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THE :» 

NEWBERRY 
LIBRARY, 
CHICAGO. 



SE NN COLLECT lOjv 



— m 



jgt^*^j 



** 



fei 



Donated to the Newben^ Library 
1894. V 







HALF-YEARLY ABSTRACT 

OV THS 

MEDICAL SCIENCES. 

JULY— DECEMBER, 
1863. 



LONDON: 

BAVILL AND IDWARDS, FBINTEB8, OHANDOS BTSEET, 

OOVENT OABDSN. 



THE 

HALF-YEAELT AESTEACT 

OF THE 

MEDICAL SCIENCES: 

BIIITO 

A FBAOnOAL AND ANALTTIOAL DIOBST OF THB OONTBNTS OF THB PSINOIPAL 
BBITISH AND CONTINENTAL MBDIOAL WORKS PUBLISHED 

IN THE PRECEDING SIX XONTHS '. 

1 

TOeSTHBB WITH A 

SERIES OF CRITICAL REPORTS ON THB PROGRESS OF XEDICINB AND 
THE COLLATERAL SCIENOBS DURING THE SAKE PERIOD. 



EDITED BT 

W. H. RANKING, M.D. Cantab., 

raLLOw or thb kot4L coixsoa or phtsiciams or lomdon, phtuciaii to thb MO&rouc akd 

MOAWICH HOSFITAI.; 

AND 

G B. EADCLIFFE, M.D. Lond., 

rsLi.ow or tbb rot al collbgb or phvbicia?i« op london, 

rBTKCIAM TO TXV WBtTXlllBTaR HOSPITAt, AMD TO TBS NATIONAL H08PITAI. rOB THB PARAX.TBIO ABD 

BPILBPTIO. 



Appantu nobis opos est, et reinu exqnisitis ondlque et collectis, arcessitis, comportatis. 

OlOBRO. 



VOL. xxxvm. 

JULY— DECEMBER, 1863. 

LONDON : 
JOHN CHURCHILL & SONS, NEW BURLINGTON STREET. 

EDINBURGH '. XAOLACHLAN AND CO. DUBUI: FANNIN AND CO. 

XDOCCLXIT. 



Vol. XXXIX. will appear on the 1st of July, 1864. 

Booki, ko., for notice, to be sent as soon as published (carriage free) 
to John Chubohill and Sons, New Burlington Street; or to Dr. 
Badoliffe, 25, Cavendish Square. 



LIST OF BRITISH AND FOREIGN PERIODICALS REFERRED 
TO IN **THE HALF-YEARLY ABSTRACT." 



Aftnals of Anatomy cmd Physiology, 

British Medical Journal. 

British and Foreign Medico- Chirur- 

gical Bevieto, 
Dublin Quarterly Journal of the Me- 

dical Sciences. 
Dublin Medical Press. 
Dublin Hospital Gazette. 
Edinburgh Medical Journal, 
JSdinburghNewPhilosophical Journal. 
Glasgow Medical Journal. 
Indian Annals of Medical Science. 
Journal of Psychological Medicine, 
Lancet. 

Liverpool Med.-Chirurgical Journal, 
London Medical Examiner. 
Madras Quarterly Journal of the 

Medical Sciences. 
Medical Circular. 
Medical Times and Gazette, 
Microscopical Journal. 
Pharmaceutical Journal. 
Statistical Journal. 

AXEBICAV. 

American Journal of Medical Scimtces. 
American Monthly Journal, 
Canada Medical JoumaL 
Charleston Medical Journal m*d 

Beview. 
Montreal Monthly Journals. 
New York Journal of Medicine. 
North American Medico-Chirurgieal 

Review. 
North-Western Medical JoumaL 
Philadelphia Medical Examiner. 



Annales de Chimie et de Physique. 

„ d'Hygihne PubUque. 

„ Medico-Psycologique. 

„ d^Oculistique. 

„ des Sciences Naturelles. 
Archives Ginirales de MSdecine. 
Bulletin de VAcadimie de MSdecine 
Comptes Bendus. 
Guzette des Hopitaux. 
Gazette Hebdomadaire de MSdeein 

et de Chirurgie. 
Gazette MSdicale de Paris. 
Journal de Pharmaeie et de Chimie. 
V Union MSdioale. 



Annalen der Chemie und Pharmaeie. 
Archiv fur Physiolog. und Patholog. 

Chemie und Mikroskopie. 
Canstatffs Jahresbericht, 
Deutsche Klinik, 

Monatsbericht derAkademie zu Berlin, 
Mailer's Archiv far Anatomie, ^e, 
Schmidts Jahrbucher. 
Vierteljahrschrift fur die Praktisehe 

Heilkunde, 
Zeitschrifif&r Bationelle Mediein. 



ITALIAir. 

Annali Universali di Medicina, 



o>If 



201935 



+4 



NOTICE TO CORRESPONDENTS. 



The Editors request thcU all eoTMimnicoHons he forwarded {fre^ to John 
Chubchill and Sons, New Bwlington, Street, London, 

* 

The Editors are compelled to remind their American correspondents, that no 
parcels are taken in unless the entire charge he paid upon them. 



CONTENTS OF VOL. XXXVIII. 



PART I. 

PRACTICAL MEDICINE, PATHOLOGY, & THERAPEUTICS, 
Sect. I.— General Questions in Medicine. 

(a) Oaneeming Mjfffiene, 

ABT. TA^BM 

1. On tbe Unfayoarable Infloence of Sadden Change of CUmate. 2V. J. Seftry 

Bermet 1 

2. How People may Live and not Die in India. Miw Nightingale .... 4 

3. On Nursingr npon the same Princii^e as that of tbe IVeaoh Scears de Charity. 

Lord Brougham . . 7 

4. On Iodine as a Deodorizer and Disinfectant. I>r. B. W. Bioharehon ... 8 
6. On tbe Medicinal Use of Ars^cated Mineral Waters, with special reference to that 

oTWhitbeck. Dr. &eorge J£oHn»on 9 

6. On Tobacco, in its Relations to the Health of Indhidnals and Cknnmunities. I>r. 

B. W. Bichardwn . II 

7. Puddings without Eggs. Dr. 13 

8. Poisoning by Milk, Dr, . . . . . . . . . . .16 

9. Epidemic from Eating the Meat of a Diseased Cow. Dr. Hu§8mann ... 16 

10. On Measly Pork. M. Delpeck 17 

11. On Sigoatera, or Hsb-Poison Disease. Dr, .18 

(b) Concerning Aeute Di$«au». 

12. A Contribution to the Therapeutics of Continued Fever. Dr. T. King Chamber$ . 20 

13. On the Prevalence of Typhus Tever in London. Mr. ... 22 

14. On the Disinfecting Treatment of Cholera. Dr. Mackag 25 

16. On the Treatment of Rheumatic Fever. Dr. J. Birkheck Nevint .... 28 

16. Statistics of the Treatment of Rheumatic Fever. Dr. T. King Chambert . . 31 

17. Report of the Trial of Sarracenia Purpurea, or Pitcher-Plant, in Small-pox. Mr. 

J. F. Morton 33 

la Are Scarlet Fever and Measles Distinct Diseases? Dr.WUki .... 86 

19. Dr. Jenner on Impediments to Successfhl Vaccination. Dr, .... 39 

20. A Fatal Case of Varicella. Dr. Frederick J. Brown 40 

21. On tbe Treatment of Malarious Fever by the Subcutaneous Injection of Qumine. 

Mr. W.J. Moore 41 

22. On the Fevers of the South-East Coast of Africa. Mr. Charlet J. Mellor . . 42 

23. On the Use of the Sulphites m Diphtheria. Mr.JohnLjfoU 46 

21 Case of Malignant Pustule. Dr, Jamee Edmunde 47 

lie) Concerning Chrome DUeaeee, 

26. On Tuberculosis. l>r. J. Hughee BenneH 49 

26. The Connexion between Tuberculosis and Insanity. Dr. T. 8, Ctotiefon « . 63 



VIU CONTENTS. 

ABT. PA6H 

27. On the Precaution calculated to Prevent the Transmission of Sjphilis by Vaccinar 

tion. M.Diday 66 

28. On Rheumatic Gout. Dr. Fuller 67 

29. Tertiary Syphilis without History of any Primary or Secondary Stages. Mr, 

Hutchimon 63 

30. On a Valuable Diagnostic Sign of the Existence of Acquired Syphilitic Taint. Dr. 

H. Critchley Brodrick 66 

Sect. II. — Special Questions in Medicine. 

(a) Coneeming the Nervoue System. 

3t, Influence of Hypertrophy of the Heart and Disease of the Cerebral Arteries in the 

Production of Apoplexy. Dr.: A. Eulenbur^ 67 

32. On the Relation of Chorea to Rheumatism, Valvular Disease of the Heart, and 

Pregnancy^ Dr.Kirke* .. . . . , .67 

83. On Hemierania, or Migrain. Dt: E: Du Bois-Seymond 73 

3-1. On the Employment of Shampooing in certain Affections of the Muscular System, 

especially, in Lumbago. Dr. Eetradem . . .74 

85. On Nightmare. Dr. Thomcu HodgHn 76 

36. Case of Acute Myelitis, in which Recovery was materially assisted by Cod-liver (XI. 

Dr. Radclife 77 

87. Case of Incipient " Wasting Palsy " Cured. Dr, J, Bugselb Reynolde ... 79 
83. On Ephemeral Mania. Dr. J. C. Browne 81 

39. On Spiritualism as a Cause of Insanity. 3f . BurUt 84 

40. On the Us^ of Digitalis in the Treatment'Of Insanity. Dr. C. L. Robertson , . 86 

41. On Bloody Sweating from the-Head in Dementia Paralytica. Dr. F. Servaes . 88 
43. Notes on Haematoma of the External Ear in the Insane. Dr. W. Phillimore Siiff, 91 

43. The Pathological Relations between Puerperal Mania and Albuminuria. Dr. 

Arthur Seott Donkin 92 

44. On Catalepsy; Mr. Thomas Jones 96 

45. On Rabies. M. Bouley . .98 

46. On Muscular Hallucinations. M. Eugenie Semerie 103 

47. On the Cerebro-Spinal Lesions consequent upon.Diabetes. M. Marchal (de Calvi) 106 

48. On the Incubation of Hydrophobia. M. Renault lOZ 

49. The Effect of Petroleum or " Rock-oil " in a case of Beriberi. Mr. S. Arokeum . 107 

60. Case of Prolonged and Profound Sleep, occurring at intervals dikring Twenty 

Years. Dr. W. &. Gimson 108 

61. Notes on the Use of the Ophthalmoscope in Affections of the Nervous System. Dr. 

Hughlings Jackson ..110 

(b) Concerning the Respiratory System,. 

62. On Capillary Bronchitis. Dr. Hyde SaUer 112 

63. On Pseudo-Gangrenous Bronchitis. M, Empis 119 

64. On the Inefficiency and Dangers of Cauterisation in the Treatment of Crovp. 

MM. Fischer and Bricheteau 121 

66. On Asthma. Dr. J.-Burdon Sanderson 123 

66. On the Management of Pulmonary Tuberculosis, with Special: Reference to the 

Employment of Alcoholic Stimulants. Dr. Austin Flint 124 

67. On Chronic Congestion of the Lungs. M. Bouchut 126 

68. Cases- of Whooping-cough treated with Bromide of Ammonium. D^: Harley- . 129 

69. On the Treatment of Whooping-cough by felrgot of Rye^ Dr. O. Griepenkarl . 131 

60. A Cheap Spirometes. Dr. W. E, Bowman 131 

(c) Concerning the Circulatory System. 

61. On Pericarditis consequent upon Pysemia. Dr. Kirkes . . ... 133 

62. On *' Le Bruit de Moulin." M. MttreULecalUe 187 

63. On "Graves* Disease.?* 2)r.ir. »ar6iirto».JB6yW* . . , . ..IW 



CONTENTS. IX 

AST. rAOS 

94. On '* Graves' Disease." Dr. Layeoek 138 

85. On " Graves' Disease." Dr, William Moore 138 

66. Gircnmscribed Aneurism of the Walls of the Left Ventricle. Dr, Wale$ . . 140 

67. Case of Embolus of the Pulmonary Artery. Dr. Vanderpool 142 

08. On Dilatation of the Lacteals. Dr. T. OrcAnger Stewart 143 

69. On the Double-Pulse and Double Heart-Sounds. PrqfenorSkoia , . . .145 



(d) Qtneemi'ng the AUmeniary System, 

70. Cases of Throat Dyssesthesia, with Clinical Remarks. Dr. Hatfield Jonee . . 146 

71. On the Use of Ipecacuanha in the Treatment of Tropical Dysentery. Dr. J. Ewart 148 

72. On the Influence of a Lonsr Course of Nitric Acid in Reducing the Enlai^ment of 

the Liver and Spleen which sometimea results from the Syphilitic Cachexy. 
Dr. Budd 152 

73. On the Physiological and Pathological Import of Cholesterine. Dr. Auetin Flinty 

jun 168 

74. Observations on the Treatment of Tsenia, especially by the Use of Oil of Male-Fern. 

Dr. OgU 162 

76. Two Cases of Cancerous Disease of the Pancreas. Dr, Wcard 164 

76. Case of Abscess of the Spleen Discharged into the left Lung. Dr. A, A, ManteU, 168 

77. Fatal Obstruction of the Bowels from the Presence of an Hydatid Tumour springing 

from the Mesentery. Dr, J. Sutherland 170 



(e) Ooneeming the Qeniio-Urinary System, 

78. A Question as to the Pathological Distinctions in Cases of Diabetes. Dr. Daniel 

NobU 170 

79. Case of Diabetes treated by the Use of the Turkish Bath. Dr. R. H. Gholden . 175 

80. Effects of Diet and Drugs in the Treatment of Diabetes Mellitus. Dr, Andrew 

Smart 177 

81. On the Excretion of Sugar and Urea under the Use of Benzoic Acid in Two Cases 

of Diabetes Mellitus. Dr. Stochvie 179 

82. A Case of Encephaloid Disease of the Bladder, with Remarks on the Semiotio 

Value and Treatment of Hematuria. Dr, Banking , . , . . .180 



PAET n.— SUEGEEY. 

Sect. I. — General Questions in Subqest. 

83. Observations on Pysemia. Jfr, Bichard Quain • . 184 

84. On the Use of Bromine in Hospital Erysipelas, fto. Dr, J, S, Brinton . . .186 
86. On Periostitis and Osteomyelitis. M, Boeer 190 

86. On Tumours in Voluntai^ Muscles, with an Analysis of Sixty-two Cases, and 

Remarks on Treatment. Mr. Teevan 191 

87. On the Danger of Temporizing too much with Encysted Tumours. M, Fleury . 191 

88. On the Importance of Tapping Joints Distended with Fluid. Prqfeeeor Jnxani . 193 

89. On the Efficacy of Villate's Lotion for the Cure of Caries and Sinus. M. NoUa . 194 

90. On the Efficacy of Artificial and Mineral Tar in the Treatment of Diphtheria, Ulcers, 

and Cutaneous Affections. M. Bouehut 194 

91. Certain Consequences of the Bite of a Viper reappearing periodically for Thirty- 

nine Years. M, Demeuret . 196 

92. New Instruments for Discovering the Presence of a Ball or other Metallic Body 

within a Wound— viz., N^laton's Porcelain Probe, and Favre's Galvanic 
Probe. Mr, 196 

93. A Case of Traumatic Tetanus in which a Nerve was Divided with seemingly Satis- 

&ctory Results. Dr, Fayrer . 197 



Z C0NTSNT8. 

Sect. II.— Special QussnoNS in Suboert. 

(a) Come&rmi^ tk« Semi <mi Nnek, 

AUT. Pi.01 

1)4. On Iridectoiqy in Destroetive Ule«ration of the Cornea. Mr. J2. BmdentU Carter 198 
96. Clinioal Data respecting Amanroeis, more especially r^ecting that form of it 

supposed to be induced by Tobacco. Mr, JonathaH Mutchinton . . . 201 

96. On Smoking as a Cause of Optic Atrophy, Ac. Mr. Erne$t Sort .... 203 

97. On a Lesion of the Conjunctiva eoiactding with Heraeralopia. M. Bitot . . 204 

98. On the Treatment of Strabismus at the Boyal Ophthalmic Hospital, Moorfields. 

Mr. Qeorg* Lawton 20{f 

99. Double Vidon with each and both Eyes. J>r. BeOtuna 207 

loa On the Diagnosis and Treatotent of Syphilitic Tubercle of t^e Eyelid. Mr. J. Vot 

SotoMon 208 

101. An Uadescribed Lesion «f the Conjunctiva, associated with Night-Blindness. M. 

Bitot 211 

102. The Fibrous Tunic of the Eyeball, or " Ocular Tunic." and its Relations and 

. Bearings in Ophthalmic Practice. Mr. Hornet WaUon 212 

103. On Affections of the Tympanum, and their Danger to Life. Dr. Von Troelt$ch . 216 

104. On a Peculiar Form of Otitis and Deafhess Induced by the Immoderate Use of 

Tobacco and Fermented Liquids. M. Triquet 217 

106. On Syphilitic Disease of the Mouth. Prxffetaor Sigmtmd 219 

106. A Case of Pneumatocele of the Skull following Fracture of the Petrous Bone, in 

which the Patient Recovered. M. Chevanee 226 

107. A Symptom of Fracture of the Base of the Skull. M. Dolbeau . . . .226 
106. A Specimen of Fracture of the Odontoid Process of the Axis, with Perfect Anchy- 
losis of its Apex with the Occipital Bone, and Partial Luxation Forwards of 
the Atias. Mr. Philip Bevan 227 

109. On a Simple Mode of Removing Foreign Bodies fVom the Gullet. Mr. . 231 

110. On the Normal Position of the Epiglottis, as determined by the Laryngoscope. 

Dr. €Hbb 233 

111. On the Treatment of Hoarseness and Loss of Voice by the Direct Application of 

Galvanism to the Vocal Curds. Dr. Morell Mackenzie 236 

112. On the Performance of Tracheotomy in Children. M. Qiraldet .... 238 

(}i)Coneemingt\9Cke9t and Abdomen, 

113. Operationfor Compression of the Spinal Cord. Dr. H. A. Potter , . . .239 

114. Recovery after Transfixion of the Thorax by an Iron Bar. Dr. C. W. JSoyland , 241 
116. Treatment of Gunshot and Penetrating Wounds of Chest and Abdomen by Her- 
metically Sealing. Dr. B. Howard 242 

116. Case in which the Sac of a Spina Bifida was Successfhlly Removed by Operation. 

Dr. Wilton 243 

117. Case in which a Breast-pin was Swallowed by a Child, and passed by Stool Twenty 

Hours after. Mr, Thomae Annamdale 244 

118. Desmption of a New Instrument for the Relief of Retention of Urine in Cases of 

Tight Strictures of the Urethra. Dr. Patrick Heron Watton . . .246 

119. On the Successful Treatment of Severe Stricture of the Urethra by Gradual Dis- 

tension, at a Single Sitting. Mr. Henry Thompton 247 

120. On the Treatment of Incontinence of Urine. Mr. Robert Johns .... 249 

121. On Tubercular Disease of the Urinary Organs. Dr. Kueemoud .... 261 

122. On a New Application of Elastic Bands in the Treatment of Strangulated Hernia. 

M.Maitonneuve 264 

123. Case of Inguinal Hernia Treated Successftdly by Professor Chisholm's Method. 

Mr. James J. Dickinson 266 

124. On Hemorrhage from the Rectum. Mr. Syme 268 

126. A New Method of Treating Inflammation of the Testicle. Mr. Beany . .269 

126. A Simplified Apparatus for the Radical Cure of Varicocele. Dr. Packard . . 262 

127. On the Means of Controlling Haemorrhage in the Removal of Scrotal Tumours. 

Dr. J. Fayrer 263 

Hi, Observations on Sterility in Man. Mr. Curling 266 



CONTENTS. Xi 

(c) Concerning the Upper JExtremity. 
ABT. fAsa 

129. An Easy Means of Bedncing a Dislocated Hnmeras. 2)r, Oamu . . .268 

(d) Concerning the Ii{ferior Extremity, 

130. A Case of Elephantiasis Arabam of the Lower Extremity SuccessfUly Treated by 

Tying the Femoral Artery. Dr. R. Q. H. Butcher 268 

131. On Excision of the Knee- Joint. Dr. B. G. H. Butcher 271 

132. Luxation of the Head of the Fibula. Dr. Jos. O. Bichardeon . . . .273 

133. On Chopart's Operation. Mr. Hancock 274 

13^ On the Treatment of the Early Stages of Hip-Joint Disease in Children. Dr. Wm. 

Price . . . ... 276 

135. Carious Ee-union of an Amputated Toe. Dr, Bichard W. Day . . . .276 



PAET III.— MIDWIFERY. 

MiDWIFEBT AND DISEASES OF WOMEN AND CHILDREN. 

(a) Concerning Pregnancy and Parturition, 

136. Spontaneous Uterine and Extra-uterine Gestation Proceeding to the Full Term. 

J£r. C. B. Cooke 278 

137. Slowness ofthe Pulse In the Puerperal State. M. Blot 279 

138. A Case of Induction of Premature Labour by Dr. Barnes's Method. Mr, F, M, 

Corner 280 

139. Tartrate of Antimony as an Oxytoxic. Dr. Parker 281 

140. On Supporting the Perinaum. Mr. John Bustell ....... 284 

141. A New Mode of Proceeding in Placenta PrsBVia. Dr. W. S. Moore , . .286 

142. On Broncho-Pneumonia in Lying-in Women. Dr. Bohert Bamee , . . 286 

143. A New Method of Embryotomy and of Decapitation. M.PaJot . , . ,287 

144. Dislocation of the Ensiform Cartilage occurring during Pregnancy. Dr, Bohert 

Sim 288 

146. Case of Utero-Flacental Adhesions which give rise to Severe Symptoms. Dr. 

Delord 288 

148. Tubular Pregnancy followed by Recovery and Three Natural Labours. Dr. Fabbri 290 

147. Case of Extra-uterine Foetation, the Foetus being in the Sao of a Hernia. M. W. 

MiiUer 290 



(b) Concerning the Dieeasee qf Women, 

148. A Cafie in which a Large Calculus was expelled (torn the Bladder of a Female 

through the Urethra by the Natural Efforts. Dr. Beatty . . . .291 

149. On DysmenorrhcBa and Sterility. Dr. Oreenhalgh 292 

160. On Supra-pelvic Heematocele. M. Qosselin 293 

161. Three Cases of Artificial Urethra. Mr. I. Baker Brown . . . . .293 

162. On the Use of Medicated Pessaries in the Treatment of Uterine Diseases. Dr. 

Tanner 296 

163. A Pessary Betained Thirteen Tears. Dr, Kidd 298 



(c) Concerning the Dieeatet qf Children, 

154. Operative Surgery in Children. M. Quermnt 298 

166. Practical Observations on the Treatment of Purulent Ophthalmia in Infants. Mr, 

Wordaworth 301 



XU CONTENTS. 



REPORTS ON THE PROGRESS OF THE MEDICAL SCIENCES. 



I. — Eeport on Practical Medicine, 



ABT. PAOB 

' 1. Dr. Maelachlan : A Practical Treatise on the Diseases and Infirmities of Advanced 

Life 307 

2. Blue-Booh^ 1863 : The Fifth Report of the Medical Officer of the Privy Cooncii . 309 
8. Blue-Book, 1863 : Army Medical. Department : Statistical, Sanitary, and Medical 

Reports for the Year 1861 322 

4. Blue-Bookt 1863: Report of the Royal Commission on the Sanitary State of the 

Indian Army 326 

6. Dr, Chapman : A New Method of Treating Disease by Controlling the Circnlation 

ofthe Blood in Different Farts of the Body 332 

Dr. Jackson: An Experimental Inquiry into the Effect of the Application of Ice 

to the Back of the Neck on the Retinal Circulation 331 

6. Dr. Badeliffe : Practical Hints on the Treatment of Nervous Fahi and Neuralgia . 335 

7. Dr, Wite : Remarks on the Hsemostatio Treatment of Cholera, Hemorrhage, 

Exhaustion, &c 340 

8. Dr. Begbie: On the Diagnostic Value of an Accentuated Cardiac Second Sound . 344 

II. — Report on Midwifery, 

1. Dr. Hewitt: The Diagnosis and Treatment of Diseases of Women, including the 

Diagnosis of Pregnancy 351 

2. Mr. T. Spencer Wells : On Ovariotomy in Great Britain 367 

8. Dr. Peaslee: A Case of Double Ovariotomy, in which the Patient was Saved by 

Daily Injections into the Peritoneal Cavity for Eight Weeks . . . .861 



HALF-YEARLY ABSTRACT 

OF 

THE MEDICAL SCIENCES, 

ETC. 



PART I. 
PRACTICAL MEDICINE, PATHOLOGY, & THERAPEUTICS. 



SECT. L— GENERAL QUESTIONS IN MEDICINE. 

(a) conceenino hygiene. 

Art. 1. — On the Unfavourable Influence of Sudden Change 
of Climate, 

By J. Henry Bennet, M.D. 

{Lancti^ September 6, 1863.) 

The attention of the profession has not yet been drawn to the un- 
favourable influence exercised upon health by the sudden change 
from a northern to a southern, or from a southern to a northern 
climate, so constantly experienced in these railroad days. And yet 
tlids influence exists, even for the strong and well, and is still more 
decided in the case of invalids. It ought, therefore, to be recog- 
nised and taken into consideration by those who send patients 
abroad, in order that they may instil caution into their minds, and 
point out the mode in which any bad effects from the change of 
climate may be avoided. Dr. Bennet says : — 

" During the last few years I have four times left England in 
October, arriving within a week or ten days in the south of Europe, 
at Mentone; and four times I have left Mentone in May, and 
arrived soon afterwards in England. At Mentone I am at once 
called upon to take charge of a number of fellow-countrjmen, 
winter emigrants like myself. On my return to London I see many 
of them as they arrive or pass through, or hear of them if they, as 
often occurs, pass to other allegiance. The autumn and spring 
illnesses from which they often sufler did not at first strike me as 
presenting anything peculiar; but gradually, as experience has 
mcreased, I have become aware, first, that these morbid accidents 

XXXVIII. 1 



2 PBACTICAL MEDICINE, ETC. 

present themselreB each year with stereotyped regularity; and, 
secondly, that they are, in a great measure, referable to the sudden 
change of climate rendered possible by rapid railway communica- 
tion, of which advantage is taken owing to the very natural desire 
to get over the journey as quickly as possible. 

" The most marked peculiarity of our climate, as distinguished 
from that of the continent of Europe, and especially from that of 
the Mediterranean basin, is the great quantity of vapour which our 
atmosphere contains. According to Admiral omy th, the atmosphere 
of England contains habitually double that of the Mediterranean 
region. His data are substantiated by a series of observations which 
I made last winter with the wet and dry bulb thermometers at 
Mentone. I found the diflference between the two was nearly 
always throughout the winter very great, generally varying from, 
five to ten degrees Fahrenheit. We nave the proof also of this fact 
in our white-blue cloudy sky, and in our mitigated summer heat. 
The watery vapour screens the earth from the sun, and absorbs its 
heat ; and hence, in part, pur mild summers. The absence, or the 
sooner diminished amount, of this watery vapour in the atmosphere 
of the Mediterranean region gives a dryness, a clearness, an elas- 
ticity to the air which is very peculiar. It enables the light and 
heat of the sun more easily to reach the earth, and accounts for the 
clear deep blue of the sky and for the scorching heat of the sun's 
rays even in midwinter. As a necessary corollary, the nights are 
clear, brilliantly illuminated by stars and moon, and cold by com- 
parison with the day. 

" Professor Tyndall, in his lecture on * Heat considered as a mode 
of Action,' recently delivered at the Royal Institution, has shown 
more clearly than any of his predecessors how great is the heat- 
absorbing power of aqueous vapour, and its consequent influence 
upon climate. The heat-absorbing power of moist air varies with 
its density. It is as high as ninety-eight when the barometer is at 
thirty inches, and but sixteen when the barometrical pressure is only 
five inches. Thus the nearer the aqueous vapour is to the earth, 
where the barometrical pressure is the greatest, the greater its heat- 
absorbing power, and the greater the protection it affords from the 
scorching effect of the sun's rays dunng the day, or from extreme 
radiation of heat during the night. Professor Tyndall applies these 
facts by stating that the removal for a single summer night of the 
aqueous vapour from the atmosphere of England would be attended 
by the destruction of every plant which a freezing temperature could 
kill. On the other hand, the day would be as scorching as the night 
would be cold. 

" These facts give us the key to the Mediterranean climate — to 
its hot sunshine during the day in winter, and to its cool nights. 
The diminution of aqueous vapour in the atmosphere, on the one 
hand allows the sun's rays to reach the earth during the day ; and, 
on the other, allows the earth's heat to radiate rapidly into space at 
night. 

" In October, invalids leave England's moist atmosphere when 
the weather is already getting cold, and the evenings and mornings 



PRACTICAL KBDICINB, ETC. 3 

are fogfcy. The express train is often taken at Paris for Marseilles, 
and in sixteen or twenty hours the dry sunshiny Mediterranean 
re^on is reached. There it is still summer ; the sun is powerful ; 
the temperature high, usually above 70° Fahr. The liver and skin, 
which were already in England relieved from the stimulus of our 
mild summer heat, are called violently and suddenly into action. 
The result is diarrhoea, bilious attacks more or less severe, skin 
irritation, urticaria, boils, &c. Diarrhoea is so common that few 
northerners escape ; and it is universally, but erroneously I believe, 
attributed to change of food, to wine, and to such influences. 

** These attacks are most severe with those who hurry their de- 
parture from England, push rapidly to their destination, and reach 
the south in September or early in October. In my opinion the 
last week of October is quite early enough for invalids, or even 
healthy northerners, to arrive in the south of Europe. The cool 
weather of autumn does not begin until about the second week in 
November ; and a month or six weeks of hot, oppressive southern 
weather, with a liberal allowance of mosquitoes, is generally damaging 
to the health of * north country people.* The worst cases of bilious 
derangement that I have to attend each autumn are amongst such. 

" By the end of April, or the early days of May, the sheltered 
S.iviera undercliff begins to be disagreeably warm. Moreover, fine 
midsummer weather has been enjoyed so long that it becomes 
diflBcult to believe that winter still reigns in the north. The invalids 
are tired, also, of their six months' absence from home, and their 
hearts are set on the return. Once the homeward journey has 
commenced it is generally rapidly carried on, and many arnve in 
Paris or in England eamr in May, much too soon for their own 
good. In the north of Europe, if the wind is from the south, in 
April and Mav the air is mild and balmy, and vegetation makes 
rapid strides ; out until the mountain lands of Norway and Sweeden 
are freed, or partly so, from their canopy of snow, which does not 
take place until June, a north-east wind brings cold, chilly weather, 
and night frosts. It is this cold, chilly atmosphere, an atmosphere, 
too, more or less loaded with moisture, that often meets the invalid 
on his return home. The skin and liver, previously in full operation, 
are checked suddenly if the journey has been a rapid one ; extra 
work is thrown on the lungs and kidneys ; and very often severe 
attacks of influenza, of coryza, of bronchitis, of haemoptysis, are the 
result. 

" I have pointed out the evil ; I must now point out the remedy. 
It is to ignore the facilities afforded by express trains and to make 
both the southern and the northern journeys in such a manner as to 
become acclimatized to the great changes. 

" Serious invalids who intend to winter in the south of Europe, 
are better out of England the last week in September, or early m 
October ; but, as we have seen, their winter residence is scarcely fit 
for them before the end of October. The two, three, or four inter- 
vening weeks should be spent on the road. 'A ^uiet, leisurely 
progress southward allows the human economy to graaualiy accustom 
itself to the change of climate. A favourite station with me is 

1— a 



4 PBACTICAL MEDICINE, ETC. 

Fontainbleau, thirty miles south of Paris. The climate is conti- 
nental, drier than "that of England, the hotels are good, and the 
forest scenery is very interesting and beautiful. A week or ten days 
may be spent there both pleasantly and profitably for health, much 
more so than in Paris, 

" Further south we have Valence, Aix, Nimes, Aries, &o. I 
would, however, more especially recommend a small watering-place 
which I may nearly lay claim to have discovered, as far as my coun- 
trymen are concerned. It is Gr^oulx, a five hours' picturesque 
drive from Aix-en -Provence. Greoulx is merely a village, with a 
large comfortable hotel, in its own grounds, erected over a hot 
sulphur spring, one of the most powerftil and longest known thermal 
waters of the south of France. Its celebrity, however, is all but 
entirely confined to that part of France. I myself found it out by 
the map, whilst trying to discover an autumn and spring inter- 
mediary station. I visited it last May, and was much pleased with 
the scenery from Aix, with the hotel and its grounds, and with the 
very lovely district in which it is situated. There are two wild 
mountain rivers — the Durance and one of its tributaries — within a 
mile of the house, and fishing and shooting are provided for the 
inmates, with all the resources of French social country life. The 
hotel makes up some 200 beds. Greoulx is quite out of the beaten 
track, far away from railways, amongst the hills of Provence, and 
a residence there must have many charms. I sent a little colony of 
my Mentone friends and patients there this spring, and they were 
all delighted with it. There is an intelligent resident French phy- 
sician. Dr. Jaubert. I do not think a pleasanter place could be 
found to spend a fortnight in on the way south. 

" The same course can be followed by invalids on their return 
north. The departure from Mentone, Nice, Cannes, or from Italy 
or Spain, can take place at the end of April, or on the first day of 
May ; and a leisurely journey may be made towards the north, so 
as to reach England by the end of May or the first day of June. 
Gr6oulx is open on the 1st of May, and is even thus early very 
lovely J the deciduous Itrees in full leaf, and the nightingale in full 
song. A fortnight at Gr6oulx, a week at Fontainbleau, and May is 
pleasantly consumed, and England and its climate reached by slow 
stages, which neutralize the risks attendant upon the ' oannon-bair 
style of travelling." 



Aet. 2. — How People may Live and not Die in India, 

By Miss Nightingale. 

(British Medical Journal, October 22, 1863.) 

The paper of which we subjoin the abstract was read by Dr. 

Scoresby Jackson, at a meeting of the National Association for the 

Promotion of Social Science, recently held at Edinburgh. 

Miss Nightingale commences by stating that her paper dealt with 
one of the most important social questions of the day, viz., how the 
British race was to hold possession of India, and to bestow upon its 



PBAOTICAL aCEDICINB, BTO. 5 

vast population the benefit of her own civilization. The Eoyal Com- 
mission on the sanitary state of the anny in India has shown that 
unless the health of the British army in India could be improved, 
and the enormous death-rate reduced, this country would never be 
able to hold India with a British army. The average death-rate of 
the troops serving in India is no less than 69 per 1000 per annum. 
That death-rate, moreover, does not include those who are invalided, 
and who died on the voyage to England, or soon afler their return ; 
but taking it simply as it was, and assuming the strength of the 
British army at 73,000, it proved that such an army would lose on 
an average of years an entire brigade of 5037 men per annum ; 
sometimes it would be half that number, but in other years it would 
lose two such brigades. It was said that the death-rates of the war 
year being the highest (not from wounds), peace, and not sanitary 
measures, was the remedy. As well might it be said that because 
the British army had nearly perished before Sebastopol not from 
wounds, but from want of every supply of civilised life, peace, and 
not the supply of the wants of civilised life, was the remedy. The 
Boyal commission has shown that, if the death rate were reduced to 
even 30 per 1000 per annum (double that of home stations since 
these stations had improved) to India would be saved a tax equal to 
1000/. sterling. Iteferring next to the question how this great death- 
rate in India had arisen. Miss Nightingale is afraid the reply must 
be that British civilisation was insular and local, and that it took 
small account of how the world goes on out of its small island. The 
ordinary system of dieting British soldiers in India was more adapted 
to a cold climate than that of out-of-door farm servants doing work 
in England. More than this, the occasional dram at home was com- 
muted by regulation in India into a permission to drink two drams 
— i.e., six ounces of rum spirit every day. And, at the same time, 
the men had little or nothing to do. The craving for spirit induced 
by this regulation-habit of tipplinj; led to increase of drunkenness ; 
so that, with over-eating, over-drinking, total idleness, and vice 
springing directly from these, the British soldier in India had small 
chance indeed of coping with the climate — so-called. The regulation 
allowance of raw spirits which a man might obtain at the canteen 
was no less than eighteen gallons and a half per annum, which was. 
Miss Nightingale believes, three times the amount per individual 
which had raised Scotland, in the estimation of economists, to the 
rank of being the most spirit-consuming nation in Europe. Of late 
years malt liquor had been partly substituted for spirits. So much 
for intemperance ; but not to this and its kindred vice alone, or to 
this mainly, was to be laid the soldier's mortality in India, as had 
been falsely supposed. The diseases from which the soldier mainly 
suflf'ered there were miasmatic. There were foul-air diseases and 
foul-water diseases — fevers, dysenteries, and so on. Intemperance 
might cause liver disease, and put the man into a state of health 
which prevented him from resisting miasmatic causes. There was 
no drainage either in town or country. There was not a single 
station drained. If such a state of things existed at home we should 
know that we have fevers, cholera, and epidemics to expect. As 



6 PEACTICAL MEDICINE, ETC. 

regarded water, there was certainly not a single barrack in India 
which was supplied, in one sense of the term, at all. There were 
neither water-pipes nor drain-pipes. Water was to be had either 
from tanks into which all the filth of the neighbouring surface was 
washed by the rains, or from shallow wells dug in unwholesome or 
doubtful soil. So simple a piece of mechanism as a pump was un- 
known. Water was drawn m skins, carried in skins on the backs of 
men or bullocks, and poured into a sort of vessel in the barracks for 
use. The quantity of water was utterly insuflScient for health ; and 
as to the quality, the less said about that the better. The construc- 
tion of barracks where men had to pass their whole period of service 
was another illustration of how completely home civilization was 
reversed in India. As soon as the soldier came to India he was put 
into a room with 100, or 300, and in one case, with as many as 600 
men. To take another illustration. Our home British population 
was about the most active in the world. But as soon as the same men 
went to India they were shut up all day in their hot close barrack- 
rooms, where they also ate and slept. They were not allowed to 
take exercise ; all their meals were eaten in the hottest part of the 
day, and served to them by native servants ; and they lay in their 
beds idle, and partly sleeping, till sunset. ** Unrefreshing day sleep" 
was, indeed, alleged as one of the causes for the soldier's ill-health. 
The Indian social state of the British soldier was not only the reverse 
of the social state of the soldier at home, and of the class from which 
he was taken, but there was a great exaggeration in the wrong 
direction, and people were surprised that British soldiers died in 
India — and they laid the whole blame on the climate. Miss 
Nightingale proceeds to refer to the results of the inquiry of the 
Eoyal Commission as showing that there was not a shadow of proof 
that India was created to be the grave of the British race. The 
evidence, on the contrary, showed that all the climate required was 
that men should adapt their social habits and customs to it. The 
recommendations made by the Eoyal Commission for improving the 
health of the British army in India amounted to this : You have in 
India such a climate ; if you wish to keep your health in it be moderate 
in eating and drinking, eat very little animal food ; let your diet be 
chiefly farinaceous and vegetable. Use beer or light wine, but 
sparingly ; drink coffee or tea ; clothe yourself lightly to suit the 
climate, wearing thin flannel always next the skin ; take plenty of 
exercise, and use prudence and common sense as to the times of it. 
So far for personal habits. What follows pertains to government : 
Be particularly careful to have a plentiful supply of pure water laid 
on tor every purpose ; drain all dwellings ; have no cess-pits ; attend 
rigidly to cleansing, not only surface-cleansing ; never crowed large 
numbers iiito the same room ; build separate barrack-rooms instead 
of large barracks ; place these so that the air plays freely round 
them J raise them above the ground, with a current of air beneath ; 
never build in a wet hollow, nor on a sludgy river bank, which 
would be avoided even at home. But if we would make India about 
as healthy as England, only somewhat hotter, let us have improved 
agriculture and agricultural drainage. If all these improvements 



PSJLCTICAL KEDICIKE, BTC. 7 

were carried out, the normal death-rate of the British soldier 
would be not 60 per 1000, but 10 per 1000, say the Commis- 
sioners. Miss Nightingale then refers to the cause of the preva- 
lence of epidemic diseases among the natives of India. The worst 
condition of the most neglected district at home, multiplied many 
times over, was, to say the least of it, the normal condition of 
every city and town in India. Not one city or town was drained. 
Domestic filth round people's houses beggared description. Water- 
supply was from wells or tanks in ground saturated with filth. 
Domestic conveniences were wanting. The air in and for some 
distance around native towns was as foul as sewer- air, there being 
no sanitary administration and no sanitary police. There was not 
a town which did not want water-supply, draining, paving, cleansing, 
healthy plans for arranging and constructing buildings, together 
with agricultural drainage and improved cultivation all round. 
These things the people could not do for themselves. But the 
Indian government could do them. Three health departments (one 
for each of the Presidencies) had been recommended by the Biyal 
commision, together with a home commission to help those de- 
partments in bringing the appliances of home civilization in India. 
The work was urgent. Every day it was left undone added its 
quota of inefficiency to the British army, and its thousands of 
deaths to the native population. Danger was common to European 
and to native. Many of the best men this country ever had had 
fallen victims to the same causes of disease which have decimated 
the population of Hindostan. The real, the main point — the great 
discovery of the Eoyal Commission was this : Look to the state of 
your stations first, then look to the hills for help. The stations and 
cities were in a condition which, in the finest temperate climate in 
Europe would be — have been — the cause ofhalf the population being 
swept off by disease. And, on the other hand, no climate in the 
world — certainly not that of India — could kill us if we did not 
kill ourselves by our neglect. The question was no less a one than 
this : How to create a Public Health Department for India — how to 
bring a higher civilization into India P What a work, what a noble 
task for an Indian Government. No "inglorious period of our 
dominion" that, but a most glorious one ! 



Art. 3. — 0/i Nursing upon the same Principle as that of the 
French Soeurs de Charite. 

By Lord Brougham. 

(British Medical Journal, October 17, 1863.) 

At the recent meeting of the Social Science Association at Edin- 
burgh, the President, Lord Brougham, in his opening address, made 
the following remarks on the introduction into this country of nurses 
trained like the French Sopurs de ChaHtS ;•—•" It was more than 
once urged at our last congress that the invaluable attendance in 
French hospitals of Sceurs de Charite made their establishment ia 



8' PBAOTICAL KEDICINB, ETC. 

thiB country not only expedient, but a kind of duty. There is great 
satisfaction in finding that steps have been taken with much success 
towards the attainment of this object. The most important by far is 
the foundation, by the sister of our colleague. Lord Granville, Lady 
G. ib'ullerton (so well known for her excellent writings), of a sister- 
hood under a Paris superior, in a spacious building, for which her 
coadjutor, Miss Easton, has nobly contributed 5000L These ladies 
being Eoman Catholics, their sisterhood is of the same persuasion, 
and this somewhat interferes with their attendance in hospitals. 
But Miss Brownlow Byron has established another body of the 
same kind — the All Saints' Home, in Margaret Street— and there 
are no other attendants than these sisters at the University College 
Hospital. This is a great benefit gained; and undoubtedly the 
exertions of this association, and of those ladies especially who are in 
co-operation with us, have mainly effected it. It is plain that the 
duties of nurses offer a great and constant means of female employ- 
ment, as our amiable and able colleague Miss Hope, and her coad- 
jutors in this town, have shown, confirmed by the excellent training 
schools for nurses under Mrs. Balfour. The SoBurs de ChaHU also 
perform the service of nursing the sick at their dwellings. I re- 
member that, when attending M. de Tocqueville's funeral at Cannes, 
the feeling most generally expressed by all present was thankfulness 
for the comfort .which attended the last weeks of his life from the 
care of those excellent persons. Surely those who have introduced 
this sisterhood into our country are worthy of all acceptation. 
They well deserve to be the countrywomen of Florence Nightin- 
gale — and no higher panegyric can be pronounced." 



Art. 4. — On Iodine as a Deodorizer and Disinfectant, 

By Dr. B. W. Richardson. 

(Medical Times and GazettCy September 26, 1863.) 

At one of the recent meetings of the British Association for the 
Advancement of Science, at Newcastle, Dr. Eichardson made some 
short observations on this subject. He said : — " The iodine should 
be placed in a common chip-box, such as is employed by pharma- 
ceutists, the lid of the box being replaced by a covering of "leno," 
or the iodine may be placed in the ornamental vases on the mantel- 
shelf of a room. The smell of iodine could thus be communicated 
to the air of an apartment, and air so purified was not only fresh 
and agreeable to the sense of smell, but any organic matters present 
in it were destroyed. In extreme cases the iodine should be placed on 
a dish or plate, and the heat of a candle being applied beneath, the 
iodine was volatilized, and a room was quickly purified. Dr. 
lEichardson said that in cases of small-pox a knowledge of the facts 
he had named was most valuable. In rooms occupied by sufferers 
from this painful disease, organic matters floated largely in the air, 
rendering the air most offensive. He (Dr. Richardson) had suc- 
ceeded, in all cases, in rendering such air inodorous by the volatili- 
sation of iodine. He had also observed the singular fact, that when 



PSACnCAL ICZDICIKE, ETO. 



the air was greatly charged with organic materials, the smell of the 
iodine was for a long time imperceptible, so that in truth the iodine 
method of purification was also a ready and practical test of the 
purity of an air. Dr. Eichardson thought the iodine plan was quite 
as efiective as the liberation of free ozone — it was, indeed, in principle 
the same, and was so simple that every person could employ it." 



Aet. 5. — On the Medicinal Use of Arsenicated Mineral 
Waters^ with special reference to that of Whitbeck, 

"Bj Dr. Geoboe Robinson, formerly Lecturer on Practice of 

Medicine at the Newcastle-on-Tyne College of Medicine. 

(Lancet, July 5, 1863.) 

At the Cambridge Meeting of the British Association, Dr. John 
Davy gave an account of a small mountain stream in Cumberland, 
Whitbeck by name, which contains a minute quantity of arsenic, 
and which has been used bv the inhabitants of an adjoining village 
from time immemorial, without any marked effect, bad or good, and 
which has proved equally inert to animals, with the exception of 
ducks and swans. Dr. Kobinson accompanied Dr. Davy in one of 
his visits to this stream, and as one of the results of this visit, he is 
now induced to ask — whether a natural combination of arsenic^ such 
as that occurring at Whitbeck^ will not in many cases be found a 
more efficacious therapeutic agent than any artificial solution oj 
arsenical compounds ? 

He introduces the subject by some general remarks upon the 
action of arsenic, and the eases in which arsenic is likely to be 
beneficial, and then proceeds : — ** In brief, then, I submit that in 
these and many other diseases where the administration of arsenic 
is indicated, that remedy may be most safely, eff'ectually, and 
pleasantly gi^en by the internid and external use of a naturally 
arsenicated water. 

" The greater safety would result from the excessive and constant 
dilution of the medicinal substance by pure water, thus preventing 
any irritating or injurious effect upon the system. This is distinctly 
proved by the fact of the daily and habitual imbibition of the 
Whitbeck water by the inhabitants of that village, as detailed by 
Dr. Davy. 

•* The greater efficacy of the natural over any artificial solution of 
arsenic must be mfiuenced by two chief circumstances — Ist, the 
adjuvants constituted by the pure air, delightful scenery, proximity 
to the sea, and the complete change of mental and bodily associa- 
tions, involved in a visit to a district like that of Whitbeck ; and 2nd, 
the peculiar state of combination inwhich the chief remedial substance 
exists in^this particular water. And on this point I may be allowed 
to quote verbatim, the remarks of Dr. Davy and Mr. Church, 
premising that the fact of the arsenical impregnation of the Whit- 
oeck water was determined some years back by Mr. Zenner, ana- 
lytical chemist of Newcastle, and was then understood to be the 



10 PBACTICAL KEDICINE, ETC. 

necessary effect of the existence in this mountain of large masses ot 
arsenical pyrites (mispickel). 

" Dr. Davy thus describes the water of Whitbeck : — *It had the 
general character of the mountain streams of the Lake District, 
was perfectly clear and colourless, and tasteless. Of the several 
specimens obtained I found the specific gravity the same, and the 
same as that of distilled or rain water. When evaporated to dry- 
ness the residue was very small, a pint yielding about '25 of a grain ; 
and from the difi'erent specimens tried, not varying more than one- 
tenth of a grain. In each instance this residue was found to consist 
chiefly of common salt ; it tasted of this salt, and in solution was co- 
piously precii-itated by nitrate of silver. Mixed with the common 
salt was a little magnesia and lime, both probably in combination with 
sulphuric acid, as sulphate of lime and of magnesia, the presence of 
the acid being denoted by nitrate of bar3?te8 ; a trace, too, of oxide 
of arsenic was detected in each, and, it may be inferred, in combi- 
nation with potash, a trace of which was also obtained. The arsenic 
was detected not only by the test of the ammoniaco-nitrate of silver, 
but also by reduction to its metallic state by sublimation after mixture 
with ferrocyanide of potassium. Of the several specimens of water 
tried, that procured in October, when the stream was about its 
ordinary size, afforded a somewhat stronger trace of the metal than 
either the earlier or the later : the one in August, 1861, taken when 
the stream was swollen after rain ; the other in January, 1862, during 
a frost of several days* duration, when probably the water was 
frozen at its sources— the stream being then lower than common. 
In noticing, however, the later, I should except the last — that 
taken in August last, when the stream, was of about its average 
volume, and the indications of arsenic nearly the same as those of 
October. In the instance that the trace was strongest, judging from 
comparative experiments with oxide of arsenic — experiments of 
reduction by sublimation — the quantity of oxide contained in the 
pint was only about '008 frrain, or -064 grain to the gallon.* " 

" Mr. Church says : * The reaction of the water as it issues from 
the earth was faintly but unmistakably alkaline; on testing the water 
after ebullition the effect was more decided. The water from many 
other sources in the neighbourhood of Whitbeck, where decomposing 
granite is of common occurrence, has an alkaline reaction. The 
water, on examination, gave distinct indications of the presence of 
arsenic. This element, which here probably exists as an alkaline 
arsenite, occurs, not as a mere trace, but in determinate quantity. I 
have satisfied myself that in some seasons of the year the quantity 
present approaches a good fraction of a grain of arsenic (metallic) in 
each gallon of water. The arsenical water is habitually used for 
every purpone by the inhabitants of the little village of Wnitbeck.* 

" From these analyses it will be seen that the arsenic exists in the 
very same form as that in Fowler's solution — namely, as arsenite of 

r)tas8; and from the circumstance of common salt being also present, 
have no doubt that a minute quantity of iodine is likewise contained 
in it. I may add, in reference to this point, that the sea is only a 
mile distant from the base of Black Comoe, the mountain from which 
this stream descends. 



