritic croup, tracheotomy is seldom indicated, particu-
larly because of the rapid spreading of the diphtheritic process. 16.
If it has been made, cauterization has to follow it. It. The most
violent laryngeal catarrh does well with an appropriate regimen and
antiphlogistic treatment. The proof of this is the great number of
so-called cases of croup which are reported to be cured.

The article of Dr. Luszinsky's, Dr. Hauner refers to, h^s been pub-
lished in Journ.f, Kinderk, 1857, 9, 10, and some extracts of it may be
found in N. Y. Jour, of Med. March, 1858.

According to Dr. Luszixsky, there are four indications in croup,
which are — ^I. To alter the peculiar crasis of the blood. This indica-
tion requires antiplastics, of which hepar sulphuris, sulphate of cop-
per, and tartar emetic are either too uncertain, or too dangerous,
because repeated vomiting would be injurious by congestion of the
brain, and mercury, which readily injures by producing diarrhoea,
salivation, and general mercurialism. Better than all of them, are
alkalies, wliich Luszinsky seems to have recommended prior to
Lemaire and Marechal, of Paris. The hydrate of potash or soda is
most antiplastic, but they are not easily tolerilted ; the bicarbonate
is the most digestible, but the abundance of carbonic acid in the
chemical composition of the bicarbonate of potash or soda diminishes
the medicinal effects of the alkalies ; therefore, he gives the carbon-
ate of potash or soda, from one half of a drachm to two drachms
every day. 2. To prevent the localization of the inflammation in the
larynx. This indication requires no bleeding nor leeches, but, in the
first stages of the disease, cold applied to the larynx, and large blis-
tering plasters, kept in suppuration for some days. 3. To remove
the spasm of the larynx by narcotics. 4. To destroy, or remove the
pseudo-membranes, which have been formed. The best caustic in
these cases is a solution of from four to eight grains of nitrate of
silver in an ounce of water, which is to be applied by a brush. Emet-
ics are necessary where pseudo-membranes are loose, or beginning
to loosen in the larynx or bronchi.

These and similar remarks Dr. Luszinsky repeats, while replying
to Dr. Hauner's article.

The case of croup reported by Dr. Cox£, in which a thoroughly
antiphlogistic method g[ treatment was resorted to, is somewhat
doubtful as to the correctness of diagnosis.

388

Dr. Wasson advocates, in croup, the administratioii of large doses
of calomel, and the introduction into the larynx and trachea of a
solution of nitrate of silver, of the strength of 30 or 60 grains to the
ounce of water.

Catheterism of the larynx is, in France, performed by Dr. Loiseaxj.
A succAsful case of his is communicated by Trousseau, who says,
that he remembers from his own practice only three cases of genuine
croup getting well without tracheotomy, and that, without this oper-
ation, the chance of recovery has been that of 1 to 100. The first
cauterization was performed by a solution of nitrate of silver, the
second by a saturated solution of tannic acid, which Dr. Loiseau
thinks to be greatly preferable. Alum and tannic acid , powdered,
were blown besides into the pharynx and the nasal cavities.

E. Bakthez has come, by experiments, to the conclusion, that the
local applioation of a solution of chlorate of soda is more effective in
macerating pseudo-membranes than chlorate of potash. He therefore
ordered instillations into the trachea of chlorate of soda gr. j. ta iv.,
and water gr. xxx., after tracheotomy had been performed and the
pseudo-membranes were known to spread through trachea and bron-
chi, and had them repeated every quarter of an 'hour. Before he
made these applications, almost every child died after tracheotomy,
because the pseudo- membranes could not be removed from below the
canula. Afterwards but very few died. After each instillation, a
severe cough used to set in, which always brought up a part of the
solution, and some macerated pieces of pseudo-membranes. When
he instilled water instead of his solution, the same cough ensued,
but nothing but the water was thrown out. It is remarkable indeed,
that these results obtained in the same epidemic, in which by far the
greater number of patients died after the operation without succeed-
ing instillations. Therefore, the remarks of Dr. See, in tlie session
of March 24th, of the Soci6t6 M(5dicale des Hopitaux, are not to the
point, when he reminds Dr. Barthez of the fact, that the mortality
changes with the year and the genius epidemicus.

Dr. Mayer feels bound to recommend glycerine as a local ap
plication to tho rima glottidis, from whence it is expected to glide
down into the larynx. Dr. Shetton reports to have applied, in a few
severe cases, with a favorable and even unexpected result, an oint-
ment of extr. bellad. and ungt. hydr., either to the sound skin over
the trachea, or to a blistered surface.

Dr. KoRTUM considers tartar emetic as the very best remedy in
croup, but gives it in another way than it is usually prescribed. He
prescribes for a child of one year of age, from ^^ to -J grain every
two hours ; for older ones, comparatively larger aoses, thinking the
alterative effect on the blood most important, and nothing less
desirable than the mere emetic effect in the shortest time possible.
The author seems to be almost positive about the favorable result,
but considers new attacks imminent, as long as the purgative effect
of the medicament has not also showed itself.

Dr. PuDON publishes some cases of croup where the local application
of cold water, according to Priessnitz's rules, and emetics of sulphate
of copper, were sufficient to cure even severe and obstinate attacks.

S89

Dr. Misaouz, too, takes pain to eulogize, for the hundredth time,
flie sulphate of copper as an emetic.

In tne Harveian Society, Dr. Fuller referred to a case, in which
there was a large scrofulous tumor in the trachea, accompanied with
a croupal sound during expiration, in contradistinction to the in-
q[>iratory sibillation of genuine croup ; when meeting with the same
qrmptoms in another case, he therefore gave his opinion against the
operation. The child died, but this time the case proved to be one
of gfenuine croup.

Mr. Thompson exhibited in the Pathological Society of London, the
specimen, and reported the case of a villous growth from the vocal
<^rds in a girl of eight years, causing sudden death by suffocation,
after occasional attacks of impeded respiration had preceded for two
Years. A warty growth occupied the situation of the superior and
inferior vocal chord of each side and the intervening ventricle, a very
narrow, almost imperceptible interval existing between the opposing
growths, before the larynx was opened. It consisted of very minute
villi thickly coated with pavement epithelium.

Dr. A. YoGT reports, and illustrates by drawings, a case of diph-
theritic inflammation of the tonsils and all the respiratory tubes, par-
ticularly interesting for the rapid reproduction of false membranes,
and for their extension downwards, as far as into the bronchi of the
4th and 5th class.

Prof. BouGHUT says, that the last period of croup is accompanied
with general ansBsthesia of the skin. This ansBsthesia will increase
in proportion to the accimiulation of the fibrinous secretions in the
trachea, and is produced by the impediment to the free entrance of
air into the lungs. Thus anaesthesia shows the difficulty in respira-
tion to have proceeded to such a dangerous hight, as to positively
require the immediate performance of tracheotomy.

Dr. Rochester arrives at the conclusion, that tracheotomy, from its
intrinsic gravity, is never to be lightly or indiscriminately under-
taken ; that ,it affords a possibility of recovery, when hope from
other resources cannot reasonably be entertained ; and that moment
having arrived, it should not be neglected or delayed.

Dr. Passavant objects to Prof Pitha's f'Progr. Vtert.^ 1857-1), proceed-
ing in performing tracheotomy, to the separate use of instruments
fixr making the incislbn, and for dilatation, and to the canula being a
simple one. In the latter point we think Dr. P. is perfectly right, al-
tiioagh Dr. Guntner asserts that a double canula hurts the mucous
membrane of the trachea and leaves too little room to the ingress of
air. Dr. G. further expresses the opinion, that a lateral aperture in
the canula will always moderate the stream of ingressing air ; and
oonsiders the experience of Prof Schuh, who almost always saw pneu-
monia follow on tracheotomy, to be not at all general. In six cases
Dr. G. has seen no pneumonia, except where it was present before
the operation was performed.

Like the average of European writers. Dr. Sauer is in favor of the
performance of tracheotomy. He is by no means of the opinion,
which has been expressed sometimes to show, that even the diagno-
818 of croup is difficult and uncertain. Guersant, to have a sure di-

390

agnosis, thinks the presence of pseudo-membranes absolutely neces-
sary. Trousseau gives the following physiological explanation : If
the cough sounds croupy in the whole course of the disease, there is
no narrowing, except of the glottis ; but if the cough,, after having
been croupy in the commencement, goes on becoming weaker and
soundless, there is certainly an appendix present, not vibrating and
usually consisting of a plastic exudation. The number of erroneous
diagnoses is very small ; among 54 cases of Bretonneau's, and 22 of
Cook^s, there was no mistake proved by the post-mortem examina-
tions ; in 193 cases given by Dr. Sauer, in 21 only, no membranes
were found. The rate of mortality is exceedingly high, between 80
and 90 per cent. Medication has proved to be very unsafe, nor semi-
caustic applications to be of much use ; the operation alone is suo-
cessful. Although Trousseau has himself deserted his former prin-
ciple of performing the operation as soon as possible, our author
urges the fact, that strength will fail rapidly, and the normal consti-
tution of the blood undergo dissolution by procrastination. Not to
operate at all, even in olden times^ Casserio, and Laurenteo Keister,
reprimanded as unscientific, cowardly, and unchristian.

Dr. Saxer thinks but to operate near the larynx, where blood ves-
sels are rare and small. Trousseau used no ligature in 127 cases;
Baum, 9 in one. Many of the patients died after the operation, of
bronchitis, pneumonia, and pulmonary emphysema ; in which small
abstractions of blood are not contraindicated. Where swallowing
is impeded, the tube ought to be used. The author's other remarU
correspond with the usual opinions and orders of all good surg^ns
and writers. As to the mode of performing the operation, he recom-
mends a slow and cautious proceeding. His cases are six, of whom
three proved successful. Two girls of 2J and 4 years, and a boy of
3 years, died ; 3 boys of 3|, 4, and T years, recovered.

Tracheotomy, according to Dr. Petit, is an absolute necessity in
the asphyctic stage of croup. Whenever the disease has progressed
to its last stage, it is highly injurious to rely on the merely mechanical
effect of emetics ; at all events, every case in this progressed stage will
perish without the operation being performed. The presence of pseudo-
membranes in the larger or smaller bronchial tubes, and complica-
tion of croup with bilateral pneumonia have always been considered
as contraindications to the performance of tracteotomy. As to the
former, the exact diagnosis is impossible in the majority of cases.
Undoubtedly the pseudo-membranes are usually found in larynx and
trachea; wherever they fill up the small bronchia, the operation
could not be performed, because of death ensuing by rapid suffoca-
tion ; where only a part is obstructed, it is available at all events
to procure as much air as possible. Besides, instillations of warm
water, and alkaline solutions, may be employed to dissolve the exudar
tions. As to the complication with bilateral or simple pneumonia, there
are, wherever it is present, two causes leading to suffocation ; either of
which it can but be highly advantageous to remove. Dr. Petit ex-
presses the hope, that in future times, through the opening in the
trachea, some mechanical help may be found in bronchitis, tubercu-
losis, etc. We do not doubt that Dr. Petit will be highly pleased and

391

surprised by our countryman's (Horace Green's) successes obtained
by injections of nitrate of silver.

Dr. A. YoGT, after publishing a case of croup in a girl of seven
years, which ended fatally a fortnight after the operation of trache-
otomy was performed, examines all the prejudices still prevailing
against this operation, in Switzerland. Especially, he treats of the
fact, tliat wounds of the trachea are by no means fatal, but heal
readily ; and examines the amount of danger resulting from arterial,
veiuous, or parenchymatous bleeding. While not underrating these
dangers, he completely denies any danger arising from the entrance
of air into the veins, or from emphysema of the cellular tissue. The
cause of consecutive affections of the lungs, he finds less in the low
temperature of the entering air, than in deficient moisture, in defi-
cient expectoration of tracheal mucus, in consequence of the morbid
absence of the epithelial covering, and in the possibility of foreign
bodies coming into contact with the pulmonary tissue.

Prof. GuERSAXT has added to the number of his instruments, and
describes a tenaculum, an oesophagian forceps, and a caoutchouc probe,
destined to serve as a conductor to the silver canula. The rest of
his essay is dedicated to some practical remarks, of which the fol-
lowing advice is perhaps deserving of particular notice : To remove
false membranes from the vocal cords and epiglottis, a small pledget
of lint is tied with a double string, one of the ends of which is firmly
fixed to an india-rubber catheter, which is carried upwards into the
larynx. This apparatus raises the glottis, and, through the pharynx,
appears in the fauces ; it can thus readily be passed several times
up and down through the larynx, so as to remove the false membranes
adhering to the parietes.

We commend Dr. Makhni's excellent essay on tracheotomy to those,
who, after all the efforts made to introduce this operation into more
general practice, and after all the brilliant successes obtained in the
most dangerous cases, still hesitate to adopt it in their own practice.
The author gives an accurate review of its utility and its dangers,
neither overrating the one, nor concealing the others. The proofs of
what he wants to prove are numerous enough in literature, which he
is thoroughly acquainted with.

Dr. Crequt's dissertation shows a full knowledge of his subject.
Some of his notices are of particular interest, as, for instance, the fact,
that of his 30 cases there are twelve in which no false membrane could
be seen in the fauces, while it is well known that in a great number
of cases of croup, in France, it descends from the fauces down-
wards ; and his confirming the old experience that in some fatal
cases of croup there is apparently no cause to be found in the small
size and extension of the membranes ; and finally, his experiments,
made after the example of Barthez, on the dissolving influence of
some saline solutions on the substance of false membranes. Chlorate
of soda macerates a false membrane more rapidly than either chlorate
of potassa or nitrate of potassa ; bicarbonate of soda effecting mace-
ration even slower than any of them. Of all the children on whom
the operation of tracheotomy was performed, not one under three
years of age recovered. In one, a severe hemorrhage persisted.

392

even after the introduction of the canula, and covli not be stopped
even by perchloride of iron. The child died some hours after the
operation had been performed.

Tracheotomy was performed in the case of a female infant of seven
months, for the removal of a foreign body. The operation was un-
successful, the infant dying with the symptoms of puhnonary oedema,
perhaps " because the foreign body, a crumb of bread, bad been de-
tected in one of the bronchi." There is no report of a post-mortem
examination.

Dr. Ellis reports a case of croup, in which tracheotomy was per-
formed, in a boy of 15 months of age. "Patient died next day. No
post-mortem examination was made. Dr. Lyman operated on a child,
3 years and 4 months old ; patient died 30 hours after the operation
was performed, from rapid membranous exudation at the bifurcation.
Dr. Wyman opened the trachea once with a penknife, and inserted a
quill ; the child died 24 hours after. Dr. Cabot has operated twice^
without success. Dr. Buckingham operated successfully on a girl of
3 years and 11 months, and removed the canula on the 27 th day.

Mr. Spence reports five cases of tracheotomy in croup, to which
we feel obliged to direct the attention of the profession, because of
this operation being too little thought of in this country and in Eng-
land ; whereas, on the Continent of Europe, it is performed on an ox-
tensive scale, and with no small success. Mr. Spence's cases occu^
red in children of 4^, 3^, 4, 5, and 2^ years of age, the first, fourth,
and fifth of whom recovered, the second and third died. In none of
them was there any great amount of bronchial affection, and in none
of them did the croupous exudation seem to have taken place to any
great extent on the tracheal mucous surface, although the tenderness
over the trachea prior to the operation, and the appearance of the
lining membrane, as seen on opening the tube, proved that it was to
some extent implicated. The author remarks, that bronchitis, or
broncho-pneumonia, almost invariably iDccurs after tracheotomy is
performed, and is one of the great objections to the operation in
cases of croup, the inflammation being brought on by the operation
itself, and the necessary presence of the tube.

These circumstances do not seem to explain sufficiently the
broncho-pneumonia frequently following tracheotomy, since Prof.
Schuh, of Vienna, in the Wiener Medicinische Wochenschrifly 1857,
published his able article on this subject. According to him the
main reason is, penetration of the air to the air-cells of the lungs by
too short and immediate a way. This assertion is made probable by
the fact, that all the cases of broncho-pneumonia above mentioned
occurred in the right lung, and by the other fact, that the right
bronchus is by far the widest.

A case of successfully performed tracheotomy is related by Mr.
Bird.

Another case, in which the operation was performed for chronic
laryngitis, and proved successful, is reported by Dr. Cabot.

Dr. Bribosia communicated recently, to the Academy of Medicine
at Brussels, some observations on tracheotomy, which are of the
highest interest, and elucidate the favorable influence of this opera-
tion.

893

Mr. Marttn detailed, in the Western Medical and Surgical Society,
the particulars of a case of croup occurring in a child of 3( years,
who was able to endure the doctor's injudicious treatment for three
weeks, before it gave way and died.

Dr. Salzkr relates two cases of tracheotomy performed for croup.
The first occurred in a boy of 3J years. No pneumonia followed,
and the canilta was removed on tne seventh day. The second case
was that of a boy of 5 years, who was entirely asphyctic, and suffer-
ed from pneumonia also. He died after 34 hours.

Dr. Fuller published, in the Medico-G hirurgical Transactions^ vol.
Ix., 1857, seven cases of tracheotomy, performed for croup, three of
which terminated successfully. He then enumerated 23 operations
of tracheotomy performed in England, including his own, nine of
which were successful. Since the appearance of Dr. Fuller's paper,
five additional cases have been published, of which three had a
favorable result. There is no doubt, then, that this operation is pro-
ductive of a great saving of life. But the author is opposed to its
early performance, as recommended by the French surgeons, and
dieapproves of its performance where the patient has been out of
health prior to his attack of croup ; if his illness has been preceded
by pneumonia or severe bronchitis ; if he is suffering from any
exanthematic or other disorder ; and finally, lays particular stress
on tiie fact, that the operation itself barely admits air and does not
remove the disease, which is to be treated as before the operation.

Mr. Browning relates the case of a boy of two years and tdn
months of age, who had been suffering from a barking cough, with
hoarseness, for five months before croup became manifest and re-
quired the operation of tracheotomy. The canula could be removed
after five days, large quantities of false membranes having been
eliminated through it.

Dr. Klett reports the case of croup in a pale, anaemic, and already
cyanotic girl of six years, in which tracheotomy proved successful.

Dr. Millard's dissertation is of high statistical and pathological
value, beside the accurate records of 55 observations ; of particular
interest are the systematic tables containing the statements on the
operations which have been performed. In 1857, tracheotomy has
been performed, in the " Hopital des Enfants Malades,'' 70 times ; in
the first half of 1858, 54 times.

1857. 1858.

MaleB 89 Beoovered. . . . 4 Males 23 Recovered — 4

Females.... 31 << ....12 Females.... 31 <' — 9

70 16 54 13

Thus the proportion of recoveries is most favorable in girls, but
Bometimes the reverse has taken place ; as in 1854, when of 23 boys
on whom tracheotomy was performed, 11, and of 6 girls not one re-
covered. Therefore, the sex seems to have no influence on the sue-
cess of the operation.

394

Of the 62 girls who were subjected to the operation in the eighteen
months of 185T and 1858, there were of

2 years, 7, of which number died, 7, recovered,

U " 6

6 " 4

6 « 5

4 " 3

3 " 1

" 2

" 1

1 «

((

In 1850 and 1851, out of 8 cases of tracheotomy performed on
patients of 6 years and over, 7 recovered. In 1852, out of 16 cases,
at the same age, 8 were successful ; in 1856, 5 out of 9 ; of the other
4, one, of 8 years, died on the operating table ; one died of a severe
attack of measles, supervening on the thirteenth day after the opera-
tion ; the 2 last ones died, no particulars being given, but a few
hours after the operation.

Of 62 boys operated upon during the eighteen months of 1857 and
1858, 30 were under 4 years of age. Not one recovered, as is shown
by the particulars of the following statement :

2 years old

3 "

were

13, of
17

whom di
tt

ed, 13, r<
17

8Coven
(1

»d,

4 "

' tt

8 "

The chances are the less favorable the younger the patients. In
early age the operation is more difficult and dangerous, the trachea
being narrow, and the region in which the instruments are to operate
limited ; immediate accidents are more to be feared ; the results are
more uncertain, because of the difficulty of alimentation, indocility of
the patients, and want of vital resistance ; and the chances from
eruptive fevers, or convulsive attacks are more doubtful. Eruptive
fevers are particularly dangerous when complicated with croup ;
nevertheless, beside the two cases of croup complicated with measles,
recovering after tracheotomy, described by uuersant some years
ago, a third case of the same class is reported, which ended success-
fully.

As to the time when the operation is to be performed, the author
proves, by his statements, that the sooner the asphyctic condition is

39B

removed, the more favorable are the chances of recovery ; bnt there
are no chances at all wherever symptoms of a general poisoning of
the blood have appeared. Of 19 patients who recovered, 3 had been
sick before the operation was performed for 2 days, 5 for 3, 5 for 4,
3 for 5, 3 for 6 or more days.

Of complications of croup, there are four of principal interest :
general diphtheritii^, inflammatory diseases of the respiratory organs,
convulsions, which are, fortunately, rare, and troubles of the diges-
tive organs. Fifty respirations or more in a minute are an unfavor-
able symptom after tracheotomy has been performed, and require the
utmost care and attention to the state of the respiratory organs.

Of the 70 operations performed in 1867, there were in

Janoaiy 3, of whom recovered, 1

Fclaruary 4 " 3

March 6 «

April 7 " 2

May 3 «

June 6 " • 2

July 4 « •

AnguBt 6 " 2

September 6 " 1

October 6 " 1 '

November 5 " 1

December 16 " • 3

70 16

Of 63 operations performed in the first 7 months of 1858, there
were in

Janoary 10, of whom recovered, 2

FelHToary 6 " 1

March 15 ** 7

April 11 « 3

May 7 "

Jane 6 '*

. July 9 « 7

63 20

Of the 9 operated upon in July, 4 were boys, of whom recovered 3,
and 5 girls with four recoveries.

As to the medication preceding tracheotomy, the first indication is
not to injure. As injurious, the author considers leeches, vesica-
tories, mercurial frictions (which Trousseau declares to be as dan-
gerous as blood-letting), purgatives, and emetics of tartar emetic or
sulphate of copper (for their purgative effect) ; he considers as well
calomel, as bicarbonate of soda, to be of little use. Emetics of
ipecacuanha are, in his opinion, of some use, but only by their
vomitive effect ; chlorate of potassa is always given, because, when
producing salivation, it is thought to favor the expulsion of false
membranes. On cauterization of the larynx, onr author does not

396

pronounoe his opinion, as it would not affeot the consequences of
tracheotomy but by hindering alimentation by the superficial wounds
of the pharynx. He attributes no value whatever to the efforts made
to the purpose of defibrinating the blood, as by alkaline remedies,
and is of the general persuasion, that the chances of success arc the
more favorable the less energetic medication has been.

In the 22 cases of recovery, after the performahce of tracheotomy,
the canula was removed —

Onthe drddayin 1

« 4th ** 5

** 6th " S

" 6th " 3

" 7th " 1

" 11th " 2

" 12th " 2

" 13th « 2

" 14th " 1

« ^17th « 1

" •29th " 1

•

And the wound was perfectly cicatrized —

On the 14th day in 1

" 19th " 3

." 20th " 1

" 2l8t " 1

" 25th " 1

" 27th " 1

« 28th " 1

« 29th " 2

" SlBt « 2

" 32nd " 2

" 36th « 1

" 37th " 1

" 38th " 1 •

" 40th « 1

" 42nd " 1

" 46th « 1

" 6l8t " 1

The remaining part of Dr. Millard's book, the perusal of which we
cannot but highly recommend, contains a minute description of the
operation with all the particulars ; and further remarks on the ali-
mentation and medication after the performance of the operation
and local and general complications and their cure.

397

Prof. BoucHUT has invented a tube through which the child is
wftnted to breathe as long as the exudations of the larynx are not
ramoyed. This hollow tube is to be put into the cavity of the larynx,
and has some peculiar shape so as to adhere to the vocal cords.
Prof. B. asserts that they are brought in with the greatest ease, not
at all preventing the motions of the epiglottis ; that they are well
tolerated by the larynx ; that they afford the possibility of removing
aq>hyxia in croup without resorting to tracheotomy ; that false
nokembranes find their way easily through tiie tube ; and that this
new invention will prove highly useful in small places, where there
is no proper assistance, etc., for performing tracheotomy.

Reference is taken to the experience of Dr. Horace Green, of New
York, showing that probes may be introduced into the larynx, and
that they are well tolerated by this organ. Sestier reports ten cases
of introduction of a canula into the larynx, with good success.
Among the few cases in which Prof B. has employed his " tubage,"
is that of a girl of 5| years, suffering from croup, which had pro-
ceeded as far as to the stage of asphyxia and aneesthesia. The tube
was introduced and the croup got well ; but the child died from
pneumonia. The results of the post-mortem examination were the
following : In the auditory canal, in the nostrils, and on a sore place
on the arm, there were false membranes. There were some also left
on the pharynx and on the posterior surface of the arytenoid cartila-
ges. No more false membranes were left in the larynx and trachea ;
the mucous membrane was thickened, rugous, granulated, and pale in
the trachea, red in the region of the vocal cords. The mucous mem-
brane was neither softened nor ulcerous. The vocal cords were not
injured, somewhat thickened by swelling of the mucous membrane,
and the ventricles of the larynx appeared to be less deep. No diph-
theritic exudation was found. The bronchi were intensively red, the
mucous membrane granulated, not softened, but covered with a puru-
lent exudation. The right lung was slightly adheriug to the costal
pleura. Several pulmonary lobes were hepatisated, crude tubercles
were numerous in the lungs, and several bronchial glands were
tuberculous. A boy of 3J years of ago, (buffering from croup and
laboring under several attacks of suffocation to such a degree as to
be almost asphyctic, had the tube in bis larynx for 40 hours, and ex-
pectorated through it some thick cylindrical membranes. When a
new severe attack of suffocation occurred, Prof Bouchut's assistants
performed tracheotomy. The child recovered, but few false mem-
branes were brought up afterwards. The Professor's opinion is, tliat
the child would have come over this attack just as well as over the
preceding, and that his assistants had no reason to perform the opera-
tion, instead of further confiding in the sufficient effect of " tubige." .
He further says, that the tube was introduced very easily ; that no
attack of suffocation occurred after its introduction ; that the func-
tions of the epiglottis were by no means hindered, and the child was
speaking with a loud, clear voice ; and that a tube of a diameter of
eight millim., and a length of from two to three centimetres, is able
to allow of the passage of enormous false membranes, from trachea
and bifurcation.

398

This new method has made a great stir at Paris. They have dis-
cussed it in their journals, societies, and academies ; they haie
ordered and made and read reports ; questions of priorily have been
raised, for certainly Prof. Bouchut would not like to tell that anybody
before himself had ever introduced an instrument into the larynx.

Drs. Eetbabd, of Lyons, Loiseau, of Montmartre, Briois, of Paris,
declare to have been the first to catheterize the larynx ; even tiie
name of that American, Horace Green, is mentioned. Dr. Loiseau
has a sealed note of his opened, deposited by him in the archive of
the Academy of Paris as early as in the year 1851, in which a tabe
is described through which medicaments may be introduced into
the larynx. By means of a double-valve tube and a small forceps,
he declared to be able to extract false membranes ; in no case he
left the tube within the larynx. A pretty voluminous probe was
used by him, in diseases of the larynx, abready in the year 1840.
The " tubage" of the larynx, for the mere purpose of effectiiig a free
passage for air, would seem to be indicated only in oedema of the
larynx and in functional troubles of the epiglottis. Tracheotomy,
however, could not be rendered superfluous by it. To tear off fwe
membranes from the larynx, perhaps a brush-formed instrument, like
the "dcouvillon'' recommended by Dr. Engut, would be deemed snfS-
cient.