PBAOTICAL MSDICINB, ETC. 11 

" Another great medicinal advantage offered by this mineral water 
is that it may be employed in the form of baths. For proof that 
arsenic, especially when in solution, is capable of being absorbed 
through the unbroken skin, I may refer to the well-known and 
justly celebrated works of Dr. Alfred Taylor; and on the same 
authority, confirmed by other testimony, it may be stated that this 
substance does not accumulate in the system. Continued doses of 
the mineral water of Whitbeck may therefore be given without any 
fear of poisonous symptoms suddenly manifesting themselves. In 
fact, the chief beneficial efiecta of arsenic probably result from the 
greater actiyity induced by it in all the eliminating organs of the 
hody, by which retained secretions and other noxious matters are 
discharged, and a more healthy action of the depurating tissues 
induced. Of the general salubrity of the district now under con- 
sideration, and of its many agreeable features as a place of resort 
for invalids, I can speak in the highest terms, and from personal 
experience, having for the last seven years visited it annually as a 
pleasant and salutary change from Newcastle. It is easy of access 
from all parts- of the kingdom. There are within a short distance, 
especially in Whitehaven, several medical practitioners of high 
character and great ability ; and were a demand to arise K>r 
increased accommodation for strangers, consequent on the use of 
the Whitbeck water as a remedial agent, there is every reason to 
think that the public-spirited nobleman who is the chief landed 
proprietor in that neighbourhood, and to whom the country is in- 
debted for that' beautiful part of England having been rendered 
more accessible, would afford all reasonable facilities." 



Aet^ 6. — On Tobacco, in its Relations to the Health 
of Individuals and Communities. 

By Dr. B. W. Kichabhson. 

(Social Science Review,) 

Tn this elaborate paper Dr. Eichardson describes in detail all the 
effects which, in his opinion, are produced in the body by tobacco 
as it is used by smokers^ Condensed into a few sentences, the details 
may be summarized in the following manner : — 

1. The effects that result from smoking are due to different agents 
imbibed by the smoker : viz., carbonic acid, ammonia, nicotine, a 
Tolatile empyreumatic substance, and a bitter extract. The more 
common effects-are traceable to the carbonic'acid and ammonia; the 
rarer and more severe to the nicotine, the empyreumatic substance, 
and the extract. * 

2. The effects produced are very transitory, the poisons finding a 
ready exit from the body. 

3. All the evils of smoking are functional in character, and no 
confirmed smoker can ever be said, so long as he indulges in the 
habit, to be well: it does not follow, however, that he is becoming 
the subject of organic and fatal disease because he smokes. 

4. Smoking produces disturbances: (a) In the blood, causing 



12 TBACTICAL MEDICINE, ETC. 

undue fluidity, and change in the red corpuscles : (5) on the stomach, 
giving rise to debility, nausea, and in extreme cases sickness: 
(c) on the heart, producing debility of that organ, and irregular 
action : (d) on the organs of sense, causing in the extreme degree 
dilatation of the pupils of the eye, confusion of vision, bright lines, 
luminous specks, and long retention of images on the retina ; with 
other and analogous symptoms aflecting the ear, viz., inability clearly 
to define sounds, and the annoyance of a sharp ringing sound like a 
whistle or a bell : (e) on the brain, suspending the waste of that 
organ, and oppressing it if it be duly nourished, but soothing it if 
it be exhausted : (/) on the nervous filaments and sympathetic or 
organic nerves, leading to deficient power in them, and to over- 
secretion in those surfaces — glands — over which the nerves exert a 
controlling force: (ff) on the mucous membrane of the mouth, 
causing enlargement and soreness of the tonsils — smoker's sore 
throat — redness, dryness, and occasional peeling off of the membrane, 
and either unnatural firmness and contraction, or sponginess of the 
gums : (h) on the bronchial surface of the lungs when that is already 
irritable, sustaining the irritation, and increasing the cough. 

6. The statements to the effect that tobacco smoke causes specific 
diseases such as insanity, epilepsy, SL Vitus's dance, apoplexy, 
organic disease of the heart, cancer, and consumption, have been 
made without any sufficient evidence or reference to facts ; all such 
statements are devoid of truth, and can never accomplish the object 
which those who propose them have in view. 

6. As the human body is maintained alive and in full vigour by 
its capacity, within certain well-defined limits, to absorb and apply 
oxygen ; as the process of oxydation is most active and most required 
in those periods of life when the structures of the body are attaining 
their full development ; and as tobacco smoke possesses the power 
of arresting such oxidation, the habit of smoking is most deleterious 
to the young, ^jausing in them impairment of growth, premature 
manhood, and physical degradation. 

If the views thus epitomized, in relation to the influence of 
tobacco smoking on individuals, are true, we are led without any 
difficulty to the consideration of the influence exerted by the habit 
on communities and on nations. That which smoking effects, either 
as a pleasure or a penalty, on a man, it inflicts on any national 
representation of the same man, and taking it all in all, stripping 
from the argument the puerilities and exaggerations of those who 
claim to be the professed antagonists of the practice, it is fair to 
say, that, in the main, smoking is a luxury which any nation, of 
natural habits, would be better without. The luxury is not directly 
fatal to hfe, but its use conveys to the mind of the man who looks 
upon it calmly, the unmistakeable idea of physical degradation. 
Dr. Eiehardson does not hesitate to say that if a community of 
youths of both sexes, whose progenitors were finely formed and 
powerful, were to be trained to the early practice of smoking, and if 
marriage were to be confined to the smokers, an apparently new and 
a physically inferior race of men and women would be bred up. Of 
course such an experiment is impossible as we live ; for many of 



PSACTICAL KBDICINB, ETC. 13 

our fathers do not smoke, and scarcely any of our mothers, and thns, 
to the credit of our women, chieHy, be it said, the integrity of the 
race is fairly preserved : with increasing knowledge we may hope 
that the same mtegrity will be further sustained : but still, the fact 
of what tobacco can ao in its extreme action is not the less to be 
forgotten, for many evils are maintained because their full and worst 
effects are hidden from the sight. 

Again, on the ground of the functional disturbances to which 
smoking givesrise in those who indulge in it, an argument may be used 
which goes very deeply, and cuts none the less sharply because, in 
one sense, it is ridiculous. Put down the smokers of Great Britain 
at a million in number — they are more than that, but let it pass :— 
Why should there exist perpetually a million of men, not one of 
whom can at any moment be writ down as in perfect health from day 
to day P Why should a million of men be living with stomachs that 
only partially digest, hearts that labour unnaturally, and blood that 
is not fully oxydised P . In a purely philosophical point of view, the 
question admits of but one answer, viz., that the existence of such 
a million of imperfectly working living organisms is a national 
absurdity, a picture which, to a superior intelligence observing the 
whole and grasping it, would suggest a mania, foolish, ridiculous, 
and incomprehensible. 

Dr. Richardson cannot say more against tobacco, however, with- 
out being led into a wider question, the use of luxuries altogether ; 
on which question, he says, " If I were equally fair for tobacco as 
against it, I should be forced to give it a place as one of the least 
hurtful of luxuries." It is on this ground, in fact, that tobacco 
holds so firm a position : — that of nearly every luxury it is the least 
injurious. It is mnocuous as compared with alcohol, it does infinitely 
less harm than sugar ; it is in no sense worse than tea ; and by the 
side of high living altogether it contrasts most favourably. A 
thorough smoker may or may not be a hard drinker, but there is 
one thing he never is, a glutton; indeed there is no cure for gluttony 
and all its train of certain and fatal evils, like tobacco. In England 
this cure has been effected wholesale. 

The friends of tobacco will add to these remarks, that their 
" friendly weed " is sometimes not only the least hurtful of luxuries, 
but the most reasonable. They will tell of the quiet which it brings 
to the overworn body, and to the irritable and restless mind. Their 
error is transparent and universal, but notwithstanding it is practical 
truth ; for, in their acceptation, tobacco is a remedy for evils that lie 
deeper than its own, and as a remedy it will hold its place until those 
are removed. 



Art. 7. — Puddings without Eggs. 

By Dr. . 

(Social Science EevleWf July 25, 1863.) 
It would be difficult to compute the number of unprincipled 
adventurers who thrive by means of sham appeals to the judgment 



14 PEICTICAL MBDICINE, ETC. 

and improbable promises to the ear, of a discriminating (P) and 
highly gullible public. 

These adventurers comprise a motley group, from the itinerant 
^Bculapii, or street vendors, up to the advertising millionnaires, 
who offer nostrums to cure every species of disorder to which 
humanity is heir. Hence, we have innumerable specifics for most 
real or imaginary ailments ; plaisters that eradicate corns, roots that 
cure the toothache, lozenges that remove the asthma, candies that 
put to flight the influenza, syrups that soothe the throes of infancy, 
and alleviate the rheum of old age, pills that rectify the most shat- 
tered constitution, draughts that insure perfect health and longevity, 
powders that, if they do not exactly bring the dead to life, may very 
possibly effect the contrary process. 

All are constantly advertised in a manner at once flashy and 
attractive, replete with paradoxical terms, unknown to any recog- 
nised or intelligible pharmacopoeia ! 

The success attendant upon impostors of this class, has led others, 
not less morally obnoxious, into the field : now, our bread can be 
made without yeast, our puddings without eggs, and our pastry 
without butter! So that if a determined stand be not made 
against such innovations upon the accustomed arrangements of our 
cuisine, there is no telling what may be set upon our tables, and how 
soon our bodies may become attenuated lor want of the usual 
elements necessary K)r nutrition. Lately, a packet of a so-called 
'* German Baking Powder" has been submitted for our inspection. 
The prospectus in which it is wrapped, sets forth in most glowing 
terms the praise of this very questionable commodity : it asserts that 
bread made with this powder is more nutritive and wholesome than 
that ordinarily manufactured, and that a larger amount of the " staff* 
of life" is obtained from the same quantity of flour, by the use of 
this wonderful ingredient ! To the dyspeptic it is invaluable, as it 
is one of the most effectual preventives of indigestion ; it is also, we 
are assured, equally valuable (P) in making puddings and pastry, 
which it deprives of all their indigestible proportions, and if dripping 
or lard be used instead of -butter, it removes all unpleasant taste ! 

It appears, from the results of a chemical analysis of these 
powders, that **they consist of carbonate of soda and tartaric acid, 
combined with a small proportion of rice or other flour: when mixed 
with water, as occurs when pastry is made, carbonic acid is 
liberated, and tartrate of soda formed : they are used chiefly to 
render pastry light, and do not generally contain any ingredients of 
an injurious character, although of course they are in themselves 
non-nutritious. Egg powders are more objectionable, because some- 
times coloured with chromate of lead, and also for the reason that 
they are substituted for eggs, and not possessing an/ of their nutri- 
tive properties."* 

The inventor of this remarkable powder must have had unflinch- 
ing faith in the credulity of the public, as well as a knowledge 
of their reluctance to employ their reasoning faculties, when puflfing 

* The Lancet. 



PBACTICAL MEDICINE, ETC. 15 

advertisements are submitted to their attention. To onr mind it 
does not require very subtle penetration to discover the fact, that a 
mere powder composed of soda and tartaric acid, mixed with a small 
portion of rice flour, though free from more objectionable compounds, 
cannot become a proper substitute for e^gs and butter ; yet that 
many act upon such a supposition there can be little doubt, as we 
have ascertained that aoout one ton per day of the questionable 
article is consumed. Apart from such palpable fraud itself, the use 
of these baking powders should be discountenanced on social and 
hygienic grounds ; the employment of cheap and inferior substitutes 
for the genuine article is fraught with mucn evil in cookery, even 
more than in trade ; these practices stand as a temptation in the way 
of domestic servants, who, possibly accrediting, in some degree, the 
virtues so falsely and impudently aflSrmed to reside in these com- 
pounds, are induced not only to cheat their employers out of the 
nutriment which their bodies ought to receive, but to rob their 
pockets into the bargain. 

Art. 8. — Poisoning by Milk, 

By Dr. . 

(Medical Times and Ga^ette^ January 31, 1863.) 

A number of persons occupying two of the principal hotels at 
Valletta, Malta, were seized, on the morning of the 17th inst., with 
symptoms of irritant poisoning. The Malta Times states that — 

" All the sufferers were seized within twenty minutes to two or 
three hours after breakfast ; and as the only article of diet common 
to all was milk, and as on other occasions of similar seizure the 
cause was clearly traced to that article, it is reasonable to infer 
that in the present instance the milk used for breakfast contained 
the poisonous ingredient. This conclusion becomes almost a certainty 
when it is known that several persons, living in the same hotels, 
who had not taken milk that day, escaped, while, without one 
exception, those who had taken it were seized with the alarming 
iUness described. Several families in Valletta, it is said, were 
attacked in like manner the same morning, after partaking of milk 
for breakfast ; even a cat, which had taken some, showed the same 
symptoms of having been poisoned. Towards the end of last year a 
number of exactly similar cases happened at Sliema, where the whole 
family of a field officer, with one exception, was poisoned, evidently 
by goat's milk ; and about the same time other cases occurred among 
the officers and men of her Majesty's ships Marlborough, Algiers, 
and Firebrand, but with no fatal consequences. We have also heard 
of other cases occurring from time to time. Poisoning by milk, 
therefore, appears to be not an uncommon occurrence in Malta ; 
but we are not aware if experiments were ever made by scientific men 
to ascertain beyond doubt the real cause of the milk assuming this 
dangerous character. The natives attribute it to the goats browsing 
on a particular plant belonging to the natural family, Euphorbiaceaet 
or sporgeworts, which they call tenhuta, and which, they say, pos- 



16 PBlCnClL HBDIOINB, BTC. 

sesses the property of rendering the milk poisonous to human 
beings, without ind^icting any serious injury on the animal itself. 
On the other hand, we have heard this popular belief ridiculed 
by some of the more learned Maltese physicians, although we 
must confess we never could perceive upon what grounds. We are 
glad to learn that his Excellency the Governor has ordered a search- 
ing inquiry into the matter, and we hope the result wiU be the 
adoption of means, if possible, to prevent such serious endangering 
of life by a common article of daily food for the future." 

It is well known that the latex of most of the plants belonging to 
the order JSuphorbiacea has acrid and purgative properties ; and it 
has also been observed that in certain districts of America the milk 
and flesh of cows have been rendered poisonous by particular 
pastures, without the health of the animals being affected. like 
mstances of numbers of people being poisoned by milk have been 
noted in various parts of the continent ; amongst others, at AuriUac, 
in France, and at Hereford, in Westphalia. The latter cases 
have been long popularly attributed to the cattle having fed on the 
Euphorbia esula. Such a notion has, nevertheless, been negatived 
by continental toxicologists, on the ground that cattle refuse the 
Euphorbia as long as grass and other wholesome vegetables occur in 
their pasturage ; yet this may be only the cause why such accidents 
do not occur more frequently. It is a mistaken idea that the instinct 
of ruminants in the choice of herbage always leads them to refdse 
poisonous plants. Oxen will eat the berries and leaves of the yew, 
and frequently die in consequence, either from the immediate effects 
of the poison on the nervous system, or subsequently from inflam- 
mation of the alimentary canal. 

A.RT. 9. — Epidemic from Eating the Meat of a Diseased Cow, 

By Dr. Husemann of Detmold. 

(Medical Times and Gazette, December 13, 1862.) 

Dr. Husemann, of Detmold, gave an account to the Congress of 
German naturalists and physicians, of a new epidemic disease, which 
had been observed by him m August, 1862, and which was caused by 
eating the flesh of a diseased cow. About 150 persons were affected. 
The epidemic was novel in etiology as well as with regard to 
the symptoms. There were three forms of it: one was very 
mild, the patients suffering from diarrhoea without fever ; another 
was more severe ; there being rigors, febrile symptoms, vomiting, 
diarrhoea, cerebral symptoms, and violent pains m the abdomen, 
with great sensitiveness to pressure : the symptoms continued for 
about a week. The third form was the most severe ; there was 
generid collapse, coldness of the extremities, scarcely perceptible 
pulse, etc. Death ensued in three cases, and convaiescence was 
much protracted in the others. The post-mortem appearances were 
gastro-enteritis, and hypersemia and extravasation m the cerebral 
meninges, the blood being dark and very fluid. There was no 
retention of urine, and no difficulty of deglutition, whereby the 



FBACnOAL MBDICIVS, BTC. 17 

epidemic was distingmshed from cholera, and from poisoning with 
sausages. The cow had had a fracture of the ribs and plearisy, and 
it was, therefore, probable that the meat had been x>oisoned in con- 
sequence of pysmia. The meat was poisonous whether roasted or 
boued. 



Aet. 10. — On Measly Fori. 

Bj M. Delpech. 

(BriiUh Medical Journal, February 21, 1863.) 

M. Delpech has just read a paper at the French Academy of 
Medicine on the hygiene of measly pork. 

The " leprosy" of pork, he concludes, consists in the presence of 
cysticerci in the tissues of the animal, and especially in its muscular 
tissue. 

Taken into the human stomach with the meat raw or not well 
cooked, these animals are the most common, if not the sole source of 
the development of this etitozoon. 

The researches, however, of Weiss of St. Petersburg on the flesh 
of raw beef, and the curious facts collected by M. Judas from the 
reports of the military medical men, who have pointed out the en- 
demicity of the animals in Algeria, show that further investigations 
are required to prove that the afiection has no other origin. 

The cysticerci exposed for some length of time to a temperature 
of 100° centigrade (212° Fahr.) are destroyed, and the flesh con- 
taining them thereupon loses its hurtful properties. 

The cysticerci are rarely found in the fat. Measly pork, there- 
fore, cooked in the neighbourhood of the abattoirs, under the surveil- 
lance of the police, may be safelv employed as an article of food ; 
and the fat may be also safely employed. 

The cysticerci in the pig are derived from the ingestion of the 
ova of tne taenia solium, or some other species of worms enclosing 
the ova, which they find in human excrements. This diseased con- 
dition of pork results originally from the filthy condition in which 
the pigs are kept. 

It would be well to spread these facts widely and authorita- 
tively amongst those who breed pigs. During life, the characters 
of this condition of the pig are obscure. The presence of sub- 
lingual vesicles, when it exists, is the only sure sign. 

These different conditions have caused the authorities to prohibit 
the sale of diseased pork ; but we may now consider that tnis pro- 
hibition should be removed. Moreover, the loss ought to fall on 
the person who fed the animal, and not on the butcher who buys it 
for sale. This would cause the breeder to be more careful in the 
keeping and feeding of his pigs. 



xxxvni. 



18 PBACTICAL MEDICINE, ETC. 

Art. 11. — On Siguatera, or Fish-Poison Disease. 

By Dr. . 

{Social Science Review^ July 19, 1863.) 

There are six varieties of poisonous fishes already known and 
described— viz.: the perches, the gurnards, the flounders, the spares, 
the gobies, the sardines, and the globe fishes, the last including two 
forms — the Diodon and the Tetrodon, 

Confining our attention exclusively to these poisonous fishes, we 
find that they are most common in the following localities — at all 
events, that they have been discovered in these localities more 
frequently than elsewhere : in the Caribbean Sea, off Brazil, New 
Caledonia, the Seychelles, the Chinese Sea, the Malabar coast and 
other parts of India. 

It should be remarked, that in these poisonous fishes the digestive 
organs, the spawn and the liver, are invariably most dangerous ; 
and that there are many fishes that may be eaten with the greatest 
safety when those parts are avoided. Another fact worthy of notice 
is the age o f the fishes : some are dangerous when they have 
arrived at maturity. The Lethrinus mambo, for example, can be 
safely eaten when very youne:, but afterwards is exceedingly dan- 
gerous. Some naturalists attribute the poisonous qualities to the 
food found in the seas frequented by certain classes of these fishes. 
This is true under some circumstances, as in the case of the Meletta 
venenosa, which at certain seasons of the year feeds upon a green 
monad which covers the sea in large quantities. Wherever this 
green monad is seen the Meletta is poisonous, but wherever it has 
not appeared the same fishes are eaten with the greatest safety. 
MM. Fonssagrives and M6ricourt acjree with M. de Rochas in his 
opinion respecting the spawn, and with him consider it as the most 
poisonous part. If such be the case, it could soon be determined 
by ascertaining whether the injurious properties of the fishes are 
permanent, whether in the same species adults only are poisonous 
in their effects, and whether there is poison in those fisheis only 
which contain spawn. To decide these questions, comparative ex- 
periments might be made with the male and female fishes of the 
same species inhabiting the same streams of water. If it were 
found that the latter only were injurious, the difficulty would be 
satisfactorily solved. 

The Spanish colonists gave the name of Siguatera to that union 
of symptoms which results from the eating of poisonous fishes indi- 
genous to hot countries. The symptoms which arise are of two 
kinds — severe attacks of indigestion or gastro-enteritic poisoning ; 
or an icy coldness and depression, accompanied with great nervous 
disturbance. The symptoms are the same, whether severe enough to 
cause death, or only to excite inconvenience or temporary derange- 
ment ; they differ only, i. e., in intensity. Gastro-enteritic Siguatera 
has all the appearance of a severe attack of indigestion — viz., 
nausea, vomiting — first of the food, then of mucus — coldness, de- 



PBACTICAL MEDICINB, ETC. 19 

pression of the pulse, cramp, and diarrhoea. The nenrous type of 
symptoms — viz., convulsion and paralysis, which characterize the 
process of poisoning bv fishes, are not to be found in any case of 
metallic poisoning. They seem to arise from a combination of 
accidents, as if they had been produced by different vegetable 
poisons of narcotic and acrid character. When the Siguatera 
assumes a gastro-enteritic form, the sufferer is, in general, quickly 
restored to health ; while the nervous symptoms leave behind them 
the most serious traces of debility and irregularity. These have 
been known to continue for eight or nine days. 

As illustrating the way in which the members of crews of vessels 
are poisoned by the eating of poisonous fishes, the following facts 
from the " Linnaean Transactions " for November, 1860, are valuable. 
The history of the circumstance was communicated by Mr. H. 
Jameson, of her Majesty's ship Winchester, to Sir William 
Burnett. The accident occurred on board the Dutch ship Fostilliojit 
lying in Simon's Bay, Cape of Good Hope. The Winchester being 
near, Mr. Jameson was called to render his services to the sufferers. 
On arrival he found that the boatswain's mate and purser's steward 
had been suddenly taken ill after eating a part of a well-known 
deleterious fish, common in Simon's Bay, and called the toad or 
bladder-fish— the Diodon. They had been warned that the fish was 
poisonous, but were resolved to try the experiment, the boatswain 
declaring that the liver was not poisonous, but a great delicacy. 
They had partaken of dinner at twelve o'clock ; immediately after- 
wards they partook of the fish, and scarcely ten minutes had elapsed 
when the boatswain became so ill that he was unable to raise himself 
without the greatest difficulty ; his face was somewhat flushed ; his 
eyes glistened, the pupils were rather contracted ; his mouth was 
open ; the lips were tumid and somewhat blue ; the forehead 
covered with perspiration ; the pulse weak, quick, and intermit- 
tent. The patient was extremely uneasy and in great distress, 
but still conscious ; he complained of pain from constriction of the 
throat, and appeared inclined to vomit. It was with difficulty he 
could swallow a powder with some warm water. His state quickly 
assumed a paralytic form ; his eyes became fixed in one direction ; 
bis breathing was difficult, and accompanied with dilatation of the 
nostrils ; his face was pale, and covered with cold perspiration, his 
lips livid ; his consciousness and pulse failed, and in scarcely seven- 
teen minutes after partaking of the fish he was dead. The symptoms 
exhibited by the purser's steward were of a similar kind. He also 
died within twenty minutes of the time after he had partaken of the 
fish. 

The quantity consumed between the two men was only the liver 
of one fish ; the liver might have weighed about four drachms. 
The entire fish measured only from six to eight inches in length. 

Other examples similar to the above have been recorded by 
Praeger ; in all, death was rapid, but we cannot stop to chronicle 
these, as the effects were the same as in the instances above cited. 



2-a 



20 fsjlctical medicinb, etc. 

(b) concbbning acutb diseases. 

Art. 12. — A Contribution to the Therapeutics of Continued 
Fever. 

By Dr. T. King Chambers, Physician to St Mary's 
Hospital, <Si;o. 

(Proceedings of the Royal Medico-Chirurgical Society, April 28, 1863.) 

Analysis of 214 cases of continued fever : — 
108 treated on " general principles ;" 

106 treated on a uniform plan of continnons nutriment and 
hydrochloric acid. 
The first series occurred during the six years ending September, 
1857 ; the second series during the five and a half years ending 
March 3l8t, 1863. 

Seasons for the cases being fairly comparable : — 1. They are each, 
a consecutive series. 2. They are spread over a considerable period 
of years. 3. All treated by the same physician, and under similar 
circumstances. 4 Diagnosed and recorded by independent regis- 
trars. 5. The equality of the cases is shown by the equality of the 
mean duration of their convalescence. 

Of the first series .— 

of 13 entered as typhus, 3 died ; 
of 39 entered as typhoid, 16 died j 
of 56 of doubtful type, 3 died. 
Of 108, total of continued fever, 22 died. 

Of the second series ;— 

of 19 entered as typhus, none died ; 
of 48 entered as typhoid, 2 died ; 
of 39 of doubtful type, 2 died. 
Of 106, total of continued fever, 4 died. 

Excluding from the first series 2, and from the second 1, who died 
within two days of admission, and gave therefore little scope for 
judging of the effects of treatment, there remains less than 1 in 5 as 
the death-rate under the first treatment, and less than 1 in 35 as 
the death-rate under the second treatment. Therefore the second 
method of treatment is a powerful means of preserving life. 

[In the discussion which followed the reading of this paper. Dr. 
Murchison said that the treatment recommended by Dr. Chambers 
closely resembled what he had followed at the Fever Hospital, during 
the last 18 months. The treatment of typhus and allied fevers by 
the mineral acids was a very old one ; it had long been the favourite 
treatment in many parts of Europe, particularly in Germany and 
Sweden. At the same time, he had not that implicit faith in it 
which Dr. Chambers appeared to have, and he must protest against 
Dr. Chambers's inference that his treatment was calculated to pre- 
vent 16 out of every 18 deaths from fever. Dr. Murchison had 
employed the mineral acids, in conjunction with wine and abundance 



PBJLCmCJLL MBDICIITB, BTO. 21 

of flaid nntriment, in upwards of 1500 cases, and althongh he had 
often seen the most marked improvement (cleaning of the tongue, 
&c.) follow the use of the acids, his statistical results had been 
much less favourable than those now announced to the Society. He 
was convinced that, with more extended experience, Dr. Chambers 
would be compelled to modify his opinion. Dr. Chambers's statis- 
tics were open to several fallacies. 1. The cases selected for com- 
paring the results of different plans of treatment had occurred at 
different periods, instead of at the same time. 2. In both series, 
the form of fever had not been determined in a large proportion of 
the cases, and no details had been given to enable any one to judge 
of their nature or severity. Many of the cases " of doubtful type" 
had probably been examples of simple fever, which was rarely fatal 
under any method of treatment. The results would be materially 
affected by the proportion of cases of simple fever or febricula in 
either series. 3. The rate of mortality in the first series, treated 
'• on general principles," was far above the average mortality from 
fever in general hospitals, and hence it was nob a fair standard of 
comparison. The total mortality in this series (including febricula) 
had been 20 per cent., for typhus alone 23 per cent., and for enteric 
fever no less than 41 per cent. 4. The ages of the patients suffering 
from the different forms of fever had not oeen given. Age exercised 
little or no influence over the rate of mortality of enteric fever ; but 
in the case of typhus, the results of different methods of treatment 
could never be satisfactorily compared without taking the ages of 
the patients into consideration. Under twenty years of age, typhus 
was rarely fatal ; above fifty, the mortality was nearly 60 per cent. 
5. The number of cases was too small to warrant any decided 
opinion as to the advantages of the treatment recommended. The 
second series included only 19 cases of typhus and 48 of enteric 
fever, diagnosed as such. A practitioner, with extensive experience 
in fever, mi^ht often have 20 cases of typhus in succession under his 
care, without losing a single case ; but then if he lost 5 cases, the 
total mortality would be 20 per cent. During last autumn, of 41 
successive cases of enteric fever, under Dr. Murchison's care, only 
2 died, one from perforation of the bowels, and the other from acute 
tuberculosis — lesions not likely to have been cured by any treatment, 
yet the rate of mortality for the entire year had been considerably 
greater. Most of the 41 cases had been severe, but in none had a 
drop of hydrochloric acid been administered. Dr. Murchison 
doubted if hydrochloric acid possessed advantages over the other 
mineral acids. Although he believed that the treatment of con- 
tinued fevers by the mineral acids, together with an uniform system 
of nourishment, was justified by our knowledge of the pathology of 
fever, as well as by experience, he was confident that Dr. Chambers's 
statements were calculated to make those who heard them too san- 
guine as to the results to be obtained from it.] 



22 TBACTICAL HBDICINB, ETC. 

Art. 13. — On the Prevalence ofTyplim Fever in London. 

By Mr. . 

{Lanaei, October 31, 1863.) 

Typhus fever has been epidemic in London since 1861. The fact 
and its cause are ably commented on in an editorial article of the 
Lancet^ to which the statistics of the London Fever Hospital supply 
the text, and from which we take the following passages : — 

" The admissions into the London Fever Hospital form the only 
accurate measure of the fluctuations of the disease in question, inas- 
much as the returns of the Registrar- General include all forms of 
continued fevers and deaths from many other acute diseases under 
the common designation typhus. It may be mentioned, however, 
that it appears from the Eegistrar-General's Eeports that the deaths 
from * typhus ' in the metropolis, which in 1860 did not exceed 1392, 
rose in 1862 to 3635, and during the first nine months of the 
present year (January 3rd to October 10th) have amounted to 
2111. 

*• In the years 1858, 1859, and 1860, true maculated typhus had 
well-nigh disappeared from London. In 1858 the number of cases 
admitted into the London Fever Hospital did not exceed 15, several 
of which were of doubtful character, and for many months not a 
single example of the disease was observed. In the year 1860 the 
number of admissions into the Fever Hospital for all causes did not 
exceed 391, of which the typhus cases constituted but a small 
fraction. At this time, indeed, the Committee of Management con- 
templated the conversion of tlie institution into an hospital for 
general diseases. In October, 1861, the number of admissions began 
to increase, and in 1862 it rose to 2699, or exceeded the largest 
number of admissions in any previous year of the hospital's history 
by nearly 1000. This great increase was entirely due to typhus 
fever, and it may be mentioned that during a great part of 1862, 
patients were almost daily refused admission for want of room. The 
cases were most numerous in the months of March, April and May. 
As the summer of 1862 advanced, the epidemic appeared to subside, 
and, with the exception of a slight exacerbation in the cold months 
of November and January, it has continued to do so until the 
autumn of the present year, when it has again experienced a rapid 
increase. On August 31st there were in the Fever Hospital 80 
patients, of whom a considerable proportion were suffering from 
diseases other than typhus fever. At the end of September there 
were 134 patients, and on October 20th, 188 ; during the last fort- 
night numerous applicants have been refused admission, all the beds 
being occupied. The whole of the increase has been due to typhus. 
The fluctuations of the epidemic will be readily understood by 
referring to the monthly admissions for typhus into the hospital 
since September, 1861, which have been as follows. From tnese 
numbers all cases other than typhus have been carefully ex- 
cluded. 



FSACTICAX MEDICINE, ETC. 



January ... 


1861. 


1862. 

142 


1863. 

... 123 


Pebruary ... 


— 


154 


... 91 


March 


— . 


210 


... 85 


April 


— 


225 


... 92 


May 


— 


215 


... 49 


June 


— 


163 


... 43 


July 


— . 


145 


... 65 


August 


— 


143 


... 66 


September 


2 


103 


... 97 


October ... 


32 


108 


... 104* 


November... 


8 


122 


_ 


December ... 


21 


97 


— 



" The epidemic has throughout been confined to the poorest and 
most densely populated parts of the metropolis. In 1862, 1827 cases 
of typbus were admitted into the Fever Hospital. Of the 56 
districts into which London is divided, St. George s-in-the-East fur- 
nished 179 cases ; St. Pancras, 162 ; the City of London, 157 ; St. 
Marylebone, 116 ; Lambeth, 107 ; Hoi born, 101 ; Greenwich and 
Deptford, 93; and the Strand, 56 : whereas, not one case of typhus 
came from St. George's, Hanover-square, from which patients suffer- 
ing from other forms of fever were derived. Of the cases admitted 
from January 1st to October 20th of 1863, it will be seen from the 
table which we have prepared (p. 522), that 277 have been brought 
from the South Division of the metropolis, 215 from the East, 144 
from the North. 103 from the Central, and 50 from the West. The 
parishes which have supplied the largest number of cases are St. 
George's-in-the-East (103), Bermondsey (77), Lambeth (72), Mary- 
lebone (73), St. Pancras (46), Greenwich and Deptford (43). and 
Stepney (41). The several districts and parishes have exhibited re- 
markable fluctuations in the prevalence of the disease. Thus, during 
the first six months of this year, the East Division of London fur- 
nished 159 cases, and the North 121, but the South only 73. Since 
July 1st, these proportions have been reversed, the South having 
furnished 204 cases, the East 54 cases, and the North 23 cases. 
During the first three months of the year, 60 cases came from Mary- 
lebone ; but in the subsequent six months, only nine cases. On tlie 
other hand, during the first six months of the year, only 7 cases came 
from Bermondsey, 10 from Lambeth, and 2 from Rotherhithe ; but 
since July 1st, Bermondsey has supplied 70 cases, Lambeth 62, and 
Botherhithe "25, St. George's-in-the-East and St. Pancras are the 
parishes which have furnished the most constant and equable supply. 
The recent increase of typhus has mainly occurred in the parishes of 
Lambeth, Bermondsey, Kotherhithe, and St. George's-in-the-East ; 
although the admissions into the Fever Hospital during the last three 
weeks indicate a slight increase in almost all the parishes of 
London. 

" All the patients who have been admitted into the Fever Hospital 

* This number only includes the admissions from Oct. 1st to Oct. 20th, 
inclusive. 



24 7BACTIC1L HEDICXSK, STC. 

anfTering from typhus have belonged to the very poorest class ; and 
many of them have been in a state of extreme destitution, verging 
on starvation, for weeks or months before their illness. During the 
year 1862, no fewer than 32 deaths from starvation were reported 
as having occurred in London ; while a large number of patients were 
sent to the Fever Hospital whose complaint was not fever, but ex- 
haustion consequent on want. 

" The circumstances preceding the present epidemic of typhus in 
London did not differ from those of previous epidemics. T?^here was 
no failure of the crops in England, but for some time before there 
had been great distress amongst the poor of London consequent on 
the organized system of strikes, the effects of which had only been 
temporarily averted by the relief from the societies for promoting 
the short-hour movement. As in 1826, 1836, and 1856, an artificial 
scarcity was the result. In addition to this, the great distress in the 
provinces caused the poor population of London to be condensed by 
the arrival of labourers from the country in search of work. It was 
ascertained that almost all of the first cases admitted into the Fever 
Hospital were male tramps, with no fixed residence, out of employ- 
ment, and who had been suffering for many weeks from want. There 
was no evidence, however, that they had come from infected localities 
or imported the fever into London. Only a small proportion of them 
were Irish, and none had arrived recently from Ireland. The cause 
of the epidemic, in fact, appeared to have been overcrowding con- 
sequent on an extraordinary amount of destitution. ' 

** It is worthy of remark that a similar observation was made with 
regard to the epidemic of typhus at Preston in the autumn of 1862. 
According to the most reliable evidence, true typhus fever had not 
been seen at Preston for a long time before the outbreak in question, 
and no attempt had been made to show that it was imported. But 
the population had been for months before in a state of great desti- 
tution, and the result of this destitution was overcrowding. From 
the daily reports in the Times it appeared that numerous cottages 
at Preston were untenanted, from the inability of the previous tenants 
to pay the rents ; and that it was the practice for several families to 
congregate in one house. As many as six different families are said 
to have been collected in one house of the average size for one family. 
Moreover, the result of the Government inquiry into the matter was 
to show that the first cases of true typhus observed at Preston oc- 
curred in a family of four persons, who had been living in a small 
room with only 600 cubic feet of space, and who were in a state of 
extreme want. The immense amount of pecuniary relief sent to the 
distressed operatives in Lancashire, the ability with which this relief 
was distributed, and the energetic measures adopted by Government 
in conjunction with the local authorities for arresting the spread of 
the fever after it commenced, probably prevented an epiaemic of 
typhus like that which resulted from the Irish famine in 1847. Not- 
withstanding the great distress, it has been repeatedly stated that 
throughout the cotton districts of Lancashire there has not been a 
single death from starvation. 

*' It is a remarkable fact that Edinburgh, where typhus fever was 



rBACnOAL MBDICIHE» BTC. 85 

fbrmerly so preralent, has hitherto remained exempt from the present 
epidemic. lisst year, indeed, when the disease raged so furiously 
in London, we are informed by Dr. Christison that typhus had 
almost flattered the inhabitants of the northern capital with its ex- 
tinction. Dr. Christison thinks that typhus has of late years been 
wearing itself out at Edinburgh, and attributes the circumstance to 
a change in the constitutional type of epidemic diseases. But if this 
be so, how are we to account for the disease being so rife in London 
"while it is almost unknown in Edinburgh P Are we to suppose that 
the constitutional type of epidemic diseases is difi*erent in the two 
cities ? Surely it is more rational to refer the London epidemic to 
local causes, which have not been in operation at Edinburgh. 

" The rapid increase in the prevalence of typhus in London, oc- 
curring so early in the autumn, forebodes a serious amount of the 
disease in the coming winter. As a rule, typhus increases during 
the cold months, and does not reach its greatest intensity until 
early spring. The mote severe the winter, the more prevalent will 
the disease probably become. With the above facts before them, the 
physicians of the London Fever Hospital have opportunely addressed 
a communication to the Medical OflScer of the Privy Council, to 
which we especially invite attention. They point out the necessity 
for making provision for the isolation of the patients, and justly 
observe that to retain typhus patients in the dwellings of the 
poor, or to receive them into ordinary hospitals or into workhouses, 
under the same roof with other patients, is inevitably to extend 
and intensify the disease. We understand also that the Committee 
of Management of the Fever Hospital contemplate the erection of 
temporary wooden buildings for the accommodation of additional 
patients, and we earnestly trust that this proposal may be carried 
into execution without delay. If by such a measure the hospital 
succeed in arresting the progress of the epidemic in any district 
of the metropolis,. it will be entitled to the lasting gratitude of 
the community. Prompt isolation of the sick, however, although 
necessary, is not sufficient. Our Medical Officers of Health and 
local authorities must bestir themselves, to prevent the crowdipg of 
our poor population, and to enforce ventilation ; while a portion of 
that great stream of public liberality which has flowed so freely north- 
wards must be directed towards our London Poor." 



Aet. 14. — On the Disinfecting Treatment of Cholera, 

By Dr. Mackay. 

{Madras Quarterly Journal of Medicine, April 1863.) 

Dr. Mackay treated the three cases which are given below in the 
Hospital at Perambore, Madras. He also refers to the three other 
cases treated in the same establishment subsequently, and with the 
same satisfactory results. CoTimenting upon them, he says : — 

" We are aware that it would be absurd to draw any conclusions 
firom so small a number of cases, but it will be admitted that ^v0 



26 FSICTICAL MEDICINB, BTO. 

successive cures, at a time when the disease was prevalent and fatal, 
is encouraging ; and they are recorded in the nope of attracting 
attention to the disinfecting treatment of this disease, which, as far 
as we know, has not hitherto been fairly tried. We do not mean 
to say that calcis chlorinata is the best remedy to use, but 
it happened to be the only one of the class at hand. It is 
a powerful stimulant which may add to its efficacy, and it is 
remarkable how well it was retained in the above cases, whether 
given by the mouth or as an enema. Besides the remedies 
mentioned, the floor of the hospital ward and the patients* beds 
were frequently sprinkled with a solution of chloride of lime, thus 
keeping up a continuous exhalation of chlorine gas, which must 
have been inhaled by the patients. The surface of the patients' 
bodies was sponged with a tepid lotion composed of Norton's 
Deodorising Fluid. Chloride of lime was also put into the vessels 
in which the evacuations were received, these were at once carried 
away and their contents buried under ground. Whether ^ny of 
these measures have any beneficial influence on the patients there 
cannot be a doubt that they should never be neglected, with a view 
to preventing the spread of the disease. The disinfecting treatment 
has been found useful in typhus and enteric fever, and is surely 
worthy of a fair trial in cholera." 

Case I. Cholera Spasmodica : Cure. — Private Dalliah, sBt. 27 years, 
was admitted at 9 a.m. on the 15th November, 1862. Stated that he 
had been purged four times since 7 a.m. Hi8 pulse was good and his 
skin natural. A dose of chalk mixture with catechu and opium was 
given ; within half an hour after taking this, he had two loose motions, 
slightly coloured ; the medicine was repeated. At 11 A.M. he vomited, 
and again at 1 P.M., both times bringing up fluid not quite colourless. 
At 2 P.M. he had a watery colourless motion, after which he complained 
much of cramps in the legs. An enema was then given, composed of 
liquor calcis chlorinat. Dl xxx ; Aqua 5 ij> and repeated in half an hour. 
A draught was also given composed of liq. calcis chlorinat. ni xz; 
Aquae 5 ij ; and frictions with turpentine ordered to be used to the 
extremities. The enemas and draught were retained, and he had no return 
of vomiting or purging for three hours; but the cramps continued, pulse 
became weaker, and his voice sank. During the night he had several 
watery colourless motions, and vomited twice. Cramps continued. The 
enema was re])eated, the quantity of liq. calcis chlorinat. being increased 
to 3 j. His pulse became very low^ ammonia sesquicarb. in aqua camphora 
was ordered. The cramps now ceased, and did not return, and the patient 
gradually rallied. During tbe day of the 16th he passed three watery 
colourless motions, no urine ; but his pulse improved gradually, and he was 
able to retain some aiTow-root congee. A sinapism was applied to the loins 
in the evening. On the morning of the 17th he was reported to have had 
three watery motions of the same kind during the night. No urine ; pulse 
the same ; he was then ordered pot. chloras. gr. v ; acid, hydrochloric, dil. 
IR X ; camphor, gr. v ; to be given in water every two hours. He took 
five doses during the day^ passed a little urine (first at 9 a.m) and had three 
watery motions slightly tinged with bile. From this time he gradually im- 
proved. His recovery was tedious, but he had no return of the cholera 
symptoms. On the 2l8t he had a threatening of congestion of the lungs, 
which passed off under the use of counter-irritation, &c., and he suffered 



PXACnCAL MKDICOrS, STC. 87 

from debility for aoine time. He u natmallj a weakly man, and was not 
fit to return to his duty till the 14th of the following month. 

Cask II. Ckoleru Spasmodica: CWfV.— Private Sheik Mootooa, et. 27 
years, came to hospital on the 15th of November, 1862, at 1 P.M. Said 
he had been purged several times ; his pulse was good, and he was given 
chalk mixture with catechu and opium. During the next hour he 
was puiged three times — the first two motions were slightly coloured, 
the third like rice water, and he vomited once. At 2 p.m. an enema 
with liq. Caleb chlorinat. ia xxx. was given, and repeated in half an 
hour. These were both retained. At 3 p.m. he took a draught with 
liqr. calcis chlorinat. f\ xx. Up to 5 p.m. be bad no return of vomiting 
or purging, but complained of cramps, for which frictions of turpentine wwe 
used. Between 5 and 7 P.M. be bad three scanty motions, after which he 
became very restless, and pulse very weak, his face looked ghastly, aod voice 
sunk. An enema was given containing liq. calcis cblorioat. 5 ji <^d re- 
tained. During the night he took three duses of ammon. sesquicarU gr. ▼, 
in camphor mixture, and was able to rvtain some congee. On the morning 
of the I6th his pulse was hardly perceptible, but skin not quite cold : face 
and voice still sunk ; no urine ; n& return of vomiting or purging. The 
ammon. sesquicarb. was continued, and he was ordered to have as much 
congee or chicken broth as he would take. 

4 P.M. — Four motions since the momiog, watery, but slightly coloured ; 
no vomiting ; no urine ; no cramps ; pulse slightly improved. Ammon. 
sesquicarb. continued, and a sinapism applied to the loins. On the morn- 
ing of the 17th was reported to have had two motions during the night, 
watery and again colourless ; bad passed no urine : pulse not improved. 
The following mixture was ordered. Potass, chloratis gr. v ; acid, hydrochl. 
dil. Tti xxx ; camphor, gr. v ; in aquae 5 j i to be given every two hours. 
At 4 P.M. he had taken five doses of the mixture, bad had two watery 
coloured motions, retained some nourish men t» and passed a little urine (the 
first at 8 A.M.) His pulse was improved. In this case the secretion of 
urine was very slowly restored, and the patient had a tendency to coma. It 
was not till the morning of the 20th that urine was passed in any quantity 
under the use of diuretics, counter-irritation to the loins, and fomentations 
to the abdomen. From this time the patient rallied rapidly and was dis- 
charged on the 26th. 

Case III. Cholera Spasmodica: Cure, — Private Sheik Ismael, set. 84 
years, was admitted into hospital on the 17th November, 1862, at 11 a.m. 
Stated that he had been purged five times since 2 a.m., his pulse was 
pretty good, but he complained of cramps in the lower extremities and 
muscles of the chest. He was immediately given liq. calcis chlorinat. 
HI XX ; aquae 3 j. Up to 4 p.m. he had three watei^'colourkss motions, and 
also vomited fluid of the same appearance. He had taken three of the above- 
mentioned draughts. The cramps had been relieved by frictions with turpentine. 
His pulse was getting very weak, and voice sunk. The draughts were 
ordered to be continued, and an enema was given immediately, com- 
posed of liq. calcis chlorinat. 5j ; aquae 5. i^; ^^i* was retained for half 
an hour. 

During the night he took six doses of liq. calcis chlorinat. ; had five 
copious rice water evacuations. On the moining of the 18th, he passed 
some urine, his pulse was very weak, but the temperature of ihe skin good, 
and he had no more vomiting. He was now ordered ammon. hydroch. 
gr. V ; acid, nitro muriatic, dil. in, xv. ; aquae 5 isa* every three hours. The 
next motion was watery, but slightly coloured. From this time he gradually 
improved, and was discharged well on the 25tb. 



*28 PBACTIGAL HEDICINB, BTO. 

Aet. 15. — On the Treatment of Rheumatic Fever. 

By Dr. J. Birkbeck Nevins, Lecturer on Materia Medica, 

Royal Infirmary School of Medicine, Liverpool. 

(British Medical Joui*ncU, August, 1863.) 

In a paper read 24th June, 1863, at a meeting of the Lancashire 
and Chesnire Branch of the British Medical Association, Dr. Neyins 
Bays : — 

" The plan of treatment about to be laid before you is one for 
which I am not able to claim the credit of originality, but it is a 
method which I have adopted for above fifteen years both in private 
practice and in an union hospital containing above one hundred and 
fifty beds ; and I think that, if its advantages were more generally 
known, it would be more frequently practised. During this period 
I have made trial also of the various modes of treatment which have 
prominently occupied the attention of the profession ; viz., the opiate, 
the alkaline, the lemon-juice, and the do-nothing treatment; but I 
always return to my accustomed plan, with confidence rather in- 
creased than diminished by the comparison with others. At the 
same time, I am bound to confess that this treatment will come 
before you with one very serious defect, which it is vain now to 
attempt su])plying — viz., the absence of detailed clinical reports of 
the cases treated ; and I am unable, therefore, to say how many 
have been cured, or how many days have been required before the 

Eatients could walk about, how many before they could leave the 
ospital, or how many before they could go about their work as 
usual. Such phrases as * I feel very confident,' * I am thoroughly 
convinced,* and the like, are the nearest approach to accuracy now 
attainable ; and I am well aware how much this absence of exactness 
lessens the value of any conclusions respecting the result of treat- 
ment in such a disease as rheumatic fever. With these preliminary 
remarks, I will now proceed to the details of the method. 

It is impossible to observe many cases of rheumatic fever without 
being struck by the periodicity of the disease, as shown by the 
general aggravation of the pain and other symptoms as niaht comes 
on, and also by the copious sweating, which enfeebles the patient, 
rather than relieves him. The long continuance of the illness, and 
its liability to return after apparent recovery, and the length of time 
requisite for regaining strength, are also well-known features. In 
some of these particulars, but especially in its periodicnl exacerba- 
tions and in its sweatings, Heberden and others, and Dr. Davis of 
University College, in a very able paper on the subject, have at 
different times noted its similarity to ague, and advocated the em- 
ployment of cinchona or quinine for its cure ; and it is this drug 
upon which I look as the basis of the treatment to be proposed to 
you. At the same time, the experience of the profession generally 
nas shown the great value of iodide of potassium in chronic rheuma- 
tism; and, remembering the tendency of this disease to become 
chronic, I always combine this medicine with the quinine, and 
comrr^ence their administration from the earliest date at which the 



FBACTICAL MEDICINE, ETC. 29 

patient comes under my care. The presence of acute pain and high 
febrile excitement does not, in my experience, form any objection to 
their employment ; and the thick creamy fur upon the tongue disap* 
pears more rapidly under their use than under the diiTerent methods 
which I have compared with it, either in my own practice, or when 
noticing that of my brethren in the profession. The dose never 
exceeds two grains of quinine four times a day, with five grains of 
iodide of potassium added to each dose. 

"The pain and loss of rest are, however, so distressing to the 
patient, that we have been advised to administer opium in quantities 
only limited by the effect produced. And the employment of this 
drug as far as may be necessary for subduing the pain is a very im- 
portant point ; and I therefore always leave two or three doses of 
opium pill or of Dover's powder with the nurse, which are to be 
given successively, if the patient is in severe pain ; but I very rarely 
indeed £nd that the patient has even asked for more than a single 
dose in the twenty-four hours, which I attribute to the speedy 
and more permanent relief obtained by the following element of the 
treatment, to which I attach very great importance. This is, the 
employment from the very first of steam-haths^ even when the patient 
is so helpless that it is impossible to move him from the bed on which 
he is lying. These steam baths relieve the pain and check the dis- 
tressing perspirations in a degree which I have failed to obtain by 
any other mode of treatment ; and they are administered with the 
greatest ease in the following manner. 

" A couple of common red bricks are to be placed in an oven hot 
enough for bakinj? bread, and in half an hour or little more they are 
suflSciently heated for the purpose. The patient's body -linen having 
been previously removed, these two bricks are to be folded up in a 
piece of common thick flannel thoroughly soaked in vinegar and laid 
upon two plates ; and one is to be placed about a foot distant from 
one shoulder, and the other about equally distant from the opposite 
leg ;* and the bed-clothes are then to cover the bricks ana the 
patient closely round his neck. A most refreshing acid steam bath 
IS thus obtained ; and the supply of steam may be kept up, if 
necessary, by removing one brick and replacing it with another 
hot one kept in reserve. When the patient has been in the bath for 
about fifteen or twenty minutes, the bedclothes and plates should 
be removed, and the patient instardly mopped all over very rapidly 
with a towel wrung out of cold water, and then should be quickly 
rubbed dry.f Dry warm linen must be put on at once, and dry bed- 
clothes must replace those which were on the bed previously. The 

* Care must be taken not to put the bricks too near the body. I have 
known the thigh blistered in a patient who was unable to move away from 
the heat which was accidentally very near it. A dry napkin thrown over 
the wetted one will prevent this accident, if the bed is* too narrow to allow 
sufficient space. 

t The under sheet can be removed, aud a dry one substitnted by fastening 
the comers of the dry sheet to those of the damp one. Very little difficulty 
is generally met with in simply drawing the old sheet from under the patient, 
when the dry one follows it, and is left in its place. 



30 PBACTICAL MEDICINE, ETC. 

?atient generally experiences great and speedy relief from this bath, 
^he exhausting acid sweats are materially diminished ; and the 
necessity for opium, as already mentioned, is almost at an end. 

"But here the objection naturally presents itself; a patient in 
rheumatic fever suffers so severely from the slightest attempt to move 
him, that we are frequently obliged to leave him several days 
without changing his linen, from the pain occasioned by the attempt 
to remove it even leisurely ; and we have just been told to change it 
quickly, which implies that the case cannot be a very severe one, or 
this direction could not be carried out. The difficulty is really 
of the most trifling character, if the simple precaution is adopted 
of tearing the nightshirt open from top to bottom down the back. 
The sleeves are then slipped over the patient's arms almost without 
moving them; and the torn edges of the linen are gently tucked 
under his sides, from which they can be just as easily withdrawn 
the next day. And by this means he is freed from the discomfort 
of lying day after day in linen soaked with acid perspiration ; and 
this is done without the smallest pain to himself or trouble to his 
nurse. For many years 1 used large lumps of quick lime, and 
"wrapped them up in cloths soaked with cold water ; and, as soon as 
the lime began to slack, the patient was enveloped in a steam bath 
from simple water ; but in many places it is difficult to obtain quick 
lime, and the vinegar is also more refreshing to the patient ; so that 
the vinegar and hot bricks have now quite superseded the lime-bath. 

" These, then, are the essentials of the treatment : quinine and 
iodide of potassium from the first, and the steam hath, with the sub- 
sequent cold sponging ; and, as an adjunct, opium in small doses, 
when necessary to procure sleep. 

" It now remains to speak about the success of the treatment. 
During the fifteen years it has been in use, I have only had occasion 
to apply a blister over the heart in three instances ; and this was 
done because the patient complained of uneasiness in the chest, 
not because there was any distinct evidence of pericarditis. There 
has not been one case of distinct rheumatic affection of the heart ; 
but the absence of clinical reports puts it out of my power to state 
how many cases have been thus treated. I can merely say that they 
have been numerous. 

Next, as regards the duration of the disease : it is extremely rare 
that it is necessary to give two steam-baths in bed, the patient being 
almost always able to have the second whilst sitting upon a chair ; 
from which you will draw your own conclusion as to the rapidity of 
improvement. I am surprised when the patient is not able to walk 
about the room, a little at any rate, in little more than a week ; and 
I have a strong impression that he is more frequently able to do this 
within the week than not. But, here, again, the absence of exact 
reports must be taken into account. I further think that from two 
to three weeks is the average duration of the case before the patient 
is able to walk up and down stairs and to go out of doors for exer- 
cise or pleasure. Itelapses are not common ; and the patient has not 
the lingering convalescence which I have observed under other 
methods of treatment. 



PRACTICAL MEDICINE, ETC. 31 

''The steam-baths and subsequent cold douche should be con- 
tinued after the patient is able to walk about, as they contribute to 
the healthy action of the skin, and promote the free mobility of the 
joints * 

** If there is great tenderness of any one particular joint, the opiate 
embrocation, containing in addition either chloroform or tincture of 
aconite, should be gently painted over the part two or three times a 
day ; but, in the early stage, the employment of friction appears 
nnadvisable whilst the pain is very acute. 

** The recommendations of the method now presented to you are : 
that the patient's strength is husbanded from the first, and he has 
neither the protracted disease nor the lingering convalescence often 
observed, tain and sweating are more quickly relieved than by 
any other treatment I have seen. Relapses are very rare ; and so 
far I have not seen any case of cardiac afiection occurring as a con- 
sequence of the rheumatism. I have a strong conviction that, if the 
method is fairly used in two or three cases, it will leave the same 
favourable impression upon the minds of those who try it that it has 
produced upon my own, and upon the students who have watched 
its employment in the hospital to which I have alluded." 



Art. 16. — Statistics of the Treatment of Rheumatic Fever, 

By Dr. T. King Chambeks, Physician to St. Mary's 

Hospital, &c. 

(British Medical Journal^ August, 1863.) 

In a short communication read at one of the recent meetings of 
the British Medical Association at Bristol, Dr. Chambers says : — 
" Since May 1851, 1 have had under my care at St. Mary's Hos- 
pital 243 cases of rheumatic fever. Of these, 

26 were treated with 5J of nitrate of potash three times a day ; 
174 with bicarbonate of potash ; viz., 

141 with 3j or more every two hours ; 
33 with less quantities or less often ; 
32 (during the first year) in various other indeterminate ways ; 

* These baths are very easily given, by placing the patient naked upon a 
chair, and putting a can containing a couple of gallons of boiling water under 
it. Blankets are then to be folded round his neck, and made to surround 
him like a tent, reaching to the floor. In about five or ten minutes, a red 
hot brick should be put into the can, which renews the supply of steam. 
The patient soon perspires ; and in fifteen or twenty minutes the blankets 
should be removed, and a couple of quarts of cold water should be poured 
over bis shoulders ; or, if he is afraid of sucb heroic treatment, he should be 
mopped from head to foot with towels wrung out of cold water. By this 
means be is invigorated instead of feeling weakened, and depressing per- 
spirations do not follow the bath. The patient should sit upon a pillow or 
doubled blanket, on a close- bottomed chair, not upon an open cane-bottomed 
one. I have known a patient scalded by the accidental neglect of this 
precaution. 



32 PBACTICAL MEDICINE, BTO. 

" To the last 11— that is, to all since May last — no special drufffil 
have been given, only a little opium when the pain was very 
bad. 

" No selection of cases was made. 

" 1. Results on the duration of the Illness, 

"Of those treated with nitrate of potash, the mean stay 

in hospital was 40'0 days 

Of those treated with 3j bihoral doses of bicarbonate 

of potash 34-3 days 

Of those treated with less quantity of the same . 400 days 

Of those treated without drugs . . . . . 30*0 days 
** If we exclude the last class, the number of which (11) is too 
small for statistical deductions, it would seem that, though smaller 
doses have no effect, yet that full doses of the bicarbonate of potash 
have some influence in shortening the duration of the illness, from 
the time of commencing it to that of the patient being sufficiently 
convalescent to leave the house with safety. 

" I may remark here that any other measure of the duration of 
the disease is quite untrustworthy for statistical purposes. The 
different degrees of susceptibility to pain exhibited by different 
patients, the desire of some to extenuate, of others to exaggerate 
their sufferings, renders it impossible to register truly even the 
exact day when the pain ceases : whereas, in such a short period .'as 
they last after the commencement of treatment (viz., two or three 
days), the exact hour would require to be noted. It is equally im- 
possible to decide when, or even whether, the swelling or redness is 
all gone. Those who have set clinical clerks to observe these facts, 
know how little the case books are to be relied upon. 

** 2. Results on the Consequences of the Illness, 

" In respect of their several preservative powers against the con- 
sequences of rheumatic fever, I find that — 

" Of the 26 treated with nitrate of potash, there were attacked with 
inflammation of the heart while under treatment (carefully excluding 
all those admitted with it already existing) five, or 19*2 per cent. ; 
four having pericarditis, and one endocarditis only. Four have 
died ; two of inflammation of the heart, and two of sloughing back. 

" Of the 174 treated with bicarbonate of potash, there were 
attacked with inflammation of the heart nine, or only 5.3 per cent.; 
and none have died. 

" It would seem from this, at first sight, as if bicarbonate of pot- 
ash had some preservative force. But the fact is, that nearly all of 
those treated ty the alkaline method have been subjected also to 
what both rational physiology and the subjoined statistics seem to 
show has a much more powerful influence than any drug in keeping 
the heart from inflammation. I refer to blanketing the patients. 

** Up to May 1855, no difference was made in the bedding of my 
patients with rheumatic fever from that of others in the ward : but 
after that date they were ordered to be enveloped in blankets, and 



PBACTICAL UEDICINB, XTC. 33 

no linen was allowed to touch the skin. In nearly erery case the 
orders were strictly obeyed. 

" Of 63, either bedded in sheets, or who had toil fully thrown off 
titeir blankets, six contracted newly pericarditis at least, if not endo- 
carditis as well ; three had a relapse of pericarditis on old cardiac 
disease ; one bad endocarditis alone ; nearly 16 per cent, had in- 
flammation of the heart ; and four died. 

" Of 180 in blankets, none contracted pericarditis ; none died ; one 
had a relapse of pericarditis on old cardiac disease ; five had endo- 
carditis alone (in one of these cases of endocarditis it was brought 
on daring convalescence by the patient being dowsed with cold 
water for an accidental hysteric fit) ; one a relapse of endocarditis 
on old cardiac disease. 

** Not 4 per cent, have had inflammation of the heart. When it 
came, it was of a milder character, and was generally to be accounted 
for by some imprudent exposure. That is to say, that bedding in 
blankets reduces from sixteen to four, or by a good three-quarters, the 
risk run by patients in rheumatic fever ** 



Art. 17. — Report of the Trial of Sarracenia Turj^urea^ or 
Pitcher Plant J in Small-^ox, 

By Mr. J. F. Marson, Surgeon to the Small- pox and 
Vaccination Hospital, London. 

^ (Lancet, July 4, 1863.) 

A communication, seemingly of great promise, from Mr. Chalmers 
Miles, of the Eoyal Artillery, was read some time since at a meeting 
of the Epidemiological Society on the use of sarracenia purpurea 
in small-pox. The specimens of the plant which accompanied the 
paper were submitted for trial at the Small-pox Hospital, the root 
oeing the part of the plant particularly recommended for use. Mr. 
Marson proceeds :— 

" The root was said to be the part of the plant that, when made 
into a decoction, afforded the best form of giving the medicine. 
There was about enough for three persons only in the canister 
transmitted by Mr. Miles to this country from Kova Scotia, and 
given to me. I had therefore to make up my mind what were the 
most desirable cases of small-pox in which to test its efficacy. I 
fixed on, first, a malignant case — one of those attended with haemor- 
rhage from the mucous surfaces ; second, a severely confluent case, 
such as my experience has taught me usually dies, owing to the 
great amount of eruption ; and third, if possible, a corymbose case, 
one of those rather rare and nearly always fatal cases of small-pox. 

" To give the remedy a fair trial, it was necessary to have the 
case on which to try it in the early stage of the disease, during the 
first few days of eruption. There was but little small-pox in London 
at the time the plant was first submitted to me for trial, and, although 
I was on the watch for such cEises as I have mentioned, several 
months elapsed before I had a suitable opportunity of trying tho 

XZXYIII. 3 



34 PBACTIOAL MEDICIKB, ETC. 

efficacy of the alleged remedy. Of course I wished to meet with 
the cases I had fixed on free from any suspicion of their having 
been vaccinated. This was absolutely necessary, because vaccina- 
tion has a great influence in modifying what may be called the 
normal course of small-pox. After several disappointments, unne- 
cessary further to detail, small -pox became epidemic in the autumn 
of last year, and the opportunities of trying the sarracenia became 
numerous. About the same time Mr. Miles returned to this 
country, and he was good enough to write to me and place at my 
disposal any amount of the sarracenia I might require, to be for- 
warded through the agency of Messrs. Savory and Moore. 

" I tried the decoction of sarracenia made from the root, by sim- 
mering an ounce in a pint and a half of water for four hours, until 
reduced to a pint ; and a quarter part was usually given for a dose 
twice a day, for two days or more. I also gave, in some cases, the 
liquor sarracenise supplied by the same firm. In all fifteen patients 
have been treated with the sarracenia, selected for their severity, as 
I have described — such cases as I believed would not get well under 
ordinary treatment. They have all died. 

" The cases were selected on admission in the early stage of the 
disease on account of the severe symptoms manifested, and because 
I felt it was of no use to try the efficacy of the sarracenia on mild 
cases or vaccinated cases, which I knew very well would recover 
without anything being done for them beyond the exhibition of 
ordinary care, the giving of salines if required, occasional aperients, 
suitable diet, &c. 

" I cannot say that the sarracenia had any effect whatever. It 
did not save life ; it did not modify in the least the eruption of small- 
pox ; it did not influence any of the secretions ; it did not increase 
the secretion of urine ; in only one instance did it seem to act on the 
bowels, and this seeming effect might easily have been from other 
causes. The particulars of the fifteen cases taken daily at the time 
of the trial of the sarracenia are appended to the report. 

" Two cases have been admitted into the hospital that had taken 
a decoction of the leaves aud stems of the sarracenia before admis- 
sion. The first, a very mild case, having four vaccine cicatrices, 
was highly modified, I believe, by the vaccination. The second case 
was confluent, was without vaccination, not severely confluent, and 
was wholly unmodified. They both recovered. The recovery, 
might, perhaps, by some be attributed to the sarracenia, but I believe 
it had nothing to do with it. The vaccinated case was, as I have 
said, very mild — due, I believe, to the vaccination. As to the second 
case, about half our confluent unvaccinated cases recover with ordi- 
nary treatment. 

'* In conclusion, I may state that had I found the sarracenia do 
any good, I should have taken an earlier opportunity of reporting 
the fact to the profession. As it failed, I thought it well to defer 
this report, that others might, without bias, try the plant during the 
present epidemic of small-pox, and favour us with their opinion of 
ita reputed power of controlling the course of the disease in its 
severe forms." 



FBACTICAL MBDICINB, ETC. 85 

Cases of Smallpox treated with Sarracenia (1862). 

1. Margaret C , 18 years of age ; small-pox, coDflaent, with manor- 

rbagia ; un vaccinated. Was admitted into the Small-pox Hospital, October 
8, 1862 ; fourth day of illness, second of eruption. Took a quarter of a 
pint of the decoction of sarracenia at one o'clock at night, October Sth, and 
a quarter of a pint, in two doses, the following day. She would not after- 
wards take any more, and died Oct. 12th. 

2. Mary Ann B , 11 years; small-pox, malignant; unvaccinated. 

Admitted Oct. 22nd ; fourth day of illness, second of eruption. Took two 
onnces of the decoction of sarracenia, made from that sent by Messrs. 
Butler and McCulloch, every six hours, until the pint was consumed, 
beginning on the day of admission. Died Oct. 25th, in the evening, seventh 
day of illness, fifth of eruption. 

8. John M , 11 years; small-pox, confluent; unvaccinated. Ad- 
mitted Oct. 22nd ; fifth day of illness, second of eruption. Took the same 
evening two ounces of the decoction of sarra«enia (Butler and McCulloch), 
and continued it every six hours until the pint was consumed. Died Oct. 
28th, eleventh day of illness, eighth of eruption. 

4. Elias H. F , 48 years, a machinist from Massachusetts ; small-pox, 

confluent ; unvaccinated. Admitted Nov. 6th ; eighth day of illness, fifth 
of eruption. Took the decoction of sarracenia, that sent by Mr. Miles, in 
quarter-pint doses, beginning the day of admission, twice the following day, 
and one dose the succeeding day. Died Nov. 13th, fifteenth day of illness, 
and twelfth of eruption. 

5. John H , 18 years, baker; small-pox, confluent; unvaccinated. 

Admitted Nov. 18th ; fifth day of illness, second of eruption. Began the 
decoction of sarracenia the following day; took two quarter- pints one day, 
and two quarter- pints the following day. Died Nov. 25th, twelfth day of 
illness, ninth of eruption. 

6. George D , 25 years, labourer; small-pox, confluent; unvaccinated. 

Admitted Dec. 2nd ; fifth day of illness, third of eruption. Began the 
decoction of sarracenia same day ; took one quarter-pint dose, two doses 
the following day, and one the next. Died Dec. 10th, thirteenth day of 
illness, eleventh of eruption. 

7. William B , 17, baker; small- pox, confluent; unvaccinated. Ad- 
mitted Dec. 8rd ; fifth day of illness, second of eruption. Began the decoc- 
tion of sarracenia next day ; took two quarter-pint doses, and the remainder 
the following day. Died Dec. 20th, twenty-second day of illness, and nine- 
teenth of eruption. 

8. Charles B , aged 19, footman ; small-pox, confluent; unvaccinated. 

Admitted Dec. 11th ; fourth day of illness, second of eruption. Began the 
decoction of sarracenia Dec. 12th, and took the pint on that and following 
day ; continued it through another pint, and died on Dec. 21st, fourteenth 
day of illness, and twelfth of eruption. 

9. John J , aged 25, draper's assistant ; small- pox, confluent ; vac- 
cinated in South Wales in infancy ; no cicatrix. Admitted Dec. 11th ; 
seventh day of illness, fifth of eruption. Began the decoction of sarracenia 
the following day ; took the pint during the two days, Dec. 12th and 13th, 
and continued it through another pint. Died Dec. 15th, eleventh day of 
illness, ninth of eruption. 

10. John Z , aged 33, confectioner ; small-pox, confluent ; vacci- 
nated near Como; one indifferent cicatrix. Admitted Dec. 11th, second 
day of eruption. Began the decoction of sarracenia Dec. 14th, and con- 
tinued it to a double dose, two pints. Died Dec. 18 th, eleventh day of 
illness, ninth of eruption. 

3—3 



36 FBACTICAL MEDICISTE, ETC. 

11. James H , aged 21, labourer; small-pox, confluent; un vacci- 
nated. Admitted Dec. 19th ; sixth day of illness, fourth of eruption. 
Began decoction of sarracenia same day. Died Dec. 28th, fifteenth day of 
illness, thirteenth of eruption. 

12. Thos. U. J , aged 22, draper's assistant ; small-pox, confluent ; 

unvaccinated (cut twice for cow-pox in Essex without effect). Admitted 
Jan. 19th, 1863 ; eighth day of illness, sixth of eruption. Began on the 
day of admission, one drachm of liquor sarracenise every four or five hoars 
— one drachm being stated to be a full dose ; took three bottles, in all an 
ounce and a half, of the liquor sarracenise ; no efiect. Died Jan. 24th ; 
thirteenth day of illness, eleventh of eruption. 

13. Ann O , aged 30, barmaid ; small-pox, confluent, hsemoirhagic ; 

vaccinated at Lymington, two indifferent cicatrices. Admitted Jan. 24th ; 
fifth day of illness, third of eruption. Began the following day with one 
drachm of liquor sarracinsB every four or five hours; took an ounce and a 
half of the liquor ; no effect. Died Jan. 28th, being the ninth day of ill- 
ness, and seventh of eruption. • 

14. Thos. C , aged 35, stone sawyer; small-pox, confluent; unvac- 
cinated. Admitted Jan. 3l8t, 1863 ; eighth day of illness, sixth of eruption. 
Began with the liquor sarracenise on the day of admission ; one drachm for 
a dose every five or six hours ; took six drachms. Died Feb. 6th. 

16. James U , aged 39, labourer ; small-pox, confluent ; unvacci- 
nated. Admitted Jan. 31st ; sixth day of illness, fourth of eruption. 
Began liquor sarracenise same day ; took six drachms. Died Feb. 6th. 



Art. 18. — Are Scarlet Fever and Measles Distinct Diseases? 

By Dr. Wilks, Assistant Physician to Gny*s Hospital, and 

Physician to the Royal Infirmary for Children. 

{Medical Times and Gazette^ Jan. 31, 1863.) 

In some clinical notes on Scarlet Fever, delivered not long ago 
at the Royal Infirmary for Children, Dr. Wilks says, enforcing 
what he says by the narration of certain cases : — 

" At one period in medical history the two affections were con- 
founded, but since that time a very broad line of distinction has 
always been made between them, and, as a rule, no difiQculty exists 
in their separation. Every medical man must, however, at times 
have been puzzled in his attempt to declare to which exanthem the 
particular case belonged ; the difficulty arising from the apparent 
mixture of the two diseases, rather than from the mere mildness of 
the case, although this constitutes a difficulty of another kind ; for 
those who have witnessed an exanthem in a public school must know 
how differently children are affected, and how, in several cases, un- 
less from a knowledge of the existence of the disease in the insti- 
tution, they would scarcely have recognised the true character of 
the affection. 

" We now allude rather to cases where the patient is very ill, and 
the symptoms well marked, but partaking of characters belonging 
to both scarlatina and measles, so that it is with difficulty a de- 
cision can be arrived at concerning the true nature of the illness, 
A. question, therefore, has often arisen whether Sydenham did right 



PBACTIOAL MBDICUTB, BTa 37 

in drawing so distinct a line between the two affections — whether, 
indeed, they be not modifications of one another, or whether they 
may not be often combined. Some have thought, and such theory 
is held by many Grerman writers, that the disease which constitutes 
the difficulty, and which is apparently made up of scarlatina and 
measles, is, m fact, a third affection of an altogether distinct character, 
-and that three exanthemata should be recognised — scarlatina, mor- 
billi or measles, and rubeola, the latter being the name given to the 
affection of which we are now speaking. 

" The method to be taken in forming a conclusion would be pro- 
bably of the same kind aa that adopted with respect to the contro- 
verted theory of the distinctions of continued fevers — that if be- 
longing to the same species one would propagate the other, and the 
two would be found associated ; but if belonging to different species, 
each would produce its like, and very distinctive characters would 
be preserved to them. So if it be found that the exanthemata of 
which we are speaking are found variously intermixed, occurring in 
all forms in the same localities or the same houses, it would be a 
strong argument in favour of their identity. If, on the other hand, 
they are found distinct, it would be almost a proof that they had a 
nature sui generis ; and this, we think, wiU be found to be the case 
with respect to these diseases. Measles or morbilli is one form of 
disease, and scarlatina another; whereas in all probability, the 
rubeola is a third affection, distinct from both, and thus explaining 
the difficulty arising from the apparent combination of the two, and 
explaining also the fact of the re-occurrence of measles or 
scarlatina. 

" Dr. Copeland states that some authors believe rubeola to be a 
specific contagious disease. Some consider it a variety of one or 
other of the diseases which it so closely resembles — of either measles 
or scarlatina. Some consider it a variety of scarlatina, others allied 
to measles, and others that there is no essential difference between 
measles, scarlatina, and rubeola. According to this, rubeola should 
be regarded as the connecting link between measles and scarlatina : 
and Dt, Copeland himself rather thinks that it is a combination of 
both, and not a disease sui generis, 

** The disease of which we speak may be characterised, in short, 
as an affection having the eruption of measles, with the throat of 
scarlatina. Our own attention v* as drawn to the subject many years 
ago, when attached to the Surrey Dispensary, and a difficulty 
occurred to us long before we knew that any similar trouble had been 
met with by others ; as for example, on visiting a child, and finding 
its skin covered with a measly rash, and, at the same time, a cough 
existing, with wheezing, coryza, and the general aspect of measles, 
we were just on the pomt of pronouncing the case to be measles, 
when the neck was observed to be swollen, and, on looking at the 
throat, it was seen to be injected, and the soft palate tumid, as in 
scarlatina. Always having been in the habit of regarding the throat 
affection as the most important feature of such a case, we changed 
our diagnosis to one of scarlatina, but then were rather annoyed to 
hear that the child had already had this latter disease, which was 



38 FBACTICAL MEDICINE, ETC. 

described ia such an unmistakable way that there could be no doubt 
of the fact. The same diflSculty has since often occurred ; also the 
statement that children have had measles and scarlatina twice : as 
well as the announcement which one is obliged constantly to hear, 
of one disease rapidly following the other, as only lately, where we 
were told of the case of a child who was said to have had scarlatina 
before the rash of measles had entirely disappeared,— a most un- 
likely circumstance. 

" At the Infirmary for Children, our experience being gained 
mostly from the out-patients, an opportunity for seeing the diseases 
at their heiglit is not so great as tor witnessing its effects or the 
sequelae; but in these we can every day see that the subject of 
which we speak requires further elucidation ; for example, in the 
following cases : — 

Case 1. — A child, 2 years old, was brought to the Infirmary with dis- 
charge from the ears, and enlarged glands in the neck. On making in- 
quiries as to scarlatina, the mother stated that, four weeks before, the child 
had a fever, but which the doctor said was measles. Was it not rather 
this third disorder, the apparent combination of the two, or rubeola ? 

Case 2. — A child, 8 years old, came to the Infirmary with renal dropsy ; 
the mother said that a month before she was covered with a rash, like that 
of measles, and she had a cough ; but, at the same time, the neck was 
much swollen, and the throat was sore. Soon afterwards the skin desqua- 
mated. Was this merely a mistaken diagnosis, or was it a case of rubeola t 

Case 3. — A boy, ajred 5, was brought to the Infirmary, with large 
suppurating glands in the neck, just as seen after scarlet fever. On making 
inquiries as to the occurence of this disease, the mother said that a month 
before the child had what was called measles. There was a cough, and 
a running from the nose and eyes. The mother said that the child had had 
measles before, and this was the second attack. 

Case 4. — A girl, aged 5. Nine days before she was taken with a 
cough and cold, followed by rash, which both the Doctor and the mother 
considered to be measles. In a day or two there was great swelling of the 
throat. When she appeared at the Infirmary, there was no desquamation 
of the skin ; but the neck was very much swollen, just as after scarlet 
fever, and there was some brouchitis, and in a few days there was discharge 
from the left ear. The case showed an apparent combination of the two. 
Was it not rather an instance of a third disease ? 

Case 5. — A girl, aged 4, came to the Infirmary very ill, wasted^ skin harsh, 
mouth aphthous, and lymphatic glands in neck much enlarged. There was 
ulceration of the gums of the lower jaw, and a portion of the alveolar 
process was exposed. This was subsequently removed, and the two incisors 
of the lower jaw fell out. The whole history suggested scarlet fever, but 
the mother said that the child had had measles three weeks before, and 
that one child in the house had died of it. 

" Alihoufrli most medical men would consider it an insult to sup- 
pose that they were unable to recognise a case of scarlatina or 
measles, yet the relationship of these two diseases remains in such 
obscurity, that we would suggest that some unprejudiced person, 
with a large field of experience, should commence the study of the 
exanthemata in children de novo.** 



PBACTICAL MEDICISTB, BTC. 



39 



Art. 19. — I^r. Jennet on Impedimenta to Successful 
Vaccination. 

By Dr. . 

{Lancet, October 31, 1863.) 

Just at this time, while the question of vaccination and its im- 
'pediments and the duration of its protective power are of the 
nighest interest, and ought if possible to be settled by exact obser- 
vation, the statistical results of Yaccination and Eevaccination in 
the Army just issued in Dr. Balfour's report have considerable 
Talue. They afford information supplementary to that obtained in 
the course of the recent Privy Council inquiry. During the year 
1861, in an average force of 88,955 men, there were fifty -one cases 
of small-pox reported, of which four were fatal. They are all stated 
to have occurred in men bearing marks of vaccination. The following 
table shows the results of vaccination during the year in those re- 
spectively who bore marks of previous small-pox, who bore good 
marks of previous vaccination, who bore doubtful marks, or oore 
none at all: — 





« 




li 


^1 


II 


lit 

111 




CUu, 


n 


Ri!£Ult!9. 


li 


If 


ill 


Total. 








1'^ 


5 


tH 


a 




SoMl«f*,\ 




' A perfect vaceine pti^taie 


4&\*A 


4S4'e 


23«B 


338' 


430 'fl 


i^t r 


W53 


' A modified ditto 


i&B^a 


157 "4 


€05 -a 


377-5 


31S-7 


BeOTQlttJ 




Afttilure hi ,.......,.,.,.. 


389- 


35B- 


2G7-fl 


30fl-fi 


350 -7 ' 


Tottti „. J 


lOOO* 
345 'G 


407-3 


1000- 


1000' 1 
627*3 


IQOO- 
41fi'6 


{ A perfect T4cdne pusttde 


Becmita 


m^ 


] A TOodifted ditto ..„..„. 


266 S 
387-7 


210 'fl 


301 3 
237-4 


203 
370-1 


2^ G 
3^43 ■ 


A tbilure La .*....,.,....., 


Tptji! ......... 


1000- 


1000' 


1000' 


1000' 


ItXXl" 



In connexion with these figures, which suggest some singidar 
doubts as to vaccination and vaccinators, we insert the following 
unpublished letter by Jenner, the illustrious author of vaccination, 
on the impediments to its successful practice. Very few persona 
have seen the letter, and it is certainly of curious interest : — 



40 pajlctical medicine, etc. 

''Berkeley, Dea 4th, 1817. 

** Sir, — ^I was absent from home when your obliging letter of the 
24th of November arrived ; but I do not think that this is likely to 
occur again for some time, and shall, therefore, be very happy to 
take your little family under my care at the time you mention — the 
latter end of January. 

" Our arrangements must be carefully made, as the children must 
be met here by proper subjects for transferring the vaccine lymph ; 
for on the accuracy of this part of the process much depends. It 
may be necessary to observe also, that amongst the greatest impedi- 
ments to vaccination (indeed the greatest) is an eruptive state of the 
skin on the child intended to receive the infection. 

" On this subject I wrote a paper so long ago as 1804,* and took 
much pains to circulate it; but 1 am sorry to say that the attention 
that has been paid to it by the Faculty in general has been by no 
means equal to its importance. This is a rock on which vaccination 
has been often wrecked ; but there is no excuse, as it was so clearly 
laid down in the chart. 

" I am, Sir, your obedient and very humble servant, 

" Edw. Jenneb. 
**To W. J. Denby, Esq., St. James's- square, London." 

We are indebted for this interesting document to Dr. Diamond, 
of Twickenham House, whose erudition and literary tastes are well 
known. 



Art. 20. — A Fatal Case of Varicella. 

By Dr. Frederick J. Brown, of Kochester. 
{British Medical Journal, Oct. 17, 1863.) 

Case. — William D. H , aged 3| years, was first seen by me on 

August 80th, 1862. He had been ill about five days with chicken-pox. 
The vesicles were desiccating ; but there were two apertures in the skin of 
the back, as if portions had been punched out, resembling the perforating 
ulcer of the stomach. One aperture was equal in size to a groat ; the other 
was rather smaller. There was induration and livid redness of the skin of 
the back, in a diffuse form, constituting erysipelas. The child was suffering 
from irritative fever. I ascertained that the urine was passed in bed, because 
the child dreaded to be lifted out. The course of the erysipelas was to affect 
the whole of the abdominal wall. Peritoneal effusion took place, with 
diarrhcea ; and the child died on September 10th. 

The death-certificate was as follows : — Varicella, 17 days; erysipelas, 12 
days ; peritonitis, 4 days. 

The treatment consisted of the application of nitrate of silver dissolved in 
Bweet spirits of nitre (gr. v to 5 j) to the erysipelatous skin, and of zinc 
ointment to the ulcerated apertures. Quinine was administered internally. 
Very little nourishment was taken by the child, although beef-tea and wine 
were ordei*ed. 

I have brought this case forward, because it is the only fatal case of 
varicella that I have ever seen. I once saw an ulcer in the abdominal wall 

* This paper was published in the Medical and Physical Journal for 
August, 1804. 



PBJLCTICAL MBDICIKE, ETC. 41 

equal in size to a balfpeoDy, in a qaadroon child ; but it was not a punched- 
out ulcer. That child recovered. 

In the case under consideration, it is probable that the wetting of the skin 
by uriue may have determined the fatal event. 

I do not know whether perforating ulcers have been ever observed before, 
either as an occasional occurrence in the scabbing stage of varicella, or as an 
event in the course of low forms of erysipelas. It was not a case of ordinary 
sloughing. There was no appearance of gangrene. 

The sanitary condition of the house was bad. The privy was close to the 
house, and waste water was permitted to run into the privy, so causing 
agitation and dilution of the night-soil, from which evaporation would be 
constantly going on. The child occupied the basement story, and was 
lying within a few yards of the privy. Another child was suffering from 
deep ulceration of the gum and cheek ; and a week or two after the death 
of the child whose case has been narrated, there were two children ill with 
swelling of the glands below the ear, accompanied by pallid countenance 
and feverishness. These circumstances are evidence of defective sanitary 
condition, and show that the family was suffering from blood-poisoning. 



Art. 21. — On the Treatment of Malarious Fever hy the 
Subcutaneous Injection of (Quinine. 

By Mr. W. J. Moore, Bombay Medical Service. 
{Laihcety August 1, 1868.) 

In a short article on this subject, Mr. Moore says : — 

** T have employed this mode of treatment in upwards of thirty 
cases of intermittent fever, and in several cases of remittent, and 
with almost invariable success, the former class seldom requiring a 
second application, the latter generally subsiding after the fifth or 
sixth injection. Since the period I commenced to use quinine in 
this manner I have been surprised and pleased to find in one of the 
medical periodicals that the same plan has been pursued by Dr. 
Chasseaud, of Smyrna, who reports 150 cures, and especially recom- 
mends the system in fever complicated with gastric symptoms, when 
the exhibition of quinine by the mouth is often ' inefficient, difficult, 
and hazardous.' 

" I use the strongest solution of quinine wHich can be prepared — 
viz., thirty grains of quinine, eight or ten drops of dilute sulphuric 
acid, and half an ounce of water. Of this I inject from half a drachm 
to a drachm, the former quantity containing some four grains of the 
active agent. With the exception of a little sulphate of soda if the 
bowels are confined, I use no other remedies whatever in uncom- 
plicated cases of any type of malarious fever. When the spleen is 
enlarged, or if a leucocythemic condition is present, I prescribe, as 
an additional curative agent, one or other of the preparations of iron 
— very frequently the citrate of iron and quinine. 

*'I generally inject beneath the skin over the outer belly of the 
triceps extensor muscle, and sometimes over the deltoid. I have, 
however, used the syringe with equal effect on the thigh and calf, 
and in cases of enlarged spleen have thought the action of the remedy 
increased by injecting over that organ. I use a small glass syringe 



42 PBAOTICAL MEDICISTB, ETC. 

with the screw action, and furnished with a sharp silver point some 
half an inch in length. The latter is introduced beneath the in- 
tegument half an inch or less, and the pain is not greater than the 
pnck of a pin. Indeed, patients have frequently declared thejr would 
rather submit to this process than taste the bitter of quinine. I 
have never seen the slightest inflammation or irritation follow the 
operation, except in two instances. In one of these this result was 
due to the instruments employed — namely, a small trocar and common 
glass syringe ; in the other, to quinine in suspension being used instead 
of in solution. Indeed, I have reason to think that quinine in sus- 
pension is very irritating to the tissues, and this is what physiologr 
would lead us to expect, as it is certain that when a fluid material is 
introduced into the areolar structure, it will be absorbed more directly 
than any solid mass could be. Therefore, to avoid irritation of the 
parts, and also to prevent * choking ' of the syringe (and which 
instrument was procured from England), I insist upon a perfectly 
clear solution of the alkaloid. 

"The best time to inject is shortly before the expected cold fit, but 
it may be done during the first stage with the effect of lessening and 
sometimes stopping the whole paroxysm. Latterly, when a patient 
presents at the morning visit, who expects an accession during the 
day, I have injected at the time, and nearly invariably the fever has 
stopped. 

** In cases of remittent I have endeavoured to inject during the 
remission, but do not wait for this period. In severe cases the 
injection should be repeated at intervals of six or eight hours. 

"I believe four or five grains of quinine injected beneath the 
integument are equal in their effects to five or six times that amount 
taken in the stomach ;. also, that the effects are more certain than 
when taken in the ordinary method ;. also, that relapsing attacks 
are less common than when the remedy is administered by the 
mouth." 

Art. 22. — On the Fevers of the South-East Coast of Africa. 

By Mr. Charles J. Mellor, Medical Officer of Dr. Livingstone^s 
Exploring Party. 
{BrUish Medvcal Journaiy October 25, 1862.) 
The fever of the Zambesi, as found by Dr. Livingstone in 1858, 
was described as of the sthenic intermittent kind. That, however, 
of the last year has rarely assumed this character, being generally 
of the asthenic remittent type ; when intermittent, being only so for 
a short time, and always resolving into remittent. As it was first 
observed in 1858, the paroxysm was sudden ; there were few pre- 
monitory indications ; the patient had chills and rigors, with head- 
ache, pain in the temples, and aching of the loins. In the hot stage, 
there was complete stoppage of secretions ; the headache became 
more and more severe ; occasionally there was delirium. The 
tongue did not always change with the progress of symptoms : it 
might remain healthy-looking through this stage. It was when 



PBJLCTICAL MBDICIKIS, BTC. 43 

these symptoms are established that the Liying^stone specific must 
be ^veD, if the first stage had been allowed to pass without its 
admmistratioQ. The composition of this powder is the following : 
IBhubarb, gr. x ; resinous extract of jalap, gr. viij ; calomel, gr. iv ; 

auinine, gr. iv. This quantity used to be given in five pills, with 
le view to relieve the prima via quickly. Quinine was given 
about an hour after the pills, and continued every two or three 
hours, in five or ten-grain doses, to cinchonism. The greater the deaf- 
ness produced, the greater was the assurance of speedy restoration. 

Generally the force of the attack was spent hy the full action of 
the pills ; and it was not uncommon for the patient to resume his 
occupation on the third day after that of the attack. The excep- 
tional cases were those in which the fever had been brought on by 
exposure to wet or sun, and the treatment had been delayed ; or in 
which obstinate vomiting was present. Quinine was continued in 
five-grain doses until perfect restoration was secured, when the 
ordinary three-grain dose, taken with coffee early in the morning, 
was resumed. The attacks were sharp, but short, quickly gave way 
to treatment, and left the patient apparently none the worse. 

In the past year, however, the fever has taken a less active form ; 
the symptoms have been less decided ; the stages ill-defined, or 
none ; and treatment less efficacious. So irregular have the symp- 
toms been, that the sthenic dass is now the least often found ; very 
rarely is the intermittent form met, and, when purely so at the 
onset, it soon becomes remittent. The symptoms may be classed, 
according to their regularitjr and force, under three heads : 1. Those 
of the sthenic form of fever, in which they are most highly developed 
and defined; 2. Those of the asthenic form, where no order is 
followed — a prolonged cold or hot stage, or absence of one stage 
altogether, ending in great exhaustion, relieved only when full 
perspiration is procured ; 3* The ephemeral — a mild form of the 
sthenic, in natural sequence, and lasting but a short time without 
any complication. The sthenic form is that generally met with 
in first attacks, and answers to that described oy Dr. Livingstone 
in his letter to Sir James Clark in 1859 j but the treatment' has 
not been so successful in producing rapid cures. The purgative • 
" specific" has had to be repeated frequently before relief came ; 
ana when this has been necessary, and time been lost, the cure has 
been by so much delayed ; so that, in place of three days, we must 
say seven, as the average time of each patient on the sick-list. Head- 
ache has always been the last symptom to leave ; and, so long as it 
has lasted, large doses of quinine have been continued. 

But when the patient has had frequent attacks, the stages become 
less marked, and the symptoms less amenable to treatment. The 
premonitory symptoms are ill-defined. The fever may be ushered 
in by the patient feeling chilly, or as though currents of cold air 
were passing over the spine; or there may be a distinct rigor. 
This state may be continued for twenty-four hours, or alternate for 
that or a longer time with headache and heat of skin. There may 
be no cold stage at all, or no hot stage ; or the paroxysm may consist 
only of alternations of the two ; the headache, pains in the loins, and 



4A FBACTICAL KEDICIKB, BTC. 

languor, meanwhile increasing. There may be vomiting from the 
outset ; when this occurs, the case is always tedious. Or the cold 
stage may be so prolonged that reaction is with difficulty induced. 
The tongue may be foul, or clean throughout ; but relief will not be 
afforded until the secretions are restored healthily, and free perspi- 
ration procured. The symptoms may be so few and undeveloped 
that they are scarcely noticeable ; and a man who has had fever 
frequently will only be able to appreciate them for what they prog- 
nosticate. If left alone, they recur again and again, graauaJ]^ 
prostrating the patient, and ultimately merging into the remittent 
form when they have almost exhausted the strength of the victim. 
It is in the insidious progress of these symptoms that the opportunity 
is lost of treating actively. The first symptoms may be merely 
giddiness, and a feeling of languor, not calling for more than a 
stimulant. If they recur, the same remedy is used with quinine. 
But, though relieved, the patients are not cured ; they become jaun- 
diced gradually, and sickly-looking ; and now the tongue for the 
first time may become foul, though, unless there be other evidence 
of hepatic derangement, it is as often clean and pale throughout. 
And now, when the system has already become debilitated, the diffi- 
culty arises in the treatment, as the means taken to relieve the 
liver, whether mild or active, cannot be depended upon to relieve the 
system thoroughly, as in the sthenic type of the disease. The liver 
may be relieved ; but generally relief is not obtained, and the pros- 
tration becomes greater the oftener this form of medicine is adminis- 
tered. It is generally in this condition that vomiting sets in, frus- 
trating every attempt to push in sustenance or medicine. 

The oftener a patient suffers in this way, the more spurious and 
irregular is the process of the fever. The mtervals of attacks never 
permit him to resume work long ; headache and giddiness, loss of 
appetite and sleep, keep him constantljr ailing. He seems to be only 
cured so long as he is under the full influence of quinine. Large 
doses have been given to patients suffering in this way — ten or 
twenty grains every day, so long as the slightest indication of the 
approach of an attack existed, or the symptoms from the last one had 
not entirely disappeared. But, though lessening the severity, they 
have never warded off* an attack, nor lengthened the intervals be- 
tween the paroxysms. 

It is not unfrequent that after sthenic fever, a patient may, after 
regaining health, suddenly lose appetite and sleep, and have pricking 
sensations through the skin, with constipation or diarrhoea. These, 
if allowed to take their course, or if only treated individually, resolve 
into periodical returns, and, progressing in development, assume the 
remittent form. In treating each symptom as it arises (when point- 
ing to functional disorder in any organ) specifically, antiperiodic 
doses of quinine are given ; and, should this combination of treat- 
ment prove ineffectual, it has been found best to treat for the removal 
of vitiated secretion, and restoration of healthy action in the liver 
and any other organ affected ; following with quinine to cinchonism, 
and continuing its use in large doses almost to cinchonism until 
every symptom shall have disappeared. As a rule, this treatment ii 



FBACTICAL MBDICINB, ETC. 46 

sufficient ; bnt when a patient falls into this form of fever, he is in a 
low condition of health, pale, and dyspeptic. Vomiting may set in 
at any time, and, if it be long continued, will delay the core ; for 
until the remedies can be retained, and the secretions restored in 
healthy form, no permanent relief can be expected. Generally, when 
vomiting is severe, there is jaundice, sometimes with pain over the 
hepatic region. So soon as medicines can be retained, a large 
dose of calomel and jalap is given. In addition to large bilious 
evacuations by stool, the urine is frequently found deeply tinged by 
bile. 

The same complications may occnr in the process of the sthenic 
form. The liver, thoui^h relieved at first, may suffer blockade a 
second time ; jaundice may be universal in a few hoars, with tender- 
ness over the liver ; or there may be complete arrest of the secretion : 
and, when this amounts to suppression, the circulation becomes 
clogged ; the heart's action is troubled, and frequently a mitral bruit 
is heard ; and there is a feeling of weight at the prsecordia. As the 
functions of the liver and emunctories are restored, the heart's action 
becomes more natural ; but bruits have remained until the strength 
and flesh have been made good. In two cases, an ansemic condition 
remained after treatment had reproduced healthy action of the liver 
and kidneys. If a loud bruit de diable was heard along the course 
of each jugular, as well as a loud mitral murmur, both gradually dis- 
appeared as health and strength returned. 

In the asthenic variety, a murmur has commenced with the 
earliest symptoms, and has progressed and faded away with them. 
Indistinct at first at the heart's apex, it has grown more defined, 
being accompanied when loudest with a bruit along the jugulars ; 
and it has died away as it commenced. But, in its progress, the 
heart's action is troubled ; the patient feels oppression and distress 
in the region of the heart; he cannot sleep from the continuance of 
these sensations, and finds it difficult to lie on either side with 
comfort when there is bruit de diable along both jugulars. The 
cause of this may be found in the ansemic state into which patients 
rapidly fall after long-continued spurious fever, or after long-continued 
sthenic, in which the treatment has been active, and heroic doses 
(twenty grains of the specific, repeated three or four times in the 
course of twenty- four hours) have been used. Corroborative of this 
view, we find frequently oedema of the lower extremities, without any 
indication of renal disorder, blanched skin, small weak pulse, and 
tendency to syncope. 

After many attacks, the spleen frequently suffers. Attention is 
first directed to it by pain and tension beneath the ribs, simulating, 
from its suddenness and acuteness, pleuritic affection. Percussion 
and auscultation will soon define the limits of the enlargement, as the 
spleen presses forward immediately against the cartilages of the 
lowest ribs, and the anterior edge forms a distinct prominence. 

As sequelae, may be mentioned intractable diarrhoea ; headache, 
general, or hemicranial, or over the brow; vertigo; and, in the 
asthenic, oedema of the legs. Ulcers form from the smallest abrasion, 
and will not heal until the general tone be improved. 



46 PBACTICAL MEDICINB, ETC. 

There is a modification of the symptoms of this fever : it is simply 
the mildest form of all the stages in natural sequence. It does not 
require the active treatment of the sthenic, but it must be at once 
combated with the usual means in smaller doses ; and quinine must 
be continued to cinchonism. If neglected, it will recur as intermittent ; 
soon, however, becoming remittent. Those who have been longest 
resident in the country have these slight attacks. The strength is 
very slightly affected by them. The treatment is based on the prin- 
ciple that the prima via must be relieved and healthy secretion 
restored, before any permanent good can be effected. With this 
view, the composition of jalap, calomel, and rhubarb, is given at the 
outset, and repeated agam and again, until the secretions are fully 
relieved, and restored to healthy characters. In obstinate cases^ 
other drastic purgatives are combined, until thorough purgation has 
been effected. Eecovery is tedious and protracted in proportion as 
this object is quickly or tardily achieved. 

But in asthenic cases, where the stages are irregular, and where 
there is often diflSculty in inducing reaction after a fitful, long- 
continued cold stage, the purgative is given in smaller doses with a 
stimulant ; and (if there be no vomiting) reliance is placed in pro- 
ducing as quickly as possible the full influence of quinine. 

Complications of vomiting, headache, pains in the renal region, 
loss of rest with extreme restlessness, are treated by ordinary means. 
A full dose of morphia given after purgation, often relieves all these 
symptoms and induces sleep, from which the patient awakes almost 
restored to health. 



Art. 23. — On the Use of the Sulphites in Diphtheria. 

By Mr, John Lyall, Newburgh, Fifeshire. 

{British Medical Journal, January 31, 1863.) 

Mr. Lyall writes a short note to recommend the employment of 
these remedies in this case ; and he thinks that the result is 
calculated to confirm the sanguine expectations of Dr. Polli as to 
their power as disinfectants and antiferments. Diphtheria, he tells 
US, was prevalent in his neighbourhood, and ordinary means, local 
and general, had proved to be very unsatisfactory. Then he 
proceeds : — 

"After a time, I began to use sulphite of soda in half-drachm 
doses every six hours, or every four nours where the case seemed 
more urgent. As the improvement following the use of this remedy 
has been apparently very marked, I have written this brief note in 
order that its value may be tested where diphtheria at present 
prevails. The prescription I have been using is the following: 
sulphite of soda, Jss; water, "^iv. A tablespoonful (5ss) to be 
taken every four or six hours." 



PfiACTICAL MEDICINE, ETC. 47 

Aet. 24j. — Case of Malignant Pustule, 

By Dr. James Edmunds. 
(Medical Timet and Gazette^ January 31, 1863.) 

A fine, tall, bulky man, fifty years of age, who had led an active business 
life, lived freely, and suffered from gout, and from symptoms which had 
been referred to disease of the muscular texture of the heart, was occupied 
on the 16th of last December in superintending the construction of a con- 
servatory in his grounds at Hackney, and at 10 p.m. he took supper, and 
went to bed " as well as possible." 

At midnight, he was seized with a rigor, and with severe pain across the 
lower part of the loins and through the hips. At 3 a.m. he found his 
" tongue greatly swollen," and his articulation very difficult ; he became 
rapidly worse, and, early in the morning, sent for me, but I was unable to 
visit him directly. 

At 11 A.M. I found him in bed, with a countenance indicating considerable 
distress and profound toxaemia. The mouth was open, the saliva was run- 
ning over the lower lip, and the tongue was thrust upwards by a remarkable 
swelling in the sublingual space ; there was the greatest difficulty in utter- 
ance, but no huskiness of the voice ; the pulse was weak, and be was very 
feeble when out of bed. Only the under part of the tongue was visible, but, 
by means of a tablespoon, I managed to see that the roof of the mouth, 
the palate, and the pharynx were unchanged in appearance, as also were 
the hps, the cheeks, the gums, and the tongue itself. The tongue had a 
" dried-beef" look about the tip of its upper surface, and, with the swelling 
beneath, looked as if it were mounted upon a small thick muffin, about as 
big as itself, and of the colour of the mouth. The swelling was symme- 
trical, and it completely filled that space within the lower jaw which is 
usually occupied by the tongue. The mucous covering was not obviously 
altered, but close inspection discovered an indistinct pallid mottling, ana- 
logous to that change of surface which precedes ordinary gangrene. Upon 
applying a finger the mass was not very sensitive ; it was soft and yielding, 
as if it might contain pus infiltrated through its texture, but it was not 
quaggy, it did not pit, and it was utterly destitute of that brawny feel 
"which attends ordinary carbuncular inflammation. Beneath the lower jaw 
there was some swelling and considerable tenderness. 

I could scarcely believe that the patient had arrived at this condition in 
less than twelve hours ; but he emphatically assured me that he '* went to 
bed as well as I was." 

Ten years' active practice had not previously presented a similar case to 
my observation ; and beyond considering it as gangrenous cellulitis, I was 
at a loss for a designation ; and beyond the risky procedure of making a 
free incision beneath the tongue, I was also at a loss for any effectual 
treatment. 

I explained the nature of the case to the patient and family, and particu- 
larly guarded the latter against infection. I directed the patient to wash 
out the mouth frequently with a solution of nitro-muriatic acid, and to take 
a full dose of carbonate of ammonia immediately ; and it was arranged by 
telegram for Dr. B. W. Kichardson to meet me in consultation at two o'clock. 
At this visit the patient looked worse, and the submaxillary swelling and 
tenderness were greater, although the mouth and the utterance were about 
the same, and there was neither affection of the pharynx nor huskiness of 
the voice. The only clue which we could obtain as to the origin of the ma- 
lady was the fact that, three or four days before, the patient had eaten some 



48 PRACTICAL MEDICINE, ETC. 

jugged hare which was '*high," and that beneath the tongue a ragged tooth 
in the lower jaw had produced a sore, through which a putrid infection 
might have occurred, and near to which he remembered that some of the 
meat had lodged until the next day. We decided that, at all hazard, a free 
incision must be made into the mass ; and Dr. Richardson further suggested 
that some solution of iodine should be inserted into the incision on pledgets 
of lint, so as to permeate the diseased textures, and, if possible, prevent^ 
by chemical action, any further blood-poisoning. Our recommendations 
were at once acquiesced in, and a long bistoury was plunged by the side of 
the frajnum linguae downwards and backwards into the mass for an inch and 
a-half, when its point was turned outwai*ds so as to emerge upon the end of 
the finger beneath the root of the tongue, and the knife was drawn forwards 
so as to cut its way out, and produce a most effectual incision. No bleeding 
ensued, and a corresponding incision was instantly made under the other 
side of the tongue. The mass did not cut like ordinary flesh, nor in the 
least like carbuncle, but like soft flesh, or ripe Stilton cheese ; no pus ex- 
uded ; and the cut surface presented a mottled pale and pinkish appearance. 
Pieces of lint soaked in a solution of compound tincture of iodine diluted 
with three parts of water, were thrust into the opening, and were to be 
changed every hour ; the surface of the mass and the contiguous parts were 
also to be frequently swabbed with the solution by means of a small sash- 
brush. The room contained a good fire, and the windows were thrown open. 
Some fragments of iodine also were placed about the room to exhale into 
vapour, and, as Dr. Bichardson thought, to produce an ozonising, and, 
perhaps, disinfecting effect upon the atmosphere. The patient was to take 
large doses of carbonate of ammonia, and champagne ad libitum. 