Dr. Latoub, in his report on the meeting of the Academy of Medi-
cine at Paris, on the 2nd of Nov., says tiiat the " tubage ^ cures no
more and no better than tracheotomy, nor does it prevent the propa-
gation of false membranes into the trachea, nor even the operation
of trachedtomy itself which it was deelned necessary to peirfbrm in
one of the reported cases. Undoubtedly the " tubage " is not an easy
operation, and prdbMy has not been performed at aU, as it is hardly
conceivable how the children would have been able to speak with a
tube in their larynx. D. Loiseau employs injections only, made by
means of catheterism of the larynx, of solutions of tannic acid ; Del
Bauchet prefers alum, and both like Dr. Costilhes, who thinks proper
to attribute the death of a girl of 2 years suffering from diphtheritic
angina and croup extending as far down as into the bronchi, to
some internal swelling due to the employed nitrate of silver, arc
opposed to the nitrate of silver. We venture to remark, that the
former gentlemen may have good reason for their opinion and its
expression, but we think that the " medical society of the Seine
department " would do better not to allow their members to render
themselves so utterly Tidipulous, as Dr. Costilhes is permitted to do in
the society's report. He once presumes, that a case of diphtheria
with false membranes from the pharynx to the bronchi would not
hav^ perished without the use of nitrate of silver, and presuming,
talking and printing is one and the same thing. We are sorry to state,
that such has been unfortunately the case with our brethren at
Paris ; if it was not. Prof. Bouchut would never have taken it into
his mind to ruin the public opinion on his physiological learning
and his common sense and his veracity, in the course of a few weeks.
Unless the French character was so very versatile, the word taken
in its favorable and unfavorable meaning, we could not but consider

399

^tjDr. Bonchni/s case as fully hopeless, The following is, according to
report given by Mb. Crequt, one of his cases, and modem modes
treatment : A strong boy of 10 years suffered from diphtheritic
~ ktion, in the fauces and larynx ; there were laryngo-tracheal
^friioiichi, roughness of voice, and cough. Cauterization had no favor-
/^idble effect; therefore "tubage" was resorted to — ^with no better
-^pooess. Because there was no success visible, Dr. Bouchut took
ip wieiimonia to be the reason of it and made a venesection. When
; iflie child became no better, he performed tracheotomy — and the boy
\ .VBCOvered, but not without having, for a time, suffered from anasarca
" and pleuritic^exudation consequent on Dr. B's. most injudicious treat-
[ m&oL No more, than in treatment, is Dr. B. successful when mak-
ing up his mind to deal in statistics. He asserts, that the number
(not percentage) of deaths from croup has been steadily increasing
•iiice 1826. ni the first years after this period one death from
cicmp occured among a population of 3000—6000 inhabitants, be-
oanse tracheotomy was performed in but few cases. Afterwards,
when more operations were performed, one death from croup occur-
led in from 1400 — 3000 inhabitants. He states that the increase in
liie number (not percentage) of deaths from croup dates from the
time of Bretonneau's book on diphtherite, and Trousseau's lectures,
and the introduction of cauterization, caustic instillation, and trache-
otomy into practice, and that these facts are the causes of the [large
number of deaths from croup. B. says so.

"and B. is an honorable man.^

In his opinion, as he emphatically states, the large number of| ^
deaths from croup is not produced by a greater frequency or severi-
ty, of the disease, but by hemorrhage, diphtherite of the artificial
wound, and secondary pneumonia, which are the effects of premature
operations as performed by Trousseau and others. These have to
oome up for the difference between the former and the present
number of deaths from croup.

Prof. Trousseau has completely refuted him. His statistics he
shows to be ridiculous, and his "tubage" dangerous, because of
consecutive necrosis of the larynx, useless when the croupous process
descends into the trachea ; and he disbelieves we think justly, that
it has been made at all. Finally he shows that Dr. Bouchut is far
from right in asserting that it is dangerous, and bad practice to
perform tracheotomy early, proving by statistics, that among 69
operations on moribund patients there were recoveries to the amount
of 21 per cent., while 64 per cent, recovered of 39 patients who were
operated upon in an early stage of the disease.

As to the size of the canuTa, the same author is of the opinion,
that a larger size is always preferable to one that is too small, the
former bemg, sometimes, able on Its own account to suppress hemor-
rhages.

As to after-treatment Prof Trousseau expresses the opinion, that
a good operation with 'careless after-treatment will prove unsuccess-
ful in every case, whereas an unskillful operation with a good after-

400

treatment will save one third of the patients. The utmost care
ought to be taken of the patients. They require a nourishing diet ;
difficulty in swallowing is sometimes removed by closing the canula
for a moment. In diphtheritic croup no vesicatory ought to be
applied. The air entering the trachea must be warm and damp.
The canula must produce no pressure on the neighbourhood of the
wound. The canula will usually be removed on the sixth or ninth
day, sometimes on the fourth, sometimes not before months or years
have elapsed.

Dr. Demarquay shows that patients suffering from croup, are an-
aesthetic in the last, asphyctic stage of the disease.

In Dr. Bohk's opinion Croup may be either descending, or ascend-
ing ; severe cases will generally migrate through the whole length
of the respiratory organs, and sometimes, like acute exanliiems,
jump suddenlv over to remote parts. Croup is either idiopathic, or
diphtheritic (progressing from the pharynx into the larynx), or
catarrhal (developed on the basis of, and out of a simple laryngeal
catarrh J. To this variety those cases of croup belong which are ob-
served m the premonitory stage of measles. The croupous process
in the larynx and trachea is seldom fatal by itself, death being the
consequence of croupous bronchitis." All the symptoms in the entire
coui:se of the disease are fully explained by the inflammation, the
presence of false membranes, and the paralysis of the glottis.

Mr. Matthieu exhibited before the Paris Academy of Medicine, a
new instrument, which is very much like a lUhotome cachi, and by
which he claims to perform the incision of the trachea in a safer and
quicker manner than by any one else.

Prof. Langenbeck has invented a double hook, which is destined
to fix the trachea and to show the exact place, where the incision is
to be made between the two halves. By removing tiie two halves
from each other the instrument is, at once, a dilatatory for the easier
introduction of the canula. From practical experience we dare say
that it is a useful instrument ; in some cases the sharp hooks might,
perhaps, be somewhat longer and and less bent.

Dr. NEUD()RrER describes a double canula, of which the outer half
can be removed as well as the inner half. We no not perceive that
such an apparatus is needed at all.

401

VI. ORGANS OF THE NERVOUS SYSTEM.

1. Atlee, W. F., a Monger of the Genus Feracephatus. — Amer. Jour.
April.

2. Forster, Contributioyis to Pathological Anatomy and Histology,

3. Hunt, J. A., Letter to the Editors Peninsular Journal, — Penins.
Jour. March.

4. Jackson, on a very rare Form of Monstrosity ; Two Heads one on
the Head of the Other, — Boat Med. Jour. March.

5. Pitha, Report on the Occurrences in the Chirurgical Clinique at
Prague. — Prag. Viert. 1.

6. Minutes of the Obstetrical Society of Edinburgh. — ^Ed. Jour. March.

7. Gibb, Double Sub-pericraneal CephalhcemaloTna. — Trans. Path. Soc.
Lond. IX p. 380. Lancet. Jan.

8. Brlinnicke, on the Pathology cf Cephalhasmatoma. — Joam. f. Kin-
derk. 5, 6.

9. Bierbaum, Cephdheematoma Verum. — Preuss. Ver.-Zeit. 38.

10. Friedrich, on Cretinism. — Bl. f. gerichtl. Anthrop. 6.

11. Klose. C. W., Idiotism in Silesia, a Sketch from Forensic Medi-
cine. — Hcnke's Zeitsch. 1.

12. Paasch, Commotio Cerebri and Wound of the Cranial Bones. —
Joum. f. Kinderkr. 3, 4.

13. Jacobi, A., on Irregular Development qfthe Infantile Cranium, and
the Etiological and Prognostic Importance cf the Premature Closure
of the Fontanels. — N. Y. Jour, of Med. Jan.

14. Buschke, E., Ueber Craniosclerosis IbtaHs Bachitica und Verdickte
Schudel meerhaupt, nebst neuen Beobachtungenjener Krankheit. pp.
54. (On Total Bachitical Cranio^derosis and Thickened Skulls in
General, vnlh New Observations cf Oust Disease.)

15. Otterbourg, in Practical Medical Society of Paris. — Un. M^. 125.

1 6. Budd, Case of Acute Meningitis Treated by Early Bloodletting. —
Ed. Jour. Jan.

17. Mosmant, E. G., Essai sur la congestion ciribrale. — Thfese. Paris,
p. 38. (Essay on Cerebral Congestion.)

18. Lesueur, Meningitis Tuberculosa. — Gaz. d. Hop. 8.

19. Friedleben, in Congress of Naturalists and Physicians. — Schmidt's
Jahrb. Nov.

20. Pace, J. M., Cerebro-Spinal Meningitis. — New Orleans Med. and
' Surg. Jour. May.

21. Wyihes, J. H., Apoplexy, with Sudden Death in Children.-^N orth
Am. Med. Chir. Rev. Jan.

22. Murray, J. J., Bemarks on Tujo Cases cf Poisoning by Opium in
Young Children. — ^Ed. Jour. Feb. — ^N. Y. Jour, of Med. May.

23. Lodge, R. T., on a Case cf Poisoning an Irfant by Syrup of Pop-
pies. — Lancet. Sept.

402

24. Meeting of the Medical Society at Vienna, — Zeitscb. d. Ges. d.
Aerzte zu Wien. 50.

25. Chambers, The Value of Mercury in Acvie Hydrocephalus. —
Lancet. June.

26. Tapping in Hydrocephalus, — Lancet Aug.

2*1. Lawrence, Puncture of the Head in Hydrocephalus. — Med. Times
and Gaz. Jan. 2.

28. Phillips, R., on the Treatment of Infantile Hydrocephalus by I^astic
Pressure, — ^Lancet. Jan.

29. Heyfelder, J. P., Punctio Hydrocephaly — ^D. Klin. 46.

80. Wilks and Bryant, Chronic Hydrocephalus in Four Stages; Death,
— Lancet. Dec.

31. Bristowe, Cancerous Orouihs Connected vrUh the Membranes (f
the Brain, and Producing Hydrocephalus.

32. Davis, W. L., an Hydrocephalic Belie, — Sav. Jour. Med. July.

33. Graham, Ch. W., Hydrocephdhid Disease, — Brit. Med. Jour.
Jan. 9.

34. Ayres, H. B., a Case of Congenital Hydrocerdyrd Hernia. — North
• Am. Med. Chir. Rev. Jam.

35. Valenta, A., and Wallmann, H., Hydromeningocete above the Boot
of the No8e of a New-born Infant, — Zeitscb. d. Ges. d. Aerzte z. Wien.
25, 26.

36. Valenta, A., and Walmann, H., a Bare Tumour above the Boot of
the Nose of a Netv-bom Infant, — Ibid. 14.

37 Pech, E. A., Auswaht einiger sdtener und lehrreicher FaUe, beobach-
let in der chirurgischen Klinik der Chirurgisch-Medicinischen Aka-
demie zu Dresden, Dresden, pp. 32. (Same Bare ^nd Instructive
Cases, etc,)

38. Shaw, Case of Encephalocde, Presenting at the Boot of the Nose. —
Trans. Path. Soc. Lond. I. •

39. Ravoth, in Tran8a(^ion of the Obstetrical Society at Berlin. — Mo-
natschr. f. Geb. May.

40. Legroux, Dispersed Congenital Sclerosis Cerebri. — Gaz. d. Hop. 74.

41. Fall of ChUdfrom a Third-Story Window, — Lancet. Sept.

42. Brierre de Boismont, on Mental Alienation, — Bull. Gdn. de Th<5r.
M^d. Chir. p. 556.

43. Homs, H., De VHiridit^ comme Cause de VAIiinaiion Mentale. —
Thfese. Paris, pp. 56. ( On Hereditariness as Cause (f Mental Alien-
ation,)

44. Hewett, S., Congenital Hydrocele of the Neck, — Lancet. Aug.

45. Ross, 0., an Unsuccessful Case of Acute Spinal Meningitis, — Cbic.
Med. Jour. April.

46. Gaund, on Epidemical Irritation of the Spimt Meninges in (he
Asylum for Young Girls, at Niort, — Arch. Gdn. Jan.

4T. Green, W. A., Case of Spina Bifida. — South. Med. Surg. Jour.
July.

408

48. Wilson, J. 6., Sjpina Bifida SticcessfuUj treated by Ligature and
Puncture, — Med. Times and Gaz. Oct. 9.

49. Jackson, J. B. S., Peculiar form of Spina Bifida ; urith Imperfora-
tion of the Duodenum and Rectum. — ^Bost. Med. Jour. Dec. 2.

50. Robin, F. L. F., Du Spina Bifida. Thfese. Paris. (On Spina
Bifida.)

51. Spina Bifida with Club-Foot. — Lancet. June.

52. Luschka, on a GongenUal Hygroma Cysticum Perirusdle xdth
Fc^m in Foau.—N'Mch. Aich. XIV. 4,5.

53. Leach, £., Case of Spina Bifida, xdth Congenital Extension of the
Uterus. — Penins, and Indep. Med. Jour. Dec.

54. Behrend, Fr. J., The History of Spina Bifida, its Development and
Treatment, and Report on a Succes^ut Cure by the Use (f Collodion,
Joum. f. Kinderk. 7, 8.

55. Adams, W., Spina Bifida, in the Lumbo-Sacral Region, tghich had
Ruptured in Ulero, Associated with Talipes Vanis of Both Feet, —
Trans. Path. Soc. Lond. IX p. 440.

56. £bra, J. M., Du Traiiement du Spina Bifida par les Injections
Jodies. Th^se. Paris, pp. 43. (On the Treatment (f Spina Bifida
with Jodated Injections.)

57. Glaser, J. A., Cases of Congenital Cystic Hygromas in the Sacral
Region. — Virch. Arch. p. 187.

58. Moynier, on Chorea,— Vn. U6d, 67, 69.

59. Bourg-uignon, H., a Short Review on Therapeutics, as far as the
Treatment of Chorea is Concerned, — Bull. G^n. de Th^. — M^-
Chir. Aug. 30. Sept. 30.

60. Keiller, Fatal Case <f Chorea in a Giri. Oct 15.— Ed. Jour. July.

61. David, Arsenic in Chorea. — ^Bost. Med. and Surg. Jour. Feb. 25.

62. Gillette, on Large Doses of Tartar Emetic in Chorea. — Gaz. Heb-
dom. 7.

63. Roger, Tartar Emetic in CAorco.— Un. M^. 76, 77, 78.--Gaz. d.
Hop. 80.

64. Wible, B. M. Ethiology of Convulsions.— J^ortii Am. Med. Chir.
Rev. Jan.

65. Minervini, G., on Eclampsy in Irfants. — Naples.

66. Achenheim, L., Leaves from the Note-Book of a Wed-Indian
Practitioner, — Lancet Sept

67. Reynolds, Pathology of Convulsions, with Especial Rrference to
those of Children. — Lancet. Feb.

68. James, L. A., a Case (f Infantile Convulsions SucoestfuUy Treated
by a Free Inhalation of ChhrqforwL'-^mc. Lane and Obs. Sept.

69. Yon Dem Busch, Convulsions in an Irfant^ Tredded with Chloro-
form. — Joum. f. Kinderk. 3, 4.

70. Lawrence, S., Case (f Infantile Convulsions, Succes^vUy Treated
by Carbonate if Iron, tfter FaHure cf Other Means. — iMi. Jour.
June.

404

71. West, 0. W., Beport on Three Cases of TetaniLs. — Sav. Med. Jour.
Nov.

72. Lauderdale, B. W., Ldter to the NashviUe Journal, — Nashv. Jour.
Sept.

73. NeudOrfer, J., Notices from the Chirurgicdt Clinique at OlrmUz,^
Oest. Zeitsch. f. prakt. Heilk. 36.

- 74. Gibb, Hemiplegia in a Nevibom Irfant — Lancet. Nov.

75. Cothenet, E., Du Diagnostic des Paraplegics. Thhse. Paris, pp. 29.
(On the Diagnostics of Paraplegia.)

76. Vogt, W., Die Essentiellc Ldhmung der Kinder. Bern. pp. 86.
Schweiz. Monatfich. — N. Y. Jour, of Med. Jaa 1859. (On Essen-
tial Infantile Paralysis.)

Dr. Atlee, gives the following account of a monster of the genus
peracephalus : '* The monster has no head or upper extremities. The
trunk and lower extremities are of a size corresponding with those
of a well formed foetus of seven months. A want of perfect sym-
metry, however is very manifest in the two halves of the trunk,
which is remarkable for a number of elevationSy.with depressions
between them. These elevations are due to the accumulation of a
great quantity of cellular tissue. This sort of lumpy condition exists
likewise in the lower limbs, which present, in addition, several other
imperfections. The feet are turned inwards, and they possess but
four toes, two of which, the smallest, on one foot, are not sepa^ted.
The external organs of generation are those of the female ; the anus
exists. Upon ^e front of the trunk, between the umbilicus and its
upper extremity, is something having the appearance of a small
empty bag or bladder, attached by a rather narrow pedicle. Both
above and below this bag is a small tuft of hair. Towards the sides
of the thorax, in the place usually occupied by the nipples, are small
round orifices."

Prop. Forster publishes a case of absence of both eyes in a new-
born child. There were no anterior lobi, no optic, nor olfactory
nerves, but a cyst between the dropsical third ventricle and
the pituitary gland. There is no doubt that this anomaly has been
the consequence of a dropsy of tbe anterior end of the medullary
tube during the earliest period of foetal life.

Dr. Hunt publishes the case of a monstrous child, the anatomical
description of which is, verbally, the following : " The child's head
and face were about a medium between a human and a frog. Its
eyes, neck, breast, shoulders, and arms, were exactly like those of a
frog.

No less incomplete is the description of a monster, by Prof. Jack-
son. The child weighed nine pounds, and lived for a month. There
was a second very small head, with some cranial bones, but, probably,
without cerebrum, on the head of the normal.

Prof. Pftha observed the case of a boy of twelve years, who suf-
fered, in consequence of a fall, from a fissure of the upper portion of
the frontal bone, in which hair was impacted. The hair being re-
moved from the fissure after twenty-five days, a perfect cure was ac«

405

complished. Another case of a foreign body penetrating into the
stmctore of the cranium occurred in a boy of four years of age.
The foreign body was extracted without trepanation, and the cure
was perfect in a fortnight.

Db. Keilleb reports the case of a new-bom infant, having a large
tumor on the left parietal bone, of the size of an egg. A hard rim of
bone could be felt all around at the base of the tumor. No treat-
ment was ever had recourse to, nor required.

A cephalh»matoma on each side of the top of the head came under
the observation of Dr. Gibb. The child had been born after a labor
of a quarter of an hour, without assistance of any kind. The swell-
ing on the left side was the largest, and fully the size of a hen's i^gg.
It did not communicate with the other one, and pressure produced no
effect on the child, who was in every respect healthy. The tumors
were found to be encircled apparently by an osseous ridge, which
seemed elevated with the tumor, as it were, lying in a sort of depres-
sion in the bone. The first was completely absorbed in thirty-nine
days, and the second in fifty days.

In a child of twenty-four hours, who had been bom easily, and
without artificial means. Dr. Bierbaum observed a cephalhaematoma
of two inches in length, and one and one-half in breadth, on the su-
perior and posterior part of the right parietal bone. It was soft,
encircled by an osseous margin, the skin not discolored. Warm aro-
matic fomentations were of no use, embrocations of mercurial oint-
ment and iodide of potassium proved successful. Another cephalhae-
matoma came imdcr Dr. Bierbaum's care in a boy of eight and one-half
years of age ; it was situated on the inferior and anterior part of
the left parietal bone, was the size of half a hen's egg, soft, elastic,
fluctuating, surrounded by prominent osseous margins ; skin not dis-
colored. Nothing could be found to explain the tumor, which became
larger with the use of warm fomentations, and, when incised, exhib-
ited a large quantity of black liquid blood, and healed rapidly.

Prof. Friedreich has published an article, written in his clear and
simple manner, on the forensic and anthropologic relations of cretin-
ism, omitting expositions on its bodily and psychical ones. We
therefore, are satisfied to merely announce it.

Dr. Klosb publishes some statistical reports on the frequency of
idiotism in the plains of Silesia, in which an undulated soil, abun-
dibice of water, and a peculiar condition of the atmosphere are re-

Brted to exist These, and a particular individual disposition, Dr.
lose counts among the causes of idiotism, which may be developed
with feverish symptoms, especially in older children of from two to
three years, but is by no means of an inflammatory character. Ma-
laria influences seem to be prominent. The brainfof such juvenile
idiots is mostly small and hard, the cranium smaller than usual.
Deafness and dumbness is a very common occurrence. A fatty
fibrinous infiltration takes place between the neurilema and the cer-
ebral tubuli ; a degeneration, not only impeding the transmission of
impressions on the nerves, but also injuring the nutrition of the
medullary and cortical substances. Its injurious influence on the
mental faculties of the organism is, therefore, easily understood.

406

Prof. Huschkb, the great measurer and weigher of crania and
brains,'*' died, while this last work was being printed ; and never
was a man more fortunate to leave after him a work, that would of
itself procure to its author immortality in the annals of pathological
anatomy. Every sentence of this book being valuable, we regret not
being able to give more than a meagre report of its manifold con-
tents. But whatever we inay select is worthy of the highest interest.
The new case of total osteosclerosis described by our author, is that
of a girl of seventeen years of age, whose skull (the normal weight
being 600 grammes), weighed as much as 4,117 grammes. The
microscope showed, that the medullar (Havers') canaliculi were
large, and very numerous on the surface, narrow and very few in the
interior of the sclerotic bones, and that the osseous canaliculi were
more spheric and irregular in site and shape. The chemical compo-
sition was also abnormal, the constituents being phosphate of lime,
65.59 ; carbonate of lime, 11.12 ; sulphate of magnesia, 1.14 ; cartr
ilage, very little fat, etc., 22.15. No flnorate of lime was found.
After all, the bones taken as a whole, proved exceedingly solid, but
fragile, when tried in small pieces, very white in their interior, but
yellowish on their surface ; the latter color being the relic of extrav-
asated blood or other pigmentous matter. Another skull, in the
possession of the author, and apparently only in the beginning of
sclerotic development, weighed, inferior maxilla exclud^d^ 1,075
grammes ; and a third, in t£^ museum of the University of Jena, of
the same description, is that of a young baboon, in which all the
bones covering the hemispheres had undergone the sclerotic anomaly.

The superior half of the skeleton, in the physiological state, exceeds
the inferior half by a greater amount of calcaria. But this preval-
ence is not only absolute, but also relative, the single bones contain-
ing a larger average proportion of earths iff general, and lime in
particular. There is also a physiological craniosclerosis in families
as well as nations ; the thickest and hardest skulls being found in
African negroes, whose crania, although they be not absolutely
heavier than Caucasian ones, undoubtedly have a greater weight in
relation to the size of the cranial cavity. Further, the crania of the
flesh-eating negroes of Guinea are much harder and heavier than
those of Persians and Hindoos. Moreover, it is altogether note-
worthy, that the human organism in Africa is throughout prominent
for the exceedingly strong development of the substances and orgaSas
taking the lowest place in human chemistry and physiology, vis. :
bone, fat, and sexual organs, etc. Of undoubted morbid total crani-
osclerosis, there are only ten cases ; those of Malpighi, 1697 ; Guvier,
1822; Ribalt, 1828; O. Forster and Bojanus, 1826; Ilg, 1822:
Kilian, 1822 ; Otto, 1822 ; Vrolik, 1848 ; Albers, 1851 ; Buschke,
1858. The disease does not affect the auditory bones, the condyles
of maxillar and occipital bones, and the styloid process of the tern-

* This great work, published at Jena, in 1854, bears the title : '' Cranium, cere-
brum and mind, of men and animals, described according to age, sex and race, from
new methods and investiffationa." It contains nearly two hundred pages, in foL^
and is couS&boMj the results of more than ten years' hard labor.

407

poral bone. There are some symptoms of the disease in the posterior
part of the cranium and basis cranii, but most affected are the bones
of tho face and the frontal, parietal and cribroid bones. Thus the
disease takes its origin in the anterior portion of the sknll, particu-
larly in the superior maxilla, and proceeds upwards and backwards,
terminating in the basis cranii, in the neighborhood of infundibulnm
and appendices. Two observers have been so fortunate as to meet
with the preceding disease in the living. The average amount of
earthy matter is very considerable in all ^ them. While the normal
proportion of earthy matter to organic substance in cranial bones
has been found by Professor Frerichs to be = 2.1 (or 1.6) : 1 — ^it is
in the sclerotic bones from 8.5 to 4.4 : 1. Generally the carbonate
of lime is reported to have been found increased, which proved to bo
the like in spongy bones. All the cases were those of juvenile in-
dividuals, or at least the disease had commenced in childhood.

The extension of the disease over the greater part of the cranium,
contrary to the nature of local exostosis, proves tne abnormal process
to be the result of vicious general development. Professor Buschke,
in opposition to the rest of the authors, pronounces the nature of the
disease rachitic. The first origin must be traced back to early
infancy, perhaps to foetal life. Very probably the bones in early in-
fancy were soft, suc<;ulcnt, and full of blood-vessels, and the cranium
and cerebrum like the rest. After the period of rachitic, spongy
thickening, and consequent mollification, osteoporosis was followed
by the stage of rachitic ebumeation, which continued to go on by the
support of chronic inflammation. Now, in the first period of rachitis
the bone is soft and spongy ; its layers, while not less in number,
secede from each other. The osseous substance is darker and more '
copious, the medullar cells larger, etc. ; but in the period of sclerotic
ebumeation tho peculiar osseous cells become denser, more numer-
ous, the canaliculi thinner, medullar canals and diplo^ are gradually
obliterating. The vegetation of the inner lamina of the bones is said
to stop, in the physiological state, after the tenth year of life ; and
the dura mater does not form new layers before, the regressive pe-
riod of cerebral development takes its commencement in advanced
years. After the fiftieth or sixtieth year of life, resorption com-
mences to lose power, the cerebrum becomes smaller, the veins
narrower, arteries wider. If this development commences in earlier
life, the above-named disease, is originating, which, when the hyper-
ostosis of the cranium is external ; that is to say, when but the ex-
ternal surface is affected, does not affect the cerebral functions, but
gives rise to serious trouble of the mental faculties when internal,
and produces spasmodic affections, neuralgias, and paralysis.

The conditions necessary to the development of cranio-hyperosto-
sis are first, abundance of lime ; secondly, congestion, and sometimes
chronic inflammation. It is a characteristic fact that the bones, the
development of which is the quickest after birth, show the greatest
disposition to hyperostosis, as the maxillar and cranial bones. Abun-
dance of lime may be produced by such food as meat. One of the
patients is reported to have been a very hearty eat^r. Or, as has been
the case in Huschke's individual, there is little excretion of lime by

408

the urine. Or there is a metastasis of lime in such a way, that lime
is resorbed in certain other places, and introduced into the substance
of the cranium. Probably a number of causes cooperate to the same
effect. But, at all events, it must be borne in mind, that the phtholo-
gical process, great though the anomaly may be, is in a majority of
cases to be explained by, and to be considered as, an extravagance
in Dormal physiological development. The expositions of this fact,
as published by Buschke, supported by his genius, extraordinary
learning, and knowledge of literature ; and further, the remarks on
ossi6cation of the sutures mad^ on the last pages of this excellent
work, we have the satisfaction to state, fully corroborate the views
held by us long ago, and laid before the profession in a short essay
on the premature closure of the fontanels and sutures, and their pa-
thological importance {N. Y, Jour.qf Med.^ Jan., 1868); a subject on
which we have, in this very volume (Part I., Art. vii.), submitted
some new and interesting facts and observations to the critical ex-
amination of our readers.