At 10 P.M. Dr. Richardson and myself held another consultation. The 
patient's countenance was much improved, and he said he felt better. 
Articulation was easier, the tongue more movable, and the incisions were 
discharging copiously. There was no huskiness of voice nor affection of the 
pharynx, and the pulse was better. We congratulated ourselves and the 
family upon the possibility of recovery, as, notwithstanding the wonderfully 
rapid advent and increase of the disease, it appeared to have made no pro- 
gress during the last seven hours. The treatment was to be continued, and 
we were to hold another consultation at 8 a.m. 

In the night, however, a cab was sent for me, and, on arriving, I found 
that the patient had just died. I learnt that a second rigor had occurred at 
midnight, and that he became rapidly worse ; the discharge was more pro- 
fuse from the mouth, and began also to come from the nostrils ; the swelling 
under the jaw increased enormously, and extended backwards to beneath 
the ears ; the voice became husky and the breathing difficult ; he became 
very restless, turned across the bed on to his back, and died at 3 a.m. The 
discharge was never really black (Dr. Richardson termed it sepia-coloured), 
and the odour, although exceedingly disagreeable, was never gangrenous. 
The throat swelling, which came on so rapidly after the second rigor, was 
examined by me just after death, and it precisely resembled, in external 
outline, the enlargement which accompanies the deadly forms of scarlet 
fever. There was, however, no rash upon the skin, and the commencement 
and location of the first symptoms had nothing in common with that disease. 
The body ran rapidly into putrefaction. 

The room was disused, the linen burned, and other precautions were 
adopted. The patient's wife, who attended closely to him, was very pros- 
trate and ill for a week or two afterwards, and she ascribed this to having 
** caught a whiff of his breath.** The son, however, who applied the iodine 
and changed the pieces of lint| and helped the patient about in bed, is quite 



FBACTICAL MEDICINE, ETC. 49 

well, and no member of the family has since suffered in any way like the 
patient. 

The onset of this frightful malady was marked by the midnight rigor, and 
at 3 A.M. appeared the difficulty of utterance. Precisely as midnight 
recurred there was a second rigor, and this again was followed by rapid 
extension of the local symptoms, and death at the recurrence of 3 o'clock. 
Profound toxaemia from the first stamped death upon this gentleman's coun- 
tenance ; and the immense scarlet-fever- like enlargement of the throat, 
which came on after the second rigor, only aided, by mechanical pressure 
upon the larynx, that vital prostration which had, as it were, already mixed 
up death with life. 

Although I have classed this with cases of malignant pustule, yet it ma- 
terially differs therefrom — while points of resemblance and analogy are 
presented by many other diseases, €.^., scarlatina maligna, some rare cases 
of typhus, the plague, and cases of animal or venomous poisoning. 



(c) CONCERNING CHEONIC DISEASES. 

Art. 25. — On Tuberculosis. 

By Dr. J. Hughes Bennett, Professor of the Institutes 

of Medicine in the University of Edinburgh. 

{Lancet, July 4, 1863.) 

We take the following remarks on the pathology, natural pro- 
gress, and treatment of tuberculosis from one of Dr. Bennett's 
lectures on "Molecular Physiology and Therapeutics" recently 
appearing in the Lancet : — 

JPathology of tubercle. — "In endeavouring to determine the 
nature of tubercle, we must remember that it occurs in young 
persons in whom the nutritive functions are deficient in energy, 
whether from poverty and incapacity of obtaining food, from 
deficient stamina, or from causes of whatever kind which induce 
exhaustion. Hence its frequency among the ill-fed poor, in orphan 
and foundling institutions, among badly-nursed children or weak 
and dyspeptic young persons, and after acute inflammations, whoop- 
ing-cough, eruptive fevers, and other disorders that weaken the 
body. When, under such circumstances, exudation occurs in one 
or more textures, it does not undergo those changes we observe 
following inflammation in healthy persons. The vital changes are 
slow, and easily arrested. Instead of cells and perfect textures 
being produced, the efforts at vital transformations are abortive. 
The whole remains molecular and granular, or, at most, ill-formed 
nuclei are produced, which have received the name of tubercle 
corpuscles. 

** It is rare, however, that this weakness of the constitution acts 
uniformly at idl times and in all textures. Hence it may frequently 
be observed that .tubercle is more or less associated with pus and 
granule cells, or fibrous and other fjrowths ; with the exception of 
cancer, with which it is rarely combmed. 

" I regard tubercle, therefore, as an exudation, which may be 
poured out into all vascular textures in the same manner and by the 

ZXXYIII. 4i 



50 FBACTICAL KEDICINE, ETC. 

same mecliaiiism as occurs in inflammation, only from deficiency of 
vital power it is incapable of undergoing the same transformations, 
and exhibits low and abortive attempts at organization, and more 
frequently, as a result, disintegration and ulceration. For the same 
reason we observe that whenever an undoubted inflammation 
becomes chronic with weakness, the symptoms and general pheno- 
mena become identical with those of tuberculosis. Hence there is 
little difference between a chronic pneumonia of the apex of a lung 
and a phthisis ; the one, indeed, passing into the other. 

" When we endeavour to discover the oeigin of the weakneae 
producing this eflect on the exudation, we must ascribe it to imper- 
fect nutrition ; indeed, it is impossible for any observant practitioner 
to avoid noticing throughout the whole course of the disease the 
derangement that occurs in the digestive system. All writers refer 
to the deficiency and irregularity of the appetite, and the functions 
of the whole alimentary canal will be found from first to last in an 
abnormal condition : the tongue is either furred and furrowed, or 
glazed and unusually red ; the teeth are carious ; the stomach capri- 
cious — sometimes rejecting food, at others retaining it an unusual 
time, with accumulation of flatus. /There is a general indisposition 
to eat fat or fatty substances ; and the appetite is feeble, absent, or, 
in rare cases, voracious. In the former case there is thirst and 
eructation of acid matters into the mouth ; flatulence and tym- 

Sanitis of the bowels are frequently complained of; the alvine 
ischarges and egesta are as irregular as the food and ingesta. 
Sometimes there is constipation, at others diarrhoea. The stools 
are only slightly tinged with bile, and in children often consist of 
white glairy matter, like white of egg. It may also be invariably 
observed, that when by jjroper regulation of the diet, of exercise, or 
other circumstances which regulate the nutritive functions, the 
alimentary canal performs its duty, the health improves, and the 
tubercular formations diminish. 

** These, indeed, according to their excess or progress in particular 
organs, communicate to the disease more or less of a local character. 
In systematic works they have been described at length as separate 
diseases, although, in truth, they are only manifestations of one 
disease. 

** After a time the continuance or violence of the local disease 
reacts upon the constitution, and a state called hectic fever is esta- 
blished, the which, inducing exhausting diaphoresis and emaciation, 
ultimately destroys the patient." 

Natural progress of tuberculosis. — "In tracing, therefore, the 
natural progress of tuberculosis, we observe it to commence in 
debility caused by impairment of nutrition. This leads to local 
congestions and exudations. The latter remain abortive, and 
consist of molecules, granules, and imperfect nuclei, which soften 
and cause ulceration, with more or less disorganisation. The great 
contriJDution of M. Louis to the pathology of this subject was the 
establishment of a law, that whenever tubercle occurred in the body 
it also existed in the lungs, and whenever it occurred in the lungs it 
appeared first at the apex. This law, though now known to be 



FfiACTICAL MBDICINB, ETC. 51 

subject to several exceptions, is still so generally correct as to be of 
the utmost service in! diagnosis. Now, in the lungs, it was long 
supposed, and the opinion is still very general, that tubercle almost 
always proceeded onwards to a fatal termination ; yet so far is this 
from being the fact that it can easily be shown that tubercle is 
arrested spontaneously in one-third of all the persons in whom it 
occurs. Nothing is more common in examining dead bodies than 
to meet with cretaceous and calcareous concretions at the apices of 
the lungs more or less associated with cicatrices. Of seventy-three 
bodies which I examined consecutively some years ago in the Royal 
Infirmary, I found these lesions in twenty-eight. Of these, pucker- 
ings existed with induration alone in twelve, with cretaceous or 
calcareous concretions in sixteen. Since then I have examined many 
hundred lungs at the inspections in the Infirmary, and am satisfied 
that these proportions exist pretty constantly. At the Salpdtri^re 
Hospital in Paris, Roger found them in fifty-one bodies out of a 
hundred ; at the Bic6tre Hospital, in the same city, Boudet found 
them in 116 out of 135 bodies. Both these institutions are establish- 
ments for persons above seventeen years of age. 

"These lesions are so frequent, therefore, that it is important 
to determine whether they are really proofs of arrested tubercle. 
This seems to be established by the following facts : — 

" 1. A form of indurated tubercle is frequently met with, gritty 
to the feel, which, on being dried, closely resembles cretaceous con- 
cretions. 2. These concretions are found exactly in the same 
situation as tubercular deposits are. Thus they are most common 
in the lungs, and at their apices. 3. When the lung is the seat of 
tubercular infiltration throughout, whilst recent tubercle occupies 
the inferior portion, and older tubercle and perhaps caverns the 
superior, the cretaceous and calcareous concretions will be found at 
the apex. 4. A comparison of the opposite lungs will frequently 
show, that whilst on one side there is firm encysted tubercle, partly 
transformed into cretaceous matter, on the other the transformation 
is perfect, and has occasionally even passed into a substance of 
stony hardness. 5. The puckerings found without these concretions 
exactly resemble those in which they exist. Moreover, whilst 

{mckering with grey induration may be found at the apex of one 
ong, a puckering surrounding a concretion may be found in the 
apex of the other. 6. The seat of cicatrices admits of the same ex- 
ceptions as the seat of tubercles, and in about the same proportion. 
There can be no question, therefore, that these cicatrices and con- 
cretions for the most part indicate the arrestment, disintegration, 
and transformation of pre-existing tubercular exudations into the 
lungs. 

" The arrestment of tubercle in the lung is not confined, however, 
to its early stage. It may be stopped at any period, and numerous 
cases are now known where even vast tubercular caverns have healed 
and cicatrized. I here show you a series of preparations, which must 
convince the most sceptical of the truth of tnis statement." 

Treatment. — " It follows, therefore, that if we can succeed in sup- 
porting the nutritive fonctions, there is no reason why tubercle once 

4—2 



62 PBACTICAL MEDICINE, ETO. 

formed should not be gradually absorbed, and a tendency to subse- 
quent deposits completely checked. Formerly this was rarely ac- 
complished, in consequence of the idea that phthisis pulmonalis 
ought to be treated by paying attention especially to the lungs and 
respiration. Hence cough mixtures, sedatives, a warm atmosphere, 
tar vapour, and other substances to influence the local lesion. Other 
symptoms had their special treatment, such as sulphuric acid to 
relieve sweating, acetate of lead and opium to check haemoptysis, 
tonics to give strength, astringents to check diarrhoea, and so on ; 
while so far from any vigorous effort being made to improve nutri- 
tion, the diet was kept low, consisting of farinaceous substances, or 
at most milk ; and to avoid irritation, the patients were confined to 
bed or their rooms, which were kept at an equable temperature. 

" Our present knowledge has led to a complete revolution in our 
practice. Thus, moderate exercise to stimulate respiration, cold 
sponging, nutritious diet, and a bracing system have been found 
more beneficial ; at the same time avoiding anodynes and cough 
mixtures, which, by diminishing the appetite and inducing weakness, 
interfere with nutrition. Indeed it has been proved that the best 
method of lessening cough, expectoration, and sweating are the 
means which produce increase of general strength ; so that if we can 
carry out the general indication, the local symptoms may be safely 
left to themselves. 

" In doing this, we have now the advantage of possessing a remedy 
which in cases of tuberculosis is of the highest nutritive importance, 
as it gives to the system that fatty element in which it is so defec- 
tive, and in a form that is more easily assimilated, and more capable 
of adding to the molecular element of the body than any other. I 
allude to cod liyeb oil. 

** And now, gentlemen, you cannot fail to perceive how the mole- 
cular doctrine of organization and of growth not only explains the 
known facts in physiology and pathology, but constitutes the basis 
for a true therapeutics. Fatty particles, as we have seen, form the 
molecular fluid of chyle ; while out of chyle, blood, and through it 
all the tissues, are formed. Impairment of digestion in scrofula and 
tuberculosis renders chylification imperfect ; the fatty constituents 
of the food are not separated from it and assimilated ; the blood 
consequently abounds in the albuminous elements, and when exuded 
forms, as we have seen, tubercle. To induce health, it is necessary 
to restore the nutritive elements which are diminished, and this is 
done directly by adding a pure animal oil to the food. While an in- 
flammatory exudation in previously healthy persons should be treated 
by supporting the vital powers generally, so as to permit its mole- 
cules going through the transformations necessary for their growth 
and elimination ; in tuberculosis we add the constituent of food 
necessary for the formation of the molecules themselves. By so 
doing, we form good chyle and blood ; we restore the balance of 
nutrition which has been disturbed ; respiration is again active jp. 
the excretion of carbonic acid gas; the tissues once more attract 
from the blood the elements so necessary for their sustenance. 
Ihe entire economy is renovated; so that while the histogenetio 



PBACTICAL MEDICINE, ETC. 53 

processes are revived, the histolytic changes in the tubercle itself 
also are stimulated, and the whole disappears. When, in 1841, I 
first announced the virtues of cod-liver oil as an analeptic or nutrient 
in this class of cases, so little was the substance known that linseed 
oil was furnished to the Eoyal Infirmary of this city instead of it, 
when I induced Dr. Spittal to try it in his wards. At present, I need 
scarcely say, whole fleets are engaged in transporting the oil from 
the extensive fisheries where it is manufactured for medical purposes ; 
and its beneficial results are universally recognised. 

"In 1852 Dr. Wood, of Philadelphia, remarks of it in his Practice 
of Physic, (see vol. ii., p. 95, note,) that in Philadelphia during the 
ten years from 1840 to 1849 inclusive, the average proportion of 
mortiEility from phthisis was 1 in about 6*76 from all causes, or 14 8 
per cent., and the same average existed in previous years. Cod- 
liver oil was then generally used in its treatment, and the mortality 
sank in this disease during 1850-51 to 1 in 8*33, or about 12 per 
cent., and in 1851 it was only 11 86 per cent. 

" In 1862 Dr. C. J. B. Williams, in one of the Lumleian Lec- 
tures delivered to the London College of Physicians, observes, 
that the experience of Louis and Laennec gave an average duration 
of two years* life in phthisis after it was decidedly developed, 
but that since cod-liver oil was introduced, he infers, from 7000 
cases, that the average duration of life has been four years— 
that is, doubled. 

" My own conviction is, that innumerable cases which formerly 
would have died rapidly, now rally, live for years, and many of 
them ultimately recover. The hopelessness which used to seize 
npon many consumptive persons and on their friends is also now 
removed, and the resolution to combat the disease by appropriate 
diet, exercise, and other hygienic means, has added further success 
to our treatment. 

** I venture then to say, that in the same manner that in recent 
times we have diminished the mortality in eases of acute inflam- 
mation, so we have diminished the mortality and increased the 
duration of life in cases of tuberculosis, and more especially in 
that most fatal form of it — phthisis pulmonalis. In the one disease 
as in the other, this improvement can only justly be ascribed to 
the advance of physiology and pathology ; to our superior know- 
ledge of the nature of the disease, and, as a consequence, to our 
treatment of it on more scientific and successful principles." 



Art. 26. — The Connexion between Tulerculosis and Insanity, 

By Dr. T. S. Clouston, Assistant Physician to the Royal 

Edinburgh Asylum. 

{Journal of Mental Science, April, 1863.) 

A long and elaborate paper based upon the statistics of the Eoyal 
Edinburgh Asylum, ends in the following conclusions : — 

1. Phthisis pulmonalis is much more frequent, as an assigned cause 
of death among the insane, than among the general population. 



54 PBACTICAL MEDICINE, ETC. 

2. Tubercular deposition is about twice as frequent in the bodies 
of those dying insane as in the sane. 

3. Phthisis pulmonalis is the " assigned cause of death " in only 
about one half of those in whom tubercular deposition is found after 
death. 

4. The brain in the cases of tuberculosis is not so frequently 
diseased in a marked manner as it is in those dying of other 
diseases among the insane. In the majority of the cases the brain 
is paJe, anaemic, irregularly vascular, with a tendency to softeninff 
of the white substance of the fornix and its neighbourhood, and 
the gray matter of lower specific gravity, than in any other cases of 
insanity. 

5. Tubercle is not more frequently found in the nervous centres 
among the insane than among the sane, and when found, it does 
not in all cases, or even the majority of them, produce any symp- 
toms, and is not connected with any particular form of insanity. 

6. Tubercle of the peritoneum is not more frequent among the 
tubercular insane than among the same class in the sane. In the 
former it is more frequently associated with melancholia and mono- 
mania of suspicion than ordinary tuberculosis of the lungs. 

7. The average age at death of the cases of tuberculosis is about 
three years below the average age at death among the insane 
generally, and the average age of those in whom much tubercular 
deposit is found is five years below the general average. 

8. The proportion of the tubercular who had had previous attacks 
of insanity is about the same as among the insane generally. 

9. There is hereditary predisposition in seven per cent, more of 
the cases of tuberculosis than of the insane generally. 

10. Monomania of suspicion is the form of insanity in which 
tuberculosis is most frequent, and general paralysis stands at the 
other end of the scale that marks the frequency of tuberculosis in 
the different forms of insanity ; mania stands next to general para- 
lysis, and melancholia to monomania of suspicion ; while the ten- 
dency to dementia, in all forms of insanity, is greater among the 
tubercular than among the non- tubercular. A majority of the cases 
of general paralysis and mania die non-tubercular ; a majority of 
the cases of melancholia, monomania, and dementia exhibit proofs 
of tuberculosis after death. 

11. In all the cases of general paralysis which were tubercular the 
disease had commenced with depression. 

12. In a certain number of cases (about one fourth of all those in 
whom tubercle was found) the insanity is of such a peculiar and fixed 
type that it may be called ** phthisical mania." In all those cases 
the phthisis is developed so soon after the insanity that tubercles 
must have already formed in the lungs, or a strong tubercular ten- 
dency been present and about to pass into actual tuberculosis when 
the insanity appeared. We know that the chief characteristic of 
tuberculosis is an impaired energy in the nutritive processes ; and 
as a badly nourished bone becomes carious or necrosed for slight 
causes, or a badly nourished skin becomes subject to parasites, so 
disordered action results in those imperfectly nourished brain-cells 



PBACnOAL MSDICI17B, BTO. S5 

from causes whicli would not be felt by a healthy brain. It is not 
the enfeebled nutrition directly so much as the perverted action to 
which the enfeebled nutrition predisposes, that produces the insanity. 
The peculiar mental state, the incurability of the insanity, the ap- 
pearance of the brain after death, and its lowered specific gravity, 
all point to such a cause for the derangement. 

13. There is a special relation between deep melancholia with 
long-continued suicidal tendencies and refusal of food and lung 
disease — either gangrene or tubercular disorganization. 

14. There are a few cases in which the insanity is oul^ a kind of 
delirium, occurring during previously developed chronic phthisis, 
and soon passing off. 

15. The prognosis is most unfavourable if tuberculosis occurs in 
any case of insanity. 

16. Half the cases of tubercidosis die within three years after the 
commencement of the insanity. 

17. There is no proof that the " morbid influence of the pneumo- 
^astric nerve " has anything to do with the tuberculosis cases of 
insanity. 

18. Long-continued insanity does not tend to the development of 
tuberculosis more than to the production of other diseases. 

19. Phthisis is entirely latent in between one third and one fourth 
of all the cases among the insane, and in almost all the others it is 
latent for a considerable time. This latency is most frequent in 
general paralysis, in which the majority of the cases of phthisis ex- 
hibit no symptoms whatever. 

20. There are very few cases where the commencement of insanity 
benefits the phthisis, but in a few, where the phthisis is very chronic, 
an attack of insanity may be followed by the permanent disappear- 
ance of the phthisical symptoms, or attacks of mania I2.ay alternate 
with symptoms of phthisis. In by far the majority of such cases, 
however, the phthisical symptoms are merely masked, while the de- 
position of tubercle goes on. 



Aet. 27. — On the Precautions calculated to Prevent the 
Transmission of Syphilis hy Vaccination* 

By M. DiDAT. 

(Jowmal de Mid, et Chir. Prat., Oct. 2, 1863.) 
It is all important to ascertain whether the individual, from whom 
the operator is desirous of obtaining vaccine matter, is affected with 
syphilis, and the characteristic signs of the disease must be sought 
for in those regions in which its symptoms most usually appear- 
viz., the genital and anal regions, tlie labial commissures, the scalp, 
and the folds of the skin of the thighs. Notwithstanding the healthy 
aspect of the vaccinal pustules, M. Diday opines that the surgeon 
should reject all children who habitually suffer from coryza, par- 
ticularly if the edge of the incisors be indented, or if the epidermis of 
the palms of the hands or the soles of the feet does not present its 
normal consistency or colour. 



66 PRACTICAL MBDICINB, ETC. 

From the appearance of the nurse, parents, brothers and sisters, 
relations and neighbours of the infant-— in short, of all those from 
whom the child may have taken, or to whom he may have com- 
municated disease — the surgeon will endeavour to form an opinion 
of its health. Without compelling all these individuals to submit to 
a regular medical examination, a glance at the mouth, eyelids, nose, 
and scalp of the persons present, and a rapid passage of the hand 
over the occipital and mastoidean regions to ascertain the condition 
of the lymphatics, will promptly allow him to form a correct idea of 
their state of health, and by inference, of that of the infant from 
whom it is contemplated to take the vaccine lymph. 

M. Diday then supposes the case of a child previously healthy, but 
to whom the poison of syphilis has been inoculated together with 
vaccine matter. A chancre will then appear in the punctured spot, 
but in accordance with the well-known law of its evolution, it will 
first become apparent after the cicatrisation of the vaccinal pustule ; 
or, as M. Lecoq has observed, four days after the operation, the 
normal progress of the vaccinal eruption will be disturbed, and 
instead of the usual pustule, an umbilicated sore will form, promptly 
covered with a thick scab, &c. Hence M. Diday concludes that it is 
necessary : — 

1. To avoid charging the lancet in a pustule in which the sup- 
puration is protracted beyond the tenth day; the existence of a 
chancre is here to be apprehended. 

2. To reject, a fortiori, for the purpose of vaccination, all pustules 
presenting any irregularity in their aspect or progress. 

The child to be vaccinated also calls for attentive examination ; 
vaccinated subjects are used for the propagation of vaccine lymph, 
and if the eruption contains any seeds of syphilis, an entire popula- 
tion may be contaminated. To illustrate the importance of this 
inquiry, which may at first sight escape attention, M. Diday adduced 
a case, which he communicated on the ^Ist of May last to the Society 
of Medical Sciences at Lyons. 

"A patient of mine," said he, "aged 36, suffering from syphilis, 
was delivered of a child, which I attended three months after its 
birth for a specific papular erythema of the back and thighs, and for 
mucous papulae of the mouth and anus. The infant was brought to 
me every four or five weeks for six months, and several relapses of 
gradually-decreasing severity had taken place, when the mother 
determined on having it vaccinated. She carried it for the purpose 
to the Hospital of La Charit6, where the ojjeration was performed 
on the 7th of May, 18fi3. The vaccinator instructed her to bring 
back her child at the expiration of a week. On the 19th, however, 
the mother visited me with the little patient, and I ascertained the 
presence, at the margin of the anus, of an extensive mucous papula, 
not merely excoriated, but deeply ulcerated, and of an eruption of 
the same nature in the folds of the thighs. These symptoms 
assuredly existed, and were distinctly marked when vaccination was 
performed ; but the mother, actuated by selfish motives, had 
refrained from returning to the hospital, lest vaccine matter should 
be taken from her infant. Had she done so, it is highly probable 



IPBACnCAL MEDICINE, ETC. 57 

that no evil consequences wonid have followed, our internes being in 
the habit of carefully examining all children from whom vaccine 
lymph is taken, and in the present instance, the condition of the 
subject would have been detected on the most superiicial inspection. 
Indeed when I saw the vaccine pustules on the twelfth day, they 
were covered with a yellower, thicker, and more humid crust than is 
usually observed at this period." 

A child affected with syphilis has doubtless as good a right to 
enjoy the benefits of vaccination as another, and M. Diday remarked 
here that it is easy to reconcile public with private interests. When 
it is thought necessary to vaccinate a contaminated child, in order to 
prevent the lymph from being inoculated to others, the pustules 
should be destroyed with caustic ; this procedure does not diminish 
the preservative power of the vaccination, and protects the persons 
who surround the infant from the perils of accidental or imprudently 
incurred contagion. 

With regard to children, apparently in the enjoyment of perfect 
health, but to whom hereditary syphilis may have been transmitted, 
M. Diday recommends vaccination to be postponed for three full 
months after birth ; statistics drawn up by this observer, show that 
in 158 infants tainted with hereditary syphilis, the pathognomonic 
symptoms broke out before the expiration of the third month in 146, 
and at a later period in 12 only. 

Of course these figures do not imply that in doubtful cases, 
perfect health during the first three months of life is an absolute 
guarantee of future immunity. In accordance with M. Ricord's 
wise precepts, the natural anxiety of parents to elicit from the 

Eractitioner a positive prognosis on this subject, should not induce 
im to express any but a very guarded opinion. But these returns 
certainly authorize the surgeon to vaccinate a child who has enjoyed 
perfect health up to the age of three months, and who may therefore 
be considered tolerably saife from the outbreak of syphilis. 



Art, 28. — On Rheumatic Gout. 

By I>r. Fuller, Physician to St. George's Hospital, <fec. 

{Lancet^ September 26, 1863.) 

In a clinical lecture on this subject Dr. Fuller says : — 
" My experience induces me to believe that rheumatic gout is a 
disease aui generis — totally distinct from gout, and equally so from 
rheumatism. Indeed, it appears to me to resemble scrofulous inflam- 
mation more nearly than rheumatism in its nature. Call it by what- 
ever name you please — rheumatic gout, rheumatic arthritis, rheu- 
matoid arthritis, or any of its other synonyms ; but remember that 
it has no connexion with any other form of so-called rheumatic dis- 
order. As well might you regard measles as identical with scarlatina 
on the ground of their both being accompanied by an eruption on 
the skin, as to consider rheumatic gout identical either with gout or 
rheumatism on account of its being, like those disorders, accompanied 
by pain and swelling of the joints. Depend upon it, rheumatic gout 



58 FBACTICAL MEDICINE, ETC. 

has a history and patholop;y of its own ; and if it is to be treated suc- 
oessfully, its history and pathology must be carefully studied and 
its treatment conducted accordingly. 

" Pathological research has shown that in the earliest stages of the 
disease the capsules of the affected joints are distended with fluid, 
the synovial membrane is thickened and intensely vascular, and vas- 
cular tufts or excrescences exist at the margins of the cartilages ; 
that as the disease progresses tne fluid is absorbed, the interarticular 
fibre cartilages are also absorbed, and eburnation of the articulating 
surfaces take place ; that the heads of the bones become enlarged 
and altered in shape by the occurrence of interstitial absorption ia 
some parts and of osseous deposits in others ; and that foreign bodies 
of varying consistence and character are often developed both within 
and without the joints — bodies which are sometimes cartilaginous, 
sometimes bony, sometimes attached by longer or shorter pedicles 
to the synovial membrane or to the ligamentous structures, and at 
others are loose within the articulation. It has shown that these 
changes may take place slowly without any general febrile distur- 
bance or any acute local inflammatory action ; and on the other hand, 
that they may be preceded and accompanied by fever, and by pain, 
heat, and inflammatory swelling of the parts : that the bursas and 
sheaths of tendons in the vicinity of the affected joints are prone to 
be implicated in the mischief, but that neither in the joints nor in 
the adjacent bursse or sheaths of tendons are any of the ordinary 
products of inflammation found — there is no lymph, and no pus, and 
no urate of soda, as in gout. In other words, it nas shown that the 
characteristic changes which occur in the joints as the result of rheu- 
matic gout take place independently of active inflammation, and that 
the acute inflammatory action which sometimes precedes or ac- 
companies these structural changes is simply a complication 
of the disorder, and by no means necessary to its perfect develop- 
ment. 

"And what are the conditions under which these structural 
alterations in the joints occur P They are not met with in the robust 
or vigorous, in well-fed persons with sound constitutions and seden- 
tary habits ; they do not arise, like the deposits of urate of soda in 
gouty men, in connexion with excessive indulgence in the luxuries 
of the table, and defective excretion consequent on a diseased con- 
dition of the kidneys. On the contrary, they are more common in 
women than in men ; very frequently arise in persons who lead a 
temperate life, and are small eaters, and never present themselves 
in persons who are constitutionally sound, unless they have been 
subjected to some cause of nervous exhaustion and enfeebled healtli. 
Their favourite victims are the offspring of consumptive parents, 
and especially weakly women — women whose constitution is either 
originally delicate and unsound, or who from some cause or another 
have fallen into ill health. Amongst men, the most common exciting 
causes of the disease have appeared to me to be the cachexia which 
oftentimes follows excessive venery or syphilis, or the sleeplessness 
and exhaustion consequent on illtreated gonorrhceal rheumatism, or 
the depression resulting from anxiety, or from excessive and long- 



PfiACTICAL MEDICINE, ETC. 59 

ecmtinued mental exercise, or from over-fati^e or chill in persons of 
a delicate constitution or scrofulous tendency ; whilst m women the 
disease is often traceable to the cachexia entailed by perversion of 
the uterine functions. It attacks the girl just arriving at puberty, 
in whom these functions are ill performed ; it invades the stiffening 
articulations of the woman who has arrived at that time of life which 
ifl marked by the cessation of the monthly periods ; it shows itself 
during the state of debility which follows a miscarriage or a diflScult 
or protracted labour, more especially when the labour has been 
accompanied by flooding ; and it is a common sequel of over-long 
Buckling. 

" Biit whatever the exciting cause of the disease, its primary or 
essential cause is the same in all instances ; and although we are 
unable as yet to point out the precise nature of that cause, — although 
we know little of the morbid chemical actions which take place, and 
are at a loss to account for the peculiarities in the nutrition of the 
affected parts by which this form of disease is accompanied, it is im- 
possible to doubt the existence of a special form of constitutional 
disorder. The history of the complaint, its course and symptoms, 
and its pathological effects, all indicate the agency of some cause 
distinct from that which occasions gout or rheumatism. Our inability 
to demonstrate the nature of the chemical changes in the blood, or, 
in other words, to prove the formation of a special poison, is not a 
valid argument against the existence of such a j>oison. The same 
line of reasoning would be equally conclusive ag^ainst the existence 
of any special form of blood -disorder in small-pox, typhus fever, 
scarlatina, and pyaemia. The fact ia, our means of analysis of organic 
fluids are at present so imperfect, and we know as yet so little of 
the influence exerted on the functions of assimilation and excretion 
by modifications of the nervous power and other similar agencies, that 
in this, as in other forms of disease, we cannot even offer a reasonable 
conjecture as to the character of the chemical changes which take 
place, or as to how those changes are brought about. All that 
chemistry has as yet enabled us to assert is the bald fact originally 
pointed out by Dr. Garrod, that the blood in these cases does not, 
like the blood in gout, contain uric or lithjc acid. 

" Thus, then, as there is no very certain mode of diagnosing this 
disorder, and as, if it is to be treated successfully, its special cha- 
racter must be recognised early in the attack, I will endeavour to 
bring before you certain facts which will serve as guides to a correct 
diagnosis. 

"I would premise that the disease may make its approach either 
in an acute or in a chronic form. In the latter case, its true cha- 
racter is not likely to be mistaken ; but in the former it often re- 
sembles an attack of acute rheumatism so closely as to tax our 
powers of diagnosis to the utmost. There may be heat of skin and 
profuse perspiration, furring of the tongue, loading of the urine, ac- 
celeration of the pulse, and pain, redness, and swelling of the 
affected joints — symptoms which, to a greater or less degree, are 
always attendant on acute rheumatism. But even from the first 
there are certain peculiarities which ought to excite suspicion as to its 



60 PEACTICAL MEDICINE, ETC. 

nature. The skin, though hot, is less so than in acute rheumatism ; 
the perspiration does not possess the peculiar rheumatic odour in anj 
marked degree ; the pulse, though quick, is feeble ; the tongue 18 
usually less furred ; and the local pain and swelling are seldom con- 
fined to the knees and other larger joints, but invade the wrists and 
small joints of the fingers ; they are more persistent than the in- 
flammatory swellings of true rheumatism, and they attack a larger 
number of joints simultaneously. 

" If the true character of the disorder is overlooked at the first, a 
few days* observation at the bedside ought to rectify the diagnosis. 
The symptoms rarely yield to alkalies ; the tongue cleans, the heat 
of the skin subsides, and any slight odour which may have attended 
the perspiration speedily disappears ; but the skin remains constantly - 
bedewed with moisture, and becomes daily more flaccid and less 
elastic, the pulse gets weaker, and the pain and swelling of the smaller 
joints assume a more prominent aspect. The inflammation, however, 
though continuing so obstinately, is not so acute, and does not appear 
to threaten the integrity of the joint, as true rheumatic inflammation 
does under similar circumstances. Wh^n true rheumatism fixes ob- 
stinately on a joint, the fear of permanent mischief and anchylosis of 
the joint at once presents itsdf to the mind. The inflammation of 
the other joints subsides, but the pain and swelling in the one joint 
increase daily ; and it is obvious to the merest tyro in medicine that 
if that joint be not kept motionless, and leeches, blisters, and fomen- 
tations, or mercurial ointment applied, anchylosis of the joint is the 
most favourable issue which can be expected. But it is otherwise 
in respect to the inflammation of the joints which accompanies rheu- 
matic gout. Earely, indeed, in the acute form of the disease, is the 
inflammation confined to one joint ; on the contrary, three or four, 
or even a larger number, of the joints remain aflected throughout. 
There is not the same heat, or redness, or tenderness of the aflected 
joints ; the fear of adhesive or suppurative mischief does not arise ; 
the application of a splint, and of leeches and blisters, does not sug- 
gest itself; and although the joints may remain permanently enlarged 
and distorted, they do not become anchylosed. 

** When the disease makes its approach more slowly, and assumes 
from the first a non-acute or chronic form, its features are much more 
distinctive. The patient feels weak, languid, and uncomfortable ; she 
is oftentimes chilly, but nevertheless perspires on the slightest exer- 
tion ; the appetite is capricious, the pulse feeble, the urine often pale 
and clear, and the spirits are much depressed. Up to this time 
probably there may have been no e welling of the joints, and pos- 
sibly no wandering pains in the limbs, so that no suspicion is 
entertained as to the nature of the impending mischief. The ill- 
health is attributed to the eff*ect of a mercurial course, to the drain 
resulting from an excessive flow of the monthly courses, to profuse 
leucorrhoea, to amenorrhcea, or to one of the many causes which are 
productive of ill-health, and which may have been present in the par- 
ticular case in question. But after a longer or shorter period, some 
Sain or stiffness is perceived in one or more of the joints. Not un- 
requently a knuckle becomes stifl* and swollen for weeks or months 



PBACnCAL HBDICINE, ETC. 61 

before any other joint is affected ; and even though the knees or 
other of the larger joints be enlarged, the knnckles rarely escape. 
Thej are seldom red, inflamed, or very tender to the touch ; on the 
contrary, they are relieved by gentle friction, and will often derive 
benefit even from tolerably active rubbing. Effusion within the 
joint is the principal cause of their enlargement ; but the bursse and 
sheaths of tendons around the joint are also implicated, and are felt 
as circumscribed swellings. Moreover, the mischief is seldom eon- 
fined to the immediate vicinity of the joints, but the sheaths of ten- 
dons may be felt hard and swollen in the palms of the hands and 
in other parts more or less remote from the primary seat of inflam- 
mation. 

* " In the more advanced stages of the chronic form of the disorder, 
the peculiarities of the case become even more apparent. Depression 
of spirits is a prominent symptom ; the constant clammy moistness 
of the skin is quite characteristic ; the extraordinary number of the 
joints implicated in the mischief is unlike what is observed in any 
variety of true rheumatism ; and the form of the articular swelling 
is such as cannot possibly be confounded with the effects of rheu- 
matism. It is obviously due, in great measure at least, to enlarge- 
ment of the extremities of the bones themselves, and not merely to 
effusion within their capsules, or to the thickening of the surround- 
ing structures. Thus a material alteration occurs in the form, and 
oftentimes in the direction of the joints. The fingers, for instance, 
are drawn towards the ulnar or outside of the hand, and take a per- 
manently oblique direction ; whilst the enlarged and partly dislocated 
extremities of the bones, more especially of the metacarpal bones, 
project in every variety of form, and constitute the nodosities which 
have been described by Dr. Haggarth in his * Clinical History of 
Disease.' 

" Thus, then, to sum up the principal facts which have a practical 
bearing on the treatment of the disease, it may be stated : 1st. That 
the malady originates in mal-nutrition, resulting not unfrequently 
from some hereditary infirmity of constitution, but sometimes in 
connexion with cachexia induced by a variety of causes which ex- 
haust the nervous system. 2nd. That the local changes to which 
it gives rise are essentially distinct from those produced by active 
inflammation, and more nearly resemble the results which might be 
expected from a slow perversion of nutrition ; indeed, a similar 
tendency to the formation of exuberant osseous growths around the 
joints whilst the articular textures within are suffering destruction 
and decay is observed in malignant disease of the joints, and in 
various strumous affections of the joints, both of which are connected 
with a constitutional taint. 3rd. That, whether in an acute or in a 
chronic form, the malady is one and the same, due to the same 
cause, connected with a similar failure of tone in the system, and 
productive of similar changes in the joints ; the only difference ob- 
servable between the results in the acute and chronic cases re- 
spectively being that in the former they occur more rapidly than in 
the latter. 

*< If this view as to the nature of the disorder is correct—and its 



62 PEACTICAL MEDICINE, ETC. 

whole history leaves little room for doubt on the matter — it follows 
that any treatment to be successful must have for its object the 
Bustentation of the general health and the restoration of tone to the 
system. Whilst this is being effected, means may be taken to subdue 
the local irritation of the joints, and thus to mitigate our patient's 
suffering ; but the primary object must be to improve the health, 
and so to check tlie continuance of those actions on which the 
enlargement and distortion of the joints depend. The remedies 
which are moat serviceable in rheumatism and gout are of little avail 
in this form of disease. Colchicam, iodide of potassium, guaiaeum, 
hot baths, vapour baths, and other similar remedies, if prescribed 
with a view to eradicate the disease proves mischievous rather than 
beneficial. They depress and enervate the patient, who is already" 
low and exhausted ; and thus they serve to establish the disorder 
which they were given expressly to get rid of. In private no less 
than in hospital practice the mischievous results which follow this 
mode of treatment almost daily force themselves on my attention. 
In short, if the remedies above-named are to be employed at all iu 
the treatment of rheumatic gout, they should be used cautiously 
as alteratives in conjunction with tonics, and should not be 
administered as agents to be relied upon for the cure of the disease. 
The more I have seen of this form of the disorder, the more 
thoroughly have I discarded the views which, in common with other 
medical men, I formerly entertained respecting its treatment, and 
the more completely have I learnt to trust to tonics and occasional 
alteratives, in the acute stage of the disorder it may be necessary 
for a few days to administer alkalies and alterative doses of blue- 
pill or calomel, and to restrict the diet to broth or beef-tea ; but 
when once the true nature of the malady has declared itself, I believe 
that in the majority of instances the more successful plan, notwith- 
standing the acute character of the symptoms, is to administer bark 
or quinine in combination with small doses of alkalies, and as soon 
as possible to interpose and check the continuance of the enfeebling 
clammy perspiration by means of a cold shower-bath or the drippinff- 
sheet. Indeed, whether the disease be in an acute or in a chrome 
form, the general state of the system and the ever-varying condition 
of the secretions are the only rational guides to treatment. If, as 
often happens when the disease is chronic, the secretions are tolerably 
regular and healthy, if the bowels are acting daily and the alvine 
dejections are of a natural colour, if the urine is clear and remains so 
on cooling, and if the skin is neither dry nor damp and clammy, the 
most effectual remedies are bark, quinine, strychnme, iron in its dif- 
ferent forms, cantharides, arnica, sarsaparilla, the mineral acids, and 
cod-liver oil ; and they must be given in doses proportioned to the 
amount of depression they have to counteract ; lurther, their action 
must be assisted by fresh air and exercise, change of scene, and a 
generous diet : meat twice or three times daily, with a full allowance 
of porter or ale, and wine, are essential adjuncts to the treatment. 
On the other hand, if the motions are pale, calomel or blue-pill must 
be given as alteratives ; if the urine is loaded with lithates and the 
bowels are torpid, these secretions must be regulated in the ordinary 



PBACTICAL MEDICINE, XTO. 68 

way by the exhibition of porgatives and alkalies ; the diet at the same 
time must be more or less restricted, and malt liquor prohibited. 
But even in these cases care must be taken not to depress the patient; 
and while brandy or gin or whisky is substituted for the malt liquor 
and wine, an endeavour should be made to discover some nutritious 
food which the patient can digest and assimilate. If the skin is 
dammv, and the shock of cold water is followed by reaction and 
warmth of the surface, a cold shower-bath or the dripping-sheet 
shoold be employed daily, for nothing tends so powerfully to 
stimulate the capillary circulation and restore the tone of the 
Bystem." 

Aet. 29. — Tertiary Syphilis without History of any Primary 

or Secondary Stages. 

By Mr. Hutchinson, Surgeon to the London Hospital 

{Dublin Medical Press, May 20, 1863.) 

We so frequently hear histories similar to those recorded in the 
two subjoined cases, that it is difficult not to believe that there is some 
truth in them. Commenting upon them Mr. Hutchinson says :-— 

" The two following cases came under my care on the same day, and 
as they seemed to me to present good illustrations of a state of things 
which we not imfrequently meet with in practice, and which has not 
received the attention its importance claims, I venture to record 
them. I refer to the occurrence of tertiary symptoms of an unmis- 
takable character in married persons who deny all history of 
primary or secondary ones. Of course, the denial of previous 
symptoms by the patient herself must never rank as of the slightest 
value as evidence unless corroborated by other facts, of which the 
surgeon can himself judge. But very often in the cases to which I 
refer these corroborative facts are very strong indeed. For instance, 
the woman may have borne several children, none of whom have 
suffered in any marked degree. Although not a conclusive one, 
this is a weighty fact against the belief that the patient herself has 
ever suffered from self-acquired constitutional syphilis. Still, how- 
ever, the chief reason for believing that cases of the kind alluded to 
are not unfrequently bond fide is afforded by their common 
occurrence." 

Ckue 1. — Nodes and Ulcerated Throat Twenty- four Tears after Marriage — 
No History of any previous Symptoms— The Younger Children free from 
SutpiciotM Symptoms, 
Mrs. E., a healthy- looking womaD, aged 42, came to me on February 17, 
on account of a large diffused node in front of the right tibia. She de- 
scribed the nocturnal pain as having been very severe. The node first 
formed a year ago, and she then attended Mr. Childs, who told her it was 
to be attributed to the same cause as a badly ulcerated throat from which 
she then suffered. She had never had sore throat before. A portion of 
alveolus came away. At the time of the development of the sore throat 
and nod« she was living very badly, owing to her husband being out of 
work. 



64 PBACTICAL MEDICINE, ETC. 

On the moRt careful cross-questioning, I could obtain no history of any 
other symptoms in the least resembling those of constitutional 83rphiUs. It 
will be seen that these only date back one year. I could feel no doubt that 
the node was syphilitic, and Mr. Childs, from the expression he used to her, 
evidently took the same view a year ago. She obtained most marked relief 
from the medicine ordered by Mr. Childs. Now for the married history. 
She married at 17, and was three years married before she conceived. Both 
she and her husband were throughout in excellent health. Her first child, 
bom four years after marriage, died at six weeks old, after a short illness. 
Second birth, dead-bom at seven months, after a fall; third died, aged 
thirteen months, of measles ; fourth is living, aged 11, and in good health ; 
the fifth I saw, a healthy lad, aged 10 ; teeth good ; a sixth is 5, and a 
seventh 3, and the eighth is a baby, aged ten months. The last I saw, and 
he appeared in excellent health. In addition to the above, Mrs. E. has had 
two miscarriages. Without being too definite as to how the taint was 
derived, I think it roust be admitted that she is now the subject of a late 
tertiary form of syphilis, and that her younger children have not shown 
specific symptoms. Her youngest, born siuce the first manifestation of the 
taint, is healthy. My own suspicion is, that it is an instance of slight taint 
derived by foetal contamination. The father is stated to have shown no 
symptoms. 

Case 2. — Nodes, Ulcerated Throat, and Disease of Nasal Bones Seventeen 
Years after Marriage— No History of previous Symptoms — Younger 
Fart of Family Healthy, 

Mrs. M., aged 41, came to the hospital on February 17. She had a very 
large perforation of the hard palate, and diseased bones of the nares. Her 
nose was depressed, and she had also on the forehead large depressions 
without scars. Kespecting these latter, she stated that she had noticed the 
bone falling in for some years, but did not recollect ever having had any 
swelling ; on other parts of the head she had suffered much from painful 
swellings. The throat and palate had been ulcerated for seven years, and 
began at a time when she was pregnant with twins. 

Married History. — She mairied at 17, being then in excellent health. 
Was confined a year later of a dead-bom child, and was very ill at the time. 
Then followed a series of miscarriages ; and it was seven years later before 
she had a living child. This child, a girl, is now aged 17, a stout, well- 
gi-own young woman, pallid, but without any evidences of special cachexia ; 
teeth well formed ; no keratitis. It should be stated that after her first 
confinement the mother regained good health and remained well. The next 
was a boy, now aged 14, and healthy. The next is a girl, aged 12, delicate, 
but with no specific ailments. The twins come next — two boys, both living, 
aged 7, and in good health. The last is a girl, aged 2, whom I saw, stout, 
well-grown, and without any cachexia. In addition to these still living, 
there have been bom five others (at various positions in the family) which 
have died in infancy. In none of these, nor in any of the living ones, can 
I obtain the slightest history of symptoms allied to syphilis in infancy. All 
died of acute diseases. Her husband is reported to be healthy, but to have 
a peculiar ** scaly breaking-out" on his shoulder. In this case, as in Mrs. 
E.'8 given above, it is probable that the mother has obtained the taint by 
foetal contamination, although the children had never themselves suffered 
from the disease in a sufficiently concentrated form to show symptoms. 
Observe that, supposing the father to have had syphilis before marriage, his 
first living: child was not born till eight years afterwards, so that there waa 
time for the taint to have passed into a latent and feeble form. 



PSACTICAL HBDICINB, ETC. 65 

AuT. 30. — On a Valuable Diagnostic Sign of the Existence 
of Acquired Syphilitic Taint 

"By Dr. H. Critchley Brodrick, Assistant-Surgeon Madras 
Army, and Residency Surgeon, Indore. 

{Madras Quarterly Journal of Medical Science, October 1862, and 
July 1863. 

The sign upon which Dr. Brodrick insists is substernal tenderness 
—a sign, as it appears, casually alluded to by M. Eicord, but in no 
sense insisted upon as diagnostic by this eminent syphilo^rapher. 
Dr. Brodrick says :— " I believe the importance to the practical 
physician of the discrimination of this one aid to diagnosis is incal- 
culably great, and I hope in this paper to draw the attention of 
members of the profession to it, that it may be tested by them, and 
that it may unravel the thread of many a doubtful case in their 
practice as it has done in min^. 

" Substernal tenderness can only be detected by pressure over the 
bone, and when searching for it formerly, I used to knead the bone 
with the fore and middle finders, carefully, from the manubrium to 
the xyphoid cartilage. 

*' In a case of suspected constitutional syphilis, if- the patient be 
asked if he has got a pain in his breast bone, he will probably 
answer in the negative. The medical man should then knead the 
sternum carefully and gently along the whole of its course, and the 
tender spot will generally be found at the commencement of the 
lower third. With much practice and observation in this class of 
cases I now generallv succeed in touching the tender spot at once, to 
the great surprise of the patient, previously quite ignorant of the 
existence of this tenderness. 

" If substernal tenderness be found, I believe we are quite safe in 
assuming that the subject of it labours under acquired venereal 
taint, which may have been masked by divers symptoms, and be 
quite unsuspected both by the patient and the surgeon. 

" It often furnishes a clue to the cause of very anomalous symp- 
toms, and a most invaluable guide to us in treatment. 

" For the past eighteen months I have been kneading patients' 
atemums most diligently, and have been not a little laughed at for 
the same by those not previously aware of the significance of sub- 
sternal tenderness. 

•• The native doctors attached to the Malwa charitable dispensaries, 
which I superintend, all now practice this palpation in suspected 
cases, to the very great benefit of their patients. 

" Although the existence of substernal tenderness is, I believe, 
tinerringly significant of venereal dyscrasia, it must be borne in 
mind that a patient may be constitutionally syphilitic without mani- 
festing this particular sign. But, when detected, in it the physician 
has a very valuable guide for treatment. 

" Substernal tenderness is, no doubt, produced by a periosteal in- 
flammation slight in degree and, may be in its immediate effects, 
such as pain and tenderness, inappreciable to the patient. 

XXXVIII. 5 



€6 PBACTICAL MBDICINB, ETC. 

" I have hunted diseases to their source at once, in . scores of 
cases, since I became aware of the existence and the importance of 
this diagnostic sign, and the rapid improvement of such cases under 
the specific treatment indicated above, has invariabW^ confimed my 
diagnosis. I speak confidently on this point ; that I am justified ia 
this confidence any one can test easily in his practice. 

" Constitutional syphilis prevails very largely in Malwa, so that 
I have a large field in whicn to practise palpation of diseased sterna 
amongst the sick coming to my dispensaries. I have had a limited 
experience of this diagnosing amongst Europeans, but I have found 
substernal tenderness in at least twenty such, and in as many the 
sign has led to the successful treatment of the disease it indicated. 

'* In a suspected case, then, look for this tenderness ; it will 
usually be found at the commencement of the lower third, occasion- 
ally in the upper third, and very seldom in the space intermediate. 

" I now very briefly allude to some other signs of acquired con- 
stitutional syphilis, which too are alluded to by Ricord as " inguinal 
and cervical adenito," in other words, chronic induration and enlarge- 
ment of inguinal and cervical glands. • 

" I believe that whenever you find substernal tenderness— ergo 
constitutional syphilis — you will find some of the upper tier of in- 
guinal glands enlarged, hard, moveable under the finger and pain- 
less, and never single. Bicord calls this afiection " multiple 
adenito." 

" Enlargement of the posterior cervical glands is not so easily de- 
tected, but if I take sufficient pains in the search I never fail to find 
* posterior cervical adenito.* Such an adenito may very commonly 
be found between the posterior border of the sterno-mastoid and the 
anterior border of the trapezius muscles. 

" Here then we have three very valuable diagnostic signs of con- 
stitutional syphilis being present, of which I attach most importance 
to the substernal tenderness." 

Dr. Brodrick gives a tabulated account of 62 cases, with some 
lengthy comments upon them. What it concerns us especially to 
know is contained in the following paragraph. 