Dr. Otterbouro directs the attention of medical men again to the
usefulness of cold aifusions to the head in cerebral diseases.

The patient referred to by Dr. Budd, was a girl of ten years of age,
with the symptoms characteristic of n^eningitis, viz.: headache, rest-
lessness, jactation, sleeplessness, vomiting, a drawn-in belly, and
confined bowels. There was no strabismus. The patient recovered
after vens&section had been made twice.

Such cases occur but seldom, as the majority of such cases in
children, are cases of scrofulous, and dyscrasic inflammation in gen-
eral.

^ Dr. Lesueur publishes, in the Annales midicdes De la Flandre occir
dentaley five cases of meningitis tuberculosa, of which three were
cured by the method of Dr. Hahn, as described in his book De lamen-
ingite tuberculeuse itudUe au point de vue cliniquey par Henri Hahn,
Paris, 1853. Dr. Hahn's method is known to our readers to consist
principally of embrocations of tartar emetic salve on the scalp. Al-
though the five cases may not have been tuberculous meningitis, they
were, at all events, severe cases of meningitis, and the favorable re-
sult is very remarkable indeed.

In the association of German naturalists and physicians of last
year. Dr. Friedleben endeavored to show that simple meningitis must
be discerned from the tubercular form of the disease, and sometimes
could be met with, and cured too, in individuals afijected with general
tuberculosis. In Dr. Friedleben's opinion, the diagnosis of tubercu-
lar meningitis requires the presence of a protracted stage of pro-
dromi, hereditary influences, and dyscrasic symptoms ; in post-mor-
tem examinations, the bronchial glands are generally found to be
tubercular. Acute hydrocephalus and tubercular meningitis are by
no means synonymous ; ibr in the second half-year of life, where es-
sential changes take place in the organs of sanguification, hydro-
cephalus without tubercles, also cerebral hyperaemia with lethal re-
sult are not unfrequent occurrences. In all these forms of disease the
prominent symptoms must be removed, and the strength spared ;
cold afiusions have proved successful in convulsions. Cerebral tu-

409

bcrcles, especially miliary tuberculosis of the arachnoid membrane,
are by no means absolutely lethal. Dr. Koshlek reports a case of
meningitis terminating successfully in a tuberculous child, and re-
commends, in convulsiond, preparations of opium. Iodine is warmly
recommended by others. Dr. Kuchenxeister mentions the presence
of cysticerous in the brain, the inflammatory consequences of which,
with their symptoms, being easily mistaken for tubercular meningitis.
Prof. YiRCHow considers two-thirds of all the cases of infantile hy-
drocephalus to be attributable to tuberculosis. Frequently cerebral
byperaemia sets in, in such cases, the gray substance looking aneemic,
the white one, dark red, and takes a very rapid course ; and in a num-
ber of cases there are very thin tubercular nodes easily escaping ob-
servation in the choroid plexus.

Joseph H. Wythes reports in a short article, three cases of apoplexy,
with sudden death in children, the post-mortem examinations of which
are herewith given in his own language : First case — Child three
years old. "An extravasation of blood was observed between the
cranium and dura-mater, perhaps half a fluid ounce. The vessels of
the membranes were much injected, and the posterior part of the sep
torn had a large clot of blood in it. The membranes were also m
many places strongly adherent. The white substance of the brain
was full of bloody dots or points, with the appearance of infiltrated
blood in tlie posterior lobes, particularly on the right side. The right
ventricle had in it a clot of blood, with serum.''

Second case, — Child three months old. " The vessels of the arach-
noid and pia-mater were considerably congested, and the whole cere-
bral substance was softened, being about the consistence of melted
butter. A little serum was observed at the base of the left hemis-
phere of the cerebrum, but nothing abnormal in the ventricles. The
membranes of the cerebellum and medulla oblongata, were strongly
congested."

Third case, — Child three months old. '' The membranes of the brain
healthy, but its substance much congested. On slicing, it seemed
foil of bloody*doti^ X small clot of blood was found in each ven-
tricle.''

Dr. Lodge reports the case of an infant, six weeks old, sufiering
firom s3rmptoms of poisoning after having been given a teaspoonful
of syrup of poppies. The administration of a mustard-bath, and the
ready method aroused the child after some hours, at once producing
a copious perspiration.

Dr. ScmTLLER publishes a case of poisoning by syr. diacod , adminis-
tered to a new-born infant. Patient recovered after nine hours.

Dr. Murray reports two cases of poisoning by opium in young
diildren, in which the treatment proved successful. An infant aged
twelve months and a day, was allowed to swallow a quantity of lau-
danum equivalent to three grains of moist opium. Some hours were
lost before help was procured. Tickling the fauces with the finger
and with a feather, the administration of mustard iu tepid water, an
emetic of ten grains of sulphate of zinc in tepid water, the sponges
of Kemp's battery in the course of the phrenic nerve, proving una-
vailing, the stomach-pump was used with good effect. Then the child

410

was placed in a wanned bed, with hot bottles to his feet ; hot blank-
ets were applied from time to time, and sensation was kept up by
frequent shocks from the electro-magnetic coil-apparatns. The symp-
toms appeared to be alleviated when the cutaneous excretion became
copious, a fact in which Dr. Murray sees more than mere coincidence.
Opium seems to him to be excreted by the skin, while the emission
of every other discharge is impeded. For it frequently happens that
on a post-mortem examination of persons destroyed by opinm, no
trace of the poison can be obtained (Pereira, ii., 2104 ; ChrisHscm on
Poisons, 4th ed., p. 698). Either, therefore, the constituents of opium
are really present in the dead body, but cannot be detected by any
known tests, or they are digestible and assimilable ; or they are got
rid of by cutaneous excretion. Another child, seyenteen months and
two weeks old, took a solution of ^ grains of the muriate of mor-
phia. As four hours and a half had elapsed since the administration
of the poison, the application of the stomach-pump was considered
to bo unnecessary. Strong coffee was administered at short intei>
vals, and galvanism employed to keep the child awake. Then the
child was enveloped in hot blankets before a strong fire, ontil an
hour and a half later, when the skin was in a state of profuse per-
spiration.

Dr. Murray adds the following valuable remarks': With regard to
the operation of opium on the human system, infants differ from each
other as widely as do adults. Numerous cases might be quoted in
which a few minims of laudanum have proved fatal to young* child-
ren. (See Beck in Med, Chz,, 1843-44, p. 16t). For instance, Dr.
F. Kelso records a case {Ixmcetj 188t--88, i., p. 304), in which a child
nine months old was killed in nine hours by four drops of laudanum.
In another case, a child between five and six years old, died in thirty-
six hours from ha\ing taken an amount of paregoric containing from
three-quarters of a grain to one grain and a quarter of opium {Cfutfs
Eos, Bep.j April, 1844, p. 32). In a third case, a child aged seven
months, was killed by a dose of paregoric, equal to a quarter of a
grain of opium {PharmaceiU. Jour,, April, 1846, p^46'[). Dr. Taylor
cites the case of a child, four and a half years old, who was killed,
in June, 1832, by a dose of four grains of Dover's powder, contain-
ing not more than two-fifths of a grain of opium {Guy* a Eos, B^,,
1844, ii., p. 41), and Dr. Christison mentions an instance in which the
administration of three drops of laudanum in a chalk mixture, for
diarrhoea, " to a stout child, fourteen months old, was followed by
coma, convulsions, and death, in about six hours" {On Poisons, 714).
The only authenticated instance on record, which Dr. Murray knows
of a child that has survived such a dose as was administered in the
two cases detailed above, is given by Mr. Oalahan in the Dublin Med,
Press for April 22, 1846, p. 244. (See also Blanc's case, cited by us
from Bulletin de ThArapuiique Midvco-Chirurgicde, Nov. 17, 1867, p.
462, in the JV. F. Jour, of Med,, Jan., 1868, p. 117 ; and Chamber-
lain's case, cited from the Boston Med. and 8ur, Jour,, Dec. 3, 1857,
in the N. Y, Jour, of Med,, March, 1868, p. 885.)

Dr. Ghambebs cited a case of a boy who had a fit and symptoms of
cerebral inflammation, which he recovered from ; yet on the boy dying

411

some months afterwards of tubercle in the longs, old adhesions and
tubercles were found in the arachnoid. So that meningitis even of a
tubercular character, may be cured.

In Lancet, Aug., a case of chronic congenital hydrocephalus, is
reported. The child was already in a drowsy and semi-comatose con-
dition. A trocar and canula were introduced into the coronal suture,
an inch from tlie middle line, and seven or eight ounces of a clear,
pale fluid were withdrawn. Soon after, indications of relief and live-
liness were perceived. Four days afterwards, ten ounces were re-
moved from the posterior part. After four days, the child was more
restless than drowsy. Health was, however, improved. The child
was reported to have died later, apparently from inanition.

Mb. Lawrence performed the same operation on the head of an infant
of nine weeks with congenital hydrocephalus, the chief protuberance
being backward, the forehead very slightly enlarged. The child was
dull, almost in coma ; by means of a small trocar, eight ounces of
albuminous, very alkaline, and, on the addition of acid, efferves-
cing serum, of 1009 spec, w., was removed.

Dr. Hetfsloes operated on a girl of fourteen months, who had been
bom with hydrocephalus, and whose mental development was very
rapid, while the physical one was very poor. She had eight incisors
and two molar teeth ; dentition having always been very trouble-
some. There was no locomotion, because the head always wanted
support. When nine and ten months old, her head was punctured
twice, and an ounce of a clear serum was removed each time. When
fourteen months old, the circumference of the head around forehead,
temples, and occiput, was twenty-one inches, from the forehead to
occiput, over the vertex, twelve inches, from ear to ear, thirteen
inches. The head looked like a triangle, the basis being above, the
point being formed as it were by the chin. The face was folded, and
like that of an old man, the bulbi were not completely covered by
the eye-lids, the sclerotica had a dirty tint. Teeth were badly de-
veloped, sagittal suture between large and small fontanels was 1|
inches wide. Puncture was performed in the middle part of the
large fontanel ; three bottles full of a transparent clear serum, of
alkaline reaction, was removed. In the twenty-four hours following,
much more serum flowed out ; on the third day the child grew rest-
less, and had slight convulsive motions in her hands ; sopor followed,
and the child died on the seventh day. The ventrical and third ven-
. tricles were extensively enlarged ; Ihe cerebral substance around
the lateral ventricles were only a third of an inch thick ; all the cere-
bral parts were found to be present, but plain and atrophical ; the
aperture made by the trocar was still seen. There were still three
pounds of serum in the ventricles.

Six-and-thirty years ago it was known to Sir Gilbert Blane, that it
was possible to get rid of encephaloid effusion by mechanical pres-
sure, the means employed being bandages and adhesive strapping.
Dr. Phillips, in two cases he reports, constructed an elastic hoop, or
fillet, with strong india-rubber webbing, two inches wide, with
which to encircle the head. Having made the fillet purposely too
nnall in the girt, he was enabled, by stretching it with both hands

412

from within, so to adjust it as to exercise a considerable amount of
well regulated pressure around the distended cranium. Some days
after adjusting the elastic fillet, the bands became loose by the
cranial bones having approximated each other. There was also less
tension of the scalp. After a short time the fillet had to be read-
justed again, until the cranial bones touched each other. A cure was
effected in both cases. Naturally, the earliest possible age, and
where the case is not of long standing, are the conditions most fayo]>
able to remove, by pressure, the atonic, passive condition of the
meningeal vessels, resulting from absence of that resisting medium
offered by the healthy, normal calvarium. Besides, the elastic fillet
seems to be very much preferable to bandages and adhesive plasters,
which would need removing in short intervals, as soon as dimunition
of bulk begins, not to speak of the.troublsomeness of the removal of
a number of adhesive straps from the hairy scalp.

Dr. Bristowe records the case of a boy of 2| years, who had been
healthy up to the end of his second year. He died of hydrocephalus,
all the ventricles being immensely dilated. In the posterior fossa
the under and back part of the cerebellum consisted of cancerous
matter, of the size of a walnut, adhering firmly to the dura mater.
One or two pea-sized hemispherical growths, of the same nature as
the above, were discovered growing also from the parietal arachnoid
of other parts of the posterior fossa.

Dr. Davis describes the skull of an individual who died at the age
of twenty (sixteen years before the cranium came into his posses-
sion). When the subject was about seven years of age, the charac-
teristics of hydrocephalus made their appearance, and made such
gradual encroachment, that no visible depay of intellectual power
was at any time strikingly exhibited. Cadaver not over four feet
in length. The frontal, occipital, and temporal bones are beautifully
exhibited in their attachments ; but the parietals wanting their
superior articulation form but one bone. Its admeasurements are :

Horizontal circamference * . 2 ft. 10 in.

Anterior perpendicular circamference 2 " If *'

Central " " 2 " iJ «*

Posterior " " i " sl "

Yerticfd antero-pofltcrior " 2 " llj "

Antero-pofiterior diameter 1 " 4 "

Vertical « 9 "

Biparietal " .... S| «

Lengtli of right par. bone ftaia ant inf. to post. sap.

angle 1 «

Distance between the post. inf. angles of the par. bones. . 1 " 4} <'
From alv. process of sup. max. to union of sagittal with

coronal suture 9^ *'

Length of os frontis 9| "

Breadth*^' " 1" 4 '*

Length of crista galli 1 "

Sella turcica 1 «

Petrous portion of the temp, bone 3J "

Infer, petrosal sinus 7* **

Thickness <tf skull J-J "

Dr. Graham reports the case of a little girl, two years and a half
old. There was no pain on pressure being applied to the region of

418

the stomach and bowels, thougb there was the most 'urgent desire
for cold water, which was immediately reiected. The skin was cool ;
the pulse 88, soft, and moderately full ; the tongue thickly coated to
the point, and red around the edges. The bowels were confined :
there was constant picking at the nose and angles of the mouth, ana
the child awoke suddenly screaming from short sleeps ; the coun-
tenance was occasionally flushed, the urine high-colored and scanty.
There was, on the next day, strabismus, dilatation of the pupils,

Cdinff of the teeth ; the pulse was small, and very feeble ; the
pate and collapsed. The child had suffered two or three con-
vulsive seizures. In fact, all the usual cerebral symptoms, met with
in the two opposite states of overfuUness and of deficiency of blood,
were found. The treatment consisted of some doses of castor oil,
repeated enemata, and the strongest stimulants given in short intei*-
vals. The child was entirely well after four days. We have seen
many cases in which inanition was the only cause of severe cerebral
symntoms ; but we do not find, in the history of the case before us,
the least proof of its belonging to the kind of cases referred to.
Besides, it is well known that convulsions and other cerebral symp-
toms are not rare occurrence^, from no other cause but continuous
obstipation of the bowels, with or without gastric catarrhus, flatu-
lency, cte. For all these cases enemata and purgatives are the best
possible remedies, although the consecutive cerebral symptoms
appear to be of the extreme severity, and show their wholesome
effect in a short time. In the case reported by Dr. Graham, we do
not know, indeed, if his diagnosis was the correct one, although he
affirms that, by the writings of Abercrombie, Marshall Hall, Gooch,
and Evanson and Mannsell, he has learned more about these things
than " the general practitioner."

Atres reports the case of a congenital deformity, said to differ
from encephalocele and hydrocephalus, although appearing similar
to the latter.

Drs. Valenta and Wallmann call hydromeningocele such tumors
about the cranium which are filled with arachnoid fluid and formed
and enveloped by the meninges, pressed through a cranial aperture.
Thus the difference is at once given between it and encephalocele
and hydrencephalocele. Some new cases of the author are then com-
municated, and the nature of different varieties of hydromeningocele
described. Hydromeningocele, in the foBtus and iu infants, may be
found without any alteration of the brain ; of this class there are
twenty instances in the literature : or the brain is found destroyed
and other, malformations present ; of this class medical literature
numbers eleven cases. Hydromeningoceles, in adults, are rarely met
with ; Dr. Wallmann observed three cases, and collected two others
from literature.

Dr. Pech observed three cases of encephalocele. One girl, of
16 weeks, had neither cerebellum, nor tentorium, nor falx, nor crura.

Dr. Shaw relates the case of a healthy and lively child of 3 months.
Treatment was not attempted.

Dr. Ravoth's discourse, in the Obstetrical Society of Berlin, on
cerebral hernia, produced either by excessive size of the brain, in

414

consequence bf dropsy of the ventricles, or by dropey of the arach-
noidean sac, or by retarded osseous development, or by injuries
during the foetal state, Contained no new particulars.

Dr. Legroux reported, in the SocUte Midicdle des HapitauXf the fol-
lowing case of dispersed congenital sclerosis cerebri : A woman,
whose eight children had been still-born, gave birth to a ninth, who
appeared to be of good health. On the fourth day, the child was
found dead in the arms of the mother. The post-mortem examination
gave the following results : The cerebral membranes were entirely
normal ; so was tiie cerebral substance in its greater part. But on
a certain number of points it looked somewhat grejrish, and contain-
ed about ten small and hard tumors, of 0.01 centim. in diameter,
which were dispersed in the cerebral substance, and could not be
separated therefrom by enucleation. Under the microscope, they
were shown to consist of fibrous tissue, which is never found in a
normal cerebrum, of amorphous granular matter, and oi a special
alteration of the peculiar nervous tissue. The heart was filled with
black and viscid blood. Within its texture, especially in the tendi-
nous columns of the left ventricle, there were small tumors of a yel-
lowish white color, looking very much like the cerebral tumors. The
lungs were found to be pressed towards the vertebral column, and to
be of a black color, with the exception only of the anterior quarter
of the left lung, which was of the usual pink color, crepitated and
contained air.

A girl, of two years of age, fell out of a thirdrstory window on to
the pavement. The right arm was broken, the back much bruised,
the face scratched, the child was insensible, and presented symptoms
of concussion of the brain. These passing off in two days, the child
was lively and healthy.

Dr. Brierre de Boismont made the following remarks, in the
" Institute,'' on mental alimentation : Mania, or rather " perversion
of instincts with exaltation,'' is most frequent in young patients. Of
30 cases, the antecedent history of which could be learned, there was
in 18 a hereditary disposition. The parents, besides attacks of in-
sanity, were of an extremely sensitive and eccentric charcu^ter. The
children born of them were sometimes of an extremely melancholy,
sometimes of a highly gay turn of mind, always changing in their
disposition. In the 42 patients observed and recorded by Brierre de
Boismont, insanity became manifest towards puberty. The influence
of these hereditary transmissions appears to be almost unknown to
educators ; the author declares himself satisfied that in many cases
insanity is the consequence of this ignorance. The prognosis is un-
favorable. Nearly half of the number of patients were registered as
being cured, some time or other, but there were a number of re-
lapses, changes of character and temperament in such a degree, as
to disable the patients to take a position in life and follow a business.

Dr. Homo, from a number of cases observed at Bicdtre, draws the
following conclusions : That mental derangement, beside the cases
produced by alcohol, belladonna, haschisch, opium, lead, etc., is most-
ly the conseq^uence of a hereditary predisposition, particularly in
chronic affections ; that the parents of mentally deranged persons

416

have been either deranged themselves, or subject to disemses bearing
on the nervoos system, as alcoholism, cancer, and phthisis ; that de-
ranged parents, generally have children either 'dying in early age,
mostly of conyulsions, or affected with scrc^uloas or phthisical dis-
eases ; but that this hereditary transmission is not positively neces-
sary and indispensable.

Dr. Hiwnr reports three cases of congenital hydrocele of the neck.
The first is that of an infant of a month of age, who was born with
a pyst on the right side of the neck, of the size of a rather large or-
ange. It was punctured, and several ounces of fluid were withdrawn.
The cyst was unilocular. Iodine was iuiected afterwards. The case
was still under treatment when reported. The second case was ob-
served in an infant, also. The cyst had been punctured, but no in-
jection having been made, it grew again. The third occurred in a
young lady, who was operated upon when a child. The tumor had
been dissected out, but a small bit adhering to the subclavian artery,
was left. Now, in the age of 14 or 15 vears, a tumor occupied the
same situation. Two threads were passed through it to act as setons,
pus and foetid matter were evacuated, and a speedy recovery ob-
tained.

Mr. Russ reports shortly, indeed, very shortly, a case of probable
acate spinal meningitis, in a boy of three years of ag^. The doctor
administered, every three hours, one grain of calomel, and two grains
of Dover's powder. The child did not stand it.

Dr. Qauki reports the cotemporaneous occurrence of a number of
nervous symptoms in 19 girls, of from 9 to 21 years of age, residing
together in an asylum. AH at once, or after some nervous prodromi,
lasting for 24 days, the patients lost the power of locomotion, com-
plained of pain in the lower extremities, and along the vertebral col-
umn, which was aggravated on pressure, and suffered from spasms.
OpisthotanuB was present in three of the patients. General and local
bloodletting, laxatives, and opium, were the common and successful
remedies. Nothing abnormal could be found in the food ; therefore.
Dr. Oaund searches for the common cause of the disease in the con-
dition of the atmosphere. Dr. Gunsburo, when reviewing Dr. G.'s re-
port, reminds his readers of a well-known occurrence of a similar
idnd, in Franke's Orphan Asylum, at Halle, where the cause was
found in nothing but a degeneration of instinctive and involuntary
imitation.

A case of spina bifida in a new-bom child came under the obser-
vation of Dr. Green. This deformity is rarely uncomplicated, but
the complications in this case are somewhat interesting. Tliere were
''two appendages to the sac, resembling the manmise of women ; a
large hernia between Hie umbilicus and the symphvsis ; some small
openings through which the urine was continually trickling, but
which could not be followed up by the probe : the testicles, 'perfectly
formed, were hanging pendent from the middle of the symphysis ;'
there was no poms, the anus was complete and perforate at the ex-
treme anterior portion of the perineum, next to the symphysis ; at the
point of the os coccygis was another anus, which proved to be a cul-
de-sac."

416

Dr. Wilson reports the case of a child, a few days old, with spina
bifida of about the size of a small orange, rising by a neck nearly an
inch in diameter,'from the middle of the lumbar vertebrae. A ligature
was applied not' very tightly at first, and a new one put on every
day. The tumor enlarged considerably, and it was frequently punc-
tured with a fine needle. It was not till the fourteenth day after the
first application of the ligature, that the sac began to shrink and
shrivel up. The small sore left on the eighteenth day, when the tu-
mor fell off, gradually healed, by the use of (Efimple water-dressing
combined witK pressure, and a firm cicatrix was form^ in the space
of three weeks. Before the closure of this sore, a slight fissure, or
defect in the spinal canal, through which the tumor protruded, was
distinctly felt.

Dr. Jackson reports an interesting case of spina bifida, this malfor-
mation being accompanied by a number of others. The duodenum
terminated in a cul-de-sac just before the bile-duct opened into it ; the
rectum opened into the bladder at its fundus. The bidder was ex-
ceedingly small, and the urethra so narrow, as not always to allow
air to be forced through.

Dr. Adams exhibited a specimen of spina bifida, which had ruptured
in utero, the child living 4 days. Another case of spina bifida was
also ruptured during labor, the child living 19 days. In this speci-
men, the caudaequina passes into the sac, its nerves traverse it, and
then emerging from it are normally distributed.

Prof. LuscHKA publishes a case of perineal cystic hygroma, of im-
mense size, the tumor extending from the lower part of the pelvis
down to the foot on the right, to the calf on the left side. It was
multilocular, and contained clear, salty liquid, of straw color, and
neutral reaction. The single loculi were perfectly separated from
each other, and their inner surface was covered with epithelium. A
most curious combination of this hygroma was, that of inclusion of
a foetus. There was a tumor connected with the hygroma by a long
pedicle, round, soft, and grayish-red, of 4^ ounces in weight, which
contained beside an (edematous, adipose cellular tissue, a cartilagin-
ous and osseous mass, in which muscular substance, a piece of intes-
tine, and some corpuscles representing cither kidneys or testicles,
and one showing the shape, but not the microscopical tissue of the
liver were found. There were, besides, pretty large blood-vessels con-
nected with the hypogastric artery and vein. The hygroma being
perfectly like the cases formerly described, it cannot be decided
whether it was an integrating part of the foetus in foetu, or whether
hygroma and foetus in foetu were independently coordinated.

Dr. Leach observed spina-bifida in a child who lived about three
weeks. Particulars are not noted, except the oomplication with para-
lysis of the lower extremities, prolapsus uteri, and discharge of mu-
cus from the vagina and os uteri.

Another case occurred in the practice of Mr. Coghlan, in which
the tumor had ruptured during labor, and the child lived nineteen
days.

Dr. Ebra has a favorable opinion of injections of iodine, made for
the purpose of curing spina-bifida. He reports fourteen cases treated

•

417

with such injections by different writers ; ten of which are said to
have been cured, one to be doubtful, one unsuccessful, and two to
have died in consequence of the operation. The diagnosis is doubt-
ful in almost all the cases, a fact which greatly enhances the value
of the above-given statistics. .

Dr. Robin's dissertation is of some interest, because the French
literature has been well searched for the results of several methods
of operation, compression, puncture, seton, excision followed by
suture, ligature, transformation into a cyst, ii\jections of iodine.

Dr. Behbend republishes, with instructive notes, 20 cases of spin4
bifida from the literature on the subject,' witii preceding careful pa>
Hiolop^ical and diagnostic invelstigations. Therein one point in which
we disagree entirely with the author. He believes that after the punc-
ture of spina bifida has been performed, the position of the spine may
be detected by means of the pain produced by the sounding instru-
ment We know from experience, that such is not the case. In a
new-bom infant, on whom we operated, by puncture and injections,
seven or eight different times, and whom we examined carefully more
then twenty times, the spinal cord was in its entire mass attached to
the outer wall. Now, we have never observed any particular pain
in Bounding or injecting, so little so indeed, that we were unable to
account for the nature of the transverse inner wall our instrument
was always in contact with.

The indications and contraindications of operating on spina bifida,
in the opinion of Dr. Behrend, are the following :

nn>IGATI0N8. COirrRAINDICJLTIONS.

L The cUld generally well formed ; spi- Presence of other malformations, as : hy-
na bifida, an isolated and single tumor, drocephalus, umbilical hernia, para-
withoat eompUoation. lysis and delbrmity of limbs ; tumor

doable.

3. The tumor is pediculated. The tumor is not pediculated, has a broad

basis, particularly in its vertical direo-
tion.
S. TIm ikin normal, not ulcerous. SUn abnormal, incomplete, or ulcerous.

4. Pieium on the tumor produces little Tumor very sensitire, particularly on
or no pain. pressure upon its most prominent part.

5. Displacement of the tumor is painless. Displacement is very painful.

tt. Fluctuation inside the tumor easily Fluctuation not eqUable, particularly
sod equably felt. when deficient on the most prominent

part of the tumor.

In each case, the safest way will be not to operate, when only one
contraindication is given in the complex of symptoms. The modes
of operation hitherto resorted to, are the following : 1. Direct com-
pression by some or other apparatus. 2. Direct or subcutaneous
puncture, with compression. 3. Slow compression around the pedicle,
to produce adhesion, and finally excision. 4. Ligature of the pedicle,
ana excision. 5. Excision and suture. 6. Seton. 7. Seton and com-
pression. After having exposed the danger arising from even a
slight traumatic insult, the tendency to inflammation, ulceration, and
erysipelas, Dr. B. describes a case of undoubted spina bifida, of the
size of a small orange, cured by slow compression, at first by a mix-
ture of collodion and castor oil, afterwards by collodion alone. The

418

tumor diminisbed in the course of some weeks, and had entirely dis-
appeared after some months. At the same time the child took regu-
lar doses of calomel, in order to prevent meningitis, and produce
absorption. By cold applied to the head, the effect of the calomel
was increased. At last Dr. B. proposes to try, together with calo-
mel, small doses of digatalis.