" In 56, out of the 62 cases, substernal tenderness was present in 
a greater or less degree ; it was absent in 5 only — viz., in case 3 of 
congenital syphilis in an infant 18 months old, and in case 4, of the 
mother of the same infant. It was absent again in case 19, where 
the other indications of secondary syphilis had been present for 38 
days only. Absent, too, in case 23, where other unequivocal symp- 
toms proved clearly the venereal origin of disease in the nose, ozssna, 
and loss of the sense of smell. Lastly, it was absent in case 41, 
where there were present other reliable evidences of constitutional 
syphilis." 



PSACnCAL MEDICINE, ETC. 67 

SECT. II.— SPECIAL QUESTIONS IN MEDICINE. 
(a) concsbking the nebyous system. 

Art. 81. — Influence of Hi/pertrophy of the Heart and Disease 

of the Cerebral Arteries in the Production of Apoplexy. 

By Dr. A. Eulenburg. 

(Virchow's Arekit ; and Wiefner Med, Wochenschr., September 6, 1862.) 

Dr. A. Eulenburg has investigated this subject statistically in a 
prize thesis presented to the Medical Faculty at Berlin. In 42 cases 
of sanguineous cerebral apoplexy, abnormal conditions of the arteries. 
at the base of the brain — hardening, calcareous deposits, and fatty 
degeneration — were found in 29 ; in 13 cases only were the large 
cerebral arteries firee from disease. In 9 of the 42 cases there was 
liypertrophy of the left ventricle. Of the 29 cases in which disease 
of the cerebral arteries was present, there was also more or less ex- 
tensive endocarditis in 17, alterations of the valves of the heart in 19, 
and hypertrophy of the left ventricle in 6 only. Dr. Eulenburg 
hence draws the conclusion that disease of the cerebral arteries 
is a much more frequent cause of apoplexy than cardiac hyper- 
trophy. 

Art. 32. — On the relation of Chorea to Bheumatism, Valvular 
Disease of the Heart, and Pregnancy, 

By Dr. Kirkes^ Assistant-Physician to St. Bartholomew's 

Hospital. 

(Medical Times and Gazette^ June 20 and 27, 1863.) 

The following remarks are too good to be abridged, and the two 
cases which accompany them too valuable to be omitted :— 

"1. It is now well known that chorea is one of the evils to which the 
subjects of acute rheumatism, or of the rheumatic diathesis, are 
liable. This association of disease has been observed much more 
frequently in this country and in France than in Germanv, the patho- 
logists of which latter country, indeed, are disposed to doubt its oc- 
currence. (See, for exaniple, Hasse, in Virchow's * Handbuch der 
Pathol, und Therapie.' Bd. 4, p. 164.) Sometimes the chorea is 
developed during the progress, or towards the subsidence of the 
rheumatic attack ; occasionally, though rarely, it precedes the de- 
velopment of the rheumatism ; very frequently it occurs some weeks, 
or even months, after the rheumatic aflectiou of the joints has dis- 
appeared. The nature of the relation between the two forms of 
disease has been the subject of much discussion. Formerly, when 
our knowledge about chorea was much more limited than it now is, 
the development of the choreic and other nervous phenomena in the 
course of rheumatism was attributed by some to simultaneous iniiam. 
loatory mischief in the membranes of the brain or spinal cord, by 
others to sympathy of the nervous centres with coincident pericar- 

5—2 



68 PEACTICAL MEDICINE, ETC. 

ditis.* But the fact since ascertained, that rhenmatic chorea 
may occur and prove fatal without leaving any trace of inflammatioa 
about either the cere bro* spinal centres or the pericardium, shows 
that some other explanation is requisite. Dr. Begbie, who has 
written so well on ttie subject, advanced the opinion that the same 
diathesis or morbid condition of the blood whicn gives rise to rheu- 
matism may give rise also to chorea ; the irregular muscular move- 
ments, as well as the affection of the joints and of the heart being, 
in his opinion, the results of the rheumatic diathesis. (Monthly Journ, 
of Med., 1847 ; also his lately published * Coptributions to Practical 
Medicine.*) With this opinion the observations of Dr. Watson and 
Dr. Todd in the main agree. M. S^e also took the same general view, 
and even inclined to the belief that the rheumatic diathesis is the 
real cause of nearly all cases of chorea, whether any affection of the 
joints be established or not. He believed, however, that it is mainly- 
through the medium of an inflammatory affection of some one or 
more of the serous membranes, especially the pericardium, that the 
rheumatic diathesis brings about the nervous affection. (MSmoiret 
de V Acad, de Mid, Paris, vol. xv., 1850.) Cases, however, not un- 
frequently occur, and prove fatal, without exhibiting any signs of 
serous inflammation; hence such explanation cannot always hold 
good. In a paper published in the Medical Gazette, in 1850, I 
endeavoured to show that one of the most common attendants on 
fatal cases of chorea is an inflammatory affection of the cardiac valves, 
and that probably such valvular affection has an important share in 
the production of the nervous symptoms. Subsequent observation 
has confirmed me in that view, and I now believe that whenever chorea 
occurs in association with acute rheumatism, the valves of the left 
side of the heart are inflamed, and that therefore the association is 
not between chorea and rheumatism, 6,8 usually believed, but between 
chorea and valvular disease of the heart, excited by rheumatism. 
According to this view chorea occurs in rheumatism, not simply 
because of the rheumatism itself, but because the rheumatism is so 
apt to excite endocarditis, on which I believe the chorea mainly to 
depend. 

" The principal grounds for this opinion are, first, the frequency, 
if not invariableness of an endocardial murmur in cases of chorea 
associated with rheumatism ; secondly, the fact that in all the fatal 
cases of rheumatic chorea examined by myself after death the valves 
of the left side of the heart have presented unmistakable proofs of 
recent inflammation ; and, thirdly, that evidence of like inflammation 
is furnished by the records of nearly every fatal case published, 
whenever the state of the valves of the heart is mentioned. 
• " 2. Cases of chorea not unfrequently occur in which no other 
attendant morbid condition can be found than that of valvular disease 
of the heart. Sometimes such cases happen in individuals belonging 
to a rheumatic family, and in whom therefore the rheumatic diatliesis 
may be assumed to be in some degree operative ; sometimes they 

** For a full account of these views, see the valuable work of Dr. 
Burrows^ On Disorders of the Cerebral Circulation, 



P&ACTICAL MEDICIKE, STC. 69 

happen in association with some of the trivial temporary disorders, 
such as worms and the like, which have been mentioned as occasional 
attendants on chorea. Very often, however, I have failed to detect 
in such cases any evidence of rheumatic tendency to account for the 
eardiao disease, and any proof of the existence of any other ailment 
likely to explain the chorea. Whatever be the circumstances under 
which these cases of chorea occur, the evidence of valvular disease is 
usually clear, and is furnished by endocardial murmurs during life^ 
and, when they prove fatal, by structural changes observed after 
death. The existence of an endocardial murmur in many cases of 
simple chorea was long, ago pointed out by Dr. Addison, and the ob- 
servation has since been abundantly confirmed by Dr. Todd and 
others. When at the base of the heart, and attended by general signs 
of anssmia, it is of course open to doubt whether organic disease has 
any share in its production, or whether it be not entirely functional. 
When at the apex, however, where, indeed, it is most commonly 
perceived, and wnere ansemic murmurs are rarely heard, its origin in 
mitral imperfection is nearly certain. It has been suggested that 
such apex murmurs may occasionally be due to irregular choreic 
contraction of the musculi papillares of the heart, whereby valvular 
imperfection and regurgitation may be temporarily induced. Be this 
explanation true or not., and I doubt its correctness, for there is no 
good proof that involuntary muscular organs participate in the 
choreic disorder, it can only explain a temporary or momentary 
murmur, not a permanent one, such as commonly exists in chorea. 
Moreover, it is oy no means clear, as Dr. Todd long ago pointed out 
(Medical Gazette, 1849, p-664) that closure of the auriculo- ventricular 
valves would be in any degree affected by irregular action of the 
papillary muscles. One important point m connexion with these 
choreic murmurs requires to be especiaUy noted, namely, that absence 
of a murmur is no proof of the absence of even serious organic disease 
of the valves of the heart. I have repeatedly observed cases in which 
the most careful examination failed to detect a murmur, even up to 
the last day of life, yet in which after death there were unmistakable 
signs of recent acute mischief about the valves. The fact is impor- 
tant, because it warrants us in assuming^ the existence of valvular 
disease in suspected cases, even although no murmur be heard. The 
explanation of the fact is very simple ; the thickening, swelling, and 
other changes in the mitral valve, including fibrinous depositions, 
were, in the cases to which I allude, and probably therefore in others 
similar to them, observed principally, if not exclusively, on the auri- 
cular surface of the valve, above the free margin, which was thus un- 
interfered with in its power of closing and preventing regurgitation. 
The proofs of inflammatory mischief in the valves disclosed after 
death are usually quite plain, and consist of swelling, alone or com- 
bined with evident vascularity, softening and loosening of texture, a 
rough, granulated, occasionally abraded surface, and often the 
presence of separable fibrinous concretions. The change in many 
cases, however, is so very slight, and requires such careful exami- 
nation for its detection, that I am persuaded it has frequently been 
overlooked, and therefore has not been described as often as it really 



70 FBACTICAL MEDICINE, ETC. 

exists. The granules, too, are frequently so minute as to be readily 
lost sight of, unless specially sought for. Often, too, they adhere so 
loosely to the surface of the yalve that they may be readily brushed 
off in the ordinary examination of the intenor of the hear^ andthiu 
not be taken into account. Although the mischief found may thus 
be slight, and the granular deposits few and small, yet these changet 
by no means represent the amount of inflammation which may hare 
been going on during life. They represent it, indeed, no more thaa 
do the granulations on a wound after death represent the amount of 
discharge from the wound during life. Much evil may have resulted n 
from continued valvular inflammation, which leaves but little sign in. 
the degree of structural change disclosed after death. 

"3. Several recorded cases by Ingleby {Lancet, 1840), Lever 
(*Guy*s Hosp. Rep.' 2nd ser. vol. v. and vi.), Romberg ('Manual 
of Nervous Diseases '), and others, leave no doubt of the occasional 
occurrence of chorea during the pregnant state. Some of the worst, 
most furious and fatal cases of this disorder have indeed occurred 
during pregnancy. The relation which the pregnant state bearj to 
the chorea has not been clearly determined. Certain points of in- 
terest, however, are presented by the recorded cases, as analysed by 
S6e (loc» cit.), Romberg and others.* The chorea for example, 
seldom occurs before the second month of gestation, or after the 
fourth ; in one of two instances observed by myself, however, it 
commenced in the fifth month, and in the other at the end of gesta- 
tion. Similar instances of its late occurrence have been recorded 
by Ingleby and others. Sometimes, on the other hand, it begins 
soon after conception. From the third to the fifth month, however, 
appears to be the average period for its commencement (S6e), It 
is more common in primipara than in those who have already borne 
children. Also, it is more common in those who fall pregnant in 
early life than in those who do not become pregnant till'later. From 
nineteen to twenty-four is the average period of life at which it 
occurs, according to M. S^e. In one case it occurred at sixteen, and 
in several others at ages between sixteen and twenty. It may occur 
in those who have not, as well as in those who have, suffered from 
the disease on a former occasion. Its occurrence in one pregnancy 
does not necessarily entail its repetition on the patient becoming 
pregnant again, though occasionally the same patient has chorea in 
two or three successive pregnancies (Lever and Romberg). It ap- 
pears to occur independently of anything unusual or abnormal in 
the pregnant state, and of any attendant disease detectable during 
life. Once developed, it usually continues until delivery, whether 
this be premature, as often happens, or at the end of the natural 
term ; it generally ceases then, but sometimes continues longer. 

" Such are some of the main points noticed about chorea in preg- 
nancy. There is, however, nothing in them to explain the connec- 
tion. Accordingly, one is led to the belief that in this, as probably 

• For a good discussion of the subject, consult Dr. Tanner in his Sign$ 
and Diseases of Pregnancy ; see also, for refereoces tp most of the published 
oases, Dr, Charles Reeve's book on J)isease8 of the SptfuU Cord. 



PRACTICAL lUDICnS, ST€. 71 

in moat other fonu of cbovem, more is doe to the peculiar nerrous 
tempeimment of the preg^iuit perscMi, and perfaa^ to sooie attendant 
ocmaition, than to the laen pregnancj itself. Naturally the preg^ 
nant state is one whieh is attended by mudi nerrous 'excitement, 
especially when it oeenrs for the first time, and in young subjects, 
and especially, too, when it occurs under circumstances occasioning 
mueh mental distress or disgrace. This was well shown in one 
of Dr. Levick's cases {American Journal of Medical Science^ 
January, 1862), that of a young girl who had been seduced at the 
age of 16. She suffered much from the consequent shame and dis- 
grace on becoming pregnant, and soon aHer was seized with chorea, 
which killed her. The natural state of nervous susceptibility during 
pregnancy in young persons renders them also specially liable to be 
over-impressed by all causes of mental disturbance. Levick men- 
tions one case in which the death of a friend seemed to be largely 
concerned in the production of the chorea ; and another in which a 
sudden fright developed the attack. But together with these general 
and special circumstances producing an undue state of nervous ex- 
citement, and rendering the subjects unusually susceptible of anj 
additional cause of irritation, physical or moral, there probably is 
associated in most cases of chorea in pregnancy a peculiar predis- 
posing tendency to nervous affections. This is shown in the fact 
that in many of the recorded cases there had been chorea on a 
former occasion ; also that on the occasion of subsequent and quite 
natural pregnancies chorea recurred in several of them. It may be 
assumed, therefore, that the choreic tendency had all along existed 
in those attacked, but that it required the peculiar circumstances 
connected with pregnancy specially to predispose to it, and, in ad- 
dition, perhaps some direct exciting condition, like a mental nhock, 
or some associated state to develope it. Fortunately, fatal cases of 
chorea in pregnancy are rare ; but unfortunately such cases when 
they have occurred have rarely been examined thorouglily after 
death ; hence we are deprived of much that might help to an inter- 

fretatiou of the association in question. The number of oases which 
have found recorded being so few, I venture to append the two 
following to the list already published, especially since I believe 
they furnish some clue to the pathology of puerperal chorea, as well 
as of chorea in general :— 

Case 1. — A young married woman, aged 20, was admitted into St. Bar- 
tholomew's Hospital in January, 1852, being five months pregnant with 
her second child, and suffering from violent general chorea of about three 
weeks* duration. The attack bad been gradually coming on for several 
weeks before it assumed the severity by which it was characterised on the 
patient's admission. She had had no similar attack in lier former pregnancy, 
or at any other time, and had no rheumatic history. For two days the violent 
choreic movements continued without any mitigation, except while the patient 
was under the influence of chloroform, and on the morning of the third day 
she miscarried, lost a large quantity of blood, and almost inmiediately 
died. The points of chief interest disclosed on the post-mortem examina- 
tion were the following : — The substance of the spinal cord and of the 
brain, especially the cerebellum, was remarkably soft, inelastic, and pale. 
The membranes of the brain were healthy ; those of the spinal cord were 



f2 PEACTICAL MEDICINE, ETC. 

congested, and in the loose tissue immediately outside the theoa were 
large ecchymose-looking spots, consisting apparently of recently-extravft* 
sated blood. Similar apparent ecchymoses were found among the deep 
muscles of the back, on the outer surface of the heart, in the muscnliur 
tissue of the left ventricle, amid the loose tissue connecting together the 
great vessels at the base of the heart, along the costal pleura, and in the 
greatest abundance, in the tissue of the omentum, mesentery, and other 
folds of the peritoneum. On more closely examining these spots, especially 
those in the loose tissue about the base of the heart, it was found that they 
were not real ecchymoses, or extravasations of blood, but masses of small 
tortuous vessels gorged with dark, stagnant blood, which was variegated 
by pale, buff-coloured streaks, apparently of separated fibrin. So closely 
identical in appearance were the spots met with in the variou!> parts, that 
there seemed no doubt of their being all of the same nature, namely, 
portions of extreme capillary engorgement, resulting probably from soma 
cause of obstruction to the circulation therein. 

The heart was small, flaccid, and empty. The right valves were healthy. 
The mitral and aortic valves, near their borders, were studded with pale, 
soft, loosely-adhering granules. The lungs, and the various abdominal 
organs, including the recently-emptied uterus and its appendages, were 
healthy. On various parts of the trunk and limbs were numerous large 
pustules, somewhat like ordinary boils. There were also several sup- 
purating lymphatic glands in the neck, and the right mammary gland was 
enlarged, hard, unduly vascular, and many of the lactiferous tubes yielded 
a puriform fluid on section and pressure. 

The pathological appearances in this case resolved themselves, therefore, 
into a pale, soft state of the nervous centres, as commonly found in chorea ; 
soft, easily-separable vegetations on the left valves of the heart ; numerous 
patches of intense capillary congestion, resembling ecchymoses, in various 
loose textures of the body ; pustules in the skin, and suppurating lym- 
phatic and mammary glands. Nearly all these conditions were indicative 
of a contaminated state of the blood. The cause of this contamination at 
first seemed doubtful. The patient, just before the development of the 
urgent choreic symptoms, had, it was subsequently learnt, cut her thumb 
deeply ; the wound suppurated, the hand became much swollen, and at the 
time of her death the wound was still gaping and unhealthy looking. Had 
this been the source of introduction of morbid material into the blood t 
Possibly it had, although against it there is the fact that the lungs were 
healthy, and it is rarely, if ever, that these organs escape when the venous 
blood is contaminated by the products of phlebitis, or other similar noxitfus 
matters introduced. Another suggestion was furnished by the deposits on the 
valves of the heart ; these afforded indications of an inflammatory state of 
the endocardium, which was probably sufficient to have contaminated the 
arterial blood and to have brought about local obstruction in the capillaries, 
and thus occasioned the ecchymose-looking spots. The presence of these 
patches of capillary engorgement about the theca of the spinal cord may 
have contributed materially to keep up the irritation in the nervous centres 
to which the chorea was due. Without, however, commenting further on 
this case at present, let me narrate the other. 

Case 2. — In December, 1859, a healthy woman, aged 25, who had borne 
one child previously and miscarried twice, was taken in labour at her own 
home, and sent to St. Bartholomew's Hospital for assistance. The gentleman 
who attended her from the Hospital found her in a state of violent chorea. 
She was delivered of a full-grown living child in a few hours, and the move- 
ments then partially ceased, but soon afterwards recurred with increased 
severity. The patient was brought to the Hospital, and died in four days, 



PBACTICAL MEDICINE, ETC. 73 

exbanBtod bj the violence of the choreic agitation. It was ascertained 
that the chorea had commenced only three or four days before parturition ; 
also that the woman had suffered from chorea when fourteen years old, the 
attack at that time appearing to have been in connexion with rheumatism. 
The body, examined after death, appeared well nourished. The brain and 
its membranes were congested ; the cerebral substance tolerably firm. The 
spinal cord was not examined. The lungs and abdominal viscera appeared 
hesdthy. The left ventricle of the heart was a little hypertrophied ; all the 
valves were healthy, except the mitral, which presented signs of old mis- 
chief, in thickening and shortening of the tendinous cords, and of recent 
mischief, in a row of small warty vegetations along the auricular surface, 
just above the free margin. The uterine organs presented the appearance 
proper to them a week after delivery. 

In this, as in the^ previous case, there was thus signs of recent mischief 
in the mitral valve. It is on this account chiefly that the case is worthy of 
notice. The valvular affection becomes especially signiHcant when taken in 
conjanction with the fact that a similar condition of the valves existed 
(whenever the heart was speciaUy mentioned) in every one of the fatal 
I of puerperal chorea which I have found reccHrded. 



Art. 88. — On Hemicraniay or Migrain. 
By Br. E. Bu Bois-Retmond, of Berlin. 
{J(ywnicbl de Pkysiologie, July, 1860.) 

The text for this paper is supplied by the personal experience 
of the distinguished author. The principal symptoms of an attack 
of hemicrania, coming on at an interval of three or four weeks, are 
general malaise, pain in the temporal region, gradually increasing, 
never passing the median line, and disappearing towards evening. 
Pain is increased by any cause which determines blood to the head. 
The temporal artery feels like a cord ; the face is pale ; the eye of 
the side affected is small and injected ; the pupil is dilated towards the 
terminati(Hi of the attack : the ear of the side affected becomes red, 
and feels hot to sensation and touch. 

Migrain, in the author^s opinion, is a tetanus of the muscular coat of 
the arteries of half of the head, in dependence on the cervical portion 
of the great sympathetic of the side affected. The heat and redness 
of the ear at the end of the attack are due to exhaustion of the 
muscular coat of the vessel from its long contraction, the cause of 
the tetanus having ceased to act. The seat of this tetanus is probably 
in that part of the spinal cord termed by Budge and Waller the 
cilio -spinal centre. During and after the attack the spinous processes 
of the dorsal region are painful to pressure. 

When the cervical sympathetic nerve of a rabbit is galvanized the 
animal does not cry, because the rabbit is not a sensitive animal. The 
muscular pain in tetanus probably depends on compression of the 
nerves distributed to the interior of the muscles. In the case of the 
arteries the cause of the pain is probably the same, being increased 
by the lateral pressure when from any cause more blood enters them. 
We must suppose, in admitting hemicrania to be a neuralgia, that 
the sensibility of the nerves is increased. In this form of hemicrania 



74 PBACTICAL MBDICIKE, ETC. 

(for it is only 9k form of the disease) therapentio appliances onglit to 
be addressed to the cilio-spinal region. 

Commenting upon this paper, Dr. Brown- S^quard says: — 
** Migrain may sometimes be accompanied by contraction of the 
vessels of the brain, but the pain cannot be caused by contraction of 
the muscular fibres of these vessels, because the sensibility in blood- 
Tessels is lovr, and in experiments on dogs and cats (which are very 
sensitive animals)- no sign of pain is elicited where the cervical 
sympathetic is galvanized. Supposing the vascular nerves to be in 
a state of hyperesthesia, muscular compression is not the exciting 
cause of the pain, for, in a voluntary muscle, section of the tendon 
relieves the pain, though it does not remove the contraction of the 
muscle and tne pressure on its nerves* Pressure is not the cause of 
pain. A galvanic excitation of the nerves of the muscles is more 
probably the cause. Other difficulties exist in regard to Du Bois- 
Iteymond's hypothesis. One of these is that the eye is small and 
the faced pinched ; these are symptoms of paralysis of the sympa- 
thetic, and not of its irritation. The irritation must be partial : if it 
were not, epileptic vertigo would have resulted." 

In most of the cases of migrain observed by Brown- S^quard, the 
face, the ear, and the eye presented the symptoms of paralysis of 
the great sympathetic, and not those of irritation of this nerve. 

Art. 34. — On the Employment of Sliampooing in certain 
Affections of the Muscular System, especially in Lumbago. 

By Dr. EstradJire, Physician to the Baths at 

Bagn^res-de-Luchon. 

(J<mm. de M4d. tirChir, Prat., June 14, 1863.) 

This paper expatiates on the benefits derivable from shampooing, 
and enters into minute particulars as to the mode of application of 
this procedure in the various cases in which it may be required. 

Amongst other afieetions the author mentions sprains, oedema 
neonatorum, anasarca, morbid ohesily, simple and synovial cysts; 
atheromatous tumours of the scalp, slight contusions, spasmodic con- 
tractions and muscular luxations are afieetions in which shampooing 
is described as mo8t efficacious. 

Whatever be the correct theory of lumbago or torticollis, " sham- 
pooing," says Bonnet, of Lyons, "is the treatment universally 
adopted." 

Dr. Estradere adduces in illustration various cases, one of which 
was recorded in 1837 by Mr. Martin, sen., of Lyons. The patient. 
Dr. A. Petit, an eminent practitioner ot that city, had appointed 
eleven o'clock on a certain day, to meet Dr. Martin in consultation, 
and at 9 o'clock sent an apology, in which he stated that he was 
confined to his bed by a severe attack of lumbago. Dr. Martin at 
once called on Dr. Petit, and offered to give him immediate relief, a 
proposal which, of course, was thankfully accepted. 

" I placed the patient in an appropriate attitude," says Dr. Martin, 
"and in the course of j^t)e minutes, I succeeded in relaxing the 



^SACnCAL MBDICIKS, XTC. 75 

partially and irregularly coDtracted mascular fibres and in restoring 
full liberty of moTement. Dr. Petit dressed, and was enabled to 
accompany me to the house of our common patient.*' 

On another occasion. Dr. Martin relieved, in ten minutes, a man 
of a lumbago which had kept him confined for a week, and for which 
an Officier de SantS had prescribed two large blisters. As this 
gentleman declared himself entirely incredulous of the good effects 
of shampooing. Dr. Martin slily caused the patient to call on him 
at once m order to return the now useless vesicant plasters. 

In lumbago, all the muscular structures, from the neck to the 
sacrum, must be well rubbed, softly at first, and in a gradually more 
vigorous manner, with the hand, brush, or hair-glove. The frictions 
■hould be performed in every direction, vertically, obliquely, and 
spirally ; digital pressure should be applied to every spot, and the 
operation be concluded by percuraion with the hand or a wooden 
jMdlet. The patient should then perform the different movements 
of the spine, which are seldom painful when shampooing has been 
thoroughly performed. 



Art. 35. — On NiffUmare. 
By Dr. Thomas Hodgkin. 
(Britiih Medical Journal j And Dublin Medical Prett, June 10, 1868.) 
The following remarks by Dr. Hodgkin, himself a not unfrequenfc 
sufferer from nightmare, form, as it would seem, an important con- 
tribution to the true history of this distressing affection. After 
referring to some of the symptoms, Dr. Hodgkin says : — 
• " Of later years, I have observed that waking has not so completely 
done away with the conditions on which the nightmare depends, but 
that the mind, when recalled to perfect consciousness, has had suffi- 
cient opportunity to analyse them ; and a wakeful companion, in- 
terested in averting or arresting the attack, has, by recognising the 
premonitory symptoms, been able to prevent or cut short the 
paroxysm. 

" By examining the state of the pulse and heart as soon as con- 
■oiousness reminded me that the inquiry was to be made, I became 
satisfied that no material derangement could have taken place in 
that quarter. At a later period, I noticed some partial condition of 
the limbs somewhat resembling that which is felt when a part is said 
to be asleep, but to a minor degree, and without the peculiar sensa- 
tion called pins and needles. As the duration of the waking symp- 
toms increased, I became struck with the fact that the involun- 
tary movements of respiration seemed to be suspended, whilst the 
chest seemed to be passively collapsing from elasticity and other 
causes. I was natura'ly desirous to have the paroxysm terminated 
by being awakened a& soon as abortive enorts at articulation 
called attention to my distress ; but I noMced that this kind attempt 
at first rather increased than mitigated the suffering, if it tended 
in any degree to favour the collapse of the chest, as in the case 
of the hand being placed upon it. On the contrary, the most 



76 FBACTICAL MEDICINE, ETO. 

prompt and effectual relief has been obtained by so moving the 
arms that the pectoral muscles might elevate the ribs ; and it is 
now some years since I have begged that one arm might be worked 
like the handle of a pump, which completely agrees with the 
theory and practice which nave of late been ably advocated by 
Dr. Silvester in relation to the treatment of suspended animation 
from asphyxia. Keflecting on these symptoms, I recollected the 
views of the late Sir Charles Bell regarding the involuntary 
movements of respiration, and the doubts which I had entertained 
as to a particular part of the ^spinal cord, with the nerves ema* 
nating from it, bemg specially devoted to this part of the respi- 
ratory function ; and I felt almost compelled to subscribe to nia 
doctrine, the strongest argument in favour of which seemed to be 
supplied by the fact that when, in the state which I have described 
to exist, on waking in the paroxysm, I have made forced voluntary 
efforts at inspiration by raising the ribs to expand the chest, the 
diaphragm, instead of simultaneously descending, was, on the 
contrary, elevated by the pressure of the atmosphere on the abdomen 
— a result which would hardly have taken place had the normal 
provision for the co-operation of these parts been in working order. 
I felt persuaded that, if the state wnich I have described were 
not relieved by the early waking of the patient or by the efforts 
of assistance opportunely at hand, death must be the consequence* 
It is probable that persons who have been found dead in their beds 
may have so perished ; and verdicts of death from affection of the 
heart may have been recorded in consequence of the distended con- 
dition of the right cavities. 

* ■» • .* « • 

" Having commenced but not completed committing these reflec- 
tions to paper before starting for a journey on the Continent, I have 
had an opportunity of conversing upon the subject with my friend 
Dr. Foville, whose attention is well known to have been long turned 
to the anatomy, physiology, and pathology of the brain and nervoui 
system, and whose abandoning of the completion of his work is a 
grievous loss to our profession. The Doctor, afier patiently hearing 
my statement, was so far from rejecting my ideas, that he related a 
case tending to confirm them. A patient of his, labouring under 
some form of paralysis which ultimately occasioned his death, com- 
plained of being distressed with nightmare on falling asleep. The 
Doctor, having an opportunity of watching the approaches of the 
paroxysms, observed that his respiration became mterrupted, and 
then suspended, which resulted in his waking up in agitation and 
fright. Attention to position in his sleeping state to some degree, 
but imperfectly, prevented the paroxysms. Dr. Foville further told 
me, in reference to what I have said regarding the eighth pair of 
nerves, that Professor Blainville had made some experiments on the 
section of them, in the course of which he observed that the death 
of the animal was accelerated if it were placed on its back, but 
retarded by the chest being downwards, as when it is in the standing 
position ; which seems to coincide with the need to facilitate and 
maintain the voluntary efforts at respiration." 



FBACTICAL MEDICINE, ETC. 77 

Aet. 36. — Case of Acute Myelitis, in which Recovery 
was materially assisted by Cod-liver Oil. 

By Dr. Eadcliffe, Physician to the Westminster Hospital. 
(Lancet^ October 81, 1868.) 

Acute myelitis, there is reason to believe, was the most prominent, 
though not the exclusive, disorder in this case ; at any rate, this 
case affords an instance, almost unique, of recovery from an acute 
disease of the spinal cord of the very gravest character, and an 
illustration, as it would seem, of the good which may result under 
similar circumstances Irom the employment of cod-liver oil. 

Case. — George D , aged thirty-three, a groom, admitted under Dr. 

Badcliffe into Burdett ward, June 17th, 1862. A well-made, moderate- 
sized man, of florid complexion and sanguine temperament ; features unsym- 
metrical ; mouth drawn to left side ; no winkin&r movement in right eye ; 
pupiU natural, equal, and properly responding to light; head somewhat 
botter than natural; breathing chiefly diaphragmatic; pulse 120, fairly 
strong ; extremities, especially lower ones, cold ; t«>ngue protruded to right 
side, moist and pasty. Complains of pain in the back, from about the 
third lumbar to the first dorsal vertebra ; of loss of power of movement in 
both lower extremities, accompanied with partial loss of sensation ; of partial 
loss of the power of movement in both arms ; but not of any feeling as of 
a cord around the abdomen. Complains also of sleeping badly. Speech 
rather thick and drawling ; manner rather irritable; memory unimpaired. 
Pain in back increased on the application of a hot sponge. Lower extre- 
mities somewhat numb, but painful to the touch, and even to pressure of 
tibe bedclothes. No difference in temperature of the legs ; right leg per- 
fectly paralysed, the left leg can be moved slightly with a strong effort. 
Tipper extremities somewhat numb, and power of movement considerably 
impaired ; inability to grasp forcibly with either hand. Cannot tell when 
the little toes are pinched ; feeling retained in the other toes ; no reflex 
action produced by tickling the soles of either foot. Impressions can be 
felt more clearly on the right (paralysed) side of the face than on the left, 
but no well-marked difference of temperature on the two sides. No into- 
lerance of light or sound, or but the very least ; no diplopia. While talking 
to him his countenance became greatly flushed and the surface of the trunk 
hot; and he says that he often "comes over in heats and sweatings." 
Appetite moderate ; no difficulty in deglutition. Bowels constipated ; no 
tympanitis. Micturition natural; urine clear, acid, dark straw-coloured, 
and, in short, natural ; chlorides present in fair quantity. 

Previous History, — On June 6th (ten days ago) he was seized with sharp 
pain in the back and in the calves of the legs, the former pain reaching 
from low down in the loins up to the root of the neck. On the 8th he was 
able to walk about, and the walking seemed to distract his attention from 
the pain. Next day he was obliged to give up work and take to his bed. 
On the 13th, one of his companions noticed that his face was awry, and on 
making further inquiry he found that he could not close the right eye ; 
patient observed that the right half of a cup from which he was drinking 
felt larger than the other half. Twenty years ago he fell from a tree and 
ahghted upon his back, but in a week was " all right," and since that time 
has never felt any ill consequences from the accident. Was never seriously 
ill. Is moderately steady. Has been a widower three years and a hal^ 
after being married nine years. Denies all intemperance in sexual mattei-s. 



78 PBACTICAL MEDICINE, ETC. 

Dr. Latham, who admitted the patient in Dr. Badctiffe*s absence, ordered 
cupping at the loios to the extent of four ounces, and a draught of the 
liquor of the bichloride of mercury in decoction of cinchona three times 
a-day. 

June 18th. — Slept badly ; pain i^ back somewhat relieved. A blister, 
four inches by two, to be applied to the nape of the neck. 

19th. — Very thirsty; back painful. Pulse 120; respiration 20, and 
chiefly diaphragmatic. 

20tb.— Slept indifferently well. Complains of pain on each side jtuit 
above the hips. Has complete power over the bladder, aod the urine is 
normal ; but passes motions under him in bed. Has to be moved every 
half hour or so, on account of the pain in the back becoming greatly 
increased if he remains long in one position. Great pain is experienced if 
he makes any attempt to move himself. 

Dr. Radcliffe took charge of the case to-day, and ordered six ounces of 
brandy in the course of the day, and five minims of solution of acetate of 
morphia every four hours. 

21st. — Pulse 120 ; respiration 24. No reflex action on tickling the soles 
of the feet. Lies with the knees flexed, and with a pillow under the bams 
to relit)Ve the aching pain in the calves. Cannot tell which toe is pinched, 
though he feels something. Has no appetite ; is very thirsty ; and has 
profuse night- sweats. 

22nd. — Slept well. There is a slight excoriation on the inner side of the 
right thigh ; he feels the legs warmer, and thinks he has more power over 
the right leg. 

23rd. — Complains of aching pain in both arms and in the right ankle. 

24th. — Facial paralysis manifestly improving ; can almost close the right 
eye ; tongue protruded with scarcely any deflection. " Pins and needles" 
felt in both arms ; the latter ara cold to the touch, but he says they feel to 
himself warm rather than cold. A purgative enema ordered.* 

26th. — Back more painful ; cannot tell which toe is pinched. Asks for a 
mutton chop. 

28th. — Legs ached very much last evening. 

80th. — Pulse 96 ; much more power over the legs, and much less pain. 
To continue the morphia. 

July 2nd. — Power in the legs increasing ; sensation of numbness and 
** pins and needles" in the hands occasionally present. 

7th. — Legs feel numb and cold to the patient, and are very tender and 
painful to the touch ; more power of movement in the legs, and also in 
the arms. 

13th. — Dr. Fincham saw the patient for Dr. Radcliffe, and added a 
twenty.fourth of a grain of strychnia to the morphia draught. 

15th. — Scarcely any trace of facial paralysis. Yesterday and the day 
before the man sat up in bed for a short time, and got into the position 
without help. 

20th. — Strychnia increased from a twenty-fourth to a sixteenth of a 
gram. 

22nd. — Legs ache very much ; tongue put out straight, but right eye- 
lids not quite so much under command as they were a few days ago. 
Appetite indifferent. 

28th. — Back painful; legs also painful and sore to the touch ; muscles d[ 
the extremities, particularly of the legs, very much wasted, but much more 
power of movement. For two or three days the patient has got up with 
assistance, and remained sitting in a low chair several hours a day. Tur- 
pentine stupes applied to his back. 

Aug. 5th. — Progressing, but very slowly, in a right direction. Dr. 



PRACTICAL XBDICIHE, ETC. 79 

Badoliffe ordered hhn to dieoontinne the morphia and the stfychnia, and to 
take more meat, and three drachms of cod-liver oil thrice a day. 

8th. — ^The oil causes some nansea, bat it is persevered with ; gets np 
daily ; bowels act now without enemas ; power over the right eyelid re- 
oovered, and all signs of facial paralysis at an end. 

12th.— Considerably better in all respects. To have full diet and a pint 
cf porter. 

18ih. — Much stronger ; can now get oat of bed withoat assistance, bnt 
cannot stand alone; knees very stiff; sits up several hoars every day. 
Appetite good. 

27th. — Can now bear his weight on his legs if he steadies himself against 
anything. To have galvanism applied. 

80th.— The galvanism (the continaous and interrupted current were both 
tried) could not be borne, as it caused so much pain, even in feeble currents ; 
can now stand without any support. Cod-liver o>l to be increased to four 
drachms. 

S^t. 9th. — Legs less painfuL With the aid of a stick he can now walk 
about the ward. 

14th. — Went up stairs to chapeL 

16th.— Went out for a walk. 

ISth.— Leaves to-day for the country. He still takes the cod-liver oil, 
and he says that it warms and strengthens him. Circulation still very de- 
fective in the hands and feet, which are generally cold aud somewhat livid ; 
calves of the legs still sore and painful on pressure ; no pain whatever in 
the back, even on percussing the spine somewhat roughly with the knuckles ; 
the nutrition of the wasted muscles improving. 

Ndv. 11th. — Since last report he has been staying at St. Albans, Herts, 
and came to-day to report himself. Can now stand or walk about all day 
long without the least fatigue or inconvenience, and feels strong and hearty. 
General condition much improved. 

Dec. 5th. — ^Again came to show himself. He says that he is now quite 
well, and that he is looking out for a situation. 



Aet. 87. — Case of Incipient " Wasthiff PaUf^ Cured. 

'Bj Dr. J. Russell Reynolds, Physician to University College 
Hospital, Special Professor of Clinical Medicine in Uni- 
versity College. 

(Laricet, July 11, 1863.) 

W. J , a married man, aged thirty ; height, five feet six inches ; 

weight, eleven stone ten pounds ; of good muscular development ; pale com- 
plexion ; unimpaired general health ; the subject of no known hereditary 
disease ; fi^e irom gout, rheumatism, or syphilis ; daily working, in a high 
temperature, at the teasing rather than laborious occupation of piano-forte 
" regulation ;** of temperate habits, and accustomed to exercise himself in 
an open-air gymnasium — on December 27tb, I860, fell backwanls, while 
skating, and struck the back of his head ; but immediately got up again, 
felt slight ** heaviness of head," but nothing else, and went on skating. 
Eariy in February, 1861, a fellow-workman said to him, **your eye is not 

right,** and W. J found, upon looking in a glass, that the left pupil was 

much larger than the right. Vision became impaired three days later, and 
to such a degree that he could make no reliable use of the left eye. It a^- 
jieared, he ftays, * * aXL pupil, and looked like the eye of a dead fish. ' ' A week 



80 PBACTICAL MEDICINE, ETC. 

later he felt acute pain at the back of his head, with a sense of great weight 
inside tlie skull. Brushing his hair caused great uneasiness. 

In April, 1861, he became an out-patient of University College Hospital 
The left pupil was much larger than the right, there was constant pain in 
his head, great pallor of the skin, but no muscular or sensorial change. In 
July he was well. 

Towards the close of September he felt slight pain in the left arm and 
shoulder, and this he at the time called "rheumatism." After it had lasted 
for some days he was exposed for several hours to cold wind and rain, which 
especially drove in up(m his left side, during a day^s rifle practice at Ports- 
mouth. Three or four days later his arm felt ** unusual" and " weak." In 
rowing he could not keep the boat straight, but pulled it round to the left 
side. Unless making some considerable exertion of this kind he was, for 
about a week, not conscious of anything being wrong ; but afterwards he 
found that his arm became gradually more feeble ; that he could not get his 
elbow away from his side, although when resting the elbow he could use 
the left hand perfectly ; that he had difficulty in dressing himself, ' and 
after a little time was unable to accomplish this process without help. 

Oct. 15th, 1861. — Again became an out-patient of University College 
Hospital. He is pale, but fairly nourished ; lips red ; he has no general 
uneasiness, nor local pain, except occasionally, at night, in left shoulder ; no 
oedema of ankles, no blue line on gums, no eruption on skin, no headache^ 
no joint aflection. He has perfect use of all his muscles but those of the left 
arm and shoulder, which are thus affected : — He cannot move the arm out- 
wards to the very slightest degree ; but can just stir it a little backwards 
and forwards. If raised by observer it drops heavily to the side ; there is 
no rigidity ; and passive movement is painless. He can lay hold of bis left 
wrist with the right hand and move it anywhere without the least discom- 
fort. He has no power to flex or extend the forearm. He can pronate or 
Rupinate the wrist ; he can flex or extend the hand and fingers readDy and 
freely, but the grasp of the hand is notably weaker than that of the right. 
There is marked wasting of the muscles, so that the acromion appears 
sharply prominent. The deltoid, biceps, triceps, and pectoral muscles 
feel soft and flabby. None of them exhibit any contraction upon percussion, 
nor do those of the other side. No fibrillar vibrations are visible : all the 
muscles of the left arm and forearm exhibit electric contractility ; but the 
biceps and deltoid much less than the muscles of the forearm ; the anterior 
and middle bundles of the deltoid much less than the posterior. The deltoid 
cannot bejstimulated to contract so much as to affect the position of the arm ; 
but a strong current (intermittent) applied to the biceps produces slight 
movement of the forearm. These movements are painless. The differences 
in size, ascertained by measurements at several points, vary from half an 
inch to an inch in the circumference. The temperature in the left axilla is 2° 
Fahr. lower than in the right ; that of the deltoid 3" ; that of the biceps 
identical. The sensibility of the skin is normal. 

An intermittent current was applied daily, and very carefully, by Mr. 
Herbert Taylor, who found the muscles more sensitive on the 19th ; and 
on the 23rd the biceps very acutely sensitive; the contractions of the 
muscles being more frequent and stronger. 

30th. — Nutrition of muscles much improved, but power and temperature 
as before. 

Nov. 9th. — Paralysis as at first report, but nutrition notably increased, 
and electric irritability much greater. On applying a continuous current 
through the deltoid and biceps, he was able, in a few seconds, to raise 
his hand, quickly and strongly, to the level of the ensiform cartilage. 

19th. — Continuous current was applied daily from Uie 9th to the 18th, 



PSACnCAL MBDICIKB, ETC. 81 

but witbont any appreciable effect. The interrupted current was again 
leiorted to^ and on the 2lBt he could lift his hand to his mouth, and take a 
light object from off the mantel- piece. 

23rd« — Electricity discontinued on account of extreme pain in the arm ; 
and on 

Deo. 6th it was found that he had lost much of the power that he had 
gained in November. Temperature as before. Various applications of 
electricity were made without any good effect, and it was noted, on 

Jan. 15th, 1862, that the arms appeared equally developed, right and 
left^ bat that the power of movement was as before. The thirtieth part of 
a grain of acetate of strychnia was now given three times daily, and in the 
oonrse of a fortnight the arm was well. 

Since this time I have frequently seen W. J , who has retained fully 

the strength and usefulness of his arm. Upon two occasions be has suffered 
from pain in the head and dilatation of the left pupil, but these symptoms 
have rapidly yielded to treatment. 

The bearing of this case uj^on the clinical history and pathology of 
" wasting palsy" may be briefly stated thus : — 

Since the loss of power did not depend solely upon the impaired nutrition 
of the muscles, and the muscular tissue wai not primarily affected in 
W. J , it may be inferred — 

1. That neither the muscular tissue nor the ganglionic system of nerves 
was the starting point of morbid change. 

As muscular and cutaneous sensibility and electric contractility were 
persistent; and they, with the nutrition, speedily became, under treat- 
ment^ either normal or exaggerated, while voluntary power remained in 
abeyance, it mi^ be presumed — 

2. That the function of the nerve- trunks was not destroyed, and that the 
seat of " wasting palsy*' was not in them. 

Since the palsy was preceded and has been followed by signs of distur- 
bance in the cerebral functions, it is to be inferred — 

3. That the affection had its remote origin in the injury inflicted upon 
the head. 

But as there was marked diminution of electric contractility and 
sensibility, and of nutrition, and moreover as the paralysis was in the 
upper portion of the affected limb, it may be presumed — 

4. lliat loss of cerebral function was not the sole cause of symptoms. 
Since the nutrition, contractility, and sensibility were diminished, but 

not lost^ while voluntary power was entirely abolished, it may be con- 
daded — 

5. That the central functions of the medulla spinalis were, pro tantOy 
diminished, and its conducting property was in abeyance; and that, in 
the impaired nutrition of that organ we must seek for the essential fact 
in ** wasting palsy-" 



Art. 88. — On Ephemeral Mania, 

By Dr. J. 0. Browne, Assistant Physician to the Derby 

County Asylum. 

{Piychological Journal and Medical Critic, January, 1868.) 

Ephemeral mania, according to Dr. Brown, consists in a transi- 
tory isolated attack of mental disturbance, usually not exceeding 
forty-eight hours in duration, and which is apt to be confounded 

XXXYIU. 6 



82 PRACTICAL HEDICINE, ETC. 

with ordinary general mania— which malady it very closely 
resembles in many particulars. The brevity of its continuance, how- 
ever, separates it widely from mania proper, and renders it quite un- 
necessary that those suffering from it should be removed to an asylum. 
Indeed, any such removal would be prejudicial to those afflicted with 
mania ephemera ; for upon recovering themselves and awakening as 
from a troubled dream, they would obviously incur great rist of 
relapse or of regression into some more permanent affection from 
the shock at finding themselves in such a place, from the vexation 
and chagrin inseparable from a realization of their true position. It 
is, therefore, of much consequence to recognise this disorder, which is 
capable of easy cure at home, which is so fleeting and evanescent, and 
in which the mind is not overthrown nor even gravely damaged ; for 
whenever the tyranny of the attack is overpast, with wondrous 
elasticity the mmd springs up and regains its former stature and 
rectitude. 

The causes of mania ephemera are very various. Debilitating 
influences, such as deficient nourishment, impurity of the atmosphere, 
sedent«ry habits, confinement, and lack of exercise, exhausting 
exertion of mind or body, but especially of the former, unhappy 
circumstances, previous disease of a weakening or nervous character, 
excessive indulgence in stimulants, and hereditary proclivity to dis- 
ease, are all powerful in predisposing to it, as to disease in general. 
These causes are particularly potent when operating upon a nervous 
temperament. Excessive mental emotion is pre-eminently an exciting 
cause. Grief, surprise, fear, anger, or joy, is a usual precursor. A 
man may be frightened to madness as well as to death. This mad- 
ness may be of no temporary kind, but it is nevertheless true that 
the great majority of instances of temporary insanity may be traced 
to overwrought feeling in its corporeal relations. It is, indeed, 
characteristic of ephemeral mania that its immediate cause is almost 
invariably obvious and prominent, and not, as frequently is the case 
in other varieties of mental alienation, hidden and imperceptible, 
quietly, stealthily undermining bodily functions and mental powers, 
unrecognised even by watchful onlookers, except in the catastrophe 
which it' has brought about. It is further characteristic that the 
cause is generally ^uick and sudden in its operation, not slowly 
progressive, but rapidly culminating in mental derangement. The 
more violent passions, ungoverned bursts of temper, unexpected 
Borrows, family dissensions, reverses of fortune, bitter disappoint- 
ments, agitating joys, novel and powerful religious impressions, are 
most prolific exciting causes, and these acting in combination with 
certain predisposing and physical circumstances, bring about a 
temporary perturbation of the mind, just as with predisposing and 
physical circumstances of another description, they might entail 
more lasting disorder. Indeed, ephemeral mania seems generally 
to consist essentially in an alteration of the cerebral circulation, 
following upon some kind of over-excitement of the emotions. 

Case. — F. F., cet. 60, a small farmer, of nervous temperament, 
was brought to the Derby County Asylum in a strait-waistcoat, his 
legs being secured by ropes. His body was marked with several 
extensive bruises in consequence of the coercion to which he had 



FBACTICAL HBDICINB, ETC. 83 

been snbjected. He was shouting aloud short Incoherent sen- 
tences, uttering imprecations against those around, whom he seemed 
to suspect of conspiracy against him, and struggling violently to be 
iree. He did not answer the questions put to him, but continued to 
ory out and to cast furtive glances about him. He appeared to be in 
weak bodily health ; his pulse was 100, but feeble and thready, his 
face flushed, his head hot, his tongue coated with a white fur; 
respiration hurried. The pupils were slightly dilated, but sensitive 
to light ; the muscular movements were tremulous. General and 
specml sensibility were normal, as far as could be ascertained. The 
history of the case was elicited as follows. F. F. had suffered much 
grief and anxiety on account of the undutiful and cruel conduct of 
his children, also from business reverses ; and after a domestic 
quarrel, twenty-four hours prior to his admission, suddenly became 
insane. His insanity was manifested by sudden maniacal excitement 
and incoherence. He had stripped himself to his shirt, seized a crow- 
bar, rushed from his house and down the public street, threatening 
to murder any one who approached him. It was with the utmost 
difficulty he was overpowered and restrained. He had been sleep- 
less and had continued raving wildly all night. He never was insane 
before, and never had any relatives insane. Immediately on his 
admission he had a warm bath and a mild purgative. He had not 
been an hour in the institution before he became comparatively 
rational. At his own request he retired to bed. He at once fell 
into a placid sleep, and on his awakening in the evening, no trace of 
insanity was discoverable in him. He has since continued quite 
well. He has but a very dim recollection of all that transpired 
daring his excitement. 

The symptoms of mania ephemera are invariably modified by the 
period of life and circumstances of the sufferer. When appearing in 
females, produced by influences operating through the generative 
focus of the ccensesthesis, they usually partake of an hysterical 
character. The rapid evolution of the sexual organs and functions, 
or the derangement of these, sometimes induces morbid mental 
activity. Illustrative of this is the following case, with remarks, 
translated from Marc : — 

"A female, subject at each catamenial period to mental disturbance, 
encountered, while thus affected, one of her own sex, whom she 
grossly insulted, in the presence of another person. The aggrieved 
party complained; the aggressor denied the fact, and the judge 
accepted her protestations of innocence upon oath, which was made 
in good faith, as she could recal nothing which occurred during these 
paroxysms of excitement. The complainant was found liable in 
expenses ; but, discovering the witness of the injuries to which she 
had been exposed, and her declaration having been admitted, the 
falsehood of the original oath became evident. 

" In consequence of this. Professor Berends, Frankfort sur I'Oder, 
was called upon to answer the following interrogatory: — Is the 
state of the accused such as to admit that her paroxysms of anger 
are such that she cannot recal what takes place during their 
continuance P 

6— a 



64 FSACTICAL MBDICIITB, STO. 

"The report of the Professor was to the effect, that he had 
attentiyely studied the documentary evidence, and that he had 
personally, and in the presence of another medical man, investigated 
the sanitary condition . of the accused. Surgeon L., who had pro- 
fessionally attended the woman, assured him that on the arrival of 
the menstrual period, and during the discharge, she was constantly 
attacked with an orgasm and cerebral congestion, with febrife 
acceleration of pulse, and that the exacerbation was ordinarily so 
violent as to be attended with delirium. During the epoch she 
became very irascible and subject to paroxysms of furious anger : 
her own statements corresponded closely with those of her medical 
attendant." 