Of the three cases of cystic hygroma, recorded by Dr. Glaser, the
author has observed one himself, the two others Dr. Keller, of
Philadelphia. In each of them the tumor produced dystocia. Dr.
Glaser refutes the opinion of Prof. Wutzer, that young cysts contain
a limpid, older ones a bloody, the oldest ones a tar, or chocolate
colored serum ; for. he describes a cyst of cartilaginous hardness,
and with walls one-sixth 6f an inch thick, containing a yellowish
serum. One of the cysts ruptured before birth. Another was sepa-
rated from the pelvic cavity by nothing except the thin fascia pelvis,
and was observed to alter its position with every expiration or in-
spiration, to such a degree, as to induce the author for a while to be-
lieve the hygroma to be complicated with spina bifidi. Each of the
three infants was operated upon, the hygroma being punctured. In
the first, the operation was performed on the eighth day after birth ;
the child died some hours afterwards. A quart of -a brown, and
finally bloody liquid was removed. The second tumor was punc-
tured to render delivery possible. A gallon of a bloody serum was
removed. The child died after some hours. The third tumor con-
sisted of three cysts, the larger of which contained from three to
four pounds of a thin and somewhat bloody serum ; in the two
smaller ones, the liquid was yellowish white. The cmld died 124
days after the operation had been performed.

Dr. Keiller reports a fatal case of chorea in a girl, set. 15, who
had not slept for nine nights. Then the symptoms subsided, and
came on again. She took a hearty breakfast, was prostrated with
coma for two hours, and died. The urine before death was highly
albuminous. With the exception of several vegetations at the
mitral orifice of the heart, no particular morbid lesion was detected.

Dr. David reports some cases of chorea, and asserts that he has
treated many cases of chorea, occurring at different ages, and in
both sexes, with arsenic, with complete success, in from two to six
weeks. We report this mode of treatment as a mere fact, there
being nothing new in it, and arsenic having been in use for chorea
for a long period.

Mr. Gillette gives tartar emetic in chorea in the following man-
ner, as described in a dissertation, written by Emile Adolphe Bonfils
(De Vemploi de rimitique a haute dose dans une sirie de chories).
About four grains of the drug are given on the first day, about eight
on the second, about twelve on the third. Then it is omitted, in
order to avoid the accumulation of the effect of the medicament. If
necessary, somewhat larger doses are given in a second course, when
a sufficient time has elapsed after the first one. Three courses have
very seldom been found to be necessary. The number of observa-
tions recorded is large enough to attract the attention of, and trials
by the profession.

419

Dr. Koger publishes twelve cases of chorea treated in the man-
ner of Gillette, and recommends the following treatment. He gives
tartar emetic in nothing' but sugar-water, and to children of from
seven to fourteen years of age, in nearly equal doses. Tlie first day,
20 centigr. of tartar emetic are given in 100 grammes of sugar-
water ; of this^olution the patient will take a spoonful every hour,
until severe vomiting or diarrhcea will ensue. It is better tolerated
on the second day, when 40 centigr. are given, and on the third, when
00 centigr. are taken. Meanwhile the symptoms of chorea have be-
come slight, and the pulse has diminished in number : at all events,
medication is stopped for some days ; if it has to be repeated, the
doses are of 25, 50, and 75 centigr. A third term, instituted after
the same principle, would require doses of 30, 60, and 90 centigr. of
tartar emetic in 100 grammes of sugar-water. Of Dr. Roger's twelve
cases, nine recovered rapidly, two felt only short ameliorations, in one
the treatment failed completely. — A case of bl young man of eighteen
years of age, in whom tartar emetic failed to effect a cure is also
reported.

Dr. Wible publishes an article on the pathology and treatment of
convnlsions, founded mainly upon the teachings of Dr. Marshall Hall.
According to him, " the nerve-force is impressed in convulsions : 1.
By irritating agents making an impression on the elements of the
nerves, the impression being sent along the nerves to the spinal
centres, and thence reflected to the muscles. 2. By irritating agents,
snch as foreign substances making an impression directly on the
centres ; inflammation, or .its effects ; and poisons, or morbid mate-
rials, circulating in the blood, exciting the nerves directly. 3. By
mental emotions which are known to act on the spinal centres, caus-
ing them to send out motor impulses." We shall not further illus-
trate these general principles, because we do not agree with the
author in his opinion on a leading error prevailing, in his opinion,
almost all the standard books and dissertations on convulsions.
For it has been well known, even as far back as the time of J. L.
Brachet {TraU4 pratique des convulsions dans Vet^ance^ 1823), that
conynlsions are not dependent, necessarily, upon a morbid condition
of the brain ; and there is scarcely any work on diseases of children
generally, and convulsiorib particularly, which did not, long affo, con-
tain the same physiological views on our subject as Dr. Wible's.
Without, then, detracting from the value of his article, we have, as a
reviewer, simply to state, that, good though its contents may be,
they are not new.

Dr. Ashenhedi again publishes one of his unheard of pathological
curiosities, viz. : the case of a black girl, of nine years, dying "from
fright," and exhibiting, in the post-mortem examination, nothing but
the remainder of ''old inflammations of internal organs."

In Dr. Moykier's opinion, more or less marked anaasthesia of the
limbs suffering from chorea (in the majority of cases the left side) is
a frequent symptom. Atrophy and weakness of the diseased limbs,
persistent even after a perfect cure is established, is often observed.
In one case paralysis proceeded. The author confirms in one half of
his cases, the opinion of Stahly Bonteille, and Bright, on the compli-

420

cation of rheumatism with chorea ; but not at all the assertion of Dr.
S^e, that febrile diseases have a favorable influence npon chorea.
The duration of simple cases is from fifty to eighty days ; the whole
number of deaths, found in literature, were five ; in all of them postr
mortem examinations yielded no particular result. The author knows
seventeen cases of pregnancy complicated with chorea. Three of
them were interrupted by abortion, whereupon chorea healed ; nine
reached their normal end ; four were cured before delivery, five
after.

Dr. Boubguiqnon, after enumerating all the remedies recommended
in chorea, counts among the causes of the disease and the remedies
indicated the following :

1. Rheumatic diathesis : contrastimuli, tart, em., sulph. chin.,
Iodide of Potassium ; after the disease has been removed : tonics,
gymnastic exercises, sulphurated baths.

2. Chlorosis : Iron, sulphurated baths.

3. Scrofula : Iron, sulphurated baths, iodine.

4. Syphilis, Iodide of Hydrargyrum, Iodide of Potassium.

5. Pregnancy, where no exostosis is present : derivatives, seda-
tives, purgatives ; but neither will probably be successful.

6. Masturbation : Bromide of Potassium, electricity, and topic
nervina. — ^There is no new fact in these expositions, for every
reasoning physician must and will individualize ; nor will he forget
that " chorea'' is but a name for a number of symptoms. As to the
result of chorea during pregnancy, our experience goes to show
that chorea will pretty readily disappear. ^

Dr. O'Orilla discriminates diphtherite* beginning in the fauces
from that affecting the tongue first. He further mentions the cases of
two children exhibiting more or less symptoms of paresis after diph-
theria had preceded. Ho compares these facts to the extension of
inflammation from the contents of the pelvis to the membranes and
segments of the cord, which has been observed to produce paraphlegia
In some instances.

Convulsions being essentially modifications of vital actions, and
all vital actions being accompanied by, and depending on, physical
changes in the organism, convulsions must depend on modifications
of physical conditions. Though no " lesion" ii^ discoverable, we are war-
ranted in the concession that nutrition is affected. Such is the theory
of Dr. Reynolds, and certainly it is a good one, for nothing is more
injurious to the progress of pathological science than the belief that
iiseases of any system can be found without a material change being
present. What is unexplained to-day, must not be said to be unex-
plainable.

Dr. Simpson, in cases of convulsions, which seem to exist and con-
tinue without any acute or appreciable lesion of the nervous centres,
and without any recognizable point of irritation in the peripheric
parts, recommends the use of chloroform, which he, in one case, con-
tinued for twenty-four hours, except when it was necesssary to feed
the child, in another case he kept the child, more or less, under the influ-
ence of chloroform for fourteen consecutive days. Dr. Lawrence reports
the case of convulsion in a child one month old, who had been out in

421

oold weather, and was affected with attacks of convulsions, as many as
forty-nine in twelve hours. Evacuants, turpentine, ether, etc., were
used in vain ; then carbonate of iron, gr. iv., was given every two
hours, and the child got well. He concluaes that, *' if all offending mat-
ter has been ^ot rid of from the stomach and bowels, and other exist-
ing sources of irritation removed, if the circulation is tranquil during
tlie intervals of the paroxysms, and if no organic change is associated
with the malady, the exhibition of the iron cannot be too soon begun."
" The essence of such diseases lies in a hypcr-mobility of the spinal
or reflex system of nerves." No other diagnosis was made in the
case related. We dare say that where all those conditions are ful-
filled, convulsions will usually disappear on their own account.

Dr. West treated three cases of tetanus successfully with spirits of
turpentine and opium. To one patient, a girl of ten years of age,
he administered four ounces of spirits of turpentine and sixty grains
of opium in six days. There was not the slightest irritation of the
kidneys by the turpentine, nor the least narcotism by the opium.

Db. Lauderdale reports, that of eight negro children bom in the
same house within twenty months, four boys were attacked by tris-
mus nascentinum, while four girls were not at all affected.

Dr. NeudOrfer reports to have observed spinal symptoms, after
chloroform was administered, in three cases. In a girl of two and
Arfialf years, there were spasms first in the upper extremities, then
in the lower ones, finally, opisthotonus. The intensity of muscular
contractions was such as to make afraid of fractures of the bones.

Dr. Gibb reports an interesting case of hemiplegia in a still bom
child. A child bom with placenta preevia and prolapse of the funis,
had the elbow, finger, knee, and toe-joints of the left side completely
inflected, to such a degree as not to allow of extension, even by
force. The cause was found to consist of the residues of an old ex-
travasation in the right cerebral hemisphere ; the left perietal bone
was remarkably ecchymotic, and the pericranium was easily remov-
ed by the finger. Perhaps the morbid process was depending on a
kick inflicted upon the mother, on the right side of the abdomen,
some three months before her confinement.

Since the essays of Badham, Dance, and Heine, " essential paraly-
sis " of children has not been made the subject of a monograph.
Prof. Vogt treats this troublesome disease under three heads, ac-
cording to the central or peripheric seat of the paralysis, taking as
granted, that the nervous system, either in the brain, or spine, or in
the peripheric course of the nerves, must be the cause of it. Differen-
tial diagnosis between cerebral and spinal, and again spinal and
peripheric paralysis is sometimes very difficult indeed, and requires
accurate observation of all the symptoms. The pathological anatomy
is collected in the following results of post-mortem examinations,
mostly made where the patients died in the acute eclamptic and
cerebral attack of paralysis. There is hypersemia of the brain and
its membranes, which, whether it is cause or consequence of the
eclamptic attack, Brachet says it is not yet decided. So much is cer-
tain, that eclampsia is more frequently the consequence of a primary
conjestion, even where the patient suffered from ancemia before ;

only in owes of consensual eclampeia, conJGstion may be o
as the result of the attack. If tbe conjestion is difTnso, eclampsi.
geucral ; wlierc it is partial, tbe attack too, isocIypurtiaL Ita nexl
effect is either irritation or pressure on the roots of tbe nerves, wbid
lasts as long as the congestion ; sometimes paralysie may remaid
although there is no more direct pressure, only by the gradual alte^
atiou of the nervo ; of this kind are those cases particularly, wbenj
general paralysis gradually disappears, leaving only a single linifi
paralyzed. In cases of congestion, exudation is a frequent result, bin
is not neceBsary, according to Frederick, for paralytica! effects, whicT
ate observed without it. In nmnycascs of eclampsia, no congestidi
or esiidation is found, no organic change seems to have taken placas
this may bo explained by the fact, that uncoagulated blood is liablf
to flow back into the bpdy after death, and that small exudations if
the white substance, although sufficient to produce death, are difl
cult to And. In some cases, meningeal products, and hydrocephalni
is met with. If eclampsia passes without producing death, and tT
eases come to post-mortem examination at a late period, the com
quences of inflammatory lesions are sometimes discovered, as col
dcnsaiions, cicatrices, and cysts, with or withont destroyed corebi
particles.

Aft«r such results of post-mortem examioations, Killict and I
thez are certainly wrong wheu considering tbe cssentiaf paralyi
beginning with cerebral symptoms, as merely " a functional troubl
of the brain ;" neither is Bouchut right, who considers the influecc*
producing infantile paralysis, as merely peripheric.

Heine and West take the vast majority of cases to lie of spiid
origin. In the spine the same pathological alterations, as descrilM
in the cerebrum are found, or niDt found. Extravasations are not I
frequent as in the brain, but some cases arc described by Ollivid
and Hutin ; they produce either convulsious or, by pressure, para^
Bis. The usual effect of mere hypereemia of tbe spine and its mei
brancs are tonic spasms and paralysis, sometimes convulsions.

Cases of peripheric infantile paralysis gave very scanty results,,!
fact which is easily explained by the exceeding difficulty of findi^
alterations in the peripheric cfiiirae of the nerves, and by the \ongi
of time that elapsed between tlie first paralytic attack and deatS
Rilliet and Barthex made two post-mortem examinations, in whia|
nothing was found. Fliess found in a case of paralysis of the t
congestion of the spinal membranes about the hight of the bronchia
plexus. "

After all, Prof. Vogt draws the following conclusions on the natm
of infantile paralysis : 1. Infantile paralysis, which has been calls
essential, is a nervous paralysis. 2. It is the residue of a disear
going along with material alterations in eitlier the nervous centr
or nerves. 3. The material alterations cannot be anything else b
congestion, or inflammation with its consequences. 4. They may li
removed, sooner or later, by natural processes ; thus either the para
ysis is also removed, or it continues in such cases where the ncrvi
have lost already tlieir irritability.

Of particular interest ia tbe opinion of Prof. Vogt on primitive ci

428

tractions, which have been declared a disease sui generis by Tonnel^
Constant, Ouersant, Baudelocque, Weisse, KUttner (who devised the
frightful name "arthrogryposis''), and Rilliet and Barthez. Helft
and Bast believed in their identity with infantile paralysis, because
of the identity of the alterations of the nervous centres. It is their
and Babauds opinion (De la contracture des extrdmilis chez les en/ants ;
Union Mdd. 1855, Nos. 97 and 98), which Prof. Vogt adopts (as also
Hirsch, professor at Konigsberg, in his "Clinical Fragments,"
1861).

We omit to say anything on the symptoms of primary contrac-
tions, which perhaps each of our readers has had the opportunity to
obeerve, and for the same reason we give no differential diagnosis
of primary and secondary contractions, but simply state, that prim-
ary contractions (of the flexor muscles), are always combined with
paralysis of the extensors, so much so, that whenever the contraction
oeaaes, hand or foot cannot be extendi. Primary contraction,
when of a cerebral nature is always painless. If it is of spinal
origin, there is pain in the neck and between the shoulders ; the dor-
sal muscles are strained, and the contraetion can be reduced only
with pain. If it is of a rheumatic nature, there is great pain from
motion and pressure ; the limb is inflexible by force, the carpal joint
18 red and swollen ; a swelling which must be discerned from the
atonic cedema following upon anaamia and cachexia, and upon throm-
bosia of the veins.

We abstain from further extracts, because the whole little book is
80 short and concise in its expositions, and so rich in its facts as not
to allow of abbreviation without detracting from its value. One
chapter we shall dwell upon at some length, as soon as we come to
the review of Dr. Friedberg's work on the pathology and therapeu-
tics of muscular paralysis, viz.: "the progressive atrophy of the
muscles." The length of these reviews, however, does not permit us
to occupy the attention of our readers any longer ; thus we omit
gplving extracts from Prof. Vogt's therapeutical expositions. In gen-
eral, we can say, that we seldom have perused any monograph of the
length of this one, that has a greater abundance of facts and truths
in a short space, that is at the same time written in a style so clear
aad modest, and stands firmer on the basis of modem scientific med-
icine. The old Swiss professor appears to have preserved the full
▼ig^r of youth and scientific enthusiasm to his advanced age of
more than " three-score and ten."

424

VII. SKIN AND SENSORY ORGANS.

1. Morris, C, an Essay on the Faihohgy and Therapeutics of ScoHd
Fever. Philadelphia, pp. 192.

2. Witt, Oh., an Effectvud cmd Simple Bemedy for Scarlatina wnd
Measles, In a Letter to John Simon, Esq., London, pp. 24.

3.. Mead, R. H., on the Treatment of Scarlatina. — ^Med. Tim. and Gas.
June 26.

4. Goslee, L. E., The Use of Quinine and the Chlorate of Potassa in
the TreaJtment of Scarlet Fever, — Cine. Lane, and Obs. June.

5. Dutcher, A P., Scarlatina Maligna. A Case. Chlorate ^Potassa
and Stdphate df Quinine TJsefvX Remedies for (his Form <^ the Dis-
ease. — Ibid, Nov.

6. Morrison, E. A., on mb Use of Quinine in Scarlet Fever. — ^Virg»
Jour. Aug.

7. Francis, 0. R., Inhalation of Oxygen Oas. — Lancet. March

8. Hutchinson, T,, Reminiicences cf Scarlei Fe^yer, as U Prevailed in
MooresvUle^ Indiana, in 1852-1853. — Cine. Lane, and Obs. Oct

9. Bully, F. A, Cases of Scarlatina with Angina. — ^Med. T. and Gas.
Sept. 11.

10. Leroy, R., Prophylactic Treatment of Scarlatina^ with Bdladonna
and Vaccination. — 6az. Hebdom. 18.

11. Broecks, Anasorca consequent upon Scarlatina. — Presse M^
Beige. 42.

12. Two Cases of Brighfs Degeneration of the Kidneys Consequent
upon Scarlatina. — JaJirb. f. Kind. 11. 1.

13. Bourayne, J., Du Bhumatisme dans la Scarlatine. Th^se. Paris,
pp. 48. (On Rheumatism in Scarlatina,)

14. Craik, R., a Scarlet Eruption Caused by ^Hyoscyamus Niger. —
Montreal Med. Chron. Aug.

15. Kerschensteiner, Incvbation of Measles. — ^Prag. Yiert 1.

16. Trousseau, on Measles and its ComplicatiQns. — Gaz. d. H6p. 150.
— Un. M^. Ill, 116.

IT. GUnsburg, Notes on an Epidemic of Measles at Breslaw, in the year
1851— GUnsb. Zeitsch. 6.

18. Recidive Measles. — Joum. f. Kinderk. 3, 4.

19. Young, D. W., Measles a Second Time in the Same Patients. —
Montr. Med. Chron. Sept.

20. Jacobi, A., Report on the Progress of Infantile Pathology and
Therapeutics, — N. Y. Jour, of Med. Nov.

21. Mammi, Epidemic of Measles aJt Reggio.-^U Filiatre Sebezio.
August.

22. Comaz, Treatment of Measles with IHctums of Lard. — Echo MM.
Suisse. 7.

23. Veit, on Hemorrhagic Measles, — ^Virch. Arch. XTV. 1, 2.

425

24. Bemarkable Case of Metastatic Pneumonia consequent upon Meades.
— Jahrh. f. Kind. I. 3.

S5. Bishop, E., On Scarlatina and its Treatment — Lancet. Dec.

26. Marid, Bapport Particulier sur VEpidimie de Rougede Adynamique

$tii a Sivi a CaUas ( Var), pendant les Mois cPAvril, Mai, Juin et
uiUety 1868. Dragulgnau. pp. 29* (Special Report on the Epjr
demic of Adynamic Measles, at GaUas; during the Months of Aprils
May, June, and July, 1858.^

21. Elliot, G. T., Obstetrical and Medical Cases,— S. Y. Jour, of Med.
Nov.

28. Wutoderlich, 0. A., on the Normal Course of some Typical Diseases.
— ^Arch. f. Physiol. Heilk. 1.

29. Kttttner, R., Bdation between Scarlatina and Morbilli, — Journ. f.
Kinderk. 8, 4.

30. Gtelmo, Rubeola. — Jahrb. f. Kind. I. 3.

81. Hebra, MorbiUi et Scarlatina.— Wien. Allg. Med. Z. lT-22.

32. James, C. M. B., Four Eruptive Diseases Occurring in the Same
Subfect in Less than Tux> Months. — Virg. Med. Jour. Sept.

33. Salter, J., on the Shedding of the Teeth and Exfoliation of the
Alveolar Processes cfter Eruptive Fevers. — Guy's Hosp. Rep.

34. Paasch, Acute Exanthems Complicated with Traumatic Injuries. —
Journ. f. Kinderk. 8, 4.

36. Paasch, on Eruption of the Skin from Mgh Temperature. — Ibid.

36. Gallwey, M. B., on a Case of Small-Pox Supervening on Measles
and Another on Scarlatina. — Lancet. Nov.

31. Gintrac, M. E., Coincidence of Variola and Vaccina. — Journ. d.
Bord. March.

38. Riecke, C. P., on the Importance of Vaccination. — Henke's Zeit-
schrift. 2.

39. Gausd, on Vaccination and Revaccination. — ^Ibid.

40. Bertillon, on Vaccination and its Detractors, and Review of Star
iistical Conclusions. — ^Un. M^d. 61, 52, 64.

41. Riviere, Quelques Mots sur la Vaccine et ses Ditracteurs. Th^.
Paris. (Some Words on Vaccina and its Detractors.)

42. Donadieu, Quelques Considerations sur la raccine. Th^se. Paris,
pp. 60. (Some Considerations on Vaccina.)

43. Dubreuille, C, Practical Reflections on Vaccina. — ^Un. M^. Gir.
April.

44. Bertherand, Historical and Statistical Investigations on Vaccina
and VariokL-^Ann. de la Flandre Dec. 19, 20.

46. Linas, A., Sundry Publications on Vaccina, Revaccination, Variola^
etc—GsLZ. Hebdom. 83, 85, 89, 40.

46. Necessity (f Efficient Vaccination. — ^Lancet. July.

4T. Badt, on Vaccination. — Med. Centr. Z. 46.

48. Lalagade, P. D., Etudes Thioriques et Expirimentcdes sur le Vims
Vaccin d^ Enfant et de Revaccini. Paris, pp. 40. ( Theoretical and

426

Experiment/d Investigattona on vaccina virus in IrifanU and Sevao-
cinaled Adults.)

49. Grlinder, Die Schvizpoclcenimpfung eine brennende Frage der Oe-
gentmrt, Breslau. pp. 32. (Vaccination a Leading Question cf
tJie Present Time,)

60. Hochst^tter, C, IHe Kuhpockenimpfung vor dem Ai^gektarten
Theilc von Europa. Stuttgart. ( Vaccination in the Eyes cf the
Intelligent Part of Europe.)

fill. Beca, Voccinjo^iiijon by means of Magnetic Needles. — Presse M^.
Beige. 7.

62. Coste, jRevaccination on Different Farts of the Body, — Ibid. 6.

63. Borham, New Instrument for Vaccination. — ^Lancet April.

64. Kbrte, Small-pox in Utero. — Monatsch. f. 6eb. Sept.

65. Wallmann, Variola in Newborn Children. — Zeitsch. d. Qes. d
Aerzte zu Wien. 13.

66. Bailey, F. K., Case of Erysipelas Neonatorum. — Chic. Med. Jour.
April.

67. Lebertj Eeport on the Medico-Chirurgical Department of the Ho^
pital of Zurich, during the Years 1855 and 1856. — ^Virch. Arch.
XIII. 6.

68. Borchard, M., on Sclerema and its Medico-Forensic Importance.-'
Journ. de Bord. Aug.

69. Legroux, Sclerema in Newborn Children. — Bull, de Th6r.
June 15.

60. Clinical Becords. — Lancet. July.

61'. Morlau, J. A. E., De VIctire chez les NouveaurNds. Paris. Th^.
pp. 38. (On Icterus in New4x>m Children.)

62. Zsigmondy, Case of Congenital Elephantiasis. — Wien. Med. Allg.
Z. 45.

63. Jonx, on Carbuncle.

64. Hauner, Report on the Eleventh Year of the Dispensary Connected
with the Children's Hospital of Munich. — Jour. f. Kinderk. 7, 8.

65. Gibert, on Local Remedies for Eczemalous and Impetiginous Ervp-
Hons. — ^Bull. de Thdr. Aug. — Gaz. de Par. 39.

66. Siartin, Treatment of Eczema of the Scalp and Face in Children.
—Med. T. and Gaz. Sept. 4.

67. Mulago, Treatment of Tinea by the Sulphuret of Bibasic Lime.—
Un. M^. 124. — Gaz. de Lyon. Sept.

68. Astori, Fr., Cases of Tinea Favosa rc^dly Cured. — Gaz. Lomb. 34.

69. Hauner, Therapeutical Remarks from the ChUdr&n^s Hospital at
Munich.— J s\ab. f. Kind. II. 2.

70. Poland, Case of Anophthalmos. — Ophthalm.Hosp.Bep. 4.

71. Cooper, W., on Microphthalmos. — Ibid. 3.

72. Hulme, E. C, Malignant Orouih wiOiin the Eye^xdl. — ^Trans. Path.
Soc. Lond. IX. p. 865.

427

13. Prance, J., on DotMe FupUa in Both Eyes. — Ophth. Hosp. Rep.
April.

14. Samson, A., Eygiine Oculaire de rFnfance, ou Exposi des Moyens
Connus qui Peuuent Privenir ou Rendre Moins Grave les MaJadiea
Oculaires de VEnfance, Paris, pp. 48. (Ocular Hygiene of In-
fancy; or, Exposition of the Means Known to Prevent or Bender Less

Orave the Ocular Diseases of Infancy),

75. Richter, R., Beport on the Department for Diseases of the Eyes in
the Cliniqv^ at Prague, — Prag. Viert. 1.

76. Mac Millan, Ophthalmia of the Newborn Children^ Treated with
Chloride of Zinc and Glycerine. — Med. Tim. and Gaz. July. 3.

77. Poville, on the Treatment of Ophthalmia in the New-Bom, — Gaz.
d. H5p. 65.

78. Arlt, on the Treatment of Cor^junctivitis in the New-Bom, — Ann.
d'Ocul. 2.

79. Magne, on Diphtheritic Conjunctivitis, — Gaz. d. H6p. 78. — Arch,
G^n. Aug.

80. Deval, ffemeralopia Cured by Azotic Vapors, — XJn. Mdd. 78.

81. Hutchinson, J., on the Dyfererd Forms of Inflammation of the
Eye, Consequent upon Inherited Syphilis, — Ophthalm. Hosp. Rep. 4.

82. Meyer, H., Anatomy cf Deafness and Dumbness, — Virch. Arch.
XIV. 6, 6.

88. H^lie, Anatomical Examination of the Auditory Organs of a Decf-
Mute, — ^Arch. G^n. Oct. — Journ. de la Soc. Acad, do la Loire Inf.
XXXIV. 177.

84. On Otorrhceaand its Treatment. — Aerztl. Lit. Bl. March.

85. TumbuU^ L., Observations upon Otorrhoia as a Sequel to Scarlet
Fever. — Med. and Surg. Rep. April.

Dr. Morris' book is an enlarged edition of the same author's
"Lectures on Scarlet Fever" (Philadelphia, 1851, pp. 104V It is a
highly valuable work, from the very fact, that it contains tne author's
practical experience during the course of thirty years, with only
occasional glances at American and English literature. Its object is
simply a practical one, and, therefore, we have to re&^et the omission
of what we are accustomed to estimate most highly in a scientific
monograph, viz., pathologico-anatomical researches. Perhaps the
anthor, if his investigations had led him to* give the exact results of
post-mortem examinations, would have somewhat modified his opin-
ion, that diarrhoea, when it occurs, is to be ascribed to the irritation
of the putrid colluvies swallowed from the ulcers of the throat,
rather than to any direct influence of the cause of the disease on the
mucous membrane of the alimentary canal (p. 105, 172). For it is
as well understood, that ulceration of the glands of Peyer is a fre-
quent lesion in fatal cases, as it is a pathological fact, that morbid
{Sections aje very prone to develop themselves on different and even
remote parts of the same tissue.

In every other respect this book is written in a perfectly scientific
manner ; there is no uniform description of all the cases of scarlet

428

fever ; and the author gives no specific remedies. Although giving
general principles of treatment, he advocates their proper application
to each individual case, and considers nothing to be more dangerous
than to adopt empirical modes of treatment and specific remedies ;
for to their influence but few diseases are amenable.

Basing his general views upon such correct principles, his opin-
ions are by far the most scientific of any we have lately had occasion
to hear on the same subject. His treatment of scarlet fever, in iU
several forms, either " simple," " anginose," or " malignant," gene^
ally agrees with what rational therapeutics require at the present
time, and what is laid down in every good modern manual on die-
eases of infants. There are only some particular features in the
general mode of treatment of our author, which seem deserving of a
special notice. The first is the administration of capsicum, in cases
in which the eruption appears imperfectly developed from the firsts
or in which, after having been well marked, it recedes, or where the
force of the attack falls upon the throat from the very beginning,
causing great tumefaction and difficulty of deglutition. ** Whether
convulsions, or restlessness, or stupor, complicate the case, or mere
languor and exhaustion, all are but varying phases of one condition,
and that, a condition which is to be removed by appropriate stimu-
lation ; and it is in these cases that the capsicum is productive of
the happiest results." " Weak animal broths, freely charged with
capsicum, may be ^iven with great safety, even to the youngest in-
fants in this condition Should there be much local disease of

the throat, it will receive great benefit from the passage of the cap-
sicum over it. I have often administered the simple infusion when
the stomach rejected the broths, or when I desired to maintain a
more constant local impression. The common formula of a tea-
spoonful of powdered capsicum, the same quantity of common table-
salt, a large spoonful of vinegar, and a half pint of boiling water, is
an exceedingly good one. Of this, a teaspoonful may be given
every hour or two to a child of five years and upwards, followed by
a small portion of the broth, or even wine-whey" (pp. 136, 137).
" We are indebted to the West India practitioners for the introduc-
tion of this remedy to our notice hi this disease. It is not only to its
local impression on the throat that its beneficial influence is to be
ascribed. It excites the depressed forces of the digestive organs,
gives greater power to the functions of assimilation, and thus sup-
ports life by a secondary influence, even if it be not a direct nervous
stimulant" (p. 145).

We fully agree with the author's opinion of the danger of cold
applied externally to the head, in cases of great depression of the
nervous functions. Cold is too sedative to be beneficial in such
cases, although it may appear to be indicated by the quickness of
the pulse. We do not, however, approve his treatment of albuminu-
ria consequent on scarlatina. He is certainly right in asserting, that
" the perseverance in nitre and diuretic remedies in these cases with-
out first removing the local inflammation by local blood-letting, will
aggravate the sufferings of the patient without producing any in-
crease of .the secretion" (p. 168); but we object entirely to tiie use

429

of saltSy like tartrate of potassa and soda, and finally digitalis, in
oirder to stimulate the healthy action of the kidneys. We regret not
to find a single remark on some remedies, on the beneficial influence
of which we have been taught, by many successful cases, to depend.
We particularly allude to coloquint, and to tannic acid, so ably
advocated by Prof. Frerichs, in the treatment of Bright's disease.

Serous effusions, in general, take a well merited predominant place
among the complications of the disease. Our author considers cere-
bral effusion to be the most formidable of the sequelsB of scarlatina
(p. 98), although he reports (p. 94), that "only one such case proved
fatal in his experience.'' We have not been so successful, but must,
nevertheless, assert that, in our experience in the treatment of scar-
let fever, no consecutive oedema has proved so unexceptionally fatal
as pulmonary oedema, when it ran an acute course. We know of
none that recovered.

The preventative influence of belladonna, according to our author,
is not yet decided upon ; the experiments which have been made,

g've jao sufiicient proof for affirmation, nor for denial. * ' The only field
r experiment is some lal*ge institution for orphan or destitute chil-
dren, where it can be tried while all other means of prevention are
avoided. Larger numbers than can be found in private families, and
more careful observations, are necessary to settle this poinf

Finally, if it was practically important to study the early history
of scarlet fever, we should not stop with the poetical description
taken from Seneca, which seems to prove that scarlet fever was
known as a dire plague in the first century of the Christian era.
There are, undoubtedly, allusions to scarlet fever to be found in the
writings of Ooelius Aurelianus, a little earlier than Seneca, and very
probably also in Hippocrates' works. Moreover, according to a con-
temporaneous English writer, it is to be considered a fact, that the
plague so beautifully described by Thncydides, which devastated
Athens at the time of the Peloponncsian war^ was nothing but ma-
lignant anginose scarlatina.^

The object of Mr. Witt's pamphlet is to recommend the bicarbon-
ate of ammonia, as the never failing remedy in scarlet fever and
measles. Of the writers who have preceded him with specifics our
author names Letsom (1122), Wilkinson, Peart, Ricardo, Strahl, and
Biecken. If he had known the names of some others, as Malin,
Bodenius, Fischer, Loewenhardt, Schlesier, ROsch, von Ammon,
St5ber, Gross, Heine, and Gyrsting, he would, perhaps, have omitted
to carry owls to Athens. At all events, after it has been decided
upon by scientific medicine, that there is no such thing as a mo-
narchical power in a remedy, as little as there is an absolute essen-
tiality in a series of symptoms called a disease, it appears to be
unnecessary to repeat in a special pamphlet what has been asserted
a hundred times before. If we go back in search of specifics, we
shall find abundant materials for pamphlets in the long-forgotten,
all-saving methods of blood-letting, antiphlogistic treatment, cold

* Charles Coluer : ^' The Historj of the Plagae of Atheos, translated from
Thncydides, with remarks illostrative of Its P^thoio£^.^' Loodonl 1S57. We must
confcn, however, that Dr. Jonathan Osborne (Dublin Quart, Jour,, May, 1858)
appears to be more justified in assuming the *' Plague " to haye been fcurvy.

430

water, and chlorine, each of which has had its time. We think much
of the bicarbonate of ammonia in cases of scarlatina, requiring pow-
erful stimulants because of the dissolution of the blood, and general
depression of the nervous functions ; but we cannot say with Mr.
Witt, that we have been so fortunate as not to lose a patient out of
several hundreds.

Mr. Meade, having much confidence in the tincture of the sesqui-
chloride of iron in erysipelas, administered the same remedy in a
number of cases of scarlatina with good result, in doses varying
from 5 to 15 minims, according to the age of the patient, every thiee
or four hours When the throat was ulcerated, he also applied a solu-
tion of nitrate of silver to the fauces.

Dr. GosLEE uniformly " or systematically" prescribes blue mass or
calomel, followed by chlorate of potassa and quinine ; in one, two, or
three grain doses, evei^. one, two, or three hours, and orders frequent
embrocations of lard all over the surface of the body. He seems to be
sadly unacquainted with the general antiseptic and antifebrile effects
of quinine, as he, from the effects ,of the remedy, declares scarlet
fever to be but "a distinct form of remittent fever, modified by its
local symptoms of the throat and the eruption."

Dr. DuTCHEB recommends the use of chlorate of potassa and sulphate
of quinine in malignant scarlatina ; Dr. Morrison, without giving the
doses, administered quinine alone ; and Mr. Francis orders ii&ala-
tions of oxygen gas, not as a direct remedy, but for the purpose of
procuring time, by its enlivening effects, for the remedies to operate.
^ Mr. Bullet saw some good results of warm poultices in cases of an-
ginose scarlatina.

Dr. Hutchinson, after having seen many unsuccessful cases with
either judicious or injudicious treatment tried, although He *' supposed
it to he the product of some IhUchman^s imagination^" embrocations with
lard, after the method of Dr. Schneemann ; which proved to act favora-
bly in a great number of cases. The learned gentleman. Dr. H., lives at
Mooresville, Indiana. Prof. Leroy declares to have no particular con-
fidence in the prophylactic effects of belladonna ; two children, after
having been treated for epilepsy with belladonna for months, fell
sick with scarlatina. He inoculated himself with the blood, tears,
and epidermis of patients suffering from scarlatina, but never had
any other result but to produce a slight local inflammation. He there-
fore feels satisfied that inoculation is not deserving of any confidence,
nor the recommendations bestowed on it by Miguel, Noirot, Petit,
Radel, and Home.

From the records of the Francis Joseph Children's Hospital, a case
of dropsy after scarlatina is published, in which the degeneration of
the kidneys had gone as far as to colloid metamorphosis, which al-
lows of no more albumen being excreted with the urine and to be
found by chemical tests. Another case is reported to prove that the
prognosis in hydrops post scarlatinam, in spite of albumen, epithe-
lium of the canaliculi, and fibrinous coagulations being present in
the urine, is not always fatal. Whether the cause of dropsy after
scarlatina is always to be looked for in degeneration of the kidneys,
is much doubted. Ll5schner explains it by suppression of cutaneous

431

fanctions, and the procesa of desquamation ; Kubik by the peculiar
decomposition of the blood. In the opinions of both, the disease of
the kidneys is, at most, a symptom coordinate to many others, and
may just as well be absent. It must be stated, however, that ab-
sence of degeneration of the kidneys is a rare occurrence. But it
IB true, that dropsy is often developed, after scarlatina, so rapidly as
not to allow of any comparison wilii a similar rapidity of a pathologi-
cal process ; secondly, that in the urine of some dropsical patients,
there is found neither blood, nor albumen, nor any pathological ad-
dition ; and Uiirdly, that the kidneys of many of them yield no re-
sults whatever from post-mortem examinations.

Dr. BouRAYNE records a number of cases of scarlet fever compli-
cated with acute rheumatism, the nature and treatment of which he
considers to be different according to the time of its invasion. Rheu-
matism at the penod of eruption requires local applications of lauda-
num to the inflamed joints, calomel, mild alkaline salts, in severe
cases nitrate of potassa or sulphate of quinine. Endocarditis indi-
cates cupping and vesicatorics. Such cases of rheumatism as arise
at the period of desquamation, are usually of a subacute nature, and

So along with but a moderate fever, but show a great tendency to exu-
ations into pleura and pericardium ; they require tonics, vesicato-
ries, and, from time to time, mild saline purgatives ; drastics and
venesections being absolutely pernicious.

Dr. Gbaie reports the case of a child, 2A years old, who being poi-
soned by swallowing hyoscyamus niger, oeside the other symptoms
pecniiar to poisoning by solanaceaa had a bright scarlet color on
the whole surface, exactly resembling that of scarlatina, a well de-
fined papillary eruption, disappearing on firm pressure, but returning
immediately when the pressure was removed. The mucous mem-
brane partook of the same appearance as in scarlatina, though the
strawberry tongue was not so well marked. The eruption continued
for about twelve hours, and produced no desquamation referable to it.
Dr. KERSCHENSTEiyER eudcavors to fix the period of incubation of
measles by counting the number of days between the appearance of
the eruption in the first child of a family, and the one affected at a
later period. He was careful in selecting cases where no other source
of the infection was manifest. Out of 3T cases, the rash came out
between the tenth and twelfth day in 34.

Prof. Trousseau states, that there is little danger from convulsions
occurring as prodromi of acute exanthems. No bleeding must be
thought of. Where a croupous cough is heard, a hot sponge ought
to be applied to the throat. In capillary bronchitis, and lobular pneu-
monia emetics, antimonials, large vesicatories, and urtication, are in-
dicated. Epistaxis and otitis require ice, astringents, or hot water
injected into the nostrils, belladonna applied to the ear. Severe pain
in the intestinal canal opium. Very bad complications have been
found to be the following : Bronchopneumonia, ophthalmia, inflam-
mation of the mucous membrane of the nose, gangrene of the mouth
and vulva, purpura (with epistaxis, haematuria, hasmatemesis, blood
per anum). Convulsions about the end of the disease are mostly signs
of peripneumonia ; all cerebral symptoms in this stage of the dis-
ease, are highly dangerous.

432

Dr. GuENSBUBG remarks, that in an epidemic carefully observed by
him, desquamation was generally finised about the 21st day of mor-
billi. He had been told repeatedly, by good physicians and intimate
friends, that many cases of a second attack of measles came under
observation. Transmission was easiest during desquamation. The
cutaneous symptoms proved highly imimportant, as was well kno.wn
already by Sydenham and SchOnlein. Therefore, many cases are
mistaken for either scarlatina or "rubeola."

Drs. YON DuBEN, Malmsten, BdmoER, and Levin, report about ten
cases of measles occurring twice in the same children, the inte^
vals between the first and second times being from four or five
days to some months. Dr. Malmsten saw measles in a man who was
positive about having suffered from the same exanthem twice before.,
The same writer reports to have inoculated measles in his two sons,
the exanthem making its appearance on the fourth day after the in-
oculation being performed.

Dr. Jacobi, too, has observed measles returning in a child for the
third time.

No less Dr. Young reports a number of cases of recidive measles.
Four of the patients he observed himself. The two patients who had
a severe attack of measles for the first time, were comparatively but
slightly affected the second time ; while one of those who had them
slight before, had them very severe the second time.

Dr. Yeit publishes his observations and opinion on hemorrhagic
measles ; which denomination he prefers to that of former writ^
who believed the cause of the hemorrhagic spots to consist in a
severe dissolution of the blood, and considered such cases of measles
as complicated with petechia. Of the whole number of authors who
have communicated their observations and views on this subject, but
Rayer, Levi, and Rilliet and Barthez assert to have met with henh
orrhagic spots in very mild cases of measles. Like theirs, is the «x-
peri^nce of Dr. Veit, who found the hemorrhagic spots to rise in the
following manner. The time of the first appearance is the second or
fourth day of the exanthem, where, in the majority of cases , the
eruption commences becoming paler. They are either limited to a
single locality, or spread all over the surface of the body, have a still
darker color in the following days, and take even a black tinge ;
they are' round, or of an irregular shape, and of a different size up to
the size of a pea or bean ; frequently they form large plaques, or
long stripes ; they will not disappear under the pressing finger, but
show the entire nature of capillary hemorrhages in the cutis. After
a short time the spots undergo the same alterations which are seen
in sugillations, becoming bluish, brownish, and yellow, until, after
several weeks, and a copious desquamation, the skin again assumes
its natural color. Dr. Veit has seen this variety of measles in every
epidemic for the last seven years, eleven cases in one hundred and
sixty, and generally among the poor. But it would be false to as-
sume that poverty, with its consequences, is the principal cause of
the hemorrhagic variety of measles ; for poverty is common, and
hemorrhagic measles are rare ; and, with very few exceptions, it
has been robust and healthy children who showed this particular

H pnasli

■irkriety of measles ; and, finally, the concomitant fever was by no
Mneans of au adynamic, but of a sthenic character ; the coarse iif the
disease waa mild and uncomplicated, and no other hemorrhages from
any organ, except the nose, came under observation. After all,
bcmonhag'ic measles are to be discerned from petcchiie arising
sometimes a number of weeks after the exantbem has disappeared.
The latter may be observed in children exhausted by diarrbcea, pro-
tracted sickliness, and deficient nutrition, and must be considered as a
conseqaence of a real decomposition of the blood ; hemorrhagic

lasles, however, arc but ruptures of the capillary vessels wherever

i crnption happens to be of an uncomnioDly vivid color, without
\g in the least complicated with any malignant symptoms. Thus
eles show an evident difference from scarlet fever and small-pox,
' petechial spots in the latter being produced always and only by »
severe dissolution of the blood.

The post-mortem examination of a male child of two years of age,
who died of pneumonia, after having been affected with measles in
the Francis Joseph Hospital of Vienna, exhibited the following
pathological alterations : The mucous membrane of the bronchia
below ttie second ramification downwards, appeared puffed and thick-
ened, discolored, and covered with croupous exudation ; all the
bronchia were dilated. In both of the lungs were numerous lobu-
lar hepatisations, interspersed particularly near the surface of tbo
lungs, with innumerable larger or smaller cavities filled with pus,
communicating with the dilated bronchia, and surrounded by infil-
trated pulnionary parenchyma. The bronchial glands were swelled
and infiltrated with a yellow cheesy mass. Some tubercles were
fonnd dispersed in the spleen ; but no pathological alterations in any
other organ. The reporter remarks, that in, and after measles, the
blood always has a tendency to deposit croupous exudations on the
mucous membranes of the mouth, pharynx, larynx, and even of the
intestines. When the exudation is deposited on the larger bronchia,
it gives rise to lobar pneumonia ; when on tlio smaller ones, it pro-
duces lobular pneumonia ; in either case, however, only, by trans-
mitting the inflammatory process down to the lung-cells, He further
states, that, differing from what is seen in and after typhoid fever
and hooping-cough, the deposited exudation in pneumonia, following
measles, bos a great tendency to become purulent. Thus the dis-
eased parts are very generally found in the condition of "gray hep-
atiaation," either wholly or locally.

Db. Eluot publishes a case of undoubted measles, as far as the
skin was concerned, the other symptoms, however, especially iiftlic
fauces, etc., resembling scarlatina. He thinks himself almost obliged
to recognize a class of cases in which scarlatina and measles cannot
be distinguished from each other.

Prof. WiraDEw-icn has found, that the eruption of both morbiJli and
scarlatina are accompanied by a continued fever and increased tem-
perature. The fever in measles reaches its maximum immediately
before the defervescence, usually occurring on the fifUi day of the
disease, and followed by a rapid decrease of temperature. Compli-
cations only, both present and approaching ones, may modify the
^ 28

434

regular course. Fever and temperature, in scarlatina, is nsnally
higher than in measles, but in the former there is no increase before
defervescence, nor is the decrease of temperature afterwards so verj
rapid.

Dr. Kuettner considers scarlatina and measles not so di£ferent from
each other as Schoenlein thought they were, when he counted morbilli
amongst the catarrhal, and scarlatina amongst the erysipelatous
families of diseases. He at first points out such cases, which show
the exact symptoms of neither scarlatina nor morbilli, and are often
described under the denomination of rubeola. Then he refers to some
facta laid down in medical literature, the number of which he aug-
ments by a sineular case observed by himself, proving that the same
contagion produces either scarlatina or morbilli in different indi-
Tiduais. How this could be done, he does not venture to say ; but
it does not seem to be impossible for the organism to alter a con-
tagium penetrating the whole system. A severe cold, for instance,
produces rheumatism in one, catarrh in another individual.

Dr. Gelmo publishes the following facts, with the conclusioos
therefrom : 1. Particularly in the transition from one epidemic to
another, eruptions are observed, which are neither scarlatinous, nor
morbillous. 2. Such cases have been observed, sometimes in, as it
were, epidemical frequency, but each time a distinctly characteristic
epidemic, either scarlatina or morbilli, have been seen to follow. 3.
A few single cases, being anomalies of any eruptive disease, do not
entitle the assumption of a new species. 4. It must be acknowl-
edged, that the authors writing on rubeola, have described roseola,
scarlatina variegata, or the French rougeole (morbilli), amongst
their cases. 5. French authors also, as for instance Billiet and
Barthez, state emphatically that some physicians used to describe,
at once with scarlatina and morbilli, a third species, rubeola ; but
that they do not see any reason by which the assumption of its exists
ence ought to, or could be supported. 6. Therefore, there is no rea-
son why the name of rubeola is kept any longer.

Prof. Hebra's clinical lecture on scarlatina and measles gives an
exhausting exposition of the subject. His views on rubeola, as an
independent eruption, are about the same as those of Dr. Oelmo; his
therapeutical treatment is as simple and sceptic as possible. There
is no cure for neither scarlatina nor measles ; only where the dis-
eases take an anomalous course, an appropriate treatment has to be
employed according to the symptoms. Embrocations of lard he con-
siders to be useless ; in the catarrh dependent on measles, he admin-
istefs Dover's powder, and applies cold to the throat in anginose
scarlatina.

Dr. James reports the case of a boy of 8 years of age, who, in less
than two months, suffered from measles, urticaria, scarlatina, and
purpura hssmorrhagica. In this latter the spirits of turpentine are
reported to have proved remarkably useful.

Dr. Salter has seen a number of cases in which necrosis and
exfoliation of the alveolar processes of the maxillee, accompanied by
the shedding of the corresponding teeth, has been one of the secondary
consequences resulting from the attacks of the eruptive fevers —

486

■oarlet ferer, measles, and smallpox. The immediate geperic caase
of this anomaly appears to be common to the several forms of ernp-
iive fever, the rational interpretation of which fact may be found in
the following propositions of Salter's, viz.: 1. Certain diseased con-
ditions of teetn are sufficient to produce their own shedding, by the
necrosis and exfoliation of their containing alveoli. 2. In the eruptive
fevers the poison of the disease spends its chief force upon the tegih
mentary system. 3. The teeth are modified papillee — are members of
the tegnmentary system. The severity Of the previous attack of fever
seems to have no relation to the subsequent exfoliation ; it occurs
generally at about 5 en: 6 years of age, at a period where the most
active tooth development is going on in the jaw. From 4 to 8 years
are the extremest limits noticed. The temporarv molar or molars,
and the corresponding bicuspid or bicuspids, with their containing
alveoli or loculi, have always been the parts to suffix. The patients
have generally been girls, and of the poor class.

Dr. Paasch, while reminding of the fact, that exanthematio fevers
accidentally appearing in patients suffering from inflammatory dis-
OMOO, as for instance m the respiratory organs, arc a very dangerous
complication, states and proves by facts, that an often dangerous
complication is formed by accidental coincidence of a traumatic
insult and an acute exanthem.

. Dr. Gallwbt reports the following cases of complication of differ^
ent exanthema : A consumptive soldier suffered from a severe attack
of measles. When the disease was at its hight, confluent smallpox
developed itself, in the course of which the patient died. Another
soldier, twenty years old, was in the third day of malignant angi-
nose scarlatina, when confluent variola made its appearance, effect-
ing, after two days' suffering, the death of the patient.

Dr. GiNTRAC arrived, by means of facts eluciaated by a large num-
ber of quotations, at the following conclusions on the coincidence of
.variola and vaccina : Where variola sprung up, after vaccina had
began its course, vaccine has been either completely kept back or
interrupted even as long as the course of variola lasted, or has taken
a slower development. Thus there is a decided influence of variola
on the invasion and development of vaccina ; there is also an in-
fluence on the form of the pustules, which may undergo great modifi-
cations, viz.: 1. A diminution, or even a complete absence of the
variola. 2. A diminution or absence of the subjacent induration and
tnlnefaction. 3. An imperfect development of the pustules as to
color, and size. 4. In some cases a suppuration analogous to the
one in discrete variola. Nothwithstanding such modifications, the
fluid contained in the pustules was apt to transmit the contagion.
Vaccine, too, may modify variola, the more so the nearer it is to its
regular termination. 1. Inoculation of variola, performed after the
ninth or eleventh day of vaccination, is not successful. If performed
on the fourth, fifth, or seventh day, it sometimes produces pustules,
which do not contain, however, fluid matter, and are prone to desic-
cate on the seventh or even fifth day. 2. James Boyce observed,
that the pustules of variola, inoculated after vaccination, are very
much like vaccine pustules. 3. Variola occurring after vaccination

436

always took a mild course, even when in the neighbOThood or the
same house, there was confluent variola. 4. Gases of variola have
been observed to be^in with a high fever and dangerous general
symptoms, which diminished as soon as vaccine began its course. 6.
Variola, after vaccination, has no secondary fever, no swelling of the
face, no ptyalism. 6. Its duration has been brought down to eight,
six, five, even four, days.

Dr. RiECKV considers varioloid to be nothing else than variola
modified by the pre(k)currence of vaccinia ; further he adds, that
when variola itself is no perfect safeguard from the attack of vario-
loid, we cannot expect vaccinia to be more ; that a susceptibility to
Infection may be refik^uired, and that all the more spleedily, the
earlier in life vaccination has taken place. Some children cannot be
vaccinated at one time, but may, after a varying -period, acquire
the susceptibility. Di^. Riecke asserts that he has nrequently seen
the lymph from imperfect vaccinia vesicles, formed in cases of re-
vaccination and running their course in from three to six days, pro-
duce regular vesicles in those not previously affected. Gaus^ thmlm
that the undeniably more frequent occurrence of variolous epidemics
in recent times, depends partly on the loss of power in the lymph,
which, in his experience, has ceased to.produce an areola or second-
ary fever, but only a purely local disease, partly on the too early
period of life at which vaccination is generally performed, partly,
also^ on the want of proper supervision, by which many diildren are
allowed to be registered as fully protected after passing tiirough
only a vaccinia spuria. Nevertheless, it is certain that vaccination
affords no absolute, but only a temporary protection, which may be
reckoned at an average of ten or twelve years for most. To improve
the quality of the lymph, attempts have been made to vaccinate cows
with human lymph, but large experience in Sweden has proved this

froceeding to be more than useless. Inoculating cows with variola
ymph, has reproduced onl^ variola somei?^at milder than usual
The use of the true vaccima lymph is, according to Dr. Friedinger
{Frag. Viert,, I85T, HI.), uncertein in its primary transfer, but gams
in certainty by wider extension from man to man.^ In the Prussian
army, in 1854, 66,341 individuals were revaccinated ; 50,956 oiihem
had distinct scars of earlier vaccination, 9,86(^ indistinct ones, and
5,525 none whatever. Of the whole number, 54,302 were -properly
affected by the. vaccination, showing clearly the importance of its
performance.

Dr. Cause, although formerly inclined to consider variola and
varioloid as distinct diseases, now regards them as the same, var^ring
only in intensity. He considers it important —

I. To vaccinate direct from the cow, 3^. To use fresh lymph. 3.
To choose legitimate vesicles from healthy children, of not too tender
an age, and to take the lymph about the seventii or eightfi day,
before suppuration sets in. 4. Never to vaccinate before the child is
at least six months old, except when variola is epidemic. 5. Never
to break all the vesicles. 6. Where the least doubt about the regulari-
ty of the disease, or where too few vesicles are formed, to revaccinate
at once. 7. To make revaccination compulsory about the twelfkh

437

jear. 8. Where this takes, to compel a third yaccinatiob after a
proper interval.

ur. BsRiLLON conoliides from statistical investiffations, that : 1. The
mortality rates of every age is lower in the 19& century, than ever
before. 2. In the age of from 20 to 80 years, which is most sus-
pected by the detractors of vaccination, 14 per cent, died in the last
centnry, 11 in this one. 8. It is not proven that typhus has increased
in number ; quite the contrary ; and the transformation of variola into
typhus is an unfounded assumption. 4. The increasing rate of mor-
tauty, in the male sex, in France, cannot be traced to variola. 5.
These and other chargfes against vaccination depend on either ficti-
tious facts or syllogrisms.

An editorial in ihe London Lancet ag^in urges the necessity to be
cautious in the selection of lymph, to be watchful in regard to the
state oi the health of the child to be operated on, and attentive to
tbe local affection induced by the vaccination.