Art. 89. — On Spiritualism as a Cause of Insanity. 

By M. BuRLET. 

{Medical Critic and Psychological Jov/mal, July, 1863.) 

The article from which the following quotations are taken is the 
translation of a memoir originally published in the Gazette Mddicale 
de Lyon, and recently brought out as a separate brochure in Paris. 
M. Burlet says : — 

" Lyons, for its part, has already furnished a fine contincent of 
madmen from spiritualism. This city, where intellectual and other 
juggleries have always obtained a very happy success, has become, 
as it were, the stronghold of the sect. According to th^ avowal of a 
medium of Brottreux, the number of his adherents has within 
eighteen months been prodigiously augmented. ' Lyon * (says M. 
Piguier), • with its heights, the ridge of the Croix-Kousse and the 
summits of the Eourbieres, represents admirably what the spiritualists 
call a fatidical place.' Thus, it is not surprising that this city, which, 
at the end of last century, built a temple to the great thaumaturgist 
Cagliostro, accepts readily the celestial words with which the spirits 
daily favour it. The partisans of spiritualistic ideas maintain, with- 
out proof, that their doctrine is mcapable of producing mental 
alienation. Nay, one of them even pretends that spirituausm is a 
sure preservative against insanity. 

*' My object is to prove that spiritual practices act as a direct and 
efficient cause of insanity, and, consequently, that spiritualism ought 
to have a place among the causes of mental maladies. For several 
years, the Hospice of Antiquaille, Lyon, and other special estab- 
lishments of the department of the Khone have given refuge to a 
great number of unfortunates become mad from having sought for 
mediumnity. From among these I derive my observations. 

" These cases are not all that could be brought forward to prove 
the danger of spiritualism. Other special establishments of the 
department have received a good number of lunatics whose lunacy 
admitted of no other explanation than frequenting mediums. Dr. 
Carrier within a short space of time, has treated, and seen recover, 
among his patients three females who had been rendered insane by 



PBAOnCAL MEDICINE, ETC. 85 

I 

■piiitoaligm. I would re|)ly here to a remark which might be made, 
tnat I ha^e only met with spiritualistic lunatics among the more 
humble classes of society. This is true, because those patients re- 
oeived at AntiquaiUe, m the immense majority of cases, if not 
■Iwayi, are the poor and indigent. But, independently of the 
names cit«d towards the close of this paper, I know from trust* 
worthy sources, that the gates of a well-known maison de sant^, 
principallv resorted to by the rich, have admitted within its walls 
Tictims of spiritualism from among the aristocracy. It may be said 
that, haring retard to the number of those who study and practise 
intercourse with mediums, the number of lunatics is very restricted. 
This opinion is not well grounded ; the lunatics from spiritualism 
are not solely those whom it is found necessary to confine in an 
asylum. There are many, and of these I know many, who although 
they have not reached the same condition as those whose histories I 
have related, still give proofs daily of being more or less stricken in 
their intellectual faculties. 

" In America, the country which gave birth to this delusion, and 
where it is in ^reat favour, the number of cases of mental alienation 
occasioned by it is prodigious. An United States' journal declared 
in 1862, ' The majority of the mediums become haggard, idiots, 
mad, or stupid ; and it is the same with many of their auditors. 
Not a week passes in which we do not hear that some of these un- 
fortunates destroy themselves by suicide, or are removed to a luna- 
tic asylum.' 

*• In France, individuals belonging to the upper classes of society 
also become victims to the destructive power of spiritualism P An 
advocate of Paris, Victor Hennequin, who placed himself in re- 
lation with the soul of the earth by means of tables ; and who, 
under the influence of spiritualism, wrote the opuscule entitled 
Sauvons le Genre HumaiUf died in a lunatic asylum, after having 
placed his wife, who became a lunatic from the same cause, in an- 
other asylum. A distinguished man of science, Girard de Caudem- 
berg, a civil engineer, died also lunatic in 1858, after having pub- 
lished a spiritualistic book, entitled Le Monde Spirituel. Among 
all classes of society spiritualism has found adepts and victims, and, 
tmhappily, the prediction of the journal just quoted has been fully 
realised. 

" The causes of the propagation of spiritualism are the same, 
modified by the manners and knowledge of our time, as those under 
the influence of which grew and were propagated in former ages 
many analogous intellectual epidemics, sucn as the demonolatry in 
Lomoardy in 1504, in Lorrame in 1580, in the Jura in 1598, in 
Spain in 1630 ; and the vampirism in Poland, Hungary, and Moravia, 
from 1700 to 1740. Scarcely three years have elapsed (1859) since 
an epidemic of hystero-demonomania was observed at Morzine 

i Haute- Savoie), as reported in the Gazette Medicate de Lyon^ by 
)r. Arthaud. 

" * This love of the marvellous,' says M. Figuier, * is not peculiar 
to our epoch ; it is of all times, and of every country, because it ap- 
pertains to the human mind; By an instinctive and unjust distrust 



86 FSAOTICAL HEDIOIKB, ETC. 

of bis own j>ower8, man is led to place above himself invisible 
powers, exercising themselves in an inaccessible sphere. This natural 
disposition has existed at every period of the history of humanity, 
ana invested, according to the period, the place, and the manners, 
with difiTereut aspects, it has given birth to manifestations variable 
in their form, but at the bottom identical in principle.' 

" If, in other parts of France, cases of insanity induced by the 
doctrines of the mediums, are as frequent as in the department I 
dwell in, no reason to the contrary existing, it seems to me that 
there can be no doubt that spiritualism should rank among the most 
fruitful causes of mental alienation.'* 



Art. 40. — On the Use of Digitalis in the Treatment of 



"Bj Dr. 0. L. Robertson, Medical Superintendent of the Sussex 

Lunatic Asylum, Hayward's Heath. 

(British Medical Journal, October 3, 1863.) 

After some preliminary remarks upon the history of the use of 
digitalis in the treatment of insanity, and the physiological action of 
digitalis on the cerebro-spinal system, Dr. Robertson proceeds to 
state his own practical experience with regard to the meaical use of 
this drug in tne treatment of insanity : — 

" a. Dose and Method of Administration, — With a wholesome fear 
of a coroner's inquest, I have not ventured on half-ounce doses, and 
I can report nothing as to their effect. I believe they would be too 
much for the average stamina of our patients. I have never given 
more than drachm doses ; and I have usually found two or three days 
of such doses three or four times a day brought on the poisonous 
symptoms of the drug, with intermittent pulse, great reduction in 
frequency, and oppressive nausea. The respirations were also 
reduced m number ; and the specific gravity of the urine lowered, 
and, so far as I know, the quantity increased by the use, in drachm 
doses, of the tincture. .Thus, in a case of general paresis, in the 
second stage of mental alienation, on which I made some observations 
last November, the following results were shown: — 

Hour and dose. Pulse. 

" November 15. 9 a.m. Jj 81 

12 NOON 5i 67 

3.30P.M.5J 76 

8 P.M. 5j 69 

November 16. 9 a.m. Xj 81 intermit. 

12 NOON. !Patient complained of headache and 

pain at cardiac region. No medicine. 

2.30 P.M. 5j 94 intermit. 30 

6.30 „ 5j 80 „ 26 

November 17. 9 a.m. 5j 80 regular 1017 25 

7 P.M. 5j 72 regular 27 

'* Under this treatment, all the maniacal symptoms present had 



Urine. 


Respiration. 


1022 


28 




26 




28 




26 


1009 


26 



FRACnCAL MSDICINE, BTC. 87 

yielded. The treatment was kept up with half-drachm doses twice or 
thrice a day for two or three weeks to the entire and permanent 
relief of all cerebral excitement. 

^ " This and similar experiments led me to fix m j average dose of the 
tincture at half a drachm, although I often for the first few days of 
treatment give drachm doses. I have never given larger doses. I 
have always given it simply in water; and I nave not complicated 
my observations by the aomixture of any other drug.* The tincture 
has been supplied to me by Messrs. Taylor, of Vero Street, Oxford 
Street. 

" h, FortM of Insanity in which Digitalis has been employed, — ^I 
have, during the last year and a half, exhibited digitalis in the form 
of the tincture in twenty to thirty cases of maniacal excitement, 
recent and chronic, with varying results. 

" First, as to the failures. In three recent cases of mania depend- 
ing on uterine excitement, two in young girls and one at the change 
of life, I steadily pressed the use of the drug until its poisonous 
efiects, as shown in sickness and vomiting and intermittent pulse, 
were produced. The dose given was, in each case, half a drachm of 
the tincture three times a day. The result was simply that the 
patients when very sick were quiet, and that so soon as the nausea 
passed ofi* the excitement returned. Again, in two severe cases of 
recurrent mania, I only produced sickness and depression of the 
pulse, and no amendment of the mental symptoms followed this 
physiological action of the remedy. 

•• On the other hand, my success with this drug in cases of genera 
paresis, in the second stage, that of mental alienation with sympton^ 
of maniacal excitement (and in which so often in private practice aid 
18 sought pending the patient's removal to an asylum), leads me to 
regard its action in controlling cef ebral excitement, as quite specific. 
I have, of course, had my share at Hay ward's Heath of these trouble- 
some cases — and how noisy and wearing they are every asylum 
physician knows to his cost — and they have ceased to give any 
trouble under the culminating action of digitalis. 

" It is with these cases of general paresis, in the stage of mental 
alienation with maniacal excitement, that the assaults and injuries in 
asylums (which from time to time unfortunately occur) arise. There 
is such a reckless violence present, on which no moral or physical 
obstacles make the slightest impression, and this stage lasts so many 
weeks, if not months, that any remedy at all capable of controlling 
this state of things deserves a most careful trial. And such a remedy, 
I believe, we possess in digitalis, continued steadily day by day, 
while the tendency to excitement lasts, in half-drachm doses two or 
three times a day, or oftener. 

" It acts in every case of the kind in which I have given it as a 

* In many cases of chronic mania, with sleepless noisy nights, I have 
&and the following sedative mixture of value. 

R. TinctursB digitalis, tincturae cannabis Indicae, liquoris opii (Taylor), 

etheris chlorici, singulorum uncias tree. 
Dose— half a drachm, repeated at intervals of three hours. 



88 PSAOTICAL HBDIOIKB, BTC. 

specific, calming the excitement, and enabling the patient to pass 
without wear or irritation through this stage of the malady. Its 
action has been to steady the pulse, and thus apparently to supply 
the brain better with blood, and so to obviate the tendency then 
existing to effusion of serum, consequent on the inflammatory process 
going on, as we believe, in this stage of the disease in the arach- 
noid and pia mater. The researches of Wedl, quoted by Dr. 
Salomon in his able paper on general paresis, are conclusive as to 
the inflammatory process present in this stage of the disease. 

" In such circumstances the only visible result is mental quiet, and 
the action of the drug appears to be that of a oerebro-spinal narcotic. 
The functions of the stomach and bowels are not affected by its use ; 
the appetite rather seems to improve. The pulse often remains un- 
affected for weeks under the use of half-drachm doses, and the only 
result is the specific action on the cerebral excitement, I have often 
found one day's intermission of the medicine bring on all previouf 
symptoms of excitement. I have prepared a detai&d history of six 
oases of general paresis which I have thus successfully treated. The 
limits of my present communication necessarily prevent my infiicting 
their detail on you ; moreover, every member of this Association has 
such opportunity of testing the results of my experience, that it is 
sufScient for my present purpose thus generally to indicate the forms 
of insanity in which I advise the use of this drug. 

" I have also continued for many weeks with benefit to administer 
half-drachm doses of the tincture of digitalis in cases of chronic 
mania, with noisy and destructive habits. I have at this moment 
two such cases under treatment. In one the irritation is evidently 
depending on impending paralysis. 

*' There is a third form of insanity — mania with phthisis (not un- 
frequent in private practice als6), in which I nave found the 
occasional use of the tincture of digitalis of great benefit. This form 
of mania han been so exhaustively treated by Dr. Clouston in the 
Journal of Mental Science for April, 1863, that this reference to its 
treatment will for my present purpose suffice. Time, moreover^ 
warns me to bring my present remarks to an end.'* 

Aet. 41. — On Bloody Sweating from the Head in Dementia 

Paralytica, 

By Dr. F. Sebvaes, Physician to the Asylum at Lindenburg. 

(Allgemeine Zeitschrifi fiir Psychiatrie, Band xx., 1863 ; and 
Journal of Mental Science, October, 1863.) 

Within the last two years Dr. Servaes has had the opportuni^ 
of observing two cases of bloody sweat on the head in paralytic 
dementia, and he now publishes them as unique, so far as his infor- 
mation and reading extend. 

Case 1. — F , a long time insane, with widespread mnscular paralysis, 

rendering the speech unintelligible. Congestion of the head, with increased 
heat, was a frequent and severe symptom, and accompanied with a very 
quick but always small pulse. Ice was used to the head, and the attacks 
subsided in a few days. '* On one day I observed a lai^ number of drops 



PBACnCAL MIDICIirB, XTC. 89 

of Uood, dotted, on hia ho&, whieb looked m if it had been gprinkled 
viih bkxxL" On washing this ofE, freah blood exaded from other pointJ, 
like aa from the prick of a needle^ and after two hoora the face waa again 
generally bespattered. 

Whilst this went on the oouDtenance waa red, the temperature of the 
head elevated, and the poise 120, bat smaU. In two days the oozing of the 
bkx>d ceased, and in some points, where the escape had been more free, 
there appeared circular roseola- like spots. 

Snbsequently, congestive attncks of the head supervened, but no more 
ezodation of blood was noticed prior to his death. Eight days before death 
inflammatory swelling seized on the right hand, followed by the production 
of laige blister like vesicles and gangrenous spots. At the same time 
ia|>id effuaion and gangrenous sores appeared over the sacrum. On a post- 
mortem examination a considerable serous effusion was found within the 
dura mater over the right side of the brain, with shrinking of the right 
hemisphere. The further examination of the brain was delayed, and the 
viscns placed in spirit ; but when afterwards examined, it was so soft an to 
break down under the slightest pressure, and no further lesion than that 
named was made out. 

Case 2. — A. V was received, on the 9th of May, from Siegburg, as 

an incurable. Was much emaciated, and the muscular paralysis so great 
that walking was impossible, and she was confined to her bed. The skin 
was dry, and much disposed to the production of bed-sores, particularly as 
the patient was restless in bed and dirty in her habits. She was constantly 
calling out and crying, and tore clothing and bedding with her teeth. Her 
craving for food was extreme. 

Between the 20th and 31st of July, fifteen to twenty drops of blood were 
met with on the face, behind the ear, and on the hairy scalp ; almost all on 
the right side, on which also tiiere were three boils. On washing them off 
many agun reappeared ; but this happened more slowly than in the other 
case, and it was twenty- four hours before they became as widely diffused as 
at first. On the arrest of the effusion, roseola-like spots appeared for a few 
days, and then vanished. The temperature of the head, and particularly 
of the body, was reduced during this period ; and the pulse became only 42 
in the minute, small and thready. Consciousness very feeble. A large 
bed-sore shortly afterwards formed on the sacrum; and on the 13th Sep- 
tonber sudden collapse occurred, and death in thirty-six hours. A post- 
mortem examination was made forty-two hours after death. 

The rather thick scalp showed posteriorly several oozing points. On 
opening the cranium the dura mater was found loose and fluctuating from 
fluid beneath it, and on cutting through this membrane several ounces of 
straw-coloured, turbic^ serum escaped. It was now evident that the right 
hemisphere was much shrunk, so as to leave an interval of half an inch 
between the bones and its surface, whilst a number of easily torn adhe- 
sions extended between the two anteriorly, as well as between the cerebral 
surface and tentorium. A considerable quantity of bluish serum escaped 
from the spinal canal. Water was also present in the subarachnoid spaces, 
penetrating between and widening some of the cerebral sulci. The arach- 
noid was milky in aspect at the base of the brain and over the cei-ebellum. 
The blood- vessels of the pia mater were filled with blood. 

On*the anterior half of the brain, as well on its upper convex surface 
as at its base, the meninges were inseparable from the brain- substance, 
without laceration of the latter ; posteriorly, however, they could be readily 
detached. The consistence of the brain generally was very soft and oede- 
matouB, and presented numerous bloody points on section. The medulla 
oblongata was likewise softened. 



90 PBACTICAL MEDICINE, ETC. 

Efi^sion and hypersemia occurred on the under portion of the spinal cord, 
which was also atrophied and softened. The lungs slightly CBdematous. 
Liver permeated by gray, sago-like granules. Spleen soft. Mesentery 
swollen and white. 

The author believes that the blood in these cases escaped from the 
sweat-ducts, from their overgorged capillaries, the general muscular 
paralysis favouring exudation from the skin. Moreover, he calls to 
mind the disposition to altered composition of the blood in para- 
lytics, to serous effusions and sanguineous exudation, as seen in 
the sanguineous tumours of the dura mater and external ear in 
Buch patients. Something analogous may also be seen in septic 
states of the blood, where hsemorrhagic effusion takes place in the 
form of spots or petechi». 

To explain the occurrence of the oozing of blood in paralytics, 
he refers to the frequent attacks of congestion of the head they are 
prone to, as happened in his first recorded case ; and although in 
the second instance the cold surface argued against such congestion, 
yet the numerous bloody points found on cutting ^he bram after 
death indicated its probable occurrence and a dilated state of the 
capillaries. Whether the serous effusion beneath the dura mater 
could have any influence in favouring the escape of blood, he will 
not profess to aetermine. 

It is doubtful what value, in a pathological point of view, should 
be given to these two isolated cases of bloody exudation from the 
face and head. There is a lack of several particulars, which pre- 
vents our arriving at a positive conclusion whether the circumstance 
might or might not have been due to causes independent entirely, 
or nearly so, of the actual morbid condition of the patients. More- 
over, the two cases were much alike ; in the one there was evidence 
of congestion of the head, whilst in the other there was a deficiency 
of blood. The bloody points seen on slicing the brain in the latter 
case by no means indicate cerebral congestion. In forming a 
judgment respecting such oases we must bear in mind the diseased 
condition both of the blood and capillaries in most paralytic patients, 
favorable to exudation, and also the restless habits of some, instanced 
by their frequent picking or rubbing the surface and pulling out 
hair. An occasional cause of bloody points on the skin, as we have 
witnessed, is the irritation and wounding of the surface by the 
rough ends of straw used in the bedding of pfttients, for pillows, 
&c. Whether straw pillows were used in the two cases recorded 
we know not, but thmk it very probable, as they are common in 
Continental asylums. The marvellous in the occurrence of the 
swollen ear of the insane, especially of the paralytics, has ceased to 
impress the medical superintendents of asylums, now that careful 
supervision of asylums and close inquiry into such cases have suffi- 
ciently shown that that lesion is the result of mechanical violence, 
and not self-originated from the peculiar morbid state of the patients. 
And, on the whole, we are inclined to look upon these instances of 
" bloody sweating" as of mechanical rather than of vital origin. 
However, the matter is deserving the attention and observation of 
our readers. 



PBACTICAL XBDICIVE, XTC. 91 

Abt. 42. — Notes 07i Hematoma of the External Ear 
in the Insane, 

By Dr. W. Philumobe Stiff, Medical Superintendent of the 

County Asylum, Nottingham. 

(BrUUk Medical Journal^ August 1, 1863.) 

" The rabject," says Dr. Stiff, " of sanjj^neous cyst of the ear in 
the insane is of importance in a medico-legal point of view. Some 
writers allege that these hsmatic cysts are the result of injuries, 
either self-inflicted or from the employment of violence on the part of 
attendants and nurses. The statement of Gudden, in support of 
the latter view, has been most extensively circulated. He maintains 
that these sweUines are entirely owing to mal-treatment, and points 
ont that ears closely resembling those of the insane are not unfre- 
qnently met with amongst sculptures depicting pugilistic athletae. 
Singularly enough, in his efforts to bring this home to the attendants, 
he avers that he has never met with an instance in which the injury 
oonld be traced to the patient himself, or to other patients. How 
this can be reconciled with the fact that patients frequently fall on 
the ear in fits, and are struck on it by their own associates, I am at 
a loss to imagine. Again, in the lately published work of Dr. 
Kramer, * On the AuraT Surgery of the Present Day,* the observa- 
tions of that author are calculated to encourage the theory of the 
physical origin of the disease. He says—* The causes of these 
bloody tumours on the cartilage of the ear are unknown^ though we 
must admit that they are especially likely to be produced by violence 
(blows on the ear), which, perhaps, explains their more frequent 
occurrence on the left ear.* (New Sydenham Society's edition, 
page 41.) In the * British and Foreign Medico- Chirurgical Review* 
for January, 1858, I published a short memoir on this peculiar 
disease, illustrated by engravings after photographs of the altered 
ears ; and I therein advocated the contrary opinion, based upon ob- 
servation and inquiry, that the lesion is not occasioned by physical 
injury, but that it is the result of a spontaneous haemorrhage 
arising out of a pre-existing diseased condition of the vessels of the 
pinna of the ear. 

" Two cases came under my notice last autumn, strongly confir- 
matory of this opinion. Both were to be seen running tiieir course 
together, but distinct in their appearance and characteristics. The 
one was a well-marked example of hsematoma, arising without any 
external interference ; the other, a case of severe contusion of the 
ear after a blow, not presenting any appreciable swelling, but only 
ordinary interstitial ecchymosis, although this patient was predis- 
posed to hsematoma, and was the subject of partial ossification of 
the cartilage of the opposite ear." 

Dr. Stiff here relates these two cases, which he says corroborate, 
in a remarkable manner, the views of those who consider that the 
phenomenon is the result of disease, and not of accident, and that 
they may be regarded in the light of a crucial experiment, decisive 
of the question at issue, confirming the fact, in the one instance. 



92 PBACTICAL MBDICIKI, BTO. 

that hsBmatoma may be developed without the mtervention of ex- 
ternal violence, and disproving, in the other, that it could be pro- 
duced by a blow in a person predisposed to the affection. 

''It is admitted on all hands (continues Dr. Stiff) that these 
effusions occur most frec[uentlY amongst the insane, or in patients 
affected with serious lesions or the nervous centres. It has been 
shown by several pathologists that there is a pre-existing state of 
disease before the occurrence of the sanguineous effusion. The 
disease maj be observed in both ears in different stages, and occa- 
sionally the cartilage mjw become ossified without the occurrence of 
the stage of effusion. When blows are received by the same class 
of patients over the analogous structures of the eyelids and nose, 
the same morbid changes do not take place. Epilepties are less 
liable to it than chronic maniacs. Cartilaginous nodules are some- 
times developed after wounds of the ear; but their history, course, 
and pathology, are quite distinct. 

" In two specimens of hsematoma occurring in the ears of the 
same patient, Mr. Toynbee informed me that he had found the 
cartilage of the right ear greatly hypertrophied, and in some parts 
ossified. It had Haversian canals and corpuscles like normal bone. 
Bony matter was deposited in the left ear, which did not go througli 
the various stages. 

" I entertain no doubt that the disease depends upon internal or 
centric causes, and is, probably, one of the results or the atheroma- 
tous diathesis. It runs a well-defined course, the duration varying 
from a fewcdays to several years, and, unlike contusions, leaves 
structural alterations and disfigurement of the organ." 



Art. 48. — The Pathological Relations between Puerperal 
, Mania and Albumhmria, 

By Dr. Arthur Scott Donkin, Lecturer on Medical Juris- 
prudence, Neville HaJl College, Newcaatle-on-Tyne. 
(Edinburgh Medical Journal, May, 1863.) 

" Medical science," says Dr. Donkin, "is indebted to Professor 
Simpson for having first directed attention to the coexistenee ot 
albuminuria and puerperal mania, in a contribution to the Obstetric 
Society of Edinburgh, in 1856.* In this paper Dr. Simpson con-- 
tented himself with demonstrating merely the frequent coexistence 
of the two morbid conditions, without attempting to explain the 
exact pathological relation between the renal and mental affectionSy> 
leaving that to be accomplished bv future clinical investigation. 
Dr. Simpson's communication is, I believe, up to the present time, 
the only contribution we possess on the subject, eitlier in our own 
or any other language." 

Dr. Donkin divides puerperal mania into the two following dasses^ 
on the distinctive features of which he strongly insists : 

* EdiinJbwrgK Medical Jowmal, voL U., p. 796.) 



PRACTICAL KSDICINE, KTC. 93 

^ *' dasM J.— Hie mania is eisentially acate, and rang a brief course ; 
it is always accompanied by a very rapid pulse, sthenic or asthenic, 
and generally a moist skin. The attack is usually ushered in and 
attended for some time by pain and heat of head, great intolerance 
of light, sound, or of any movement in the room, tinnitus aurium, 
and pervigilium. There is a strong tendency to a fatal issue, death 
taking pli^ b^ way of coma or asthenia. 

" UUUi 11, 18 characterised by complete absence of constitutional 
disorder ; the pulse retains, or occasionally exceeds very slightly, its 
natural frequency. There is no danger to life, but the mental 
derangement is generally more or less chronic, and frequently 
merges into permanent hopeless insanity." 

**finiat constitutes" asks Dr.Donkin, ** the differential pathology 
Mween them f Those cases referrible to the * non-constitutional* 
group, which are dangerous only to reason and not to life, we can 
xeaduy understand. They are neither more nor less than cases of 
ordinaiT insanity, excited, in females predisposed hereditarily or 
otherwise to the disease, by causes incidental to parturition, such 
as nervous shock, hemorrhage, exhaustion, and a variety of other 
causes which it would be tedious and unnecessary to enumerate. 
But -what are we to understand by the other acute constitutional 
and fatal class ? There is undoubtedly something special in their 
pathology which has not been explained. They have been described 
by some authorities as instances of cerebro-meningeal inflammation 
or phrenitis. But this interpretation of their nature is no longer 
tmiable, owing to the fact that in no single fatal case have the 
traces of congestion or inflammatory action been detected in the 
brain or its membranes ; so that Dr. Tyler Smith correctly 
observes, that 'the pathological lesions found after death from 
puerperal mania do not throw any great light upon the essential 
nature of the disease. No constant morbid changes are found 
within the head, and most frequently the only condition found in 
tiie brain is unusual paleness and exsanguiaity. Many pathologists 
have also remarked upon the extremely empty condition of the 
blood-vessels, particularly the veins.' Now, this fact is the more 
remarkable, because the most dangerous and rapidly fatal cases are 
those whose symptoms simulate most closely those of inflammation 
of the brain and its membranes. These are the cases which Dr. W. 
Honter had in view when he stated in his lectures, long ago, that 
' when puerperal females are out of their- senses with fever like 
peraphrenitis, they will in all probability die.* Dr. Gooch, referring 
to the relation between the rapidity of the pulse and the fatality of 
. the disease, pointed out that the frequenoy of the pulse is the 
only aure guioe in forming a prognosis, and illustrated his observa-' 
tions by showing that * his cases which terminated fatally were all 
attended with a rapid pulse, while none of those with a slow or 
moderately excited pulse died.' Subsequent experience has fully 
corroborated the accuracy of this opinion. 

" Now, the object I have in view in offerinj? the following obser- 
vations on this important pathological question, is to demonstrate 
that the acute dangerous class of cases are examples of ura^mio 



94 PRACTICi.L MEDICINE, ETC. 

blood-poisoning, of which the mania, rapid pulse, and other consti- 
tutional symptoms, are merely the phenomena; and that the 
affection, therefore, ought to be termed ursemic or renal puerperal 
mania, in contradistinction to the other form of the disease." 

Dr. Donkin relates a long and interesting case of acute puerperal 
mania, in illustration of this theory of the pathology of his Class I. 
of puerperal mania. From the anasarca preceding labour in this 
case, and from the albuminous urine with low specific gravity, and 
yet with an absence of all fibrinous exudation, which was observed 
the second day after delivery. Dr. Donkin argues that the morbid 
condition of the urinary secretion resulted from passive congestion 
(from mechanical compression) of the renal vems. He further 
traces the maniacal symptoms to the circulation of urea in the blood 
consequent on this state of passive congestion of the kidney. 
** That uramia (he says) was the second link in the chain of morbid 
changes in this case is evident from the low density and albuminous 
condition of the urine at a period anterior to the development of 
constitutional symptoms and of cerebral and mental derangement. 
If further proof were requisite, it is furnished by the peculiar and 
distinct violet colour of the blood-serum, together with the presence 
in it of a considerable quantity of carbonate of ammonia, a product 
of decomposed urea ; these being the characters which, according 
to Frerichs, Litzman, Braun, Heller, Kletzinsky, Oppolzer, Gegen- 
bauer, Lehmann, and others, are generally found in the blood-serum 
of puerperal females attacked with ursemic eclampsia." 

But if the question arises, Why should ursemia in the puerperal 
female produce convulsions and coma in one instance, and mental 
aberration with a rapid pulse in another ? To such Dr. Donkin 
replies, that we cannot expect the poisons engendered in the 
blood by the retention of the renal secretion to be exempt from the 
well-ascertained principle of toxicology — that the action of almost 
every known poison is modified or entirely changed in character 
according to the dose, to idiosyncracy, and the like influences. 
Besides, it is quite possible that in the one disorder a species of 
poison may be developed different from that which excites the 
other. 

To the history of this case Dr. Donkin appends some able obser- 
vations on its special pathological relations to the theory in question, 
and concludes his argument with the following remarks : — " If it 
should be objected that a single case is not sufficient evidence to 
establish the accuracy of my views, I must observe that the maxim 
which applies to investigations in natural history is equally ap- 
plicable to those of pathology, namely, that although a single typical 
specimen may not be sufficient to establish a species, it is at least 
amply so to display its characters. But even should future investi- 
gation not corroborate the accuracy of my observations, yet I trust 
they will effect some good, at least, by directing others still more 
closely to the examination of one of the most important and, at the 
same time, neglected subjects of obstetric pathology. I say neg- 
lected, because I can only find recorded nve cases of the acute 
dangerous variety of puerperal mania in which attention was 



PBACTICAL MEDICINB, XTC. 96 

directed to the condition of the urine. Fonr of these are the cases 
recorded by Professor Simpson.* In all of the four, albuminuria 
existed at the outset of the mania. In one of them puerperal con- 
Yulsions occurred before delivery, with very marked albuminuria ; 
and after a rerj brief convalescence and absence of albumen, acute 
puerperal mania set in, and the urine was again found to be highly 
albuminous. In another case there were two sudden attacks of 
puerperal mania, with a week's interval between them, and at the 
commencement of each attack the urine was loaded with albumen, 
and free from it in the interval. In one of these cases tbe duration 
of the mania was two or three weeks, and the albuminuria observed 
at the outset of the disease had disappeared entirely before the 
restoration of the intellect. 

The fifth case alluded to is recorded by the late Dr. Graves, in the 
last edition of his ' Clinical Lectures.' This was the case of a young 
woman (set. 21), apparently of sound constitution. On the sixth 
day afler giving birth to a seven-months' child she became the 
subject of acute puerperal mania, accompanied with a verr rapid 
pulse (125), when admitted into the hospital, on tbe second day of 
the disease ; she had been twice bled previously. She died on the 
eighth day of the attack, and up to her death the pulse is recorded 
to have kept as high as 120. Ber skin was moist and perspiring, 
but the locnia and milk were suppressed. There was great pervi- 
gilium, she having slept twice, and on one of these occasions, after 
inking, in frequent small doses, three grains of acetate of morphia ; 
the mania closely resembled delirium tremens. Death took place 
by way of asthenia. An investigation of the body was made six 
hours after death, before decomposition could have altered the most 
delicate tissue. Attention was specially directed to tbe condition of 
the brain and uterus. ** But," observes Dr. Graves, " the most 
careful examination could discover in the brain no phenomena in the 
remotest degree capable of explaining the occurrence of delirium or 
death." He further adds, that " the structure of the uterus was 
natural, and it exhibited nothing worthy of remark in its interior. 
The rest of the abdominal viscera were healthy." The kidneys are 
not separately mentioned by Dr. Graves, but he directs especial 
attention to a symptom which he considered to be of " very con- 
siderable importance ;" and very justly so, for it was no other than 
a great " diminution of the urinary secretion." The patient is 
described as having once voided urine, and that once on the third or 
fourth day of the attack. Unfortunately, however, her urine waa 
not examined, otherwise the pathology of the case might not have 
appeared a mystery. 

• Edinhirgh Medical Journal, vol. ii., 761. Dr. Simpson, more 
recently, states that he has repeatedly seen the same connexion between 
puerperal mania and albuminuria as well as had other instances communi- 
cated to him. (Lee. Medical Times and Gazette, November 10, 1860.) 



06 PRACTICAL MEDICINE, ETC. 

Art, 44. — On Catalepsy. 

By Mr. Thomas Jones. 

{British Medical Journal, June 0, 1863.) 

This case was admitted into ISt. George's Hospital under the care 
of Dr. Fuller. It was seen by Mr. Jones, the Assistant Eesident 
Medical Officer to the Hospital, and he describes the case. 

Qa&e.— Male, aged 60, suffered from the effects of strong mental shock for 
a fortnight; altered vision and hearing three days ; sudden tetanic rigidity 
of all the muscles, which caused him to be fixed in the position in which he 
happened to be at the time of seizure ; subsequently the limbs retained 'any 
position in which they were placed ; partial loss of consciousness ; duration of 
Jit twenty two hours ; no recurrence ; good recovery. Wm. G., aged 60, is 
of strong bony frame ; about six feet in height, with well-formed muscles ; 
complexion ruddy. He is of a melancholy disposition. His passions are 
readily excited. He says 'Hhe least thing excites him, and causes him 
afterwards great annoyance and pain over the top of the head." His pr«- 
yious health was remarkably good ; he was strong and hearty until a fort- 
night before admission, when he unexpectedly received intelligence of the 
sudden death of his wife ; this caused him considerable mental depression. 
On two or three days before the present attack he was considerably an- 
noyed by hallucinations of vision and hearing. He saw varieties of colours, 
and heard various sounds, sometimes the firing of guns. On these days he 
was noticed by his fellow-workmen to be very ** absent in his mind " on 
two or three occasions, remaining in this state two minutes. 

While suffering from the above premonitory symptoms, he was suddenly 
seized, while in the act of plastering, with the trowel in one hand and the 
brush in the other, about 11 A.M. on May 2nd, with a fit. He stood erect 
on the scaffold on which he happened to be standing at the time, with his 
arms outstretched, his legs fixed, the whole body rigid and immovable ; his 
eyes were widely open ; he appeared to be quite insensible to all external 
objects. His arms were found to be so rigidly fixed in the elevated position 
that it was found impossible to pull them down ; and the trowel and the 
brush were so tightly grasped in the hands that they could not be removed. 
On two or three occasions, however, while in this state, he deliberately 
removed the trowel from one hand into the other in order to have it free to 
get his handkerchief out of his pocket to wipe his nose ; having done this, 
he resumed his statue like position. He remained in this state for two 
hours, when he was seen by Mr. Chappell of George Street, who succeeded, 
after considerable difficulty, in bringing down his arms. Notwithstanding a 
mustard poultice applied to the nape of the neck, and cold cloths to the 
head, as ordered by Mr. Chappell, he continued in the same condition 
until 4 P.M., when he was removed into the hospital. 

On admission, he was able to walk if pulled along, otherwise he would 
not advance a single step. He seemed tolerably firm on his feet ; for, on 
pushing him so as to try to put him off his balance, he would make sufficient 
exertion to regain his equilibrium. The expression of countenance was 
most indifferent ; the eyes were wide open, but his eyelids would remain in 
any position in which they were placed. He stared fixedly at vacancy. 
His attenton could not be directed towards any object. His eyelids were 
sensible to the touch ; the pupils were widely dilated, but acted readily 
under the stimulus of light. His skin was warm. The respiration was 
very superficial. Occasionally he would take a deep sigh. The pulse was 
90 ; full, intermitting every eight or ten beats. When raised into the erect 



PBACnGi.L MEDICIKI, STC. 97 

posture, he would remain so. On raising his arms they dropped. There 
was some slight rigidity on flexion and extension. The jaws were clenched ; 
hat he swallowed water without any difficulty when it was poured into his 
month. He was apparently quite insensible ; for in vain we endeavoured 
to rouse him by calling loudly in his ears ; and pinching him did not pro- 
dnoe the slightest indication of discomfort. 

I galvanized him at once pretty severely ; and the muscles electrified con- 
tracted firmly. This seemed to <^'ause him some pain; for he made a loud 
noise, and, on one or two occasions, he stood erect. Galvanism was persisted 
in for a quarter of an hour; as soon as it was discontinued, he relapsed 
into the same passive state. But the bystanders thought he seemed some- 
what ** livelier," and that he required less assistance to walk. Certainly, 
all the rigidity of the muscles had now passed off. 

The cold douche was now tried. The water was directed from some 
height on his face and head. He did not offer much, if any, resistance. 
He closed his eyes firmly, and swallowed the water that entered his mouth ; 
otherwise the treatment made but little impression upon him. 

The above means having failed to effect much good, he was sent to bed. 
He walked up the stairs (with assistance) with a firm, steady step, without 
once making a false one. When in bed, in whatever position he was 
placed, however uncomfortable, he would remain unmoved. The arms 
were raised, and they remained elevated ; I next raised his head off the 
pillow, and in that position it remained. At the same time I raised his 
trnnk, and placed it at an obtuse angle with his legs ; there it remained with 
his head in the position previously placed, turned to either side, with his 
eyes closed or opened just as they were placed. Now he presented a most 
curious spectacle, in the half- sitting posture, with the head thrown for- 
wards, eyes open, but still appearing lifeless, and his arms outstretched. I 
can compare him to nothing better tiian to a tinted statue. He remained 
in this position, perfectly immovable, several minutes, until his position 
was again changed. He seemed to have perfect control over his sphinc- 
ters ; for when a utensil was conveniently placed he immediately passed 
nrine, which was high-coloured and free from albumen. I ordered an 
enema of turpentine, with half an ounce of tincture of assafoetida, to be 
given immediately ; and the following draught every four hours : — 

Hl* Tinct. Valerianae ammoniatae 5j« 
Spirit, aetheris chlorici 58S. 
Decoct, aloes comp. ^iv, 
Infusi Valerianae 5vij. 

9*80 P.M. — ^There was considerable rigidity of the muscles. His head 
could not now be raised off the pillow, nor the body into the sitting posture ; 
otherwise he was much in the same condition. He retained the enema. 

May 3rd, 10 a.M. — He seemed much better. He spoke for the first 
time since the attack, about eight o'clock this morning, when he replied in 
answer to a question asked by the nurse as to whether he wanted the night- 
stool. From this time, he continued to talk, but still very reluctantly, and 
did whatever he was asked. He got out of bed without assistance. His 
bowels had acted freely. He took his medicine regularly during the night. 
He had about three hours' sound sleep. At present, his aspect was very 
gloomy. He answered questions slowly : it was with difficulty that any- 
thing could be elicited from him. He had perfect power of, and contsol 
over, all his muscles. His face was somewhat flushed ; pupils dilated, 
still active ; the right was a little larger than the leit. Pulse 90, now 
regular. 

On being questioned closely as to his consciousness during the fit, he said 
XXXVIII. 7 



98 PBACTICAL MEDICINE, ETC. 

that he had a confused recollection of almost everything that occurred. At 
the first onset of the attack he remembered being immovably fixed to the 
plank on which he stood ; he felt his arms fixed in an elevated position, and 
his mouth firmly clenched. He could hear distinctly those who talked to 
him, and he coiUd see them ; he felt, however, confused, and mistook one 
person for another. He remembered' the treatment adopted before and 
after his admission into the hospital. He complained very much of the cold 
douche and the galvanism ; and that the latter caused him great pain, • in 
consequence of which he remembered crying out. He felt that, however 
unpleasant this treatment was, he could not acquaint us of the fact by 
speech or any other means. He felt himself better after the galvanism ; 
he fancied he could walk with much greater freedom. He seemed much 
annoyed that his body, during the attack, was placed in the dififerent un- 
comfortable and ridiculous positions. 

9*30, P.M. — He had been less communicative during the day than he was 
this morning; he had taken his food well, and fed himself. The tongue 
was clean. The bowels had not been open since the morning. He was 
now seen by Dr. Fuller, under whose care he was admitted, who ordered 
the medicine to be continued, and a senna draught to be given the next 
morning. 

May 4th. — ^He complained of headache and depression of spirits. He 
was able to get out of bed without any difficulty, and walk about the ward. 
The treatment was continued, and he was ordered to have ordinary diet and 
a pint of porter. 

May 6th. — He complained of weakness and occasional pains on the top of 
the head, which he generally felt after any excitement. With this excep- 
tion he felt quite well. The tongue was clean ; bowels open. There was 
scarcely any difference in the size of the pupils. Tue heart's sounds were 
normal. 

May 18th. — He had no symptoms indicating a recurrence of an attack. 
He looked much more cheerful. He left the hospital to-day feeling quite welL 



Art. 45. — On Rabies. 
By M. BouLEY. 
(Jowm, de Mid. et Chir, Prat., Aoftt. 29, 1863.) 

M. Bouley's remarks were recently presented to the Academy of 
Medicine at Paris, as a report on a paper on the same subjectl^ by 
M. B^viere. The outline traced includes all the characteristic 
features, and it could not have been done by a better artist. 

Mr. Youatt, an English veterinary surgeon, was the first who 
supplied a really scientific and complete account of the early stages 
of rabies in a volume, " The Dog," which M. Bouley has translated. 
** For several hours," says the author, " the diseased animal retires 
to its basket or couch, shows no disposition to bite, and obeys, 
although reluctantly, the orders of its master. In this stage, the 
dog curls itself up, and lies with his head deeply sunk, between his 
chest and forepaws. He soon becomes restless and morose, and 
wanders from place to place, and seems to appeal in turn to each 
of his human friends for some relief to his sufferings." 

The persevering affection of dogs, even in the most advanced 
stages of rabies, for their masters and those persons to whom they 
are attached is one of the most singular and important features of 



PRACTICAL KBDICIJIB, ETC. 99 

the dise&se. So powerful are these feeling, that a mad dog often 
refrains, even when the attack is at its height, from biting persoDS 
known to him, a circumstance in which originate serious errors as to 
his dangerous condition. Indeed, it is difficult to believe in the 
presence of rabies, in an affectionate and obedient creature, in which 
the only apparent symptoms are sadness, agitation, and unusual 
shyness. The illusion may generate the most fearful consequences, 
for in spite of himself, the animal, in a sudden fit of ill-temper, or 
provoked by a castigation perhaps incurred for disubedience, or for 
naving displayed signs of partially repressed anger, will infiict a bite 
involyiug the most formidable results. 

It is under circumstances of this description that the owner of a 
dog is most usually bitten. 

iMk general, mad dogs spare persons they are fond of. Were it 
otherwise, rabies would be far more frequent in the human subject, 
as habitually the condition of the diseased animal remains unsus- 
pected for one or two days, during which he is surrounded by his 
master's family and servants. 

In the early period of hydrophobia, when the nature of the affec- 
tion is fully apparent, dogs are attacked in the intervals of the 
paroxysms with a peculiar kind of delirium, which has been first 
noticed and described by Youatt. 

This delirium is marked by strange motions which seem to indi- 
cate that the diseased animal sees objects, and hears sounds existing 
merely in what we must fain call his mind. He will occasionally 
stand motionless, as it were, watching, and suddenly bound forward 
and bite the air, or rush furiously at a wall, as if he had heard on 
the other side sounds of hostile intent. 

The dog may therefore be considered to be liable to genuine 
delusions, induced by the complaint. Whatever be the philosophical 
interpretation of the fact, it is one of great importance, which, by 
its very singularity, shoidd awaken attention, and justifies the most 
sinister suspicions. 

The symptom, however, being very transitory, and altogether dis- 
pelled by the master's voice, may well escape detection. '* The 
imaginary causes of terror," observes Youatt, "yield at once to this 
magical influence, and the animal approaches his master with the 
customary signs of afiection. 

" This condition is followed by an interval of rest ; the dog's eyes 
slowly close, his head droops, the forepaws seem to give way, and he 
seems on the point of falling. But suddenly he recovers himself, 
fresh phantasms disturb him, he fiercely glares around, and snaps as 
if to seize some object within reach, or rushes to the full length of 
his chain, to encounter an absent enemy." 

Youatt further remarks that if the dog was previously of an 
affectionate disposition, his uneasiness is most eloquent, he seems 
to implore his master's pity, and his delusions never bear any 
character of ferocity. 

Ill-tempered animals, on the contrary, and those which have been 
trained to fight, present a fearful expression of countenance. Their 
eyes are often oloodshot, and when they preserve their natural 

7—3 



100 PEi.CTICAL MEDICINE, ETC. 

colour, their brightness is dazzling, and they resemble two balls of 
fire. 

At a later stage, the dog's restlessness increases. He incessantly 
goes and comes, and wanders from one comer to another, rises, lies 
down, and continually changes his position. 

He arranges his litter with his paws and nose, so as to form a 
cushion for his stomach, and suddenly arising disperses his couch. If 
in a kennel, he never remains quiet, but keeps m6ying round and 
round. If at liberty, he seems to be anxiously seeking for some 
lost object, and peers into every hole and comer with unceasing 
agitation. 

It is a remarkable, and at the same time formidable fact, that the 
affection of many dogs for those who have the care of them, seems 
actually to increase, and their fondness is expressed by licking their 
masters' hands and faces. 

The singularity of the symptoms in this early part of the disease 
in the canine race, is deserving of every attention, especially as it 
accounts for the fatal security of the owners. They cannot conceive 
tliat a gentle, obedient animal, so profuse in its demonstrations of 
attachment, should, at the same time, be breeding the most fearful 
of all known diseases. Hence, a degree of blind confidence, and 
worse, of utter disbelief, which often proves fatal to the owners of 
dogs, especially of those which are made constant companions, and 
in their healthy condition, are the safest of friends, but may by 
hydrophobia be transmuted into the most cruel and treacherous 
enemies. 

M. Bouley opines that the assemblage of these early symptoms, is 
extremely significant, and that if the public were repeatedly 
cautioned of their real import, many accidents might be averted, 
which are at present incurred through ignorance ; for instance, the 

Sublio should be repeatedly cautioned that all dogs beginning an 
Iness must, on principle, be held in suspicion. 

That sullenness, moroseness, and agitation are further causes of 
distrust ; the snapping, barking without motive, or incessant and 
purposeless seeking about the rooms, are also very serious indica- 
tions. 

That excessive and unwonted marks of affection, perpetual licking 
of the hands, &c., are signs not to be overlooked. 

The cause of many catastrophes, in M. Bouley 's opinion, is the 
prevalent and erroneous notion that a dog which drinks readily, 
cannot be mad ; hydrophobia or horror of liquids does not exist, and 
is one of the most mischievous results of our fondness for Greek 
names. 

A mad dog, says M. Bouley, has no aversion to water. On the 
contrary, he laps up the liquid and often swallows it. Although he 
2nay not drink, he nevertheless endeavours, and often with desperate 
efforts, to do so. 

J^either does a mad dog, in the early stages of the malady, reject 
bis food, but promptly tires of it. 

It is a remarkable and characteristic fact, that whether from a 
morbid vitiation of appetite, or from an irresistible impulse to bite, 



PBACTICAL MEDICINE, ETC. 101 

the animal aeizes in Ms mouth, lacerates and often swallows snb- 
Btancei wholly unfit for assimilation. 

Straw, wool, the stuffing contained in furniture, blankets, carpets, 
enrtain-frin^es, slippers, wood, grass, earth, stones, glass, horse- dung, 
excrement, he swallows all. On dissection, the stomach of a miui 
do^ is found to be a receptacle for a host of dissimilar substances, 
which, by the very fact of their unwonted aggregation, suggest the 
idea of h^drophooia, a surmise which the history of the symptoms 
converts mto a certainty. 

It is therefore imperatively necessary to watch with care any dog 
who obstinately lacerates hearth-rugs and cushions, who gnaws 
the wooden frame-work of his kennel, or greedily devours clay^ 
straw, &c. 

Excessively copious salivation is not, according to M. Bouley, so 
positive a pathognomonic of hydrophobia, as authors have in general 
asserted. The absence of this symptom should not therefore induce 
a feeling of complete security. The mouth of some dogs afiected 
with rabies is occasionally filled with a frothy secretion, especially 
during the paroxysms. In others, on the contrary, the mucous 
membrane is in a state of absolute dryness, and assumes a purple 
colour, a fact habitually observed in the more advanced stages of the 
complaint. In some few instances, the condition of the mouth is not 
in any way remarkable. 

The drynei<s of the mouth and throat, gives rise to a symptom of 
extreme importance in its bearings on the most interestmg feature 
of the disease— viz., its transmission to the human subject. 

When the fauces of a mad dog are dry, the animal rubs his chops 
with his forepaws, as if a bone was jammed between his teeth or 
sticking in his throat. He dXso frequently gapes in consequence of 
the paralysis of the maxillary muscles, which occasionally attends 
the later stages of furious madness. 

This is a very dangerous symptom, because the master, desirous 
of relieving his dog, will put his fingers into his mouth, and thus 
receive a bite, which may be disregarded until it is too late. 

Vomiting is sometimes a premonitory sign of rabies, and the 
rejected matter consisting sometimes of blood mixed with pus, a 
mistake may occur, which in M. Bouley's own case very nearly led 
to fatal consequences, uncomplicated hsemorrhage having been 
supposed to exist, in a case which proved to be genuine hydro- 
phobia. 

A dofif vomiting blood should therefore be attentively watched. 

Another striking symptom which reveals latent hydrophobia be- 
yond any possibiUty of a doubt, is the tone and pitch of the animal* s 
bark. Such a bark, once heard, can never be forgotten, nor be mis- 
taken for any other. 

Instead of barking freely three or four times in succession, as it 
usually does, the animal utters one loud bark, followed by several 
decreasing howls, during which the jaws do not close ; the sounds 
emitted are, moreover, hoarse, damped and lower than usual. 

This brief description can of course convey but a very inadequate 
idea of the characteristic bark of the rabid dog ; but the important 



102 PSi.CTICAL MEDICINE, ETC. 

point to he established is, that the pitch of the voice is invariably 
changed, and that the bark is performed in a manner entirely 
diflferent from its habitual mechanism. When the well-known voice 
of a familiar dog undergoes sndden alteration, and is replaced by 
unusual sounds, the observer's suspicions will therefore in future 
be aroused by the mere fact of their strangeness. 

Under the influence of hydrophobia, a dog will suffhr pain in 
silence, it may be struck, or pricked, or otherwise wounded, or 
even scorched, without uttering the slightest howl or whine. 

It is not that the animal is insensible to pain; it endeavours 
to avoid it, and if its litter be set fire to, will escape from the 
flames and retire into a corner ; if a red hot poker be presented, 
and that in a paroxysm of rage the animal bites it, ne imme* 
diately recoils. Tne do? evidently feels pain, but gives no utterance 
to any expression of suffering. 

If therefore a dog receives blows without whining, the circum- 
stance should put the master on his guard. 

M. Bouley also views with suspicion any dog obstinately gnawing 
at his own skin, in determined places ; this mav possibly be the 
result of mere local irritation, but the symptom has, in general, a 
far more momentous import. 

The sight of an animal of bis own species exercises so powerful 
an influence in causing latent rabies to break out, that in doubtful 
eases, the method is always resorted to at Alfort for the purpose 
of establishing the diagnosis. It is a singular fact that all animals 
affected with hydrophobia betray the same rage at the sight of a 
dog, an observation of extreme importance, and suggestive of prac- 
tical inferences deserving of every attention. 