Dr. Lal46adi arrives at the conclusion, that microscopical and
diemical examinations show the identity of vaccine virus of a first vac-
cination, and revaocination ; that the virus taken after each shows the
same effects, local as well as general, on the system of children or
adnits ; and that direct experience in epidemics give certainty to the
opinion, that the virus of revaccinations is as efficient as that of first
vaccinations.

Botii Dr. Grdekdkb's and Mr. Hogh8trter's pamphlets on vaccina-
tion, are written for the use of the public. The first named author is
a plain, educated, scientific writer, well acquainted with the litera-
ture on the subject, and therefore follows the views of the medical
{NTofession on vaccination, its usefulness and importance. Mr. Hoch-
stetter, however, feels bound to express his utmost satisfaction, firstly,
on his and his seven children's surviving the operation of vaccina-
tion ; secondly, on the number of anti-vaccination papers printed in
the English Parliament's Blue Book, from which he quotes largely.
His feelings are expressed in that well-known prolix and oily manner,
which is .the attribute of his business ; which is that of a clergyman.

Dr. Bbca chooses to vaccinate by means of magnetized needles.
From mere politeness we report his belief that, 1. Vaccination
by means of mag^tized needles has no difficulty at all ; 2. of 1200
vaccinations, only 12 were unsuccessful ; 8. vaccine vims adheres
better to magnetized needles ; and 4. children are less troublesome
during the operation.

Dr. CosTE vaccinated himself on his arm every year, without suc-
cess ; but once the virus accidentally took on his nose. Tlierefrom,
he explains the fact, that shortly revaccinated persons, whom the virus
did not effect, may fall sick, soon after, with variola ; and concludes
tiie necessity of revaccinating on different parts of the body in order
to obtain surety.

A new instrument for vaccination is the invention of Mr. Borham,
London. It is a small instrument, convex above and concave below,
so as to adapt itself to the configuration of the child's arm, where,
by pressing it, a ridge of skin is formed, into which the lancets can
be made to penetrate by means of a cogwheel. There are sets of

438

lancets which are grooved at the points, so as to retain the Tims
more completely.

Dr. Wallman reports the following case of rariola in a new-bom
child : A female child (premature) was bom, on the 25thi of Feb.,
185T, with variola vera, forty-six pustules being found when the
child died, thirty hours ^ter birth. The mother was a healthy primi-
para, 28 years of age. While in the hospital, she was for a short time
in a room with patients affected with variola ; two pustules of variola
made their appearance on her, while she was under the endemic in-
fluence. Eight days after her haying wholly recovered, she was sent
to. the lyinff-in hospital, where she was confined. She remained in
good healu afterwards.

A case similar to this, has been under the observation of Prof
Hebra!. The mother was confined while suffering from variola^ The
child affected with pustules of variola in difierent stages of develop-
ment, was stillborn.

Dr. Jaoobi publishes a similar case, which occurred in the practice
of Dr. Michaelis, of New York. A primiparK gave birth on the 12di
of Hay to a male child, who lived only a few moments and was cov-
ered with variola, most axtcnsively so on his face and thorax. There
was nothing abnormal about the confinement, except an uncommon
painfulness of the back. The pustules of variola appeared to be in
the sixth or seventh day of their development. The mother was not,
nor had she been during her pregnancy, suffering from variola or va*
rioloid, or, as far as could be learned, Arom varicella, but there is one
interesting chai-acteristic fact in the historyof her pregnancy. When
in her fourth month, she was present at the death ^ a child, who
died from variola. For full four weeks she feltexcedingly sick, suflfer*
ing from repeated chills, and was continually afkerwards afraid of
having variola. Her puerperium took a favorable course. .

Dr. KcERTE has observed a fcetu^ of seven months who was dead for
some time, and whose mother had been affected with a slight attack
of varioloid. Upon the entire cutaneous surface of the fostus, there
were isolated, yellow re§istent spots of a round form, which being
situated in the cerium, must be attributed to a local infiltration
without having ever reached the stage of suppuration. Perhaps the
premature death of the child has kept the development of the pustules
back ; but the uninterrupted influence of the amniotic liquor may
have modificated, in this case, the local development of the contagious
deposits.

Dr. Bahjet reports a case of erysipelas neonatorum, in a child of
six weeks of age, terminating successfully. The treatment consisted
principally of Dover's powder and sulph. chin.

Pbof. Lebebt reports the case of a boy of six years, who died, after
having been sick with ervsipelas for three weeks, from exhaustion,
and with the symptoms of broncho-pneumonia. The post-mortem ex-*
amination resulted in finding this, and, without an abscess existing,
purulent infiltration of the cellular tissue between periosteum and
glabella. The cellular tissue round tbef parotis was red, serous, and
nowhere purulent.

Dr. Legboux reports two cases of sclerema neonatorum, which

439

speedily removed, in the course of some days, by frequent kneading
of the body ^" massage''), passive motions of the muscles and arti*
ficial respiration.

Dr. Haunib has never seen bad results of the removal of chronic
ezanthems, provided they were not treated with exsiccating applica-
tions, such as lead water.

After the crusts of eczematous and impetiginous eruptions have
been removed by water, according to Garot, Dr. Gibbbt applies a
mixture of 80 parts of glycerine, 2 of depurated tar, and 15 of
starch. It will lessen the pruritus, dry the sore cutis, remove the
smell, and generally operate as an astringent and resolvent at once.
H« jused the same mixture in intertrigo, pruritus of the scrotum and
anus, acne rosacea, and subinflammatory mentagra. In other cases
of prurient, eczematous, and other eruptions, he successfully used a
mixture of two parts of cod liver oil, and one part of oleum cadinuro,
c^ld hip-baths, and arsenic internally.

Mr. Stabtik, in eczema of the scalp and face in children, gave
iodide of potassium internally, and ordered the surface to be washed
with the yolk of an egg and water, and smeared with the nitric oxide
of mercury ointment (Olive oil Sii, lard Sii, powdered nitric oxide of
mercury 3iy oil of bitter almonds 9ss., glycerine 3i)-

In cases of tinea. Dr. Mulago applies, by means of a brush, to the
sore places, a hot paste composed of sulphite of lime, and recently
slacked lime ; it ought to be washed off after six or eight minutes.

Db. Haukbr has succeeded in curing pigmentous nnvi as well as
vascular ones by vaccination and revaccination.

Mb. Cooper reports the case of three microphthalmic children of one
family, all of whom show some peculiar particulars. Indeed, in
every case of double microphthalmos which has fallen under Cooper's
notice, there has been imperfect dental development ; the same holds
good in numerous cases of congenital cataract. The teeth are small,
jagged, discolored, and soon decay. The cause which impedes the
due development of the globe of the eye, or of the crystalline lens
alone, influences the growth of the teeth. Furthermore, many of
these children are stunted in stature, bow-legged, or knock-kneed, of
wayward irritable temper, and not unfrequently obtuse in intellect.

MR. France gives the following report on double pupils in both
eyes : A boy of three years of age, well developed, with normal eyes
at and after birth, who had suffered from a variolous eruption in the
first month of his life, had a normal pupil in either of his eyes, but,
besides, apertures in the ciliar margin of the iris ; in the ri^ht eye
in the exterior and inferior, in the left in the interior and inferior
margin. Posterior synechia was present in both of them. There
was reliction on neither light nor atropia. The sight was good. On
the right side, the child instinctively covered the abnormal opening,
by drawing up the inferior eye-lid ; this being impossible on the left
side, the sight was troubled sometimes by the light falling in
lajterally.

Dr. Sahson's pamphlet is well written, and contains fourteen chap-
ters with general remarks and special expositions on congenital
diseases of the eye ; on purulent ophthalmia ; on catarrhal and pus-

440

tulous conjanctivitis ; on blepharitis and keratitis ; on pannus,
strabismus, myopia, asthenopia, and amaurosis. From among the
statements of the author, we select the following : A quarter of all
the cases of blindness met with in adults, are the effects of ocular
diseases contracted in early life, particulaHy of purulent ophthalmia.
Some cases are congenital, as congenital caiaract, in which the sensi-
bility of the retina is sometimes kept intact for life, sometimes dimin-
ished in a short time. Thus the question arises, when congenital
cataract must be operated upon. Dr. Samson follows the examples
of MacKenzie, Bognetta, Ansieux, and Sichel, who operate either in
the first months of life, or after dentition is fully finished. Furulent
ophthalmia is a very common disease among young children ; being
mostly found in new-born infants, and scarcely ever after the fourth
or fifth year of life has been accomplished. This predisposition of
early infancy must not be sought in special poisonous prinoiples of
tne atmosphere, nor in a peculiar sudden inoculation auring birA,
but rather in the anatomical and physiological development of the
infantile eye. In new-born infants the cornea is thicker, the aqueous
humor less limpid, but soft and Toluminous, eyelids thin and trans-

Sarent, and receive more serous matter from the blood-vessels ;
[eibohm's glands have an exaggerated development, subconjuncti-
val cellular tissue is abundant and loose, and its blood-vessels veiy
little compressed. Of the local astringents recommended in purulent
ophthalmia, Dr. S. gives the preference to borax dissolvea in 400
parts of watei; CaiarrJuU conmnctiviHs is only palpebral in the
majority of cases, the bulbus seldom showing signs of inflammation,
especially no phlegmonous chemosis. Pustular cor\junciiviti8, ble-
pharUiSf and keratiti8f have been called, before Trousseau and Dea-
marres, by the collective name of scrofulous ophthalmia ; our author
naturally prefers the exact anatomical and pathological nomenclature
of the above-mentioned writers. The pustules commence their de-
velopment in the small glands of the conjunctiva, like aphthra on the
mucous membrane of the mouth, particularly in the inner angle of
the eye, as it contains a greater number of vessels. Blepharitis may
consist of either inflammation of the roots of the cilia, or of Meibohm's
glands, or it may be mucous, or granular. Spots on the cornea are
usually found in or near the centre ; marginal ulcers leave no spots
from their being in the neighborhood of resorbing blood-vessels.
Luscitas is but a variety of strabismus, and complete immobility, pro-
nounced pathognomonic in luscitas by Beer and Mackenzie, need not
be present. Surely there are different stages and deg^es. Strabis-
mus will degenerate into luscitas, by paralysis of the third or sixth
pair, from cerebral affections, traumatic lesions of the ocular muscles
or their nerves, adhesions, tumors in the orbits, and congenital ab-
sence of a m. rectus. In the asthenopia (want of the accommodating
faculty of the eye) of onanists, the pupil is said to lose its normal
situation, turning inwards and upwards. Amaurcteis in infancy is
reported to follow on dentition, worms in the intestinal canal, sup-
pression of eczematous and impetiginous eruptions, acute exanthems,
and — lice.
Db. Bicbteb asserts that Prof. Arlt never loses an eye from blen-

441

norrhoBa of newborn children when timely observed, with the following
treatment : After the secretion^ are removed by injections of luke
warm water, nngt. hydrarg ciner 3- ii» and extr. hyosc. is rubbed on
the forehead, ana after some days have elapsed, a solution of 1 or 2
gprains of nitrate of silver in an ounce of water is applied 3 or 4
times a day. Scrofulous conjunctivitis requires, in photophobia, mere,
prsdcip. alb. gr. viii, extr. bellad. gr. xii-xvi, fat 3. ii, to be rub-
bed on the forehead from 4 to 5 times a day. At the same time
con. mac. gr. i, or coniinum gr. |>7 to be taken internally. Local appli-*
cations of calomel, wherever there is no ulceration of the cornea and
purulent decomposition of the exudation, dissolves the exudation
rapidly. Ulcers of the cornea require one or two daily applications
of a solution of a grain of sulph. atrop., in 2 drachms of water ; thus
the pupil is dilated, the iris secured, circhlation in the internal eye
becomes free. The internus muscle is paralyzed, perhaps the recti
and obliqui also. The cure is supported by laudanum. In thicken-
ing of the eye-lid the tincture of iodine was used externally.

Ur. Foville, in simple coniunctivitis of new-bom children, orders
cold lotions of the eyes and instillations of weak solutions of nitrate
of silver, to be administered three or four times a day. Whenever
the disease is severe, the old mucous membrane must be destroyed
after the eye has been well cleansed by pouring on and injecting cold
water. A solution of one part of nitrate of silver to four parts of
water must be applied three times a day.

Dr. Macuii^n recommends, in ophthalmia of new-bom children,
the application, 3 times a day, of 5 grains of chloride of zinc well
triturated in a glass mortar with half an ounce of glycerine, and
frequent ablutions of the eyes, and application of pure glycerine. It
would appear that the use of glycerine alone has a beneficial effect
as a lubricant, and at the same time diluting the purulent discharge,
and consequently diminishing its irritating effects on the adjacent
parts.

Prof. Arlt, fond though he be of the applications of solid nitrate of
silver to the inflamed and suppurating eye-lids, rejects its use wher-
ever the patient cannot be regularly attended to, or the parents cannot
be depended upon. The indications result from the state of the con-
junctiva, which when exhibiting an infiltrated exudation, thickened
throughout, must not be touched with the caustic, while it is indi-
cated in swellings of the conjunctiva produced by accumulation of
blood and serum. In the former case. Prof. Arlt begins the cure
with ablutions and embrocations of mercury salve with some narcotic
extract, until the swollen parts of the conjunctiva, or the whole con-
junctiva have become accessible to the caustic. He has sometimes
been obliged to stop the application of the nitrate of silver either
for the given reason, or for an exacerbation of the symptoms produc-
ed either by too continued and deep cauterization, or by the negli-
gence of the nurse, infection of the air for want of ventilation, un-
cleanliness of the eyes, ojf deficient application of the cold fomen-
tations.

Dr. Maone read a paper before the Acaddmie des Sciences, of
Paris, of which the following points are the main contents : 1. The

' -' m

442

diphtheritis of the conjanctiva is of a nature similar to cronp. 2. Its
symptoms forbid to confound this dififlease with the one called pseudo-
membranous ophthalmia. 8. It is especially seen in children. 4. It
does not appear to be merely local, but is dependent on, and con-
nected with a constitutional alteration ; exutories, when applied, are
apt to constitute a complication. 5. It does not appear to be conta-
gious, only one eye having been affected in the four cases success-
fully treated by the author. 6. It is a grave and rare affection but
'accessible to cure. The same author publishes 4 cases of diphtheri-
tic conjunctivitis ; in one of them the child appeared to be perfectly
healthy when taken out into fresh air ; returning after two hours it
had diphtheritic membranes on the conjunctivn. Magne considers
this affection to be a part only of a general affection of the organism,
the skin deprived of its Cjj^idermis by a vesicatory exhibiting diph-
theritic membranes, which took two montlis to heal and not without
producing a cicatrice similar to those produced by combustion of
the cutis.

Prof. Deval relates the case of a boy of ten years of age suffering
from hemeralopia, without any manifest cause. No rational indica-
tion being present, Deval tried a remedy much recommended by
Dupont, and much used amongst the people ; he exposed the eyes
twice a day, for ten or fifteen minutes each time, to the evaporations
of a boiling cow liver. The child got well in a few days (Dupont
mim. 8ur la gouUe sereine nocturne 6pid6mique). The same remedy
is much used by the Chinese (Didionnaire de rindustris^ Paris, IT95,
tom. iv.) •

Dr. Hdtchiksok endeavors to give a detailed account of acute iritis
occasionally met with in syphilitic infants. In his opinion it is
frequently a consequence of hereditary svphilis, and sometimes occurs
at periods subsequent to infancy ; further, the form of kerato-iritis
met with in young persons and formerly known as ''agus-capsuli-
tis," and the disease known as " chronic corneitis," " interstitial cor-
neitis," " strumous corneitis,'-' are in the majority of cases a direct
result of inherited syphilis. Finally some of the cases of deposit in
or upon the retina or choroid, hitherto classed as '* scrofulous," and
certain cases of tinea tarsi, fistula lachrymalis, and other affections
of the ocular appendages occurring in children are asserted to be of
syphilitic origin.

Prof. Meyer describes the auditory organs of a deaf-mute, which were
completely and perfectly developed ; only the cerebral ventricles show-
ed the residues of internal meningitis, there being thickenings partly
plain, partly in small knots. Such a thickening was also found on
the lower wall of the rhomboid fossa, and covered the strias auditivso
entirely. Thus the origin of the auditory nerve was destroyed by
internal meningitis, which is not a rare disease, but leads to hydro-
cephalus in the majority of cases. It has been also observed in
later life. Physiologically, the normality of the auditory nerve is of
great interest; its normal structure depending more on external
irritations and irritability than on its functional juncture with the
brain.

Prof. Helie expresses his opinion, that the diffiiculty of dissecting

the auditory organs has often given rise to the belief of congenital
deafness and dumbness being mostly^ funtional lesion of the nervous
system. He points to M^nier, Tnquet, and Michel as having
published observations of cases, where the defaults of conformation
were found in the internal ear ; and goes on to describe a case ob-
served by himself, in which the external and middle ear of either
side were well formed and fullv developed. * But on the right side
there was na internal ear at all, with the exception of a short canal
appearing to be a rudiment of the vertical and inferior semicircular '
canal, and opening with its one end at the ei^tremity of the petrous
part, with its other in a cul-de-sac, without being in any connexion
with either the middle ear or the auditory nerve. The petrous part
was normal. On the left side there was no internal ear except the
cavity of the vestibulum, which was filled with a white and soft
mass of nervous tissue receiving the terminations of the vestibular
divisions of the auditory nerves. The auditory nerves were reduced
to two-thirds of their normal volume, the anterior root appearing to
be normal, the posterior was grayish and gelatinous, and without
the characteristics of nervous tissue. The othel' nerves and the
brain proved entirely normal.

In another case of Prof. Hdlie the superior vertical canal was
absent, the horizontal canal was very small, only the inferior being
normal. The other parts of the auditory organ were normal, only,
perhaps, somewhat small throughout. The auditory nerves originat-
ed from a single gray root, the posterior being entirely absent.

The majority of cases of otorrhoea consist of an inflammation of
the meatus auditorius externus producing a more copious secretion.
Children suffering from this disease are frequently affected with
diseases of the glands and laboring under general debility. Some-
times it originates after scarlatina, measles or cold ; traumatic
causes can seldom be found. Deafness never is the result of simple
otorrhoea, but is in such cases dependent upon tympanitis. There
are cfuses also where otorrhcea is but a symptom of an irritation
existing in the middle ear. Polypi of the car are often found in
company with otorrhoea, and will frequently give rise to bleeding.
The secretion must be removed, and the ear kept clean by injections
of warm water, followed by astringents. Where there Is much
pain, one or two leeches, and warm fermentations, will be useful ;
obstinate cases require counterirritants on the mastoid process and
injections of a strong solution (gr. X — XL to an ounce of water) of
nitrate of silver, to be applied every third day. The general health
must always be taken care of.

In Dr. Turnbull's opinion, as in that of the average of writers on
the subject, otorrhcsa resulting from scarlet fever is a disease which,
if it becomes purulent and chronic, is very difficult to cure. Acute
inflammation requires local depletion, suppuration in the tympanum,
slight incision in the abscess, anaemia tonics, chronic inflammations
counterirritants and weak astringent washes.

444

Vin. URO-OBNITAL ORGANS.

1. Barkow, H. C. L., Anaiomische UrUersuchungen iiber die HambUue
des Menschen, nebst Bemerkungen uber die wanrdiche und weMiche
Hamrohre. Breslau. Fol. pp. 60, n. 12 Tafeln Abbildnngen.
(Anatomical Investigations on the Urinary Bladder of Man^ wHk
Bemarks on the Male and Female Urethras,)

2. Senfbleben, Congenikd Malformaiion of the Kidneys, with Atresia
^ni.— D. Klin. 8.

3. Ghevancc, Bypertrophy (f Foetal Kidneys. — ^Med. Times. 391.

4. Isaacs, C. E., an Account of a Case of Congenital Deficiency <f the
Left Kidney, — N. Y. Jour, of Med. Sept.

5. Hutchinson, J., Bronzing of the IStein in a Boy, with Old Dis-
organization of Both Supra^renal Capsules, — ^Trans. Path. Soc. IX.
p. 414.

6. Curling, bongenitail Extroversion cfthe Bladder in a Female Child,
— Lancet. Aug.*

7. Smith, A. H., Probable Congenital Vesical Calculus in a Boy of
Two Years,

8. Congenital Vesical Calculus, — ^Lancet. Oct.

9. Lithotomy in a Rickety Child, urith Bichety Pdvis, — ^Lancet Jan.

10. Balassa, on Calculi in Hungary, — Aerztl. Lit. Blatt. March»

11. Oleimtz, J., on Lithiasis in AUenburg. — D. Klin. 43, 44.

12. The Prevalence (f Stone in the Bladder, — ^Lancet. Oct.

18. Hillman, Three Cases of Stone in the Bladder (f Females, Removed
by Dilaiation ; Recovery in Each, — ^Lancet. Jan.

14. Spencer, P. C, The Results of Twenty-Eight Operation for Stone
in the Bladder, — ^Virg. Med. Jour. July.

16. Henry, M., Large CalciUus from a Boy of Fourteen Tears. — ^Trans.
Path. Soc. IX.

16. Lotzbeck, on the Apdication of Sutures to the Bladder in the Mgh
Operation for Stone,— D. Klin. 16.

17. Noeggerath, E., on Epicystotomy, with the Report cf a Case in
which the Operation uxis Successfully performed, under the Tnost Un-
favorable Circumstances, — ^N. Y. Jour, of Med. Jan.

18. Stone in the Bladder of a Girl; Lithotrity ; Removal <fa Cystic-
Oxide Calcidus. — Guy's Hosp. Rep.

19. Curling, Lithotrity in a Child Aged Four Tears, — ^Lancet. July.

20. Erichsen, Stone in the Bladder of a Female Child SucoestfuUy Re-
moved by Lithotrity, — ^Lancet. Aug.

21. Stade, D. D., Lithotrity as Applicable to Children^ with the Report
of a Case. — Best. Med. Jour. May 14.

22. Simon, Galvanism in Incontinence of Urine in Children, — Med.
T. and Gaz. Nov. 14. ^

23. Betz, Fr., Licontinentia Alvi of Children; the Musk Smell in

446

Children ; on a Peculiar Smdling Matter in Urine and Breath. —
Memor. a. d. Pra$. III. 6.

24. Destouches, De V Incontinence de V Urine JSssentidle chez les En-
/ants. Paris. Th^se. {On Essential Incontinence of Urine in

Children.)

25. Pollock, Belladonna in Incontinence cf Urine. — Brit. Med. Jour.
March 27.

86. Hewson, A., Some Facts in Belation to the Nocturnal Incontinence
if Urine in Children. — ^Amcr. Jour. Oct.

27. Bierbaum, J., Experience in Infantile Pathology. — Joum. f. Kin-
derk. 7, 8.

28. Porster, C, on Infiltration of Urine in Children. — ^Un. M^. 68.

29. Oodard, E., Etudes sur V Absence Conginiale du Testicule. — Paris.
Tb^se. pp. 72. (Investigations on the Congenital Absence of the
Testicle.)

30. Pecb, E. A., AusuxM einiger seltener und lehrreicher F&UCy beob-
achtet in der chirurgischen Klinik der chirurgisch-medizinischen
Academie zu Dresden, pp. 32. IV Tafeln. (Selection of Some Rare
and Instructive CsLses, etc.)

31. Grodard, E., on Monorchides and Kryptorchides in Man. — Gaz. d.
H6p. 150.

32. Faussagrives, Female Hermaphrodite. — Un. M^. 128.

33. Picardat, A. A., Becherches sur les Anomalies Conginitales du
Canal de VUrithre. Paris. These, pp.41. ( Investigations on the
Congenital Anomalies of the Urethra^

34. Gaby, on the Use of Subnitrate of Wlsmuth in the Cure of Chronic
Blennorrhoea and Leucorrhoea. — Bull, de Thdr. Sept 30. '

35. Vogel, A., Medico-Forensic Notes on Qonorrhcea in Children. —
Med. Chir. Mon. Oct.

36. Browning, W. G., Singular Case of Oenito-Urinary Malformation.
Gin. Lane, and Obs. April.

37. Werner, Beport on Prof Bruns Clinique at Tubingen. — D. Klin. 2.

38. Rogers, W. C., Tepid Injection in the Treatment of Non-Congeni-
tal Phimosis in Children. — Am. Med. Monthly. Oct.

39. Streubel, C., A proper Philippica against (he Mania of Circum-
cision. — ^Prag. Viert. 2.

40. BObbelen, From Practice. Phimosis Congenita. — ^D. Klin. 20.

41. Schultze, B., Cystform Eapansion (f the Big?U Oixtriumy by Extra-
vasated Blood in a Neu:bom Child. — Monatschr. f. Geb. March.

42. King, Congenital Deficiency of One Breast in a Oirl. — Med. Tim.
Gaz. May 22.

43. Utili, Case (f Atresia Vulvae. — Raccogl. Med. di Fans. 14. — Gaz.
d. Par. 46.

44. Smart, R. B., Case of Premature Puberty. — Med. T. and Gaz.
July 14.

45. Brown, R., on a renuxrkable Case of Encephaloid Disease of the

446

Mghi Ovary, Weighing Ten Ounces and a Halff Occurring in an In-
fant Nine Months Old. — Lancet. July. <«;

46. Jones, S., Specimen of Enlarged ClUaris, — Trans. Path. Soa IX.
p. 305.

Prof. Barkow's work belongs to the number of books which will
undoubtedly secure the author the reputation of the most accurate
anatomist of the urinary bladder. This organ had been somewhat
neglected as to the measures, size, form, and position in different
sexes, and ages, and Prof. B. at last has filled the want that evident-
ly existed. The book is exclusively anatomical.

Dr. Senftleben states that malformations of the anus are usually
complicated with others. By this fact he explains the large rate ot
mortality in infants, on whom operations for imperforate anus are

Eerformed. He reports two cases, in which the Kidneys were mucb
ypertrophied, and the ureters very narrow. This condition of the
ureters is a retardation of development, the ureters, being solid in
their first formation.

Dr. Chevance reports the case of a woman who could not be de-
livered except by eventration of the foetus, although she was not
progressed to the normal term of pregnancy. The cause was found
to consist in a hypertrophy of the kidneys, weighing 250 drachms,
while the rest of the body weighed 612 drachms.

In a male infant, who died of pneumonia at the age of 8 months,
and who never before had been sick. Dr. Isaacs found, in the left
side, neither kidney nor ureter, nor a sign of the orifice of the ureter
in the bladder. The left supra«renal capsule was about the same size
as the corresponding one on the right side. The right kidney, being
2} inches in length, 1| inches in its transverse diameter, and 1^ in
thickness, and the ureters were about twice their natural size.

Dr. Hutchinson showed, before the Pathological Society, of Lon-
don, diseased supra-renal capsules, which, besides the mesenteric
glands, were the only parts diseased in a boy with bronze skin, who^
died at the age of eleven. Both renal bodies were entirely disorgan-
ized, containing chalk, cheesy matter, and firm fibrous tissue, bmd-
ing together these elements. No trace of their normal tissue was
discoverable.

Congenital extroversion of the bladder usually occurs in male
infants, combined, in the majority of cases, with fissure of the urethra
on the dorsal surface of the penis. Mr. Curuno publishes a case of
this malformation occurring in a female infant. There was a defect
of the symphysis pubis, and an absence of the anterior commissure
of the labia and clitoris. An opening was present in what appeared
to be the mucous membrane of the anterior wall of the vagina,
which might be either the meatus urinarius, or the entrance of the
uterus. Two smaller openings were present, one on either -side of
this, which might be either the seminal ducts, or else the fallopian
tubes. A slight prominence on either side of the supposed vagina
represented, to some extent, the nymphee. There was no scrotum
nor testes.