Lastly, a dog labouring under the first symptoms of hydrophobia, 
is apt to quit his master's house for a conple of days, and if not 
killed during that interval in some populous dit>trict where his 
condition has been discovered, he will return to his old dwelling 
in a far more dangerous state than when he left it. Accidents 
frequently happen under these circumstances. The first impulse is 
to welcome the truant home with all sorts of caresses ; especially 
as he returns home covered with mud and blood, in a haggard and 
truly miserable condition. At this stage of the disease, the tendency 
to bite has become imperative, overcomes the creature's feelings of 
affection, and he too often repays with a deadly bite the kindness 
which is shown to him. 

A dog, therefore, that has been absent for a day or two, and re- 
turns home in a dirty and wretched state, should be very carefully 
watched ere he is re-admitted to the same familiarity as before. 

Such are the first symptoms characteristic of rabies in the dog, at 
a period when their knowledge may lead to the sequestration of the 
animal, and avert irreparable catastrophes. 

The learned reporter then alluded to the system of mvzzling 
enforced by police regulations, with a view of preventing the trans- 
mission of hydrophobia. The measure, as it is aj)plied in Paris, is 
entirely inoperative, and not more efficacious for its intended purpose 
than if the muzzles were merely painted on the dogs' faces. It 



PSACTICi.L MEDICIITB, ETC. 108 

eattnot, indeed, be otherwise ; an efficient muzzle is utterly income 
patible with the anatomical structure of the animal. The nasal 
oayities of the dog are too narrow to admit of his breathing, like the 
horse, exclusively through the nose ; respiration cannot be com- 
pletely performed unless the mouth is more or less open. The 
tongue and the entire mucous lining of the buccal cavity copiously 
perspire, and require frequent exposure. 

At the recent dog show at the Jardin d* Acclimatation, two 
appliances were exhibited, which M. Bouley approves of, and con- 
siders likely to lead to a solution of the problem. These are the 
apparatus of M. Charrier^, of Lausanne, and the muzzle invented 
by Professor Goubaud, of Alfort. Both consist of two jointed 
parts, longer than the dog's jaws, and supplied with a spring, so 
as to open and shut in harmony with the movements of the mouth. 

This ingenious arrangement removes the objections entertained to 
the muzzles in present use. Should the event confirm this surmise, 
M. Bouley 's aversion to muzzling will cease ; for although it ia 
chiefly within doors that fatal accidents occur, it must be admitted 
that the dogs have been bitten in the streets by unmuzzled, or im- 
perfectly muzzled, aggressors. 

Art. 46, — On Muscular Hallucinations. 

By M. Eugene Sememe. 

(Oaz. Eebd, de Mid, et Chir., Feb. 6, 1863.) 

Musculation,* or the sense of muscular activity, makes us con- 
soious of our muscular efforts, and of the fatigue which results from 
them. Thus conceived, musculation should be regarded as having 
an existence distinct from touch. The reasons in favour of this dis- 
tinction long ago attracted the attention of some philosophers. 
Aristotle even, in his Treatise on the Soul, made the remark that, 
while the other senses could but reckon one single opposition by 
contraries, that of touch possessed several ; hot and cold, dry and 
moist, hard and soft, besides many others of the same kind, and 
that we did not know clearly what was the unique characteristic of 
the sense of touch. 

Cardan, that strange and subtle genius, who was able to study 
from his own experience the subject of tactile hallucinations, recog- 
nised the existence of a special sense giving consciousness of weight 
and its opposite. But it is only at a much more recent epoch that 
study has resulted in anything approaching the analysis of tactile 
sensations. Charles Bell in the first instance, and afterwards, almost 
in our own day, Belfield, Lefevre, Gerdy, MM. Beau and Landry, 
have been the promoters in this movement. The latter has summed 
up in an excellent work his opinions on this subject. 

According to Auguste Comte, Blainville has pointed out in a very 

• The word musculation was first used by Gerdy, who gave it quite a 
different meaning. It was Auguste Comte who first employed this word 
to denote the sense of muscular activity. 



104 FBACTICAL MEDICINE, ETC. 

precise manner the existence of musculation. The following is what 
this great philosopher says on this point. " I believe we ought 
finally to acknowledge eight (senses) really distinct : one general, 
touch, and seven special; musculation, gustation, calorition, olfaction, 
audition, vision, and electrition." M. Semerie ranks the latter after 
Gall and Blainville, following their increasing speciality conformably 
with that of corresponding phenomena, and measured by successive 
appearance, in the animal scale. The two extremes alone require a 
special explanation. " With regard to the first, the author adopts 
essentially the opinion of Blainville, who separates it from the general 
sense ofpresswre, reserving for it the direct appreciation of muscular 
efforts, and of the fatigue which they produce. As to the last, its 
commonly slight development in man should not hinder the acknow- 
ledgment of its distinct existence, which is very decided in certain 
animals, and more or less common to all vertebrates." We search 
yainly in what remains to us of Blainville for so precise an 
opinion. 

However this may be, musculation has, at the present day, acquired 
a right to be cited, and it is not my business to develop here all the 
reasons which concur in making it a special sense. These reasons 
have been largely dwelt upon by the authors whom I have quoted 
above, and M. Audiffard, in his inaugural thesis (Montpellier, 1859), 
recently furnished others, and made an ingenious application of them, 
attributing rheumatism to exaggerated sensations of ealorition and 
musculation, that is to say, to a true neurosis of these two senses, of 
which the fluxionary state would in more than one case be only the 
consequence. "When we consider," says he, "that all fatigue 
makes itself felt more especially in the articulations, and in the 
muscular fascines, one would be almost tempted to see in that a 
confirmation of our supposition." The object proposed in this paper 
is only to complete the history of this new sense m examining wnat 
happens to it in insanity, and to what order of hallucinations it gives 
rise. 

One ought to presume the existence of muscular hallucinations, 
and even that they are frequent, for they have for their seat the 
vast muscular apparatus and its corresponding portions of the 
brain. 

In lypemania, and especially in the forms called stupor and par- 
phobus, one frequently observes the following hallucination, which 
IS also met with in nightmare, and certain kinds of dreams. Some 
danger menaces you, an assassin, for instance; you are afraid, you 
fly : the assassin follows you ; you fly more quickly ; full of terrible 
distress ; your feet scarcely touch the earth, you cross seas and 
mountains in an insensate course ; the assassin follows you more 
rapidly still, and is about to overtake you. When this takes place 
in a dream, the climax of terror wakens you ; but in madness, the 
awaking never comes, and the situation of the patient is horrible to 
behold. In both cases, the pulse is accelerated, the skin bathed 
with perspiration. The sensation of muscular activity is sometimes 
so strong, that the patient is fatigued as though he had actually run. 
The following is another remarkable example : You wish to fly, but 



PBACnCAL HEDICIHB, STC. 105 

an inTmoible farce holds yon back ; yon wish to defend yonraelf, bat 
your arms remain without movement, in Bjnte of the most energetic 
desire to do so ; jon wish to cry, but it is impossible. Ton are im- 
moYable as a livmg stone, and yon waste yourself in superhuman 
efibrts. Although there may haye been no effective movement, 
the effort is sometimes so violent, as to cause the sensation of 
fiitiffue. 

These hallucinations belong to the class which M. Baillarger has 
ealled psycho-sensorial. Others are purely psychical, accoiding to 
the denomination of the same author. 

In certain forms of mania, especially those which are complicated 
with lesion of the motive powers, the patients are not only unconscious 
of the paralysis which creeps on, but they experience sensations 
altogether different. I^othing is more common than to hear them 
Bay that their strength is doubled, that they can walk for whole days, 
carry on their extended arm enormous weights, or thai they feel an 
unaccustomed vigour in all their members. This feeling of power 
and strength, coinciding sometimes with an advanced stage of 
paralysis which prevents the patient moving, offers a most striking 
contrast. 

The inverse takes place with many lyperaaniacs. They cannot 
m6ve or walk ; they have no muscles : with some there is even a 
sensation of fatigue m the members. The hallucination then becomes 
pflycho-sensorial. 

One might multiply examples. Thus erotic ideas awaken in mad- 
ness, as in a dream, very distinct and detailed sensations of the cor- 
responding action. 

It is by the appreciation of muscular effort that we know whether 
an object is more or less heavy. Musculation corresponds with 
weight, as vision with light, calorition with heat. Thus all the 
Bubpective sensations of weight constitute so many muscular halluci- 
nations. The sensation of weight may augment or diminish. In 
the first case the patients discover in objects they handle an un- 
accustomed heaviness. Esquirol quotes the case of a lady who 
rejected a seringue with horror because she believed it to be filled 
with mercury. But the object may be a part of the patient's own 
body, especially in the case of hypochondriacs. They sometimes 
cannot raise their arms ; their head is so heavy that they imagine 
it full of metal, and that they can no longer sustain it on their 
shoulders. Some are convinced that it is entirely made of silver or 
lead. 

Many insane persons have experienced the following sensation, 
which frequently occurs in dreams : — They are on the brink of a well, 
or on the edge of a precipice, their foot slips from under them, and 
they fall. During the whole time that the descent lasts, one feels 
besides the anxiety, a sensation which can only be rendered by these 
woi'ds : one feels oneself falling. For the rest, it is the analogue of 
what passes when one really precipitates oneself from an elevation. 
This example appears to me to characterize the case where the 
hallucination, instead of limiting itself to the arm or the head, 
embraces the entire body. 



106 PBACTICAL HBDICINB, BTC. 

When the sensation of weight diminishes or disappears, the 
patient believes himself to be so lig^ht, that he fears to be carried 
away by the slightest breath. Others feel as though effectually 
transported ; they fly through the air ; it was thus the witches went 
to their Sabbath. The following is what Jean Engelbrecht relates 
of himself: — *'0n Thursday, at noon, I felt that death was near, and 
that it proceeded from the lower to the upper extremities. My body 
became stifl*, and I lost all feeling in my feet, hands, and other parts. 
I could neither speak nor see. My mouth was paralysed ; my eyes 
ceased to perceive the light. I could distinctly hear the assistants 
say, ' feel nia legs, how cold they are ; he will soon be dead.' I had 
no sense of touch ; the hearing was also extinguished in its torn. 
Then I was carried into spa^Cy with the speed of an arrow shot from 
a how** — Brierre de Boiemont, Hallucinations, p. 265. 

In the ecstasy of mystics this phenomenon is very frequent. In 
the moment of transport they often feel themselves raised from the 
earth. Saint Theresa once believed herself to be raised so violently, 
that she threw herself down with her face to the earth, making eflbrts 
not to fly away. Another saint, while praying on his knees, felt 
himself gently raised, and remained, as he thought, for some hours 
in the same position, sevwal metres above the ground. The history 
of mystics is full of facts of this kind. 

Art. 47. — On the Gerebro-Spinal Lesions consequent upon 

Diabetes. 

By M. Marchal (de Calvi). 

{paz^Hebd. de Mid. et Chir., October 23, 1863.) 

In a memoir presented to the Academy of Sciences at Paris, on 
the 12th October, 1863, M. Marchal (de Calvi) endeavours to show 
that cerebro-spinal lesions are frequent consequences of diabetes. 
In order to this he cites twenty -three cases of diabetes in which 
cerebral congestion and apoplexy, progress in paralysis, intellectual 
disturbances, &c., supervened in the course of this disorder ; and he 
lays special stress upon one case in which the cornea sloughed and 
the humours of the eye escaped, as was the case in animals which 
Majendie unwittingly made diabetic by feeding them upon sugar. 

The fact that diabetes may be brought on bv certain injuries to 
the great nervous centres, is of course well known; but that 
diabetes may react upon the great nervous centres and produce the 
grave disturbances which have been mentioned, had not been 
suspected before the inquiry was undertaken of which the results 
are recorded in this paper. 

M. Marchal (de Calvi) is of opinion that there is a close relation- 
ship between gout and diabetes, which he considers, in its most 
common form, as gout in the blood. He looks upon gout, diabetes, 
rheumatism, gravel, and '* les dartres,'* as congenerous manifesta- 
tions of the great uric acid diathesis, and he concludes his paper by 
an exposition of his views upon these points. 



FBJLCnCAL MSDICUTE, BTC. 107 

Art. 43. — On the Incubation of Hi/drophobia. 

By M. Renault. 

{BrUUh Medical Journal^ Febroary 20, 1863.) 

In a recent commanication to the Academy of Sciences at Paris, 
M. ^Renault says, that daring the last twenty-four years he has, at 
Alfort, made numerous experiments for the purpose of learning the 
period of incubation of hydrophobia in the dog. During that period, 
131 dogs have, under conditions (which he describes), been either 
bitten by mad dogs under his own observation, or have been 
inoculated by him with the foam as immediately collected from the 
mad animals. Of this number, 6S having presented no signs of 
disease during the four subsequent months, were not further 
observed. Of the 6& others, the hydrophobia was developed at 
TariouB periods, as shown in the following table : — 

In 1 dog between the 5ih and 10th day. 

15th day. 

20th day. 

25th day. 

30th day. 

35 th day. 

40th day. 

45th day. 

50th day. 

55th day. 

60th day. 

65th day. 

70th day. 

75 th (lay. 

90th day. 



Art. 49.-2%^ Epct ofPetroletm or''Roch-oiV' 
of Beriberi, 

By Mr. S. Arokeum, Subordinate, Medical Department 

in Indian Army. 

(Madras ^uarterl'i^ Jov/rnal of Medical Sciencej April, 1863.) 

In this article Mr. Arokeum states in a very unmethodical manner 
that he has seen much good from the use of petroleum in cases of 
Beriberi, and he gives one case in illnstration. He also gives us to 
understand that others, especially the native doctors, have tried the 
same mode of treatment with similar results. 

Case. — July 2nd, 1860. — T. 0., spt. 34, a robust, healthy-looking man, 
of medium size, fair complexion, black curled hair, muscles well developed, 
father of two children, temperate habits, presented himself before me this 
moming, complaining of the following 8yn)ptom8 of some months' duration. 
General numbness of body ; formication ; unsteady gait ; torpid bowels ; 



4 dogs 


99 


10th and 


6 „ 


t» 


15th and 


6 „ 


» 


2iHh and 


9 „ 


»» 


25th and 


„ 


91 


30th and 


2 ,. 


tf 


35th and 


8 „ 


ff 


40th and 


7 „ 


ft 


45th and 


2 ,. 


tf 


60th and 


2 ., 


if 


55th and 


4 „ 


tf- 


60th and 


Idog 


» 


65th and 


4 doe» 


tf 


70th and 


2 „ 


tf 


80th and 


Idog 


ft 


100th and 



108 FBACTICAL MEDICINE, ETC. 

tongue flabby and thickly coated ; urine scanty and high-coloured ; pulse 
small and quick ; anorexia ; occasionally sudden seizure of cardiac oppression ; 
skin unusually warm. He has been indulging freely in using ardent spirits, 
adding aromatic powders to it, being persuaded by a native doctor to take it 
for the disease he was suffering from, in spite of which the cardiac and other 
symptoms became alarming. 

Omit taking ardent spirits. 
Bi. Hydrarg. chlorid. grs. v. 

Pulv. jalap. CO. 3j. 

Aquae meuth. pip. 5ij« M. statim. 
Bt. 01. petrolei 3ss. 

Acacise gummi q. s. 

AqusB menth. pip. 5ss. M. ter die. 

To commence with a dose immediately after the operation of jalap and 
calomel ceases. 

Turpentine stupe to the chest, according as the circumstance may 
require. 

9th. — Continued taking the mixture regularly as I directed, having only 
had recourse to purgatives ; and am glad to record here, since taking the 
mixture {ordered supra) he only felt the return of cardiac oppression four 
times during the week, and the other symptoms are gradually disappearing. 
He now can grasp any object firmly, and walks pretty steadily. 

Increase petroleum 58s. to each dose. Petroleum friction to legs and 
arms. 

20 th. — Since last report, I visited him three times and found him improving 
in every respect. No cardiac symptoms complained of, wishes to return to 
duty, with promise that he would show himself occasionally. — Discharged. 



Art. 50. — Case of Prolonged and Profound Sleep, occurring at 
intervals during/ Twenty Years* 

By Dr. W. G. Gimson, Witham, Essex. 

(Brkiih Medical Joumaly June 13, 1863.) 

Case. — J. C , aged 44, a farmer, had never been ill, beyond what he 

describes as a slight cold. 

In 1842 or 1843,' the patient after getting very wet and not changing his 
clothes, suffered from a severe cold, which was followed by long and deep 
sleeps, the duration of each sleep being more than twelve hours, and the 
sleep of so profound a nature that it was found impossible to awake him. 
This attack lasted nine or ten months, and ceased upon the setting in of 
very wet weather. 

In 1848, he experienced a similar attack after catching cold. This attack 
was more severe than the former, was accompanied by occasional trismus, 
lasted over a period of eighteen months, and ceased upon the appearance of 
wet weather. 

The present attack dates from the 11th or 12th of May, 1860. At this 
time the patient got very wet at a fair, and experienced considerable pain in 
all his limbs, and especially in his back. These symptoms, I am informed, 
were cured by small doses of Gregory's powder. About a week afterwards, 
the patient became very drowsy ; and when he was once asleep it was found 



PSACnCAL KEDICIHB, ETC. 109 

impomible to awaken him, the duration of the sleep being from twelye to 
twenty-four hoars. 

I was called to see him after the attack had existed for some time, and 
fmind him in bed apparently sound asleep, lying upon his left side ; breathing 
qatetly, respirations 18 in a minute ; pulse 64, regular, feeble ; skin gene 
nlly warm and perspiring ; hands and feet somewhat cold ; complexion 
dusky : there was a peculiar twitching of the eyelids, and upon separating 
them the pupils were seen slightly dilated, and fixed. 

After calling loudly in his ears, pulling him over from one side to the 
other, pinching his nails, &c., he was awakened by touching the conjunctiva 
with my finger-nail. 

He awoke with a slight exclamation of surprise, and sat up. The pulse 
was slightly accelerated ; the countenaDce heavy ; the pupils were dilated, 
but acting under stimulus of light ; his voice was low and husky ; the 
mucous membrane of the fauces was slightly inflamed ; his tongue was 
dean and moist ; the bowels had been open twice the preceding evening, 
while he was awake, His urine was reported to be high-coloured, and 
turbid on cooling. 

He had no pains nor uneasy sensation to complain of, except a deeply- 
•eated pricking across the forehead, generally felt when awake. 

He now passes about forty hours out of forty-eight in sleep ; and has 
been known to sleep more than three days without taking food ; the longest 
time, as I am informed, being eighty- four hours. 

He generally awakes as the evening approaches ; never dreams, or, if he 
does, the mind retains no impression of so doing ; he generally goes to sleep 
upon the right side, soon turns over on to the left, and so remains until he 
awakes. 

He has never voided urine nor stool even during his longest sleep, although 
he has several times laboured under diarrhoea during the present attack. 

His memory is good ; be inquires after friends whom he saw when last 
awake, and this ^fore time has elapsed, or circumstance has occurred, to 
.reoJl the fact to his mind. And he is now as capable (when awake) of 
transacting business, or of any calculation, as he was at any period of his 
life. 

Weather and the state of the atmosphere seem to exercise a direct influ- 
ence upon him; he is always more wakeful, and remains longer awake 
during wet and dull weather than at any other time, and he will frequently 
awake and foretell a coming storm. 

During the preceding two attacks he was bled, blistered, &c., and all the 
experiments were tried upon him which medicine could suggest ; but with 
no avail. My opinion was asked as to the advisability of a setou ; and, as 
I could not see any benefit likely to arise from that mode of treatment, I 

Sve an opinion against it. Upon being asked what I could recommend as 
ely to be of service in this case, I felt how little I could suggest in the 
present state of things. The appetite was good ; the functions of the 
stomach and alimentary canal, of the liver and kidneys, were carried on to 
all appearance efficiently ; the heart-sounds were clear but feeble ; respira- 
tion was free but shallow ; the surface was generally warm. What could 
be of use ? I confess I was puzzled ; nor could I, by searching through 
books, or thinking upon the case, arrive at anything like a satisfactory 
conclusion. 



110 PEi.CTICA.L MEDICINE, ETC. 

Akt. 51. — Notes on the Use of the Ophthalmoscope in 
Affections of the Nervous System. 

By Dr. Hughlings Jackson, Assistant-Physician to the Hospital 
for the Paralysed and Epileptic. 

{Medical Times and GazeUe, October 3, 1863.) 

" I have never," says Dr. Jackson, " had the opportunity of ex- 
amining the retina during a fit of epilepsy under favourable circum- 
stances. I have tried to do it repeatedly, but the difficulties, little 
and great, are to those who have not tried it inconceivably numerous. 
The following is the best specimen I can bring forwards. I have 
already publisned an examination of the eye in a case of convulsions 
induced by placing the patient erect ; but it may be said that that 
was a case of fainting only, and could not be accepted as a faith- 
ful representation of what takes place in the retina in idiopathic 
epilepsy. 

" A patient, William T., aged 8, had been attending some time 
under the care of my colleague, Dr. Brown- S6quard, for epilepsy. 
One day the porter brought the boy — who had just been taken with 
a fit — into my room in his arms. Unfortunately he did not at once 
take him to the lamp, and, when everything was arranged for 
looking, the convulsions had, I think, ceased ; but I was so much 
occupied in finding the optic disc that I noticed little else. The 
pupil, however, was still very widely dilated, and I caught the optic 
disc of one eye. It was whiter than normal, and the veins were 
large and dark. I soon lost it, and then the pupil rapidly became so 
small that I could not again illuminate the fundus. It is of course 
of great moment to ascertain the exact stage of the paroxysm when 
the disc is seen. 

" The following are notes of an ophthalmoscopic examination 
made in two cases in which the patients complained of headache with 
a little dimness of sight after a paroxysm of epilepsy. My object 
was of course to learn somewhat as to the condition of the intra- 
cranial circulation after an attack of epilepsy, and also to see the 
state of the vessels of the retina and the nervous tissue (the optic 
disc) supplied by them, in what, judging from the patients* state- 
ment, would generally be called * congestive headache.' For, as the 
arteria centralis retinae may be almost considered as part of the 
cerebral circulation, we shall, no doubt, learn from studying its vary- 
ing conditions something as to the condition of the other branches of 
the internal carotid which supply the brain. 

'* In a- case in which an epileptic complained of slight dimness of 
sight and headache after an attack of epilepsy which she had had the 
same day, the note is as follows : — 

" She [a girl, aged 8, idiopathic epilepsy — a tongue-biter] had a fit 
at 8 A.M. I examine by the ophthalmoscope at 10' 30 a.m. without 
using atropine. I find the veins remarkably large and dark, and 
the arteries also seem darker than normal. The disc is hyper- 
ffimic. 



PBACnC^L MXDICIVB, STC. Ill 

'*In another ease in which, after a fit, there wais dimness of sight 
•nd frontal headache, the veins appeared Tery large, and the optic 
disc was reddened as if flecked with red. It wa8 not uniformly 
coloured, but somewhat like white bibulous paper slightly smeared 
by red ink. 

" I have examined the retina in a case of wound of the spinal cord, 
in which there were, on the left side, symptoms like those following 
section of the cervical sympathetic (ptosis, contraction of the pupil, 
Ac ), but I could not find the least difference in the nize of the vessels 
or in the colour of the optic discs, both eyes being under the influence 
of atropine ; besides there was not, nor had there ever been, any 
defect of sight whatever. 

" I have had under my care a case of neuralgia of one side of the 
face, with contraction of the pupil and slight ptosis. As there was, as 
well as the contraction of the pupil, considerable narrowing of the 
ocular aperture, it looked, so far, like a case of paralysis of the 
cervical sympathetic ; and as there was neuralgia on the same side 
in most of the branches of the fifth nerve and hyperesthesia to the 
t^Miohy and as the least exertion made the patient sweat on the 
affected side, this opinion seemed confirmed. The affection was, 
I consider, in its mechanism, so to speak, I do not say in its cause, 
a sort of miniature herpes zoster. There was the neuralgic pain, but 
ihe changes of nutrition were represented only by a slight haste of 
the natural functions of the skin, and not by the uproar of actual 
inflammation. There was something more than paralysis of the 
branches of the sympathetic correlated with the sensitive nerves to 
the iris and face, as section of the sympathetic does not produce 
neuralgia, but this paralysis was, I believe, one link in the chain. 
Although the pupil was only one-third the size of the other, there 
was no defect of sight whatever. I did not look for defects of sight 
because the pupil was contracted, but because there might be changes 
in the retina smiilar to those in the iris. The patient could read 
small print easily, and could also see well in the distance. He had 
no dimness of sight, no 'clouds,' 'colours,' 'specks,* &c., and not 
a trace of intolerance of light. He could bear, ho said, to look at 
the fire without any annoyance. I dilated the pupil by atropine, 
and made an ophthalmoscopic examination. I round no signs of 
vascularity, the optic discs being as nearly alike as possible. This 
examination was made soon after the pain had begun, but I examined 
again a few months afterwards on a relapse of the pain ; the pupil 
being still contracted, I again used atropine. The discs were then 
quite alike in every respect. 

" I should a priori have expected to have found some slight defect 
of sight and corresponding changes in the vascular supply of the 
optic disc in such a case, and in the case of paralysis of the cervical 
sympathetic from injury to the spinal cord. The retinal arteries are 
supplied with sympathetic nerves as well as the iris, but as I could 
find no change in their calibre and no alteration of colour in the 
optic disc, and as there was no loss of sight and no intolerance of 
light, nor, in fact, any departure from a healthy state of the retina, 
it has occurred to me that the part of the cerebro-spinal axis which 



112 PBi.CTICi.L MEDICINE, ETC. 

supplies the vessels of the retina (indirectly sympathetic) may be 
dinerent to that which supplies the iris. If this were so, I should 
endeavour to ascertain if the same holds good as regards the brain, 
i.e., if it and the retina are supplied by a different region of the 
cerebro-spinal axis from that which supplies the external parts of the 
head, iris, skin, outer ear, &c. The meningeal arteries are chiefly 
branches of the same great arterial trunks that supply the outside of 
the head, so that possibly they may be under the control of the same 
part of the sympathetic system as the iris, outer ear, &c. ; whilst 
the retina and auditory expansion, although outside the cranium, 
receive branches from the arterial trunks which supply the parts 
inside, and majr be under the government of the part of the 
sympathetic which supplies the brain.'* 



(b) CONCEBNINa THE EESPIBATOEY SYSTEM. 

Art. 52. — On Capillary Bronchitis, 

By Dr. Hyde Salter, Assistant-Physician to Charing-cross 

Hospital, &c. 

(British Medical Journalf May 16, 1863.) 

Dr. Hyde Salter makes a case of this comparatively rare affection 
the text of a clinical lecture, and the case and the comments ac- 
companying it are well worthy of quotation : — 

Case. — Francisco Rondi, aged 24, presented himself among the out- 
patients at the hospital on December 22, 1862. His face was pallid, his 
expression anxious and exhausted, and he was obliged to be supported into 
the room. His aspect indicated such depression that at the first moment 
of seeing him I suggested he might be going to have fever. His tongue, 
however, had not at all the fever character, and inquiry immediately 
showed that his symptoms were thoracic. His breathing was very much 
accelerated, aud he had a constant short cough, which, without bringing 
anything up, gave him no pause or rest. This constant cough somewhat 
embarrassed our auscultation. However, the signs were so plain and so 
pronounced that there was no misreading them : they were simply these. 
Breathing hurried and laborious ; respiratory murmur clear but exaggerated 
at the apices, but from that situation downwards, everywhere, front and 
back, supplanted by an abundant, moist, crunching crackle, like squeezing 
a sponge half saturated with water, especially loud at inspiration, but also 
audible at expiration. At the upper boundary of this sound the respiratory 
murmur was heard through the crepitus, but as you descended it became 
less and less audible and the crepitation louder, which, in the lower half of 
the chest, drowned everything. It was clearly produced by the bursting of 
multitudinous bubbles, and resembled pneumonic crepitation in its charac- 
ter — in the idea that it gave — and in being mainly an inspiration-sound ; 
but it differed from it in not being fine enough — it was decidedly coarser. 
It was manifestly produced by drawing air through innumerable capillary 
tubes occupied with fluid. There could be no doubt, then, that the man 
was suffering from intense and almost universal capillary bronchitis. I at 
once ordered him into the hospital. His pulse was rather above 1 20, not 
small. The respirations I did not count. Although the morbid sound was 
of so moist a nature, there was no expectoration — the short, incessanti 



PSACnOAL USDICINE, BTC. 113 

Iwdking congh did not bring up a particle of sputum. No sternal pain. 
Ptomssion-sound normal I should mention that the part of the lung that 
seemed the most free was the upper part of the left lung in front, where, 
from the clavicle to the fourth rib, the respiratory sound was almost natural, 
except that it was strongly compensatory. 

1 ordered stheris chlorici in, x ; ammonise carb. gr. v ; tinctures scills 
11 XX ; decocti senegse 5j ; to be taken every four hours. 

Turpentine fomentations to be applied to the chest, front and back. 

This man being an Italian, I could get but little history out of him ; but 
I ascertained that his illness was but of two days' standing previous to his 
application at the hospital — that it seemed to be the result of cold, and was 
ushered in by shivering and headache. Our patient is one of the unfor- 
tunate race 6f orgim-grinders, and no doubt owes his attack to the mingled 
wet and cold which has prevailed lately, and to which his occupation has 
necessarily exposed him. 

On going into the wards the next day, I found the patient evidently very 
much worse. He was manifestly in a state of impending suffocation ; 
dyspnoea extreme — laborious and making sixty-eight respirations a minute ; 
face dusky, or rather, deeply cyanosed ; the conjunctiva even pervaded 
with the same leaden hue, turgid and sufifused ; lips purple. But he was 
lying quite flat on his back. I immediately ordered him a bed-chair and a 
shawl blanket, and had him propped up in bed. This seemed to give him 
some slight comfort. On examining his chest I found precisely the same 
signs as on the day before, only still more pronounced, and the area of un- 
invaded lung still smaller — confined to a small part of the left apex in front. 
The same fine churning crepitation, mainly inspiratory, everywhere eL<ie — 
above and below, front and back. There was audible, however, now, in 
addition to the fine sound which alone existed yesterday, a larger moist 
sound about the middle zone of the lung ; indicating either that the larger 
tubes were implicated, or that the exudation thrown out in the smaller 
tubes was passing along the larger in its progress towards discharge. The 
action of the extraordinary muscles of respiration was very strong, inter- 
■temomastoid and the inter-scalenal pits deeply RUcked in at each inspiration. 
The same sucking in was seen at the lower part of the chest — scrobiculus 
and cartilages of the false ribs — in fact, along the entire attachment of the 
diaphragm. The expectoration had just, and but just appeared : I was 
shown a single pellet of stiff muco-pus, attached to the bottom of the spit- 
toon, as the only portion that had been spat up. The respiration, as I have 
mentioned, was 68, the pulse 136 ; the puise-respiratiou ratio, therefore, 
was exactly 2. The pulse of good volume and strong. Urine scanty, in- 
tensely dark, but clear. 

I ordered the mixture to be given cver,y alternate houVy and the turpentine 
fomentation to be frequently applied, front and back. 

Dec. 25th. — Much worse ; cyanosis still deeper ; surface damp with per- 
spiration ; aspect heavier and more exhausted, at the same time more 
anxious ; the dyHpnoea was so intense that the patient could only get a word 
out now and then. The constant '* hack " has ceased, and instead there is 
a frequent cough in short paroxysms, attended, on each occasion, with the 
discharge of expectoration. This free discharge has come on since my visit 
yesterday ; I was shown a spittoon containing half a pint of it, and the 
material is so peculiar as to deserve a particular description. 

On taking up the spittoon I not only observed the frothiness of the 
Bputum, but was struck with the lightness of the spittoon, considering how 
full it was. On pouring the material from one spittoon to another this was 
at once explained ; — the whole consisted of nothing but a sort of foam, and 
was as sf)ongy and full of air at the very bottom as at the top ; it was like 
XXXVIII. S 



114 FB^CTICAL MEDICINE, ETC. 

whipped syllabub, or that beaten white of egg and cream which they pour 
over trifles, only more ropy ; but equally spongy, and aerated throughout. 
I have never seen any sputum exactly like it ; generally, however frothy, 
the froth is confined to the top, and the lower strata are free from it : but 
this was not so. On pouring it from one vessel into another it "flopped ** 
out in an elongated mass, leaving the bottom of the empty vessel as clean 
as if it had had nothing in it. There was not the slightest trace of rusty 
tinge about it. I regret to say I did not examine it microscopically. 

Pulse 128, respiration 60 ; pulse-respiration ratio, therefore, 2*13. The 
pulse was voluminous, but flabby and compressible. In consequence of the 
man's increased weakness I ordered him, in addition to the diligent main- 
tenance of the previous treatment and great external warmth, an ounce of 
wine every alteiiiate hour. 

Dec. 26th. — The man is dying. He sits supported in bed with his head 
thrown back, in a state of unconsciousness, aud with a loud rattling re- 
spiration ; eyes half closed, pupils coutracted ; face darkly cyanotic, and 
sweating profusely, as is his whole body. All efforts at rousing him pro- 
duce hardly any effect. The temperature has fallen, being at the groins 
92** Fahr. He ceased to be able to swallow, to expectorate, to cough, or to 
articulate, early this morning, about eight hours ago ; since that time he 
has been gradually sinking into a state of deeper unconsciousness. Puke 
120, respiration 44 ; pulse respiration ratio 2*72. 
Death took place at six o'clock p.m., four hours after the last visit. 
Post-mortem exatnination, nineteen hours after death. — On opening the 
chest, the first thing that struck me was that the lungs did not collapse; 
they maintained their full size in the living thorax ; the part of the 
heart left uncovered did not exceed the natural region of precordial dulness. 
The upper part of the anterior surface of both lungs presented an appear- 
ance of a slight general emphysematous enlargement of the air-cells, and 
the surface here was pale ; lower down this distended condition of Uie 
parenchyma did not exist, and the surface was red and vascular — in some 
parts bright red. The pleural surface of the lungs was uneven, some of 
the lobules standing out in relief from the others, or rather, I should say, 
some of them not coming up to the pleural level ; but there were none of 
them anything like ** camified " — all crepitated, and were full of air. On 
pressing the lung with the finger the impression remained, giving it a 
doughy, pitting character. On being withdrawn from the body the bulki- 
ness of the lungs, and their refusal to collapse, were very conspicuous. 
Their posterior parts were seen to be of a chocolate colour, passing into a 
brighter red both forwards and upwards. 

On cutting into the lung the whole structure was seen to be of a deep 
dull red, everywhere spongy, unusually so, and tolerably dry. Very little 
material escaped from the cut ends of the air-tubes, but on squeezing the 
lungs, a viscid frothy muco- purulent matter showed itself at innumerable 
points. I apprehend that the reason why it did not flow from the tubes 
without pressure was from its great viscidity. On cutting open the larger 
bronchial tubes, they were seen to be of an even deep rose red, and 1^ 
colour extended up into the windpipe, where, on a section, the redness of 
the mucous membrane, in its entire thickness, presented a strong contrast 
to the whiteness of the cartilaginous rings. The same deep redness ex- 
tended down to the finest bronchial tubes that could be cut open. Nowhere 
was there anything like ulceration, or evf»n abrasion of the surface. 

On examining the white opaque froth that everywhere filled the bronchial 
tubes, large and small, it was found to consist of two materials only — pus- 
cells aud columnar epithelium — suspended, of course, in a clear fluid (see 



PBAcncAL lupiciars, nc. 115 

llg.) : bat so nnmerou were theie bodiei that ihej corered the field with 
hanily any mtenpaoes. The mateiial wu perfectly &ee frv>m blood- 




" 8ucb,"8ay8 Dr. H. Salter, " is a picture, from beginning to end, 
as well as I can give it, of thia fatal affection. There are many 
points of interest about it : let us see what they are. 

" In the first place, I would indicate to you the points of contrast 
between such a case as this and one of ordinary bronchitis — what 
would be called now-a-days, by a pleonasm, their points of differen- 
tial diagnosis. These are of three kinds ; — as seen in the clinical 
phenomena, in the physical signs, and in the post-mortem appear- 
ances. The great distinctive clinical phenomenon was the intensity 
of the dyspnoea. The respiratory changes were suspended to a 
degree never seen in ordinary bronchitis : the man was blue from 
the day of his admission ; death by suffocation was manifestly im- 
pending over him from the time he came in till he finally succumbed. 
The clinical fact, too, of this rapid succumbing was of itself, as I 
baye stated before, a distinctive clinical feature. Again, the sputum 
ire must reckon distinctive ; ordinary bronchitis would never yield 
such a material. The peculiarity of the physical sign (for there was 
but one) was : first, its character— that it was a capillary crepitation, 
non-pneumonic, as distinctive and as individual, in my opinion, as 
the true crepitation of pneumonia ; secondly, its distribution — that 
it was not patchy or partial, but universal ; and, thirdly, its single- 
ness — ^that it was this one sign alone, not, as one gets in common 
bronchitis, mixed moist and dry sounds of various sizes. The 
^Btinctive jpost-mortem appearances were, universal non- collapse of 
lung, universal florid redness of the respiratory mucous membrane, 
and universal blockage with a viscid froth. 

" I think, too, that the point where the inflammation commenced 
and the course that it travelled were peculiar. We know that 
ordinary bronchitis travels downwards. The bronchitis of catarrh, of 
whooping-cough, of measles, always travels in this direction. A man 

8—2 



116 PRACTICAL MEDICINE, ETC. 

catches cold to-day ; to-morrow he has a sore throat ; the next day 
he is hoarRe ; the next, he has sternal soreness, indicating an affec- 
tion of the lower windpipe and large hronchi; the next, dry or 
moist sounds, showing that the affection has reached bronchiae of 
smallish size. Now, if we may judge by the physical sijjns, the in- 
flammation in this case would appear to have started in the capillary 
bronchules, for the first-heard sounds were seated in them ; as the 
case advanced, the sounds became larger ; and, on examination after 
death, we found that the inflammatory action had involved the whole 
of the respiratory mucous membrane, even into the windpipe. I do 
not mean to assert positively that the different parts of the respi- 
ratory mucous tract may not have been affected simultaneously ; and 
the reason why the crepitus appeared in the smallest tubes first may 
have been merely because they were the smallest, and therefore the 
earliest infarcted with a sufficient amount of mucus to produce a 
moist sound ; the larger tubes, from their wider calibre, requirintj a 
more abundant exudation before they could be the seat of similar 
sounds. But the fact admits of another interpretation ; viz., that 
the inflammation extended from below upwards, and that the moist 
sound registered its progress. At any rate, there was none of that 
* creeping down* which seems to be the law of ordinary bronchitic 
progress. 

•* Another circumstance to which I would call your attention is 
the extreme rapidity/ of the respiration. On the 24th, it was 68 in a 
minute — a most unusual rapidity in an adult, and a circumstance 
that of itself would constitute a most unfavourable prognostic sign. 
I do not know the law of the rapidity of respiration in the different 
forms of dyspnoea, nor do I know that it has ever been worked out ; 
but it seems to me to be, approximatively — that the nearer the 
mischief is to the parenchyma of the lungs, the more is the breathing 
hurried. Thus pneumonia appears to present us with the most 
rapid of all forms of dyspnoea ; capillary bronchitis, as in this case, 
gives us a high degree of acceleration ; in ordinary bronchitis, the 
breathing is generally by no means much quickened ; in asthma, I 
have often noticed it not at all so ; while in chronic laryngitis, I have 
seen the respiratory intervals actually lengthened. In this respect, 
rapidity of respiration appears to be in inverse proportion to respi- 
ratory distress and violence of respiratory efforts, both of which I 
have noticed to be more intense and agonizing the nearer the seat 
of the difficulty has been to the orifice. 

" Closely connected with this is the ratio existing between the rate 
of respiration and the pulse — what has been called the pulse-respira- 
tion ratio. We know that in health we have four beats of the pulse, 
or four and a half, to each complete respiration ; whereas, in this 
case, a complete respiration, consisting of an inspiration and expira- 
tion, was performed for every two beats of the pulse, although the 
heart was acting at the rate of 136 pulsations in a minute ; or, if we 
reckon each respiration as a double act (an expiration and an inspi- 
ration being each a respiratory act), there was a respiratory act to 
every heart's beat, or 136 in a minute. In this case, then, the pulse- 
respiration ratio was on the 24th exactly 2, instead of 4*5. I am 



FBACTICAL MEDICINE, ETC. 117 

unable to offer you any facts as to the law of the yariation of this 
ratio-— why it should be very much disturbed in some pulmonary 
affections, and not at all in others. Nothing but close and prolonged 
clinical observation, directed to this particular object, will furnish 
the clue to such a law, supposing it to exist. J would only commend 
to your memories the clinical fact illustrated by this case, and men- 
tioned by Dr. Walshe, that in capillary bronchitis the ratio of the 
respiration to the pulse is very high. 

"' Let me also call to your attention, in connexion with this subject, 
the carious fact, that on three days, the 24th, 25th, and 26th, while 
the man was going from bad to worse, and the condition of the 
lungs daily aggravating, the rate of the respiration, and consequently 
the pulse-respiration ratio, was constantly approaching a more 
natural standard. Thus the respirations per minute, on these three 
days, were 68, 60, and 44 ; and the pulse-respiration ratio 2, 2*13, 
and 2 72 respectively. This falling of the ratio of respiration as the 
condition becomes more aggravated, and death approaches, has also 
been referred to by Dr. Walshe. What can be the explanation of 
itP Why, as the state of the lungs gets worse and worse, the respi- 
ratory changes more and more in arrears, and the demand for air 
increasingly urgent, should the respiratory efforts become less 
frequent ? J believe the reason to be, that the increasing carbonic 
narcosis accompanying the dee[)ening asphyxia renders the patient 
less and less sensitive of the respiratory arrears, and therefore tends 
to diminish those respiratory efforts of which the sense of arrears, or, 
in other words, the respiratory distress, is the immediate stimulus. 
Whether the poisoning of the blood with carbonic acid could have 
any similar lowering effect on the heart's action, and thus account 
for the diminished rate of the pulse, I am not prepared to say. I 
have never directed my attention specially to the effect of cyanosis 
on tlie cardiac pulsations. 

" In relation to the cough and expectoration, there are one or 
two points worthy of note — one in especial. Up to two days before 
bis aeath our patient's cough was dry, hacking, and ceaseless ; and 
he spat nothing whatever. Two days before his death the cough 
became less uninterrupted, and the expectoration just commenced ; 
the day before his death the cough was paroxysmal, with consi- 
derable intervals between the fits, and attended with free expectora- 
tion on each occasion ; the day that he died there was neither cough 
nor sputum — both entirely ceased. Now all this is easy of com- 
prehension : — the character of the cou^^h changed with the appear- 
ance of the secretion ; and the day that he died the spitting ceased, 
because all power of coughing ceased. But there is one thing that 
perhaps is not so easily comprehensible, — that moist sound should 
nave existed three or four days before the appearance of the expec- 
toration. There was fluid in the tubes, but none came^rom them ; 
and that in spite of constant cough. 

•'Now you all know that commonly moist sound accompanies 
expectoration, and expectoration accompanies moist sound. But I 
would have you distinctly bear in mind that this is not always so — 
that the two are sometimes divorced — that you may have expeotora- 



118 FBACTICAL MEDICINE, ETC. 

tion without moist sound, or any sound whatever ; and, on the other 
hand, inoist sound without expectoration. The patient's case is an 
example of the last. You have expectoration witnout mucous sound 
when the largest tubes are exclusively the seat of the secretion — 
tubes so large that the mucus adhering to their sides is insufficient 
to produce a constriction, or a stoppage adequate to generate a 
rhonchus or crepitus. Tubes of such a size may have a considerable 
amount of mucus adhering to them, and yet the stream of air 
passing through them shall be so little affected that no sound 
whatever is generated. I have frequently, in cases of large bron- 
chitis, been shown day by day a spittoon with an abundance of 
mucus in it ; and yet, day by day, close auscultation has failed to 
detect any morbid, sound whatever — all was dry and clear. On the 
other hand, and this case is an example of it, I have frequently 
heard a sound asserting the existence of fluid in the air-tubes, and 
yet sputum there has been none. But, whenever this has been the 
case, two other things have also been the case ; the seat of the 
exudation has been in the remotest bronchial tubes, and the amount 
of exudation has been small. When these two conditions are 
present, I believe — nay, I am sure — that no expectoration need take 
place first or last, although moist sounds are constantly heard. The 
reason is this : — the exudation, having its seat in the most distant 
recesses of the bronchial system, has to travel over a ^reat length 
of surface ere it reaches the orifice; and being small m quantity, 
and gradually reduced in its passage partly by the desiccating action 
of the air flowing to and fro over it, and partly by absorption, it 
ceases to be recognisable, and indeed is entirely removed before it 
has reached the orifice. We know how common a thing it is, in 
cases of pneumonia, to hear its characteristic crepitation twenty-four 
or forty-eight hours before any expectoration appears. We have in 
this interval a measure of the time it takes tor the exudation to 
travel from one end of the bronchial system to the other. The 
sputum in most cases of pneumonia, being sufficient in quantity, 
does at length appear; but it need not, and if very small in quantity 
it does not, and I have known several cases in which it has not— . 
cases of undoubted pneumonia, cases in which the physical signs 
could not be misinterpreted ; and yet the crepitation has receded, 
and the patient recovered without any expectoration from first to 
last. Now this case was at first exactly of this nature, as far as the 
non-appearance of expectoration associated with moist sounds went: 
the exudation was scanty and remote, and therefore did not appear 
for three or four days ; but, increasing in quantity and travelling 
upwards, on the third day it appeared, and on the fourth day wag 
abundant. 

" In contemplating this case, I could not help being struck by 
the resemblance of the condition and the method of death to that of 
animals asphyxiated by drowning. In animals so killed, a large 
quantity ot water enters the lungs ; and they die with their smaller 
air-tubes impassably choked up with a froth, the result of the 
cliurning together of the respired air with the water and bronchial 
mucus. There seems something essentially lethal in this state of 



FSACnCAL MBDICIKB, BTC. 119 

things ; animals in whom it is induced invariably die. In the forty- 
fifth Yolume of the Medico- Chirurgical Transactions, you will find 
the details of some experiments on drowning, &c., in which I with 
others was engaged, with the view of ascertaining the best method 
of treatment of cases of suspended animation. We found that dogs 
deprived of air in a dry way for four minutes almost invariably 
recovered, whilst those deprived of air by immersion in water for 
one minute and a half invariably died. If the dogs asphyxiated in 
the dry method made, on their release, but a single gasp, they were 
•afe to recover ; while the submerged dogs, although when taken 
out of the water apparently but little affected, soon began to gasp ; 
their breathing became more and more laborious ; they staggered, 
fell over, and in a few minutes were dead. This difference puzzled 
OS at first ; but when we came to examine the lungs, its cause was 
at once manifest. The lungs of the drowned dogs were found full 
of water, quite sodden, and incapable of collapsing ; on cutting 
them, the water flowed from the cut surface abundantly, and the 
tubes were found in the state I have just mentioned — choked up 
with an impassable froth : so that on removal of the dog from the 
water the source of the asphyxia was not removed — it had been 
transferred from without him to within him ; and instead of being 
at a single point, at the orifice of the main air-passage, as in the 
dofB deprived of air by the dry method, it existed at a hundred 
points — m fact, in every air-tube of the lungs. Just such was the 
state of this patient's lungs ; cut them where you would, out oozed, 
on pressure, from every bronchial tube, a froth consisting of air and 
mucus churned up by the respiratory efforts. The immediate me- 
chanism of death from capillary bronchitis is exactly similar to that 
in a drowned animal." 



Art. 53. — On Pseudo-GangreyKms Bronchitis, 
. By M. Empis, Physician to the Hopital de la Piti6, Paris. 
(6bz. des Hdpitaux, Juin 2, 1863.) 

M. Empis makes a case of this disorder the occasion for a clinical 
lecture. 

Case. — A man, aged 40, a paper- maker, of good constitution and 
habitually enjoying excellent health, was seized early in April with cough 
and abundant expectoration of matter having a fetid odour. These 
symptoms appeared when he was apparently in the best health, and were 
unattended by any constitutional disturbance. The patient ate and worked 
as usual ; he was troubled only by the frequency of the cougli, by the 
abundance of the expectoration, and by the daily increasing fetuJity of his 
breath. His fellow- workmen complained of the odour, and this symptom 
became so unbearable that he was obliged to enter the Hdpital de la Piti^, 
under the care of M. Empis. 

On admission, his breath, especially when he coughed, was extremely 
offensive. His sputa consisted of glairy transparent colourless matter, very 
frothy on the surface, holding in suspension a number of small unequal 
I of opaque mucus, which floated free in the colourless portion of the 



120 PBiLCTICAL MEDICINB, ETC. 

sputa : the whole sputa had a peculiar very disagreeable odour, resembling 
that of gangrene of the lung. On pouring the sputa into a basin of clear 
water and stirring the mixture, the opaque masses did not communicate to 
the water the least muddy tint, as purulent sputa do. 

The conformation of the patient's chest presented nothing remarkable ; 
percussion elicited a normal clear sound in all points of the lung ; on auscul- 
tation, there were heard behind, over a space 6 or 7 centimitres in diameter 
below the angle of the right scapula, some moist mucous rdleSt with 
unequal bubbles, which were partly displaced by coughing. There did not 
appear to be any pathological modification of the voice. 

The patient felt no oppression, and could make large and deep inspirations 
without the least pain. His sleep was often itterrupted by the cough and 
by desire to expectorate. He was not able to lie on the left side, from a 
feeling of suifocation when he did so. He had a good appetite ; ate and 
digested well ; and had never had fever. 

In a clinical lecture on the case, M. Empis remarks that the 
fetidity of the breath and sputa gave at first the idea of pulmonary 
gangrene. But the sudden manner in which the expectoration was 
produced, without having been preceded by any symptoms of disease, 
and the general state of the patient, so little in harmony with the 
severity of the general symptoms ordinarily met with in patients 
affected with gangrene of the lung, forbaa the idea of this con- 
dition to be entertained. Gangrenous fetidity of the breath and 
expectoration does not belong exclusively to pulmonary gangrene, 
and may be met with in certain diseases of the bronchi independent 
of true gangrene. Laennec more than suspected this, when, failing 
to find the pathological characters of pulmonary gangrene in patienti 
who had had fetid bronchorrhcea, he suggested that the fetidity of 
the expectoration depended on a general disposition to gangrene, 
which excited the mucous secretion of the bronchi. Since that time 
M. Briquet has pointed out that, in addition to pulmonary gangrene 
properly so called, there is an affection of the bronchi which resem- 
oles true pulmonary gangrene in the special fetidity of the breath 
and sputa, but which differs from it in its symptoms, in its patho- 
logical anatomy, progress, and frequently favourable termination. 
M. Lasagne has called this condition curable gangrene. 

The quantity of the expectorated matter varies much. In the 
present case, it was about a quart daily ; but frequently it amounts 
to several quarts in twenty-four hours. In cases of long standing it 
contains, in addition to the elements already described, a greyish 
finely granular matter, not at all viscous, which is deposited at the 
bottom of the vessel. It is partially misoible with water, to which, 
when beaten up in it, it communicates a more or less muddy tint. 
The fetidity of the breath varies in degree ; on some days it is slight, 
while on* others it is very intense ; it may disappear, m favourable 
cases, with the catarrhal secretion with which it is connected. The 
expectoration is not unfrequently preceded by the formation of 
vomicae, which burst in coughing, ana discharge their contents. 