Dr. Cooper Foster operated upon 9 young children for stone ; in 2

447

of these cases, he could distinctly trace the symptoms of stone from
birth.

> A child twenty-one months of age had been subject to stone no
doubt for some time ; possibly it was bom with it. Its pelvis was
in a deformed state from rickets, with a considerable flattening from
before backwards, so that the pubis approached the promontory of
the sacrum ; the bladder was thus not only high up, but difiScult to
reach with the finger. The stone was extracted by Mr. Erichsen,
and was of an oblong figure, nearly an inch in length, and propor-
tionately thick. The case progressed favorably after the operation.

Of 135 cases of stone in the bladder, treated by Prof. Balassa,
twenty-one occurred in persons under 7 years ; thirty-two from 8
to 15 years. Besides, forty-nine children have been treated for the
same disease in the chilaren's hospital of Pesth, during the year
1843-1855. Children in early life and with coarse diet are most
subject to stone ; tfiis fact Prof. Balassa explains by inadequate food,
children, after having been weaned, being nourished with herbs,
potatoes, etc., which contains a large quantity of carbon. Thus,
carbon forms the principal part of urinarv calculi in Hungary. The
majority of Balassa's consisted of oxalic salts. Of twenty stones
having a nucleus difiering from the mass, the nucleus was of oxalates
in twelve, of uric matter in eight, wherefrom the conclusion may be
drawn, that oxalates and urates give the impulse to the formation of
stone, phosphates only increasing it6 bulk. The sound produced by
the probe is of some diagnostic importance ; the sound being sharper
with oxalic stones, which are harder ; duller with phosphoric stones,
which are less hard and dense.

Dr. GEiNrrz publishes 28 cases of lithiasis, 19 of which occurred in
individuals of 15 years and under. All of them, with the single
exception of a girl of 2| years, were males. In two, the high section
was performed ; both of them died, one 5 days, the other one day,
after the operation ; for six the lateral section was performed, and
all of them were restored to perfect health ; the youngest amongst
them was a boy of 4 years 6 months of age. The stones weighed
from 8 grains to 2| ounces, which was the weight of a stone removed
from the bladder of a boy of 13 years. In another boy of 13 y^ars,
some stones were found adherent to the inner surface of the bladder,
in a number of patients suffering from dysuria, calculi were elimi-
nated spontaneously, so as to make it difficult to decide whether
these calculi were originally in the kidneys or bladder. Calculi of the
kidneys were found in a boy of 32 weeks, who ^ed of acute tubercu-
losis, in a boy of three months who died of the same disease, and in
a boy of 23 weeks who had died of atrophy. The author is of the
opinion, finally, that many cases of dysuria in children commonly
referred to dentition, depend on and are referable to lithiasis.

Mr. Foster removed a calculus the size of a horse-bean from the
bladder of a child of five years, in 25 seconds.

Two cases of stone in the bladder of female children, each five
years and a half old, came under the care of Mr. Hillmax. In the
first case, a conical sponge tent was introduced into the whole length
of the urethra, and retained for five hours, for the purpose of slowly

448 •

dilating that canal. Chloroform having been administered, the stone
was withdrawn, after an incision had been made in the direction
directly upwards towards the symphysis pubis, because of the size*
of the stone. This was of an ovoid form, measuring fully three
inches in its longest, and two inches and three-quarters in its short-
est circumference. It consisted of laminated urate of ammonia.
Twenty-five days after the operation, the child was discharged, per
fectly free from all suffering. In the second case, chloroform having
been administered, a small,^three-branched urethra-dilator was intro-
duced, and the canal thereby dilated in the course of five minutes
sufficiently to allow of the introduction of a pair of slender, straight
lithotomy forceps into the bladder. No incision was necessary.
The stone was of an ovoid form, thickly studded externally with
small, sharp prominences. It measured rather more than two
inches in its longest circumference, and nearly one inch and three-
quarters in its shortest circumference ; it wad composed of oxalate
of lime. The child was discharged thirty-four days after the opera-
tion.

Of the twenty-eight cases operated upon by Dr. Spencer, sixteen
occurred in boys of from four to eleven y^ars of age. All of them
were discharged cured ; in every one of them the lithotome cach6 of
Dupuytren was used.

Mr. Mitchell Henry exhibited, before the Pathological Society of
London, a calculus of three ounces and three quarters, the nucleus of
which consisted of pure lithic acid, which had been removed from
the bladder of a boy fourteen years of age. It had been adherent to
the upper part of the bladder, by means of a distinct pedicle or stalk.
The surface of the stone was covered with an organized substance,
which caused the adhesion.

Dr. Lotzbeck advocates the high operation for stone, the fear of
urinary infiltration having been exaggerated according to GUnther's
statistics, and the employment of the suture of the bladder, as suc-
cessfully used by Bruns, although opposed by Bardeleben, Fitha,
and others, upon mere theoretical reasonings. He then reports the
case of a successful operation performed on a child eleven years old.

Dr. Noeggerath performed the high operation for stone on a boy of
eight years of age. The calculus measured two and one-half inches
in length, and four inches in circumference, and weighed a little
less than two ounces. It consisted of three different concentric sec-
tions, of which the nucleus was urate of ammonia, the next surround-
ing layer was composed of carbonate and phosphate of lime, and the
outer layer consistea of phosphate of lime, double phosphate of am-
monia and magnesia, animal matter, and carbonate of lime. Dr.
Noeggerath directs attention to one particular feature of the case,
viz. : the stone was not found for a long time, and by eminent sur-
geons, too, because it filled the whole of the bladder, and the instru-
ment always passed around it without producing a sound. Finally,
he reports the experiments made for the purpose of dissolving stones
by injections into the bladder ; the formula be used^was as follows :
Rp. Plumb, acetat. gr. vi., aq. comm. Svi., adde ac. acet. fort. q. s.
ad solut. perf. D. S., one smaU syringe full, to be injected twice a

449

day. From his experiments, he concludes that a superacidulated
solution of acetate of lead act^ upon phosphatic stones as a decom-
)>^singy disintegrating, and solvent agent ; the phosphoric acid pre-
viously combined with lime or ammonia uniting with the lead, the
acetic acid of which goes over to a pcurtion of the lime or ammonia,
in exchange for phosphoric or carbonic acid, while the free acetic
acid in the water renders a portion of the undecomposed phosphate
of lime soluble. The particles of stone which were left unchanged
in size and shape, had undergone such internal changes, that agita-
tion in water sufficed to turn them into powder.

A girl of twelve years, who had passed a stone when three and
one4ialf years old, was cured in Ouy's hospital, by lithotrity. Five
operations were necessary, all of which were performed under the in-
fluence of chloroform. /

Mr. Erichssn cured a delicate girl of four years by lithotrity,
another of three and one4)alf years by dilatation, and a third one, of
two and one-half years, by crushing the stone in ihe bladder.

Dr. Slade reports the case of a boy with two stones in the bladder,
consisting of phosphate of lime. The patient died of some inflam-
matory disease of the lung' a week after the operation of lithotrity
was successfully performed on one of the stones. There was no
cause of death in the bladder, or the adjoining organs.

liR. Simon has treated successfully some cases of incontinence of
urine iu children with galvanism, the current being passed along a
catheter which had been previously introduced into the bladder.
The cases were such of simple atony, and not those arising from
irritable bladder.

Mr. Pollock publishes two cases of incontinence of urine and their
cure by belladonna ; one in a boy of ten years, who had suffered for
a long time without any visible cause ; the other in a patient who
had been submitted before to the operation of lithotomy.

Dr. Addinell Hewson observed sevenl^-eight cases of enuresis
among the 292 boys in the House of Refuse of Philadelphia, with a
ratio of the diseased of 1 : 3.75 ; tliis ratio was in the white boys
1 : T, in the black 1 : 2.7. The avera^of the number was 12} years
old ; the youngest affected with the disease was seven years old, the
oldest eighteen ; the greatest number affected at any one age was
nine ; this was at the age of fourteen years. Of sixty-three cases,
the urine was of normal color in 46, very pale in 17 ; it was acid in
every one of them. The average specific gravity was 1018, amongst
the whites 1016, amongst the blacks 1020. Lowest sp. gr. observed
was 1010, highest 1027. The gpreatest number of any one specific
gravity was 16 ; in these it was 1020. Uric acid was deposited in
31 specimens, urate of ammonia (Golding Bird) in 8, urate of soda in
1, Ammon. phosp. mag. in 1 ; there was no deposit in 22. The pre-
puce and penis were discolored, and the former much elongated as
either from frequent pulling to relieve &e itching of cystic irrita-
tion, or as from masturbation ; in 46 cases 18 confessed to being
guilty of masturbation ; in 33, there was every reason to suspect
them ; in 12, there was no suspicion. Amount of drinking, and diet,

450

exerted a great influence ; a sudden fall of the thermometer, or ba-
rometer, always increased the number of patients.

Bromide of Potassium, in 2| and 3 gr. doses, tiirice daily, was tried
for its anaphrodisiac efifect. J^ine cases were completely cured after
the first week of administration, four were benefited after another
week. The remaining fifty exhibited no effect whatever. Chloride
of iron was given, for six weeks, to the uncured fifty-4bur. No
effect whatever. Tincture of cantharides was tried for two weeks ;
strangury was effected in the majority of the patients, but no cure.

Belladonna was next ^iven, ** five cbrops of Squire's juice, prepared
by Bently's process," with regard to constipation and worms. Du-
ring two nights, at the end of the first week, there was not a single
case. Among the eighty girls of the institution, there were only
two who wetted their beds, and these suffered in a slight degree
only.

Ik Mr. FoBsriRs' opinion, every case of retention of urine in chil-
dren, although small quantities may still be excreted, is of very
serious nature, infiltration in ^e perineum being easily effected, and
producing gangrene and death, in the large majority of cases. A
frequent cause of this disease are, from l£e second to the seventh
year, calculi, especially in the urethra. Of five cases reported by
Mr. Forster, only two did not result fatally, the stones being soon re-
moved ; in the three others, the stones came away throus^h the
incisions made into the perineum. Death ensued after a few dayd.

Dr. Bisrbaum has written on nephitis albuminosa, diabetes, diuresis,
anuria s. urodialysis, nocturnal enuresis, dysuria, stranguria and
ischuria, traumatic retention of urine, paralysis of the bladder, vulvo-
vaginitis, trichoma of the hair of the mens veneris, gangrssna vul-
vae, loss of blood from the sexual organs, balanitis, posthitis and
urethritis, ectopia of the testicles, and hydrocele. As we have pro-
posed to note everything new in pasdiatric literature, we do not feel
inclined to spend our soace, and to take our reader's time with
merely extracting several chapters, that would find a better place in
a manual than in a journal. Whenever a subject is to be exhausted
in a manner like Dr. B.'s, it ought not to find a place in a journal ;
in a journal, we look for something else beside what may be found
in every manual on diseases of children. Without detracting any-
thing from the value of Dr. B.'s essays, we wish simply to say, that
whatever an old gentleman knows, he must not necessarily have dis-
covered himself ; and that young man for whom Dr. B. asserts, on
almost every page, to have written, may possibly know something
without having learned from Dr. B., from merely making use of
the same sources of instruction, to which the learned aspect of Dr.
B.S little essays is due.

Dr. Oodard communicates in his inaugural dissertation a number
of interesting oases of congenital absence of one or both of the testi-
cles, with a review on many instances of the same deficiency collect-
ed from literature.

Dr. Fech publishes the case of a man with absence of the posterior
inferior angle of the parietal bone, who was obliged, therefore, to
wear a metol plate. He had an intestinal hernia when a boy, and

451

when examined by Dr. Pegh an omental hernia cohering with the
spermatical funis and testicle which were entirely atrophical.

The same author reports the case of an alleg;ed female, who was
SI years old in 1830. This hermaphrodite was wen recognized to be
a male, and died in 1857. The hermaphroditism was but external.
The scrotum was split, the membrum virile imperforate in conse-
quence of a retardation in the development of the urethra, tiie
original foetal sinus urogenitalis persisting.

Dr. KOltsch publishes two cases of premature menses in two
German girls of 7 and 8 years. The sanguineous emission was
feeble but regular, in periods of 4 weeks. The pliysical develop-
ment in general was not in proportion to that of the sexual organs.

Dr. Brown's case of encephaloid disease of the right ovary is
unique, and greatly interesting for the seat of the tumor, the age of
the patient, the rapidity with which the disease ran ita course, and
the absence of any symptom that could excite the suspicion that the
disease was malignant in character.

Dr. Picardat's pamphlet treats, in different chapters, on complete
or partial absence of the urethra, on its obliterations, on its abnor-
mal openings (epispadias, hypospadias), on anomalies in its gen-
eral form (dilatations and contractions), and on the twofold
character of its canal. There is nothing original in this little
work ; but whoever wants to find a good collection of facts on
congenital deformities of ihe urethra, from French authors, will feel
satisfied with Mr. P.'s selection. We say from French authors, for,
except Haller, Ruysch, Vesalius, and Borelli, whose latin works are
occasionally quoted, Mr. P. appears never to have consulted any
foreign authority.

Dr. Gaby observed simple vulvitis particularly in syphilitic, anae-
mic, and feeble infants, with pale mucous membrane, otorrhoea, and
intestinal catarrh. But sometimes robust children were affected.
Local application, for 8 times, of nitr. bism. was sufficient to effect a
cure.

Dr. Vooel asserts that the majority of cases of purulent secretion
of female genitals are not specific. Infection is produced by gar-
ments, sponges, sleeping in one bed with a diseased woman, immis-
sion of a diseased penis.

Dr. Browning's singular case of genito-urinary malformation, is a
case of epispadias.

Dr. Werner publishes a case of hypospadias, in a boy of eleven
years of age, on whom Prof. Bruns operated unsuccessfully.

Dr. Schultze reports a cystifcfrm expansion of the right ovary by
extravasated blood, in a still-bom child of seven months. The tissue
of the ovary was torn and broken, in some parts scarcely recogniza-
ble, by blood both fluid and coagulated, and fibrous coagulations.

Dr. Jones exhibited before the Pathological Society, of London,
the clitoris of a chUd of 6 weeks, which was about an mch in length,
and had a distinct glans and prepuce. The other sexual organs
were well fimed.

BoGBMWM «&Mbodv^«MQHiiAd ia teaatinff flie non-congenital
phimoBia of IP* TOPlatkm of the secretion

462

of the glandulae tysoni within the prepuce, by tepid injections,
repeated 2 or 3 times a day.

P^op. Streubel, in a eilly article full of ungentlemanly witti-
cisms, contests against the necessity of circumcision in cases of
congenital phimosis, declaring the elasticity of the prepuce to be so
great as to allow of a high degree of expansibility, and asserting the
generally well-known opinions of Ricord, Vidal de Cassis, Bonnafont,
Chassaignac, and aU good surgeons to be sheer nonsense.

Dr. KObbelen is of StreubePs opinion, because in one case of para-
phimosis, when, he, Robbelen, was just about to split the prepuce,
this was easily brought into its normal situation by a simple incision
of the freculum. Si tacuisses — .

IX.— MOTORY ORGANS.

I. Schwegel, The Devdopment of the Bones of the Trunk and Extremi-
ties, Viewed with Regard to Surgery, Obstetrics and Forensic Medicine.
-— Sitzungsber. d. Kais. Akad. d. Wiss. XXX. 17. (Repr. PamphL
Vienna, pp. 64.)

i, BOhm, on the Forensic Importance of (he Osseous Nucleus in the In-
ferior Epiphysis of the Femur in Newborn Infants. — Casper's
Viertelj. 1.

8.- Congeniial Absence of the Badit^ and its Muscles. — ^Lancet. Aug.

4. Johnson, A., Case of Polydactylism in which Nine Toes existed in
One Foot. — Trans. Path. Soc. IX. p. 427. — Lancet. Aug.

5. Silvester, H. R., A Contribution to the Science of Teratology. —
Lancet. Pebr.

6. Wallmann, H.» Some More Remarks on the Singularly Formed
Shoulder-Blades of a CAiW.— WUrzb. Verhandl. VIII. 3. p. 323.

T. Honel, on a Monstrous FoettAs.—rQzz. Hebd. 87. Arch. O^n. Oct

8. Adam, Malformation of the Lower Extremities. — Chic. Med. Jour.
April.

9. Blasius, E., Six Cases of Congenital Angular Curvature of the Leg.
— ^Monatschr. f. Geb. Aug.

10. .Recklinghausen, P., The Mineral Elements of Young Human
Bones. — ^Virch. Arch. XIII. 5, 6.

II. MuUer, H., Ueber die Entwicklung der Knochensubstam nebst Be-
merkungen uber den Bau RachitiscJier Knochen. — Leipzig, pp. 89.
(On the Developmeht of Osseous Substance unth Remarks on the
Structure of Rachitical Bones.)

12. Bouvier, H., Lemons Cliniques sur les Maladies Chroniquts de
VAppareU Locomoteur, PrqfessSes i rJBdpital des Erf ants Mdades
Pendant les Annies 1855, 1856, 1857. Paris, pp. 512. (Clinical
Lectures on the Chronic Diseases of the Locomotive Apparatus, De-
livered at the Hospital for Sick Children at Paris, in the years 1855,
1856, 1857.;

45S

13. Bonvier, H., Affasda Lefons Chmqwes^ etc, JDeviaiumB deh Qh
kmne VeriOprale, 20 Pland^e^, (Jiias of SO Plaies <m DeviaHoM
cf the Vertebral Column.)

14. Bonvier, H., State of Viscera in Scolums, — (3az. d. H6p. 1.

15. Gontay, Du BadnUis el du Bof^riiisme, ou mieux oMomalaxie. —
Paris. Th^se. p. 29. (On BadiUis and Bachiiism^ beOer os^o-
malaria,)

16. Bigg, E.HfOnthe Mechanical Amliances NecetUBry for the lYeat'
ment of D^ormities, Pari L Loiiacm. p. 236.

n. Fleming, Die Rfid^i^raUoer k rummungen^ besondersfmr EUern und
Erzieher. Dresden, pp. 84. (The Curvalures of the £^[nne,for the
Particular Use cf ParerUs and Pedagogues.)

18. Eolenbnrg, Contribulums to the Pathology and Therapeutics cf
Scoliosis vTUh Particular Begard to Some Modem Hkeones. — Prag.
Viertelj. 2.

19. Coote, H., on Latertd Curvature tf the Sjpine. — ^Brit. Med. Jour.
Febr. 27, March 6.

20. Wedl, on i2acAi^— Zeitschr. d. Ges. d. Aerzte z. Wien. 2.

21. Kuttner, Statistics on the Prevalence of Bachitis at Dresden, —
Joum. f. Kinderk. 1, 8.

22. Hauner, Bepori on the Eleventh Year cf the Dispensary Connected
with the Children's Hospital at Munich.~Jowm, f. Kinderk. 7, 8.

23. Badd, W., Calcareous Salts in the Treatment^ (f Bickets.—Bntl
Med. Jour. Jane. 7.

24. Ronth, A New Preparation of the Superphosphate of Iron and
Lime,

25. Little, W. J., on Unnecessary Orthopcedic Operations. IVeaiment
of NonrCongenital Diseases.— LsLncet. Febr.

26. Incipient Talipes Equinus, Consequent on h\jury of the Spine, —
Lancet July.

27. Necrosis (f the Whole Shaft of the TSna.— Lancet July.

28. Scrtfulous Disease cfihe Thumb and Lower Jaw. — Lancjpt Oct.

29. Johnson, S., Necrosis of the Tibia, in a Child 28 Days Old.—
Trans. Path. See. p. 352.

30. Klose, C. W., The SeparaHon (fthe Epiphyses, a Disease ofDevd-
opment. — ^Prag. Viertelj. 1. — Arch. G^n. Aug.

31. Gosselin, L., on Inflammation cf the Epiphyses, of Bones in Young
Individuals. — ^Arch. G^n. Nov.

32. Schuh, on Beposition cf the Luxation of the Femur in Coxalgia. —
Wien. Z. 6.

33. Bedudion of the Badius after Six Weeks. — Lancet May.

34. I^rumous Contracted Knee. — ^Ibid. Aug.

35. Chalk, 0., Morbus Coxoe. Death from Encephalitis. — ^Trans. Path.
Soc. IX. p. 353.

36. Price, Head cf the Femur Bemoved by the Operation of Excision.
—Ibid. p. 349.

464

8T. CHnicd Becords. — Lancet. Jan., Febr., Jime, Jnly, Sept, Oct

38. A Mirror of the Practice of Medicine and Surgery in (he BMpiidi
of Londim, — Lancet. Oct.

39. Beale, J. S., on a Case of DdideTvcy of Development of fhs
Superior, Posterior, and Anterior AspetA of a Foehis, — ^Lancet Nov.

40. Reiner, M., Succea^tU Di^unction of Tux> Children Connected
wiih Each other between the Tub, Isch, and (h Cocc, — ^Wien. Mei
Woch. 31,82,84,61.

41. Ravoth, Observation of a Case of Congenital LuxaHon <f the Fa-
tdla forwards and upwards, — Mon. f. (Jeb. May.

42. Lynch, Contused Wound, in a Foetus vnthin the Uterus, — Brit
Med. Jour. July. 24.

43. Congenital TorticoUis in a Young Oirl, — ^{jancet. Jan.

44. Nunn, T. W., Congenital Deficiency of the LaHssimus Dorsi.—
Trans. Path. Soc. Lond. IX. p. 427.

45. Gay, Extirpation of a Peculiar LiponuUous Tumor on the Arm of
an Infant, Becidive and Second Operation, — Med. T. and Gaz. 25.

46. Birkett, J., Congenital Supernumerary and ImperfecUy Developed
Auricles on the Sides of the Neck. — Trans. Path. Soc. Lond. IX.
p. 448.

47. Nunn, Femur and WpJoinl Taken from a Paiieni who had Bern
Affected with Talipes Equinu^s Paralyticus, — Ibid. p. 432.

48. Ramskill, Congenital Deficiency of Part of One of the Abdominal
Muscles, — Med. T. and Gaz. July, 3.

49. Steger, P. E. H., Congenital Malformation, -«- Nashv. Monthly
Rec.

50. Roberts, W., an Essay on Wasting Palsy {Couveilhier's Atrophy)
London, pp. 210.

61. Friedberg, H., Patholoqie und Therapie der Mushellahmung, MU
4 Tcfdn Abbildungen. — Weimar, pp. 350. (Palhohgy and Therar
peutics of Muscular Paralysis. With 4 Plates,)

Dr. Schwbgel's essay looks less like an original article, than like a
number of extracts from a large work of many volumes. We have
never seen a larger number of important facta and discoveries con-
densed into a small paper like that before us. To giv^ its main
contents, would be a translation ; therefore extracts being impos-
sible to make, we merely give an outline of the tendency of the
author's work. He shows the development of the bones of the trunk
and extremities from the second month of foetal life, when the first
sign of ossification is observed, up to the twenty-sixth year, at which
age the normal development of the bones is finished. He further
demonstrates of how many points of ossification the bones of adults
are composed, when the jingle points arise and join, and designs
epochs for better illustrating the process of osseous development.
The number of all the points of ossification in the human skeleton is
fifteen hundred, of which five hundred are ih the vertebrcB, tiiirty in
the sternum, one hundred and fifty in the ribs, six hundred in the ex-

466

tremities, forty in each shoulder and pelvis. The anthor proves that
ossification is developed in longer periods than is usually believed,
and that individual irregularities and deviations from the rule are
not unfreqnent ; he confirms by his investigations some former, much
doubted observations on the occurrence of vertebral epiphyses at the
intervertebral junctures, of diaphyses in the transversal processes,
etc ; and shovrs the existence of many new ones not before ob-
served. Furthermore, he points out the time when fractures iif the
intermediate cartilage between the points of ossification are possible,
and the relations of joints and ossification to each other are illus-
trated, and, finally, he shows at which time, and at what place, a
fracture will be either an intracapsular or extracapsular. With con-
siderable accuracy, he gives the measures and proportions of the pel-
vis of the new-bom and the adult, and much industry and ingenious-
ness is shown in the manner in which the author makes use of the
known progress of osseous development for the purpose of finding
the age of individuals.

Before the commencement of ossification in any of the tubular
bones, about fourteen days before the regular termination of preg-
nancy, the first ossificated nucleus is found in the inferior epipnysis
of the femur. This fact, as discovered by Beclard, in 1819, and
again examined by Casper, Ollivicr, and Mildner, has been made the
subject of renewed examinations by Dr. Boehx, who draws the fol-
lowing conclusions from one hundred and eighty-six cases : 1. The
nucleus is not found in a feeble foetus of less than thirty-eight weeks.
2. In a well developed foetus, it is as large as one-twenty-fourth of
an inch in the commencement of the tenth month of pregnancy. 8.
It measures from one-sixth to one-fiflth of an inch in a well developed
infant at the regular term of its birth. 4. Its size is in proportion to
the general process of nutrition and ossification. 5. Whenever it is
found to be larger than one-fourth of an inch, the infant may be taken
as having lived after birth. 6. Its size is growing with the develop-
ment of the bom infant. 7. Wherever the nucleus is absent, the
foetus must not be considered older than thirty-six or thirty-seven
weeks. 8. It resists putrefaction for a long time. 9. The body
being wholly destroyed by putrefaction or other means, the femur
will be sufficient to determine the age of the foetus.

Two bifid toes were exhibited before tlie Pathological Society of
London, which had been removed from a child six years of age.
There were seven toes on the foot before amputation ; or, counting
the two bifid toes as four, there were nine. The supernumeraries
were situated at the inner side of the foot, about the normal position
of the great toe.

In a child of two years of age, the entire radius was absent^ as
well as, so far as could be made out, its proper muscles. Tliere was
a wrist-joint ; but the true radio-carpal joint was not perfect, nor was
there any metacarpal bone of the thumb. The true thumb was there-
fore deficient, and^he rudimentary finger in its place, was evidently
not a thumb, but probably a second indcx-fingcr. It was removed
by Mr. Erichsen. The left hand was twisted inwards, and quite loose
at the wrist, as if paralyzed.

456

In the right arm of a child, as reported by Mr. Silvester, the radios
was eiit^ely absent. The upper part of the nlna, and the lower end
of the humerus^ were modified to compensate for the deficiency.
The defective parts in the hand were the scaphoid, trapezius, and the
metacarpal bones, and phalanges of the thumb. The pronators,
supinators, flexors, and extensors in the middle of the arm were ab-
normal, but those on tiie ulnar side were normal. The hand was
fixed in a prone position, and flexed to such an extent, that the
radial side of the mdex finger lay adjacent to the radial side of the
forearm. The left arm was more deformed. The scapula was well
formed, except that the glenoid cavity presented the form of a hemis-
pherical emmence. Little more than the lower extremity of the
humerus existed, and a small cartilaginous nodule represented the
radius. The carpus presented only the pisiform, cuneiform, and un-
ciform bones ; the metacarpus, tbe three inner bones. The little and
ring fingers were persistent

Mr. Houel presented before the Academy of Medicine at Paris, a
monster belonging to the family of pseudencephali, in which tiie
following anomalies were found : I. A nasal fissure, produced by
the absence of the nasal bones, by division of the skin, and inter-
position of a peculiar tissue. This fissure was not exactly in the
median line, but somewhat on the right side. 2. Absence of some
fingers of the hands. Cicatrices being visible. Dr. Houel attributed
these abnormities rather to spontaneous amputation than to arrested
development 3. Fracture of tlie fight leg, and wound of the left :
the fracture being, in the opinion of Dr. H., effected by the umbilical
funis. The pathological process is proved to have progressed slowlv
by the lateral peroneal muscles and the flexor muscles in generiJ,
even their tendons, being in a remarkable state of fatty degene^
ation.

Db. Adam reports the case of a child, perfectly healthy in every
other respect, in whom the patellad are both wanting, and in their
place is something like the poplitsdal space, in place of which "flatter
18 a kind of elbow, so that with this joint the child can make with its
legs the same motions towards its head as with its arms."

Prof. Blasius remarks, in his reports on six cases fof congenital
angular curvature of the leg, that malformations of that part have
the appearance as though they were the effects of mechanical
violence, with the complication of external wounds. In all the cases
the leg was bent in the shape of an angle and the skin looked as if
cicatrized ; in five the tibia was really inflected, in' the sixth the
lower end of the tibia was entirely absent In each of the six cases
there was such a malformation of the foot as is formed in a period
of foetal life when no fracture is possible. In two cases the fibula
was absent. Furthermore, the limb never reached its normal devel-
opment in spite of prolonged and systematical exercise, the reverse
of which is observed in cases of consolidated fractures. Ail these
facts seem to prove that the deformity is dependent on a persistent
deficiency of development External injury during the course of preg-
nancy was reported in one case, denied in four. AH the cases report-
ed in literature are like these new ones. The possibility of fractures

457

in the uterus however, by external violence, cannot be denied, but

Eain of any kind proves nothing. In all the reported cases continuity
as been interrupted, but consolidation has again taken place. That
consolidation will not take place in every instance is proved by the
cases of congenital rachitis, where consolidation is wanting on many
different places. Sometime it is met with in different partB of the
body. Deficiency of consolidation has been observed not only in the
leg, but in the os femoris (two cases by Maas, and one by Schubert),
and OS humeri (one case by lyOutrepont, one by Fuchs), none of
them being produced by external influences. Bupture of the soft parts
is also possible without external violence ; in a case reported by
Schubert one of the ends of the fractured os femoris penetrated the
muscles and integuments for about an inch ; it cannot indeed be con-
sidered as impossible, that soft parts should suffer in a similar man-
ner as bones. It is true that the number of cases of .congenital
rachitis are not reported to have ever been complicated with per-
foration of the soft parts, but one of Prof. Blasius's cases is a proof
of the possibility, as well as the cases of Schreiber's, in which a
genuine formation of cicatrices was found. Cicatrices, however, are
not always genuine, when the cutaneous tissue is drawn inwards ;
for sometimes there is but a deposition of fibrous tissue below the
integuments.

Dr. Recklinghausen asserts to have found by chemical tests,
that there is no difference in -the absolute amount and relative
proportions of osseous substance — neither in old and young indivi-
duals, nor in old and new formed osseous substance, nor in compact
and spongions bones. Valentin, who found that Phosph. calc. is
not deposited directly but generated from carb. calc, etc., and further
that the bones of the new-bom, and spongions bones, contain a
larger amount of carb. calc, than those of adults, and compact ones;
and Frerichs, and Yon Bibra, who found very large differences in
the composition of compact and spongions bones, and even in the
composition of several bones in the same skeleton, are simply told
that they do not know how to remove the accessory elements, the
peri-and endosteum, blood vessels, etc., from the osseous substance, in
short that they do not know how to make chemico-physiological
examinations.

Among the eminent German microscopists Prof. H. Mueller has
made himself very favorably known in a comparatively short time.
The main points of his exceedingly able essay, as far as their rela-
tion to rachitis is concerned, are the following :

1. The first genuine osseous substance, that is formed in the in-
terior of cartilages, takes its origin from the cartilaginous canals, in
which osteoid masses are developed containing stellated cells. These
become bones by deposition of earthly matter, the cartilaginous sub-
stance gradually disappearing. Such is the fact as well in the
irregular (vertebral, tarsal) bones, as in the osseous nuclei of the
epipnyses.

2. The first genuine osseous substance that is formed in tubular
bones, takes its origin from the perichondrium, the inclosed cartilage
gradually decaying, while medullary substance is formed. This is

458

done, in man, nfler precediDg deposition of earthy matter ; in birdi.
froKB, etc., Dsnally witboiit it, genuine ossification within the periovr.l
teal osaeoua tubes conimencing after the formation of medullar intOE
stitia.

3. Where intracartilaginous ossification commences in rachiticakfl
bonea, the deposition of earthy matter is deficient not only in thfr]
cartilage, but also in the newly formed osseous substance.

4. The ehape^of the medullar int^rstitia is abnormal in rachitii^.l
the destruction of the original cartilaginous substance being in^T
complete.

6. Besides, a slow trauaformation of the cartilage takes place fm
qnently instead of its normal and rapid decay.

6. The process of formation of the new osseous snbstauce is £
qncntly no less slow and incomplete.

7. In the abnormally persistent residncs of the cartilage thicllLj
layers are formed round the cells.

8. In the interior of rachitical bones osteogeneons enbatance (a
seous substance witliout earthy matter), ia extensiTety formed, somei^l
times so much so as to render the bones flexible. * n

9. The rachitical alteration is most manifest in those parts of tbfrf
tubular bones, where the first points of ossification originated.

10. Where the rachitical abnormities of ossification are very o
siderable, mere cavities arc formed in the cartilage with soft and*J
not osteoid contents.

In merely pronouncing the name of the celebrated French special
ist, Prof, BorviEB, we are sure to direct at once the attention of tl
profession to tficse valuable works containing the results of his '
doubtedly long and rich experience. The subjects treated
are so various and important, that wo cannot attempt to give eve
the shortest review of their contents. Old and new facts, the resulttfg
of former and of the author's own experience, described in a style ■
plain as it is elegant, render this work the best exposition on
principal deformities of the osseous and muscular systems,
atlas IS as beautifully and carefully executed as the book is v
written and of a scientific stamp. Our principal reason for abstain**!
ing from giving any further notices and extracts is, that all tfal
matter contained in the book has been priuted years ago, in Frend
Journals, and is, since, generally known among the professifw.

The same author makes the following remarks on the state of tlMltV
viscera in scoliotic subjects : The curvatures of the vertebral foodieBr!ir
of the spinal canal, of the spinous processes, and of the spine, are n
proportionate to each other. The curvature of the canal is small
than that of the vertebral bodies, and greater than that of theprocessnvrl
epinoei ; the flexion of the spine is diminished in each curvature, and,*/
tfaereforo, its functions are rarely disturbed. Considerable cnrvatoretfJ
only may affeot the spine, at last, so as to shorten it on the part o^ I
the concavity of the curvature ; if such is the case, the nerves on tlwi^
same side are not in the like distance from each other, as on tlMpI
side. The spinal nerves snifer least from the curvature of .T
the column, for the intervertebral foramina remain almost alwayi^l
larger than the diameter of the nerves ; such are even the worg'

465

minds. Like wants appear to produce like exertions and like
results.

Neither of the books referred to falls entirely under the head of
our review ; but we thoup^ht proper ^o give some facts from both, in
order to show the relation of muscular paralysis to the essential
paralysis of children, as set forth in the book of Professor Vogt ; the
more so because 13 cases of the 105 reported by Dr. Roberts occurred
in children of 14 years and under, and 3 new cases, introduced by
Dr. Friedberg, occurred in boys of IJ, 6, and 13 years of age.

Contrary to the anatomical cause of essential paralysis, we learn,
from the examinations of our authors, that

1. The gray substance of the spinal cord may be extensively dis-
eased without progressive atrophy of the muscles existing.

2. In some cases of this disease other parts of the spinal cord
have been found diseased, the gray substance being normal.

3. In some cases of general muscular atrophy (40 out of 105 cases
collected by Roberts belong to this class) and paralysis of the entire
muscular system, the spinal cord and the roots of the spinal nerves
have proved entirely normal.

4. Therefore, degeneration of the roots of the spinal nerves must
not be taken to be the cause of paralysis consequent on muscular
atrophy.

Neither of our authors thinks the name of the disease, as proposed
by Aran, "atrophic musculaire progressive," a good one. Friedberg
would propose the name of '^ paralysis from alienated nutrition of
the muscles," but prefers simply " muscular paralysis ; " Roberts
thinking "idiopathic degeneration of the voluntary muscles," some-
what lengthy, although physiological, suggests simply "wasting
palsy," or " Cruveilhier's atrophy," after the writer who has taken the
most prominent part in elucidating its history.

The seat of the disease is proved neither to be in the vascular
system, nor in the spinal cord, nor in the anterior roots, nor in the
peripheral distribution of the nerves, nor in the sympathetic nerve.
It must, therefore, have its seat in the muscles ; and such is the
opinion of Duchenne, Aran, Oppenheimer, Wachsmuth, Meryon,
Roberts, and Friedberg ; and it consists "in a fatty and granular
degeneration of the muscular fibre, similar (often, at least) in its
anatomical bearings, to what is observed in fatty heart, or in
muscles which have degenerated from section of their nerves. There
would seem to be an error of nutrition in the muscular fibre, not
dependent, as Dr. Meryon thought, on a general depression of the
nutritive functions — these being almost always in their highest per-
fection — but brought about under the influence of a peculiar consti-
tutional predisposition or diathesis." — (Roberts, p. 175.) The single
causes are best set forth by Dr. Friedberg, who thinks muscular
paralysis to be very generally the result of inflammation of the
muscle or a similar process. He discerns the following six divisions,
according to the principal cmm 'degeneration :

Propagated* myopethk »^ The nutritive trouble is

tied to the iniuMla^ nring organ.

"tatiojii.li.

458

done, in man, after preceding deposition of earthy matter ; in birds,
frogs, etc., nsually without it, genuine ossification within the perios-
teal osseous tubes commencing after the formation of medullar inter-
stitia.

8. Where intracartilaginous ossification commences in rachitical
bones, the deposition of earthy matter is deficient not only in the
cartilage, but also in the newly formed osseous substance.

4. The shape»of the medullar iuterstitia is abnormal in rachitis,
the destruction of the original cartilaginous substance being * iur
complete.

5. Besides, a slow transformation of the cartilage take9 place fre-
quently ipstead of its normal and rapid decay.

6. The process of formation of the new osseous substance is fre-
quently no less slow and incomplete.

7. In the abnormally persistent residues of the cartilage thick
layers are formed round tne cells.

8. In the interior of rachitical bones osteogeneous substance (os-
seous substance without earthy matter), is extensively formed, some-
times so much so as to render the bones flexible. *

9. Thd rachitical alteration is most manifest in those parts of the
tubular bones, where the first points of ossification originated.

10. Where the rachitical abnormities of ossification are very con-
siderable, mere cavities are formed in the cartilage with soft and
not osteoid contents.

In merely pronouncing the name of the celebrated French special-
ist^ Prof. BouYiER, we are sure to direct at once the attention of the
profession to these valuable works containing the results of his un-
doubtedly long and rich experience. The subjects treated of
are so various and important, that we cannot attempt to give even
tibe shortest review of their contents. Old and new facts, the results
of former and of the author's own experience, described in a style as
plain as it is elegant, render this work the best exposition on the
principal deformities of the osseous and muscular systems. The
atlas IS as beautifully and carefully executed as the book is well
written and of a scientific stamp. Our principal reason for abstain-
ing from giving any further notices and extracts is, that all the
matter contained in the book has been printed years ago, in French
Journals, and is, since, generally known among the profession.

The same author makes the following remarks on the state of the
viscera in scoliotic subjects : The curvatures of the vertebral bodies,
of the spinal canal, of the spinous processes, and of the spine, are not
proportionate to each other. The curvature of the canal is smaller
than that of the vertebral bodies, and greater than that of the processus
spinosi ; the flexion of the spine is diminished in each curvature, and,
therefore, its functions are rarely disturbed. Considerable curvatures
only may affect the spine, at last, so as to shorten it on the part of
the concavity of tiie curvature ; if such is the case, the nerves on the
same side are not in the like distance from each other, as on the
convex side. The spinal nerves suffer least from the curvature of
the column, for the intervertebral foramina remain almost always
larger than the diameter of the nerves ; such are even the worst

459

cases, and, therefore, there is not much credit to bo given to
anthors, who used to attribute several morbid svmptoms, in scoliotic
children, to the compression of the nerves. The lungs suffer verv
much. In curvatures to the right side the right lung is compressea,
particularly in its posterior part, so much so as to be sometimes
deprived of air; the posterior part of tho mediastinum is drawn in
an oblique, nearly transversal direction ; the left lung is reduced to
a smaller diameter, especially in tho antero-posterior direction ;
somewhat less so in a lateral one. If the curvature is to the left
side, the left lung is more compressed, because of the presence of
the heart, than the right lung in the reverse case. The diaphragm
extends higher into the thoracic cavity, more so on tho right
than on the loft side, in consequence of both the dorsal and
the abdominal curvature, which diminishes the abdominal cavity.
It is easily understood, that the results of auscultation and per-
cussion are very much modified by all these peculiarities of con-
formation. The heart is not affected by the pressure of the thoracic
walls to such a degree as the lungs. Its size is very seldom reduced,
more generally increased ; fatty degeneration has sometimes been
observed, but scoliosis does not seem to produce it. It was a
general belief formerly, that the pressure of the thoracic walls on
the heart was liable to endanger life ; such is not the case, as in the
worst cases of scoliosis tho heart is found to be situated on the right
side of the spine. Thus its situation, as that of the groat blood-
vessels attached more or less to the vertebral column and its neigh-
borhood, may be altered in different ways. The abdominal cavity is
greatly diminished in size, stomach and bowels are pressed down-
wards, and a great part of the intestines is situated between the
walls of the pelvis. The transverse colon may, sometimes, become
vertical ; in some cases, observed^by Cruveilhier, and Bouvier, it was
situated between liver and diaphragm. The size of the liver is not
always reduced ; sometimes it is even greatly increased, but not so
in every direction, because it gets its shape from the bones by which
it is confined on every side. Its surface is very much disfigured by
the adjoining parts of the body ; on the posterior side the vertebral
column, on the right lobe the ribs, on the lower surface the right
kidney, leave the vestiges of their pressure. Thus, the shape is
never equal in such cases ; usually the right lobe of the liver suffers
most ; the more so, if the lumbar vertebrad are directed to tho right
side. It suffers less, when they are bent to the left side, because
there is, in this case, more room for them. Tlie spleen moves easier,
and, so far, is more apt to avoid pressure. Nevertheless, its surface,
in some cases, shows superficial depressions and excavations. The
kidneys^ adjoining the vertebral column, are much affected by its
curvatures. When the first abdominal vertebrae are turned to the
right side, the right kidney is lower than the left one, and vice versa.
The kidney corresponding to the convexity of considerable lumbar
or lumboKlorsal curvatures, by being compressed by vertebra) and
ribs, becomes longer, narrower, smaller in bulk and lighter in weight ;
the kidney corresponding with the concavity compressed superiorly
and inferiorly, becomes shorter and broader, but keeps, at least, its

460

normal size. Similar remarks are made» after Bouvier, but certainly
none of the same value, in the inaugural dissertation of Dr. Gontat.

Mr. Bigo's volume is not strictly professional, but the work of a
practical mechanic. A description of 75 different instruments is
given, together with the theory of their action, and the manner in
which they should be applied and adjusted. The mechanical appli-
ances described are for deformities of the toes, of the foot, of the calca-
neous ankle (tal. valgus, equinus, varus, calcaneus), of the leg, knee,
and hip (curved tibia, genu valgum, contracted knee, and contraction
of the hip-joint). The author comes to the conclusion that, unless
mechanical appliances are constructed with a due regard to the
anatomical and mathematical conditions of malformations, they will
inevitably give dissatisfaction. This is a clear and intelligible,
practicable book, and gives testimony of a fine mechanical talent^
and good anatomical knowledge.

Dr. Fleiong's book is destined to explain, to the non-medical
reader, tiie causes of curvatures of the spme and the means of pre-
venting them. Although recommending no exclusive method, the
author nevertheless gives the preference to the Swedish medical
gymnastics.

Amongst 300 cases of scoliosis observed by Dr. Eubenbtjrg, 2*1*1
occurred on the right, 23 on the left side ; 29 patients were of the
male, 261 of the female sex. The causes of the disease was found
in —

1. Deficiency of the muscular antagonism, in 264 cases.

2. Rachitis, in 14.

8. Scrofula and tuberculosis of tiie vertebrae, in 4.

4. Traumatic injuries, in 5.

5. Acquired shortening of one leg, in 5.

' 6. Congenital luxation of the femur, in 4.

T. Empyema, in 4 cases.

The commencement of the disease could mostly be traced to from
the 7th to the 10th year ; 69 girls had scoliotic mothers. Heredita-
riness being, therefore, unquestionable, like strabismus or hernia,
an early prophylactic, gymnastic treatment is indicated.

In consequence of the frequent use of the right arm, the left one
being neglected, the vetebrsd column becomes convex to the right
side ; the muscles of the left concave side, particularly the inter-
transversarii, are shortened, and those of the convex side stretched.
This physiological fact becomes pathological by long duration ; the
curvature in the lumbar region, to the left side, is but compensatory.
By customary standing on the right leg the muscles of the right hip
are better innervated tiian those of the left. After an empyema has
been cured by emission of the pus, there is a convexity correspond-
ing with the healthy side. Rachitical scoliosis takes its origin
before the sixth year, because rachitis heals, at latest, about this
period ; it is characterized, too, by swelling of the joints ; and its
curvature is somewhat different from what is usually seen, turning
to the left in an unusually large arch. Scrofulous scoliosis has a
pecoliar, short angular inflection of some vertebral bones. It is sel-
pi iten, while deviation backwards, of the vertebral bones, or

4ei

of xnerx-enebral cutflftg^es and ligvnimts ft?e of sieocaidarT iuOukl
Dr. Ecknbiiri: objects to strndunfr mvparamsiesE of anj kind : Lis
tresanent is but gymiiftsticiJ in the Swedish nuumer, mlicsnating
vixii repose cc bnrd zDmrtre8se&

Mb. Cooie s isTcstigvDcais on InlcnJ mxmsiires of ^le «pizie
leftd TO tbe fiiDowincr ctaich»ioiKS : Tbe nrasicles Imt^ no 6h«:r in
origrinnriTtg ^le deformitr. But when the spine is corred. the mnf^les
in the cc4»cavitT contncs like the string to m hew, and if they cotnkL
net, ther would increase tiie deformitr. Tte deformitr. oince estah^
liriied. increases at diiiierent rates of progress* if unciiecked thr»ng)i
life. There is no age at which snfikaent ocmscdidatioB of the hooies
and Hnments oomrs to secure the patient from increase cd the eriL
To ediect a core, tiie spine must he alowhr pressed into its pxvtper
shape, md there hM hj means of instnmients vntil the same adap-
true fffxxess of contractaoa, whidi ensaed in the defcirmitT, ret^stalv
briies the figure. Tlierefore^ anr srstem based upon tike deTelopment
of mnscular agencies is fnndunentalhr wivm^r : when the spme is
straight and not before, can gtx^ resnh iran the action of the
extensor mnsdes. Ahhoogh it be tme, that in some earir cases the
deformity is reiy greathr lessened by the patieiit assnminir the
recnmbeiit posture, yet experience teaches that want of exercise is
followed by kiss c^ tone, and impairment of ceneral health ; nndcr
which circnmstances, the spine is little calculated to retain its nor^
mal fcvrzn icben the patient restnnes the upright posture. Mechanical
support must be constant and sufficiently firm to act upon the verte>
bral column ; henoe instmments most be strongly made.

Pr. Wedl considers the nature of radiitis to consist in a difime
and irregnlar formataon of intermediate tissue, softcniufr the osseons
substance to such a degree as to allow a knife or pin to penetrate
the osseous substance. Dr. Stiebel has proposed the opinion that the
phosphate of lime, which is not soluble in water, is kept in the blood
by means of organic acids, and directiy introduced into ^ urine
without participating in the formation of osseous substance. IV. W^
however, states that the relative absence of calcareous salts has not
been proved^ and rachitis being not a disease of the whole osseom
system, but usuaUy limited to some few bones, the general want of
lune cannot be taken as existing from an anatomical point of view.

The propcHtion of rachitical diildren in Dresden is, acoording to
Dr. Kfittner, exceedingly great, the labcning dasses being in a reir
wretched condition. Ont of 9,000 patients admitted into the chil>
dren's hospital for the last twenty years, 1,^4 were rachitical, or
had been so ; of this number, 198 children belcmged to journeymen
shoemakers, and 162 to joumeypnen tailors, beine 25 per cent, of the
whole number. Twins, and diildren prematurely born, were rather
numerous. The largest number were from two to three years old.
Of the whole number, 387 had not had the breasti or had been suckled
but a very short time ; 360 were nursed for the usual period ; and
455 for a longer time than usual. The largest number of rachitical
children was noticed in the winter months. Kfittner is inclined to
believe, that the early use of mudi bread and potatoes increases the
rachitical disposition.

464

Ms. Lynch attended a woman who fell, in tbe eighth month of her
pregnancy, against a piece of wood, and had an easy confinement
after suffering for a week. The child was dead, and had a large
contused wound, from the os sacrum to the occiput, of three inches
in a transverse direction. Skin and muscles were lorn oflF the verte-
brte and ribs. The wound was covered with a pellicle of organizin|^. I
lymph, and the margins proved to be in the commencement of cicto J
trization. '

A mild example of wir-npck has been observed at King's College
Hospital, London, in a little girl. The deformity existed at birth,
and depended upon contraction of the lower part of the sterno-mastoid
muscle, which had become attaclied to the deep fascia of the neck.
A cure haa been effected by subcutaneousjy dividing the muscle.
There was not a drop of blood lost. '

Congenital absence of the latisaimus dorsi was observed in a young
man. Part of the pectoralis major was also absent ; and, as a com-
pensation for both deficiencies, the teres major was considerably
hypertrophicd. The malformation, though causing a great change in
the shape of the shoulder, did not cause much impediment to move-
ment ; the incompleic arm was, however, weaker than the other.

Mr. BiBKETr removed from either side of the neck of a girl of seven
years of age two growths, which appeared to be intimately associat-
vd with the fibres of the platysma-myoidcs, not dipping deeper than
this structure, and being entirely cutaneous appendages. AfUr a
section was made in the long axis of each growth, the tissues of the
tobeand of thefibro-cartilage of the auricle wore clearly distiDguisbed.

In Mr. Ncsn'3 case of talipes cquinns paralyticus in an'adult, the
head of the femur was fiattcned, the shaft not larger than that of a
child of seven or eight years, the cotyloid cavity very shallow, with
some thickening at its outer and lower margin, the tuber iscbii was,
in a great measure, undeveloped.

In a case of Dr. Rauskill, the umbilicus was a little to the right
of themediaaline, and the left side was larger and "wider everyway
than the other. On the lel^ side stomach and part of the intestine
wore (juite prominent. Probably there was congenital deficiency of
a large portion of one or both of the deeper muscles of the abdominal
pariotes t"

Db. Rtkokr reports the case of an infant, whose perineum was cleft
from the symphysis pubis to the os eoccygis, in nearly a direct line,
and the greater portion of whose bowels protruded, surrounded by
the peritoneal sac.

It is a remarkable fact, that a subject of groat pathological impor- .
tance should be treated by two distinguished men, in two different
countries, with the like care, ability, and success, at the same time.
Either of the works, the titles of which are given above, will not fail
to cnrioh science and to confer honor on their authors, and singularly
enough, in many instances by the same facts, examinations, and
Ideas, If there was a necessity to prove such an assertion, this
oofncldence, like many others known in the history of medical
HOience, would bo a proof of, as it were, a scientific atmosphere
flxiatin^ )n the ecientlfic world, and surrounding all the cultivated

465

minds. Like wants appear to produce like exertions and like
results.

Neither of the books referred to falls entirely under the head of
our review ; but we thought proper \o give some facts from both, in
order to show the relation of muscular paralysis to the essential
paralysis of children, as set forth in the book of Professor Vogt ; the
more so bccauKC 13 cases of the 105 reported by Dr. Roberts occurred
in children of 14 years and under, and 3 new cases, introduced by
Dr. Friedberg", occurred in boys of IJ, 6, and 13 years of age.

Contrary to the anatomical cause of essential paralysis, we learn,
i'rom the examinations of our authors, that

1. The gray substance of the spinal cord may be extensively dis-
eased without progressive atrophy of the muscles existing.

2. In some cases of this disease other parts of the spinal cord
have been found diseased, the gray substance being normal.

4. Therefore, degeneration of the roots of the spinal nerves must
not be taken to be the cause of paralysis consequent on muscular
atrophy.

Neither of our authors thinks the name of the disease, as proposed
by Aran, "atrophic musculaire progressive," a good one. Friedberg
would propose the name of " paralysis from alienated nutrition of
the muscles," but prefers simply "muscular paralysis;" Roberts
thinking "idiopathic degeneration of the voluntary muscles," some-
what lengthy, although physiological, suggests simply " wasting
palsy," or " Cruveilhier's atrophy," after the writer who has taken the
most prominent part in elucidating its history.

1. Propagated* myopatldo panJjiia. The nutritive trouble is
pfopamted to the mude ttom a neighboring organ.

^ 'nraoinatic At p. l

466

3. Rheumatic m. p.

4. Dyscrasic m. p., from cholera, dysentery, scurvy, sypliilis,
typhus, exanthems, puerperal state, rachitis and osteomalacia, load
disease, and hereditary influence.

6. Marastic m. p., in consequence of deficient circulation of the
blood and suppressed muscular motion, from bandages surrounding
a limb for a long time, immobility of the joints (induced by organic
disorganizations, cutaneous cicatrices), pressure upon each other of
the muscular particles approximated after luxations, old age, disease
of blood-vessels and thrombosis, tumors, diminution of nervous in-
fluence.

6. Simple m. p., where there is a nutritive trouble without a man-
ifest cause. Many cases of essential infantile paralysis have falsely
been brought under this head.

Thus it appears, that the discrimination between essential paraly-
sis of children and muscular paralysis is well shown. We omit, as
not pertinent to our object, to enter any further into the discussions
of our authors, only stating, at last, their similar views as to
therapeutics.

Bemedies applied to the vertebral column, etc., are out of the ques-
tion, because there is no disease of the nervous centres. Remedies
acting on the system at large, are successful in such cases only where
the constitution is afiected by syphilis, scrofula, etc. There are two
unquestionable remedies, viz., methodical exercise, and cold mineral
and douche baths, which, however, when the disease is still in active
progress, are more likely to do injury than promote recovery.
Asides thermal and sulphur baths, frictions, with stimulating lini-
ments, and Faradization, may be relied on. A rational treatment
ought to be commenced within as early a stage as possible, and the
exciting causes, as overwork, must be strictly avoided. WHiere
contractions are, according to Friedberg, the exciting cause, they
must be treated by electricity, methodical exercise, and gradual
stretching, when flexible ; in cases of inflexible curvatures, machin-
ery, knife, and brisement force have to commence the treatment. For
particulars, we refer our readers to Dr. Roberts' and Dr. Friedberg's
books, either of which we again take the occasion to recommend to
the profession.

OUTTED ON PAGE 304

Ilauschild, £. J., Die leibiiche Fjftege der Kinder zu Hause und in der
Schxde, Leipzig, pp. 194. Mit 40 Abbildungen. (The physical
edtwaiion of children, at home and at school. With 40 drawings.)

V S/ t ^ ^^^H

1 -^ --

'k^^m

, ^^

^^^H

'■ , <'^ ': ■

^M-^ V

1 '"> i

- "J

Internet Archive Audio

Featured

Top

Images

Featured

Top

Software

Featured

Top

Books

Featured

Top

Video

Featured

Top

Mobile Apps

Browser Extensions

Archive-It Subscription

Save Page Now

Full text of "Contributions to midwifery"

See other formats