In most cases, there are no remarkable physical signs ; there may 
be no general symptoms, or there may be slight febrile reaction ; 
but in no case is the disease attended with the severe symptoms 
which ordinarily accompany gangreue. When death occurs, it takes 



FBACTICAL MBDICIVB, STC. 121 

place as the result of exhaustion produced by the excessive secretion, 
unless the patient be carried off rapidly by some acute complication, 
aoch as pneumonia or erysipelas. 

The pathology of the disease does not appear to be positirely 
determined. 

M. Briquet believes that the extremities of the bronchial tubes 
become dilated, and affected with gangrene independently of the 
other parts of the lung. M. Empis criticises the latter notion at 
some length, and says that it seems to him more rational to admit 
that the disease consists in a special pathological alteration of the 
mucous membrane of the bronchi, in virtue of which they become 
dilated, while at the same time their internal surface secretes a pro- 
digious quantity of fetid matter.. The disease then may be theo- 
retically resolved into dilatation of the bronchi ; bronchorrh jea ; and 
gangrenous fcetor. But these are neither succesi^ive nor subordinate 
one to another; they advance equally, and it is their union 
and indivisibility which constitute the special character of the 
disease. 



Art. 54. — On the Inefficiency and Bangers of Cauterization 
in the Treatment of Croup, 

By MM. Fischer and Bricheteau. 

{Medical Circular, May 2a, 1863.) 

MM. Fischer and Bricheteau, internes at the H6pital des Enfans 
Malades, at Paris, do not absolutely reject cauterization in croup and 
diphtheria, but the objections which have been adduced to the pro- 
cedure appear so well founded that they consider themselves justified 
in stating them. 

The difficulty of effectually applying cauterization in children is 
exceptional, and would not afford a sufficient reason for the rejection 
of the method, if it checked the formation of false membranes, pre- 
vented their reproduction, and could obviate the extension of the 
diphtheritic secretion. Many physicians now entertain strong views 
on the subject, and resort to cauterization of the fauces with extreme 
reluctance. This procedure affords no security against the develop- 
ment of croup; frequently diphtheritic angina has been followed by 
eroup, although active cauterization had been instituted, and had even 
been successful in effecting a local cure of the pseudo-membranous 
disease of the throat. 

" It frequently occurs," say MM. Fischer and Bricheteau, " that, 
during an epidemic, an infant is brought to hospital, who for a few 
hoars only has suffered from sore-throat. The disease is therefore 
observed in its earliest stage. On inspection of the fauces, a small 
diphtheritic patch is- discerned on the surface of one tonsil, and 
eanterization is resorted to ; but a few hours later a second pseudo- 
membranous deposit is detected on the other tonsil, and so on. 

" It has also been remarked that cauterization in no wise affects 
the primary cause of the complaint, which is of a general character. 



122 FBACTICAL MBDICIKE, ETC. 

with a tendency to local manifestations on the mucous lining of the 
respiratory organs. The pustule which would subsequently become 
a Hunterian chancre may legitimately be destroyed, but what would 
be the advantage of cauterizing ecthymatous pustules, consequent on 
infection of the system ? Syphilitic ecthyma is but the result of a 
general taint, and false membranes likewise are but the local ex- 
pression of the diphtheritic diathesis. The peculiar virus or miasma, 
the morbid poison which gives rise to diphtheria, is unknown to us, 
but betrays its existence by its consequences. It is the cause, and 
not the effect, the practitioner should contend with." 

MM. Fischer and Bricheteau believe that the morbid intoxication 
precedes the formation of the false membranes. They have on several 
occasions observed ah initio symptoms, which attested the presence 
of the virus in the blood, a rapidly fatal termiqation supervening, 
although but a very few insignificant greyish spots were discernible 
in the pharynx. If, as has been argued, the infection were consequent 
on the diphtheritic exanthema, its manifestations should be propor- 
tionate to the number and extent of the pseudo-membranous deposits, 
from which the poison is alleged to have been derived. But this is not 
the case ; the most malignant forms of diphtheria are not those in 
which the local symptoms are most considerable. The treatment 
adopted at the Hospital for Infancy also suggests to the authors 
another sagacious remark. Tracheotomy is very frequently resorted 
to in that institution ; after the performance of the operation, when 
respiration has been re-established, the entire treatment consists in 
watching the condition of the pulmonary organs, and in supporting 
the patient. Very little further attention is wasted on the false 
membranes ; they are never touched with any caustic, no local 
remedy is applied, and the confidence thus reposed in the efforts of 
nature has never been betrayed. Chloride of potash is, however, 
prescribed for a few days after the operation. 

The previous remarks are adduced for the purpose of showing the 
inefficacy of cauterizaticm ; it is further alleged to be a hazardous 
practice. 

The application of muriatic acid has induced gangrene of the fauces, 
and MM. Blache and Guiet have related cases in which cauterization 
was followed by fatal spasmodic contraction of the larynx. The 
method, moreover, is open to the objection of causing violent irrita- 
tion, and of promptly and fatally exhausting the strength of the 
patient by determining energetic effort and temporary excitement of 
vital powers. When tracheotomy becomes necessary, the previous 
application of escharotics has another great disadvantage, llie 
necessity of supporting the- system is then universally acknowledged, 
and active cauterization gives rise to «n unconquerable aversion 
to food, and to considerable pain in deglutition. The children 
obstinately refuse to take nutriment, and if they have the good 
fortune to escape the perils of abstinence^under these unfavourable 
circumstances, their recovery is materially retarded. Cauterization 
with muriatic acid is especially injurious, and one of our unfortunate 
colleagues bore witness, before his death, to the tortures inflicted bj 
the use of this agent. 



PRACTICAL MEDICIKB, STC. 123 

'^ MM. Fischer and Bricheteau's paper shows that the local remedies 
in croup and diphtheria should be selected from the class of astringent 
substances, and not from the list of escharotics. Chlorate of potash, 
alum, and tannin, should be insufflated or prescribed in gargles. If 
necessary, a solution, containing one quarter of its weight of nitrate 
of silver, may be applied with a brush ; but the lunar caustic, which 
imparts a greyish colour to the mucous membrane, and may prevent 
the surgeon from detecting genuine patches of diphtheria, should be 
cautiously avoided. 

Inhalations of medicated and pulverised fluids may also be 
resorted to with benefit. The composition of such fluids may vary 
ad infinitum, and the system has the twofold advantage of convey- 
ing the remedies directly into the respiratory passages, and as M. 
Barthez has observed, is a perfectly innocuous procedure, which 
interferes in no wise with tracheotomy, should the operation be 
indispensably required. 



Art. 55. — On Adhma^ 

By Dr. J. Baiu>ON Sanderson, Assistant-Physician to the 
Middlesex Hospital. 

(Medical Times and Gazette, May 16, 1868.) 

After stating that the deflnition of asthma as a species of disease 
must be founded exclusively on the study of its development during 
life, with but little assistance from morbid anatomy, the author pro- 
ceeds to describe the phenomena of an attack, dwelling particularly 
on the nocturnal onset of the aflection, and the complete remission 
of all the svmptoms during the intervals. The characteristic ele- 
ments of asthmatic dyspnoea are stated to be, (1) excessive expansion 
of the chest ; (2) resisted but forcible efforts to expire ; (3) diminu- 
tion of the exchange of air in tJie chest, and consequent venous con- 
dition of the blood. In the asthmatic state the chest is arched for- 
wards in extreme inspiration, the diaphragm sinks below its normal 
level, so that its power is lost, while the almost fruitless efforts to 
renew the air in tne chest are accomplished by elevation of the 
upper ribs. The expiratory muscles of the abdominal wall are in 
excessive action ; but, in spite of their efforts, air is expelled from 
the chest with extreme difficulty and in small quantity. The con- 
dition of the blood which is thus produced gives rise to the sensation 
of want of breath, and impels the patient to make conscious and 
Toluntary efforts to get rid oFthe used air, which is as it were locked 
.up in his chest, so as to enable himself to obtain a fresh supply. In 
order to arrive at an explanation of this remarkable state, so different 
from every other form of dyspncea, the circumstances must be con- 
sidered under which it is developed. Asthma comes on during those 
hours of the night in which sleep is ordinarily most profound. At 
night the respiratory function is modified ; the quantity of air ex- 
changed is diminished. This diminution is partly, though not 
entirely, dependent on a change in the respiratory function of the 



124 PBACTICAL MEDICINE, ETC. 

vocal cords, which in nocturnal breathing approach each other more 
closely than in the waking state, that muscular action by which they 
are kept apart is relaxed. The more profound the slumber the 
greater the relaxation, and the narrower the chink of the glottis (e,^,, 
in snoring expiration). Assume for a moment that this natural re- 
laxation becomes excessive. As the laryngeal resistance is normally 
greater to the egress than to the ingress of air, the chest falls more 
and more with each respiration, the inspiratory power of the dia- 

I»hragm lessens, the exchange of air is diminished, tne blood becomes 
ess arterial, and thus, without any agency beyond the intensification 
of that condition of respiration which exists in natural sleep, all the 
elements of asthma are developed. In short, it is possible to account 
for asthma as a result of disorder in the respiratory function of the 
glottis. But if it be remembered that the muscular fibres on which 
this function depends are governed by the same nerve as the con- 
tractile fibres of the lung tissue (as is shown by the experiments of 
Donders and others), it will be readily admitted that if in asthma 
the respiratory fibres of the glottis are relaxed, those of the lung 
are in a similar state of relaxation, which would afford an additions 
explanation of the remarkable dilatation of the chest. This view 
accords perfectly with what is known as to the intimate relation of 
asthma and emphysema. Emphysema cannot be regarded as the 
cause of asthma ; it would even be more correct to speak of it as its 
consequence. Emphysema results from resisted but powerful efforts 
on the part of the expiratory muscles to expel air from an expanded 
lung. This is precisely the state of things in asthma. But the 
relation between the disease and the lesion is rather that of com- 
munity of cause than of consequence. Temporary over-expan- 
sion of the lung is a constituent of asthma ; permanent ex- 
pansion cannot exist without emphysema. Under the head of 
** Diagnosis," the author distinguishes between asthma and spas- 
modic dyspnoea, in all forms of which the relation between the in- 
spiratory and expiratory act is the reverse of that which holds in 
asthma — e.ff., in the spasmodic dyspnoea of phthisis, acute bron- 
chitis, and dwells on the importance of determining the relative 
duration of the inspiratory and expiratory act, which may be best 
affected, not by listening to the chest, or observing its movements, 
but by the auscultation of the larynx. As regards treatment, the 
author has found that no remedies were useful during the attack of 
asthma excepting stimulants, of which ipecacuanha in large doses, 
alcohol, and coffee are instanced as most important. 

Art. 56. — On tie Management of Pulmonary Tuberculosis^ 

with Special Reference to the Employment of Alcoholic 

Stimulants, 

By Dr. Austin Flint. 

{American Medical Times; and Dublin Medical PresSf July 29, 1868.) 

This paper, which was read before the New York Academj of 
Medicine, consists mainly of a clinical report, based upon sixty- 



PBACTICAL MEDICIKB, STC. 125 

two cases of arrested tuberculosis. These cases are analysed and 
compared as regards points of agreement relating directly and indi- 
rectly to the management, the main objects of inquiry being the 
eyidence afforded of self-limitation, the influence of tygienic mea- 
sures, the agency of remedies, and th.e importance of alcoholic stimu- 
lants in determining the arrest of the disease. Dr. Flint considers 
that the disease is arrested whenever the general and local synjp- 
toms show it to be non- progressive for several consecutive months. 
After the arrest, the recovery may or may not be complete. In 
many of the cases the recovery was complete, while in others a 
certain amount of cough and expectoration continued for a con- 
siderable period of time, in two cases for more than twenty, and in 
one case for forty years. 

For convenience of analysis he arranges the cases in three groups. 
1. Those in which no curative or hygienic methods of management 
were employed. 2. Those cases in which hygienic measures were 
employed. 3. Cases in which remedial measures, including alcoholic 
stimulants, were supposed to have had a curative influence. 1. In 
the first group seven cases are collected, of which four recovered 
entirely. 2. The second group includes twenty cases, in twelve of 
which the recovery appeared to be complete, in eight the arrest of 
the disease was not followed by complete recovery within the period 
tiiat the condition of the patients severally was known. The ages 
in this group ranged between nineteen and fifty years, and seventeen 
of these were males. In only four of the cases are there any 
grounds for supposing that climate had any curative influence. The 
most important point of agreement developed by the analysis of 
this group of cases relates to change of habits as regards exercise 
and out-door life, and the agreement in this respect is highly signi- 
ficant. 3. The third group embraces thirty -five cases. Only one 
of these cases was treated with tonic remedies, exclusive of cod-liver 
oil and alcoholic stimulants. In four tonics were employed in con- 
junction with alcoholic stimulants, and in two tonic remedies were 
conjoined with cod-liver oil ; alcoholic stimulants and cod-liver oil 
were employed conjunctively in eight cases. Stimulants, oil, and 
tonics were used in one case. The curative remedies employed 
were only three in number; cod-liver, alcoholic stimulants, and 
tonics of iron and quinine. In five of the thirty-five cases, the 
curative treatment consisted exclusively of cod-liver oil ; in two of 
these the symptoms entirely ceased. Of these thirty-five cases, in 
fourteen the curative treatment consisted exclusively in the use of 
alcoholic stimulants ; of these fourteen cases of arrest, in nine the 
recovery was apparently complete. Generous living was inculcated 
and adopted as far as practicable in all the cases. 

The most striking and valuable of the results of the analytical 
study of these sixty- two cases is their almost uniform agreement as 
regards change of habits with respect to exercise and out-door life 
at the time of the arrest. Excluding the seven cases of the first 
class, and two in which the facts with respect to this point were not 
noted, of the remaining fifty- three, in all save three, the histories 
ahow a greater or less change of habits to have been made ; and in. 



126 FBACTICAL MEDICINB, ETC. 

many cases the change consisted in relinquishinfi: sedentary callings 
for other pursuits, in order to carry out more effectually the desired 
reformation. Eegarding the indications for the use of stimulants. 
Dr. Flint says :— 

** If their immediate effect be that of a cordial stimulant, that is, 
if they produce a sense of comfort ; if they are followed by a feeling 
of increased strength, and a greater disposition to exercise ; if they 
do not excite unduly the circulation or nervous system, I believe we 
may expect benefit from their use. Fer contra, if their immediate 
effect be discomfort ; if they are followed by a feeling of increased 
■weakness and less disposition to exercise, and if they excite unduly 
the circulation or nervous system, I believe they will not do gooa, 
and may perhaps do harm." 

With respect to the formation of habits of intemperance, he 
remarks : — 

" In not one of the cases which I have reported has there been 
developed, so far as I know, a craving for stimulants, or a reliance 
upon them, rendering it difficult to relinquish their use. I have 
had my attention directed particularly to this point of observation, 
and I have not yet found an instance in which there was any appa- 
rent reluctance to discontinue the use of alcoholic stimulants wnen- 
ever it was deemed advisable. I have not yet found an instance in 
which their use was continued after they were declared unnecessary ; 
in short, up to this time I am not aware that in a single case among 
the many cases in which I have advised alcoholic stimulants, has a 
patient fallen into intemperate habits. * * * I certainly am not 

I)repared to advocate the use of alcoholic stimulants as a prophy- 
actic ; that is, to sanction indulgence among those who may believe 
or fancy that they are in danger of becoming tuberculous. I would 
not advise their use in doubtful cases ; they should follow a clear 
diagnosis, based on signs and symptoms. In persons with the un- 
fortunate idiosyncrasy which leads to an irresistible craving on the 
slightest indulgence, the immediate effects would always contra-indi- 
cate their use in conformity with the rules which should govern our 
practice in eases of tuberculosis. And, finally, when employed as a 
remedy, they are not to be taken as a means of conviviality, or for 
any other than a curative influence." 



Art. 57. — On Chronic Congestion of the Lungs. 

By M. BoucnuT, Physician to the H6pital des Enfans Malades 

at Paris. 

(Jowrn. de Mid, et Chir. Prat, Oct. 11, 1863.) 

M. Bouchut makes the case of a girl, set. 13, recently admitted into 
the hospital with which he is connected, the text for some important 
remarks upon this subject. 

The child was the offspring of parents who had never displayed 
any tendency to pulmonary tuberculosis, and although herselffeeble 



FBACTIGAL MEDICI5B, ETC. 127 

and anaemic, she had not preyiously suffered from any serious disease. 
Two months before her admission cough set in, and once she threw 
up a small quantity of blood. The cough is now painless, and un- 
attended with expectoration; on percussion slight dulness is dis- 
covered in the ri^ht supra-spinous fossa, and on auscultation the 
Tesicular murmur is found to be evidently weaker beneath the left 
clavicle, without any increase in the length of expiration, without 
any superadded sounds, or increased resonance of the voice. In the 
corresponding region of the right side, the respiratory murmur is 
louder, and posteriorly, in the ri^ht supra-spinous fossa, the expi- 
ration is protracted, and the voice-sound louder, but no rhonchi 
whatever are audible. The child, moreover, is in a debilitated and 
ansemic condition, and occasionally subject to feverishness in the 
evening. 

Guided by these signs, which for ten days were invariably found 
the same, M. Bouchut, instead of pronouncing the case to be one of 
tubercular consolidation of the apex of the lungs, expressed his 
belief in the presence of chronic pulmonary congestion. 

This affection, already described by M. Andral, M. Darralde, and 
other observers, consists in a degree of hypersemia, which prevents 
the lung, partially collapsed, from expanding to receive the usual 
amount of air, and induces a condition nearly approaching to in- 
flammation, with induration of the pulmonary structure and con- 
sequently defective hematosis. 

An analogous congestive state may occur in the brain, liver, and 
other viscera, and clinical observation demonstrates the possibility 
of its existence in the lungs. M. Bouchut met with a case in point 
in a little girl aged five years, who had recently recovered from 
whooping-cough, but who was continually attacked with feverishness 
without any obvious cause. She still coughed occasionally, and was 
losing flesh. By careful and repeated examination of the chest, dul- 
ness was discovered in the right supra-spinous fossa, and in the same 
region, the respiratory murmur was found to be weak, the expiration 
protracted, and the resonance of the voice increased. No improve- 
ment in this condition being observable after an interval of six 
months, the child was sent to the -waters of Saint-Honor^, in the 
D6partement de la Nievre. After a short residence at the springs 
amelioration set in, and a complete cure was effected the following 
year, by a second visit to the spa. 

Cases of the same kind are not unfrecjuent after whooping cough, 
measles, pneumonia, or simple bronchitis. When they occur in M. 
Bouchut's practice, he invariably prescribes change of air, sea- 
bathing, the mineral waters of Saint- Honor6, cod-liver oil, counter- 
irritants, &c., and he has often had the good fortune of thus effecting 
a cure of what was supposed to be incipient phthisis. The remedies 
above enumerated, of course, would fail to remove tubercular con- 
solidation ; the morbid condition could not disappear in a few weeks 
or months, under the influence of change of air and mineral waters, 
and hence M. Bouchut conceives the lesion to consist in chronic 

Sulmonary congestion. At the military hospital of Val de Grace, in 
^aris, M. Champouillon has observed many facts which confirm this 



128 PEACTICAL MBDICIKE, ETC. 

view, and has seen hundreds of soldiers presenting all the signs of 
the early stage of consumption, who recovered perfectly during a six 
months* leave. 

Morbid anatomy further corroborates the suggestions of clinical 
experience ; when persons sufiering from bronchitis of a suspicious 
character, die from some intercurrent disease, pulmonary sclerosis iB 
occasionally discovered ; its physical signs during life having been 
precisely the same as those which would have been caused by 
tubercles, viz. comparative dulness on percussion, weakness of the 
respiratory murmur, prolonged expiration, and increased resonance 
of the voice. 

The foregoing remarks imply that the discrimination between the 
two diseases is necessarily difficult, and reposes upon the previous 
history of the case; but knowledge of tlie precedents does not 
entirely dispel the obscurity of the diagnosis. The embarrassment 
of the practitioner increases when permanent bronchitis is also 
present as a complication, giving rise to copious mucous secretion, 
and to moist and sonorous rhonchi. We are fortunately in posses- 
sion of a valuable touchstone, supplied by cold or warm sulphurous 
waters, assisted by country air. Those who are experienced in the 
use of those waters are well aware that they do not cure tubercu- 
losis, but are truly beneficial in chronic pulmonary congestion. 

This form of hypersemia is an asthenic affection frequently con- 
nected with scrofula or herpetic tendencies, like many local chronic 
congestions situated in other organs. Under these circumstances, 
tonics and stimulants are most appropriate at all ages. Anodyne 
beverages and mixtures, together \s ith cod oil, bark w ine, arseniate 
of soda, counter-irritants, and generous diet and wine will be pre- 
scribed with benefit, and when the season and the circum- 
stances of the patient admit, change of air and saline or sulphurous 
waters. 

M. Bouchut then alludes in detail to each element of the treat- 
ment above recommended. 

Cod-liver oil, he says, is essentially a winter medicine, and may be 
replaced by goose-grease, the fat of roast pork, or butter and salt. 
If the cod-liver oil induces diarrhoea, it should be exchanged for 
rapidly increasing doses of bark wine, the state of the bowels being, 
at the sanne time, carefully watched. 

One of the best tonics, in M. Bouchut's opinion, is the arseniate 
of soda. In the case of a little girl, aged nine years, who for six 
^months had been affected with a troublesome cough, and in whom 
he suspected the presence of chronic pulukonary congestion, he pre- 
scribed with mucn benefit the following medicine, to be taken in 
teaspoonfuls in the course of each day : — 

^. Sodae arseniatis, gr. ^^ ; 
Oxym. scillsB, 5x ; 
Syrupi papaveris, 513*. 

The oxymel of squill is an excellent expectorant which, in M. 
Bouchut's opinion, is not estimated at its full value. In general he 
exhibits the arseniate in the shape of a syrup, viz. : — 



PSACnCAL MSDICIKS, ITC. 129 

9>« Sodie aneniatis, gr. j. 
Sjr. cinchonse, ^x. 
Bose : from one to five teaspoonfuls daily. 

^Hiis remedial agent restores appetite, improves the circulation, 
mTigorates the system, and may be useful m the more advanced 
stages of phthisis ; it should, however, be administered in the absence 
of fever only. If feverishness exist, it should in the first place be 
■abdued wiu antimoniab and emetics. 

Cutaneous counter-irritation is an important element of treatment, 
frictions night and morning with croton oil, or repeated blistering 
of the chest will be found beneficial, or better still, the application 
of tincture of iodine over the walls of the chest. 

The Spas recommended by M. Bouchut are those of Enghien, 
Pierrefonds, Eaux- Bonnes, Eaux-Chaudes, Saint-Sauveur, Cauterets, 
or Luchon in summer, and in winter those of Am6lie les Bains and 
le Yemet. The waters should at first be exhibited in small doses, 
or inhaled in the shape of spray, or prescribed in the form of very 
warm baths, in which the subject should be immersed up to the 
waist only. This plan, which is much used at Mont-Dore, is ex- 
tremely beneficial as a means of producing counter-irritation. It 
induces congestion of the blood-vessels of the lower parts of the 
body, and actively promotes the resolution of the congestive or in- 
flammatory condition of the lungs and bronchi. 



Aet. 58. — Cases of Whooping-cough treated with Bromide Oj 
Ammonium. 

By Dr. Habley, Assistant-Physician to University College 
Hospital. 

, {Lancetf September 26, 1863.) 

In using the bromide of ammonium in these cases, Dr. Harley's 
object was to obtain the anaesthetic action upon the larynx and 
pharynx which Dr. Gibb has lately shown to be produceable by this 
medicine. He wished to do away with that part of the cause of the 
spasm which depended upon over-sensitiveness of the larynx and 
pharynx, and to a certain extent he seems to have been successful. 

Case 1.— Februaiy 9th, 1863.— Eliza F , a tolerably well- developed 

child, aged eighteen months, who had whooped for eight days, was first 
treated with five minims of tincture of belladonna and a quarter of a grain 
of sulphate of zinc in two drachms of water thrice a day. 

Feb. 16th. — Cough just as before. There is dryness of the throat, show- 
ing that the belladonna has produced its specific effect. The treatment is 
now (on the fifteenth day of the disease) to be changed to five grains of the 
bromide of ammonium dissolved in water three times a day. 

19th. — Cough, or rather the whoop, is already much better. To repeat 
the mixture. 

27th. — ^The child no longer whoops, but has still a slight cough. 

XXXVIII. 9 



130 PSAOTIOAL MBDICINB, BTO. 

The bronchiiio coagh lasted till the 20th of Maroh, when the child was 
dismissed as cured. 

Case 2. — Ellen S , aged four years and four months, was brought to 

the hospital on the 5th of May. She had whooped during seven weeks, and 
had an ordinary catarrhal cough for fourteen days before the whoop com- 
menced. She now whoops every time she coughs, which occurs about three 
or four times an hour, although she occasionally passes about an hour with- 
out coughing. The child was veiy stout before her illness began, and, 
although she is not yet emaciated, the mother says that she has lost a great 
deal of flesh. Skin hot ; appetite very bad ; bowels usually open twice a 
day. To have six grains of bromide of ammonium in two drachms of water 
three times a day. 

May 8th. — To-day the mother states that after leaving the hospital on tho 
5th she carefully watched the child, and found that she whooped thirty-two 
times in three hours ; but since taking the medicine the whoop has very 
much diminished, and to-day (third day of the bromide) the child has passed 
three hours without either coughing or whooping. To repeat the mixture. 

This patient was not again brought to the hospital. 

Case 8.— -Feb. 26th.— H. W. O , aged four years, began to whoop 

on the 22nd (four days ago). Had a catarrhal cough for ten days before he 
began to whoop. To take six grains of the bromide of ammonium in two 
drachms of watei' three times a day. 

March 2nd. — ^The child has very much improved. Has only a very slight 
cough. The whoop has ceased. This is only the fourth day of the treat- 
ment, and the eighth of the disease. 

Case 4. — March 2nd. — Brother (aged two years?) of last patient is now 
ill. He began to whoop on Feb. 25th (six days ago). He is also to be 
treated with the same medicine ; but in order to try the effect of very small 
doses, only one grain and a half are to be taken thrice a day. 

March 20th. —Child still whoops, though not so much as before. 

27th. — Whoop ceased two days ago (twenty-fifth day of treatment, thirty^ 
first day of the disease). 

Case 5.— March 27th. — Third child (aged three years) in same faxaWj 
began to whoop on March 22nd (five days ago). Whoops three or four 
times a day, and four or five times during the night. As this child was 
under the same hygienic conditions as the two preceding cases, it was thought 
an excellent opportunity of still further testing the effects of different doses 
of the bromide, and accordingly three grains were ordered to be taken three 
times a day. 

May Ist. — The mother did not bring the child back till to-day, and gave 
as her reason the fact of the child having ceased to whoop three weeks ago ; 
that is, on the fourteenth day of the treatment, and the nineteenth of the 
disease. The catarrhal cough, however, still continued, and for this 
ipecacuanha wine and camphor mixture were ordered. The cough ceased % 
week later. 

Dr. Harley believes that the remedy does not act by remoyinff 
the con^b, but simply by preventing the occurrence of its chief and 
most disagreeable 8ymptom---the wlioop. It also appears that the 
larger the dose of the bromide the more speedy is the cure. To 
remove the catarrhal after-cough, an ordinary expectorant is all that 
ia required. 



PXAOnOAL lUDIOTKX, BTO. 131 

Aet. 59. — On the Treatment of Whooping ^ough hy 
Ergot of Rye. 

By Dr. 0. Griepenkasl. 

(BeuiKkt KlvMk, No. 11, 1863 ; and Qoz, Hebd. de Mid. et Chir., 
Sept. 26, 1863.) 

In 1856, a boy, set. 6, a patient of Dr. Griepenkarrs, sufiTering 
from whooping-cough, was seized with convulsive ergotism, a ma- 
lady theli endemic in the neighbourhood where he lived — Lutter. 
As soon as the convulsive symptoms from ergotism made their 
appearance, the characteristic whoop of the cough disappeared, and 
gave place to simple piping inspirations. Fifteen days later, the 
patient was well — of the ergotism as well as of the whooping-cough. 
Since this time. Dr. Griepenkarl has tried ergot as a remedy in 
more than 300 cases, and he speaks most confidently as to the 
results, if only the commencement of the treatment be deferred 
until the third week of the malady, or later still, if any complica- 
tions of the disorder have yet to be mastered. He prefers a syrup 
made by boiling from 1 to 2 grammes of coarsely powdered ergot 
in water, until 32 grammes remain to be stramed off, and then 
sweetening with 48 grammes of sugar ; and this syrup he gives to 
a child of from 5 to 7 years, one teaspoonful every two hours for a 
fortnight, and then again for a few days, after an mterval of a week 
or ten days. As to the success of the treatment it is not possible 
to form an opinion from the data given, but there is nothing to lead 
one to believe that it is so encouraging as Dr. Griepenkarl would 
have us suppose. 

Aet. 60. — A Cheap Spirometer. 

By Dr. W. K Bowman. 
{Canada Lancet, Jane 15, 1863.) 

A cheap spirometer may readily be made from two tin vessels 
similar in shape to the ones figured in the accompanying woodcut ; 
the one shouM be about 20 inches long and 6 inches in diameter, 
and the other 18 inches long and 5 inches in diameter. The latter 
may be graduated into spaces of eight cubic inches by means of our 
orcunary gallon measure, which is the old wine measure of Great 
Britain, and the one that is adopted by the United States Pharma- 
copceia ; it consists, as everybody knows, of 8 pints of 16 ounces 
each, the ounce measuring 1*8 cubic inches. 

Having placed the smaller vessel perfectly upright, measure into 
it a gallon of water, less hidf an ounce, and with a rule ascertain the 
precise distance from the surface of the liquid to the brim of the 
yessel, then placing this measure outside of the tin, mark the height 
of the water as 230 c. in. In a similar manner with half a gallon 
and lOi fluid ounces, mark 134 c. in. 

Next divide the space between these two points into 12 equal 
parts, which will be measures of 8 c. inches each, and with the oom- 

9— a 



132 PRACTICAL MEDICINE, ETC. 

passes continue the graduation upwards and downwards, placing 
the figures on the inverted vessel as here shown. If its diameter 
be everywhere alike, the measure must be correct ; its accuracy how- 
ever may be readily tested by the annexed subdivisions of the same 
measure. The pulleys and counterpoise may now be adjusted to the 
graduated tin. 




Next fill the larger vessel with water so that the smaller may be 
just covered when inserted as low as possible into it, and mark the 
height of the water on the inside of the larger tin. Then raise the 
small one gently until the 174 c. in. line appears even with the 
surface of the water, and make a second mark of its level. Finally, 
put the third graduation in the large tin when the smaller is raised 
completely out of it. 

Lastly, affix two or three feet of flexible tubing and a mouth-piece 
to the top of the small tin, and the spirometer will be ready for use. 

The graduation inside of the larger vessel is to detect and obviate 
any difference in the level of the water within and outside of the 
rising vessel, which after receiving the breath should be depressed 
until the water is at its proper level, the tube being closed by the 
fingers during the adjustment and reading off. 



FBACTICAL MBDICIKB, ETC. 193 

With this scale as a ^de the York Glass Company of England 
has made a beautiiiil spirometer of this form entirely of glass, and 
oorreotly graduated into cubic inches. It differs somewhat from 
this one, in haying a perforated glass stopper in the centre, to which 
the silk-covered tubing is attached ; and also in having two cords, 
one each side of the stopper, and four pulleys which prevent it from 
turning. Thus arranged and mounted on handsome brackets, apart 
from its usefulness- in ascertaining the presence and progress of 
phthisis, it forms an elegant addition to a surgery. 



(C) CONCEENINO THE CIECITLATOET SYSTEM. 

Art. 61. — On Pericarditis consequent upon Tyc^mia. 

By Dr. Kibkes, Assistant Physician to St. Bartholomew's 

Hospital. 

(Medical Times and Gazette, October 25 and November 1, 1863.) 

Dr. Kirkes dwelt upon this subject in one of the Gulstonian 
Lectures at the College of Physicians, delivered by him in 1856. In 
the present paper he cites another case, and makes certain comments, 
and the case and the comments are full of instruction : — 

C4SE. — A boy, about 16 years old, while engaged in a fight with another 
boy, received a violent kick on the left shin, about an inch below the knee. 
This occurred on August 22nd. On the 26th he presented himself at the 
hospital, and showed his leg to Mr. Marsh, the house-surgeon on duty. 
There was a red, tense swelling over the injured part ; and Mr. Marsh, 
being struck with the peculiar haggard, anxious look of the boy, admitted 
him into the hospital, under the care of Mr. Savory. On auscultation, a 
well-marked pericardial friction sound was detected. The patient complained 
of general pains in the limbs, and of feeling very ill. There was, however, 
no swelling, redness, or particular tenderness of any joint, and, moreover, 
no rheumatic odour. The skin was hot, the pulse about 120, and the 
tongue coated with a yellowish fur. On the day after admission a few 
small pustules were detected on the front of the chest and abdomen. The 
swelliog over the left shin was incised, and much puriform matter evacuated, 
and the patient was supported with bark, wine, and good nourishment. The 
nervous agitation, however, increased, the symptoms became more typhoid, 
signs of copious pericardial effusion ensued, and the boy died exhausted on 
the 29th, three days after admission, and seven from the receipt of the injury. 

On post-mortem examination, the pericardial cavity was found distended 
with turbid serum, while flakes and curdy masses of recent lymph were 
spread over the surface of the membrane, which was intensely vascular. The 
muscular tissue of the heart, when cut in two, was found generally softer 
than natural, especially about the left ventricle. Together with this general 
softening, there were numerous buif-coloured patches, as if resulting from 
some change in the tissue rather than from actual deposit : in many places 
such discoloured pai*ts were much softened, and several were even reduced to 
diffluent, puinilent- looking masses, varying in size from pins'-heads to split- 
peas. This softened material, when removed, left little cysts or sacs in the 
substance of the muscular wall. Such masses were especially abundant about 
the base of the heart, and in the walls of the left ventricle. Several were 
close to the pericardial surface of the heart, and one at least, detected by Dr. 
Andrew, appeared to have opened into the interior of the left ventricle. 



134t niLCTlCAL HBDICIITB, BTO. 

MioroBcopio examination of the softened material exhibited little else tiian 
an abundance of oil globules of all sizes ; much granular, matter ; and many 
shreds of muscular tissue, the majority of which presented more or less 
decided evidence of granular degeneration. No actual pus corpuscles 
were observed. All the valves of the heart were healthy. 

Within the lungs were numerous ordinary pyaemic deposits, many of which 
were reduced to collections of soft, purulent-looking matter. Over several 
of these which were near the surface of the lungs, were signs of recent 
pleurisy in the form of soft lymph over highly -vascular membrane. Several 
purulent-looking deposits were also found in the soft pulpy spleen, and on 
the surface of each kidney. The liver was free. Much mischief was found 
about the left shin : the soft tissues about the seat of injury were infiltrated 
-with greyish, purulent-looking, blood-stained fluid; similar fluid existed 
between the periosteum and the bone, which were separated from each other 
all around the shaft of the tibia for a considerable distance beyond the seat 
of injury; the tibia itself, at the part where the blow was inflicted was very 
vascular, and rough to the touch. The saphena vein was free ; the femoral 
not examined. 

'' Cases of the above kind," says Dr. Kirkes, '* where inflammatioii 
of the pericardium is found associated with purulent deposits in the 
muscular tissue of the heart, have usually been described as cases of 
carditis, or acute pus-depositing inflammation of the muscular 
substance of the heart. But I believe now that this explanation is 
erroneous, and that the muscular tissue of the heart is not prinfarilv 
at fault, but is merely, by accident as it were, and in common with 
other parts of the body, the seat of secondary formations in conse- 
quence of contaminated blood, and that the attendant pericarditis is 
merely an accident of the pro2dmity of some of the deposits to the 
surface, and, it may be, of their bursting into the cavity. Let me 
state some of the principal grounds for this opinion, which it is 
especially desirable to do, since a right appreciation of the nature of 
this structural change in the heart is very important in relation to 
the treatment of such cases ; for as thejr are usually associated with 
some primary affection of a bone or joint, and as other joints are 
liable to be secondarily affected by subsequent deposits or formations 
of pus in or around them, these cases are extremely liable to 
be mistaken for cases of rheimiatism, from which disease, howcTer, 
they essentially differ, and reouire a totally different treatment. 

" 1. That the changes in tne muscular texture of t^e heart are 
induced by local formaticms or deposits from contaminated blood« and 
are not the result of purely inflammatory processes, seems evident 
from their very nature and character as exhibited on close examina- 
tion. For, independently of the fact that muscular tissue rarely 
inflames, except as the result of direct injury, the appearances pre- 
sented by the changes in question are much more like those presented 
by secondary formations in other organs than the effects of simple 
inflammation. Thus, they often occur as congested spots or blotches, 
with a pale yellowish-brown or buff-coloured centre, or as fawn- 
coloured streaks, or small, yellowish, isolated points ofpus in the 
midst of Arm and apparently healthy muscular tissue. Whatever be 
the character presented by the deposit, indeed, the intervening 
muscular tissue itself seems free from disease, or not more congested 



PSACnCAL HSDICIKB, BTC. 135 

and softened than the presence of the foreign deposit might account 
for. When the deposits are very nnmerous and close together, the 
congestion and infiltration of the interrening fibres is, as might be 
expected, yery considerable; but when the depositis are few in 
number and far apart, the intermediate tissue appears scarcely 
changed from its ordinary state. 

"2. Again, the deyelopment of symptoms referable to the heart 
was, in most of the cases of so-called carditis which I have observed, 
dearly preceded for several days by some cause calculated to giye 
rise to contamination of the blood, such as inflammation and sup- 
puration of a bone or joint ensuing idiopathically or resulting from 
mjury, as in the three cases just narrated. In one yery marked 
instance, the whole mass of blood had been yitiated by the bursting 
of a large abscess in the substance of the heart into the interior of 
both ventricles. 

" 3. Moreover, in all the fatal cases of the kind which I have 
examined after death, the lungs and various other parts presented 
abundant secondary formations, similar to those in the heart, a 
oiicamstance favouring the view that they had all originated in the 
lame general cause — namely, a contaminated state of the blood. 

"4. That the inflammation of the pericardium met with in all 
the instances was the direct conseauence of the changes in the 
muscular tissue of the heart, was rendered probable by the fact that 
in all of them some portion of the deposit was found close to the 
externad surface of tne heart; that in some the pericardium was 
softened over an abscess, and ii^ others the collections of pus projected 
above the surface, and had, probably, in some cases, given way, and 
entered the cavity. The mere proximity of an abscess, however, 
independent of its bursting, would doubtless be sufficient to induce 
inflammation in a membrane so sensitive as the pericardium. We 
see a like eflect sometimes when any other foreign substance — such 
as a mass of cancer, especially when softening — protrudes into the 
pericardium, or when this membrane is the seat of tubercular 
deposit. 

"It may, then, I think, be fairly assumed that inflammation of 
the periciurdium, when found associated with deposits of pus or like 
matter in and near the surface of the heart, is the direct result of 
such deposit, and not an independent or simply associated aflection. 
The occurrence of pericarditis in connexion with such deposits in the 
heart, and with a general vitiated state of the blood, such as some- 
times occurs after injuries or surgical operations, is worthy of being 
specially noticed, for it furnishes another set of conditions under 
which pericarditis may ensue. Among the recognised causes of 
pericaraitis, rheumatism, albuminuria, cancerous and tubercular 
deposits in or about the pericardium, justly occupy the highest rank. 
Instances of pericarditis occurring independently of any of these 
causes are usually regarded as exceptional and isolated cases, which 
scarcely admit of bemg grouped into any special class. But it is 
probable that many of these isolated and obscure cases are of the 
Idnd just considered; namely, the result of secondary formations 
in the muscular substance o£ the heart, consequent on vitiated blood. 



136 PBACTICAL MEDICINE, ETC. 

" It is chiefly because the class of cases here specially noticed are 
in many respects so very like, and yet in nature so really different 
from, cases of ordinary acute rheumatism, that it is so peculiarly 
important to read them aright. The persons in whom the series of 
morbid phenomena just pointed out, namely, pjrimary affection about 
a bone or joint (or other local cause of blood-poisoning) and secondary 
mischief m the heart, are apt to occur, are (at least so far as I have 
seen and read) weakly, hard- worked, badly-fed lads at about the age 
of puberty. So far the similarity to rheumatism is close, for boys 
of this class are not unfrequently the subjects of a first rheumatic 
attack. The disease sets in, too, like rheumatism, with pains in the 
limbs and joints, and, like it, is soon followed by cardiac or pericardial 
complication. A close examination, however, will almost invariably 
detect a manifest peculiarity even in those symptoms which seem to 
be rheumatic, as well as certain distinctive characters which are not 
met with in ordinary rheumatism. Thus, in the form of disease in 
question, the pain at first complained of in the limbs is usually fixed 
to one part, instead of being somewhat general, and shifting its seat 
from one joint to another, as is usually the case with rheumatic 
pains. The pain, too, is often referred to the bones and fleshy part 
of the limbs, rather than to the joints, as in rheumatism. There is 
generally wanting, too, the swelling and characteristic streaky rednesa 
so often found about rheumatic joints, the swelling when present 
being usually slight, and rarely attended by any redness. The 
febrile symptoms also set in with more severity than in rheumatism, 
their onset oeing usually indicated by a distinct rigor, after two or 
three days' suffering with pain in one or more limbs. 

"There is also greater disturbance both of the nervous and 
vascular systems than occurs in rheumatism ; the former denoted 
by excitement, mental distress, and agitation, succeeded by delirium, 
and usually terminating in stupor or coma ; the latter denoted by an 
unusually rapid action of the heart, the pulse generally ranging 
from 120 to 140. Moreover, the peculiar odour characteristic of 
rheumatism is absent ; and, what is a most important, and, I believe, 
constant symptom, an eruption of small pustules, quite different 
from the miliary vesicles in rheumatism, sometimes few in number, 
sometimes rather abundant, appears over the limbs, face, and trunk, 
in a few days after the commencement of the febrile symptoms. 

" Lastly, the disease runs a far more rapid, a* well as a more 
deadly course than rheumatism, death usually ensuing, with typhoid 
symptoms, in from six to ten days from the beginning of the attack. 

** It will be observed, from this brieh'Ssum^ of the main svmptoms, 
that they are those of a rapidly-poisoned state of the blood, such as 
are often exhibited in acute phlebitis or pyssmia, after surgical 
operations, rather than those of ordinary articular rheumatism. 
Injury to a joint or bone is inflicted bv a blow, which may or may 
not be remembered; or a joint may inflame from exposure to wet or 
cold ; or, again, from mere atmospheric causes, or in consequence of 
a trivial wound which has suppurated or been poisoned, inflamma- 
tion of, or absorption of matter into, one or more veins, may have 
occurred ; in one or other of such ways the venous blood may be 



PBACnOAL HEDICIKB, BTC. 137 

contaminated by some local misohief, which may have existed for 
tiro or three days, with little more than local pain. Then deposits 
take place in the Inngs, and often contaminate the arterial blood, 
from which, again, tertiary deposits ensue in various parts of the 
body, including the muscular tissue of th& heart, and, by their pre- 
sence in this latter locality, fatal pericarditis may be induced." 



Art. 62.— On '' Le Bruit de Moulin:' 

By M. MOREL-LEVALLiB. 
(Qaa. ffebd. de M%d, et Chir.^ June 5, 1863.) 

In a note read' at the Parisian Academy of Medicinie in June last, 
M, Morel-Levall^e describes a sign, which he calls bruit de 
moulin, as pathognomic of hydropneumothorax. This sound is 
not unlike the sound of a water-wheel, and it depends upon the 
Bame cause, the agitation of air with water. Its maximum of 
intensity is in the cardiac region, but it is heard at a considerable 
distance. In two cases which are given, there was effusion into 
the pleura (in one case effusion of blood), together with air, the 
cause in both being a serious crushing of the chest. M; Morel- 
Levall^e explains the sound in question hj supposing that it is pro- 
duced by the heart, the movements of this organ beating together 
the air and fluid in the pleura, just as the same movements give 
rise to a friction sound in the case of an inflamed pleura. 



Art. 63i — On " Graves^ DiaeaseJ^ 

By Dr. J. Warburton Beobie, Physician to the Royal 

Infirmary, Edinburgh. 

{Bdii/tburgh Medical Jfyurnal, September, 1863.) 

In a paper read before the Medico-Chirurgical Society of Edin- 
burgh, m July last, the view maintained by Dr. Begbie is, that the 
true pathology of the bronchocele and exophthalmos found in con- 
nexion with cardiac palpitation and vascular pulsations and dilata- 
tions, lies both in the blood and in the nervous system, but that the 
*• primum mobile " is the former ; — that an altered state of the blood 
— ^for a time stopping short of what is generally known as ana)mia, 
—but in many cases amounting to well-marked anaemia, acts directly 
on the nerves ' of bloodvessels, and on the nerves of the heart — 
" Sanguis moderator nervorum ;'* — that, as a consequence, their 
rhythmical- movements are seriously affected, and dilatation of 
the heart's chambers, and of bloodvessels, arteries, but chiefly veins, 
results ; — that for a lengthened period the bronchocele is truly a 
vascular enlargement and dilatation ; but that in course of time, 
hypertrophy and degeneration of gland-structure result ; — that the 
exophthalmos, which is not a necessary consequence any more than 
the bronchocele of the disordered state of blood, and neurosis of 
bloodvessels, depends upon> congestion and vascular dilatation of the 



138 FBACTIOiX HBDIOINE, XTO. 

ophthalmic vessels, with eflfasion of serum into the post-ocular cellu- 
lar tissue ; — ^and, lastly, that a plan of treatment directed to the 
improvement of the condition or the blood, and, at the same time, 
to the state of the nervous system, — is successful in effecting a cure, 
provided those organic changes in the heart to which reference has 
been made have not already been induced. 



Aet. 64 — Ow " Graved Disease. ^^ 

By Dr. Laycock, Physician to the Royal Infirmary at 
Edinburgh, &c. 

{Edinburgh Medical Jov/mal, February, 1863.) 

Dr. Laycock looks upon this affection as resulting from disorder 
of the nervous system, and not from anaemia. His general conelu<* 
eions are : — " 1. That the exophthalmos under consideration if 
specially due to disorder of the nervous system. 2. That it varies 
in character and diagnostic significance accordingly as it is associated 
or not with other phenomena involving the vascular system of the 
heart, and of the eyes, bead, and neck — ^the carotideal as distinet 
from the vertebral system of capillaries. 3. That it is sometimes 
of spinal, sometimes of cranial origin ; and that in either case iti 
nature and seat may be diagnosed. 4. That it occurs under a 
variety of morbid conditions of the nervous system. 

" If it might be permitted to theorize on the causes of symptom* 
atic exophthalmos from these data, we might conclude that, when it 
occurs in strangulation, it is probably due to mechanical injury to 
the cervical sympathetic by the tightened cord or other violent 
means used ; in the emotional form the condition is probably like 
that when the sympathetic is galvanized, the face being pale, and 
the eye staring ; in certain morbid cerebral conditions, such as 
mania, with epilepsy and general paralysis, the lesion is probably in 
the first instance paralysis of the sympathetic, and subsequently of 
the fifth and seventh ; and, finally, that in the class of cases under 
consideration, when the exophthalmos is symmetrical, it is spinal ; 
the cervical and upper dorsal region being the seat, together with 
the corresponding cervical and dorsal divisions of the sympathetic ; 
but when unsymmetrical, it is due to disease of the trigeminal 
ganglion and branches of the fifth pair." 



Art. 65. — On ^' Graves^ Disease" 

By Dr. William Moore, Physician to Mercer's Hospital, 

Dublin. 

(Ditblin Medical Press, May 20, 1863.) 

In a clinical lecture in which two or three cases are cited, and the 
views of various authors are fairly canvassed, Dr. Moore has these 
excellent remarks upon the pathology of this very obscure disorders 

'*^ow, of all the theories which have been advanced of the 



PIUOTICAL ICXDIOIirB, XTO. 189 

» of tiiif affection, that of M. Tronsseau, that it is a nearosis, 
sore especially of the yaso-motor system, seems to me the most 
^Mcible and explicable, and analogous to a great extent with hysteria 
and nervous irritations to which young females are especially liable, 
haying their origin in the spinal neryes. The experiments of Budge 
and Waller haye gone to show, that those branches of the sympa- 
thetic which control the iris, to a great extent do not originate from 
the main cervical ganglia, but that they have their origin in the 
spinal cord, passing through the spinal nerves to the sympathetic in 
the neck ; and further, they proved that in certain animals those 
branches which influence these motions of the iris were solely con- 
nected with that part of the spinal cord which reaches from the 
oxth cervical to the fourth dorsal vertebrse. Within this space any 
■timuliiB applied produced dilatation of the pupil, and to this portion 
of the cord they gave the term " regio cilio spinalis** 

** That the motor fibrils of the heart are derived from the spinal 
eord, as well as from the sympathetic, is now universally admitted, 
recent experiments having confirmed these views, and endorsed the 
belief that the heart is intimately related with a special motor re- 
gion of the spinal cord which corresponds with this ' cilio spinal 
region.' And further. Professor Moleschott of Zurich believes the 
^^pathetic has the same influence upon the heart as the vagus, and 
iSQncludes from his experiments that the heart is animated by four 
▼wry excitable nerves, which may easily be over-excited ; these four 
nerves, two vagi and two sympathetic, have a peculiar consensus, 
whi^ is no doubt due to the action of the ganglia of the heart, so 
tiiat the state of irritation or over-excitement which is produced in 
one of the nerves is transmitted to the other three. 

" Again, the branches of the sympathetic to the thyroid body 
are derived from the middle cervical ganglion. These branches 
ramify around the inferior thyroid artery, and end in the thyroid 
body, joining the external laryngeal and recurrent laryngeal nerves. 

" Such being the nervous distribution, any irritation communicated 
along this important tract would readily account for the palpitation, 
naLNiting carotids, and thyroid bod^, dilated pupils, exophthalmia. 
Beat of head, tinnitus, and other painful neuralgic seizures so fre- 
quently associated with this aflection. Again, the reaction of this 
mtperior vascular excitement in these cases will account for the 
uterine derangement so frequently met with. This superior regional 
▼aso-motor excitation, so to speak, depriving the pelvic viscera 
and the lower extremities of their due supply of blood. 

•« Hence we meet with irregularities and deficiencies of the 
menses, usually in direct ratio to the progression of the other symp- 
toms, at least, such is my experience ; but there seems to be an 
occasional exception to this rule, Withusen having met with one 
ease in which menstruation, in other respects normal, was checked, 
for two summers. On the first occasion, it was absent for five 
months without any apparent change in the patient's state ; while, 
on the last occasion, the visible improvement in the case coincided 
precisely with the arrest of that function. In all the cases I have 
aeen in females, the amendment in the general symptoms was 



140 PBACTICAL MEDICINE, ETC. 

consequent on a restoration of the menstrual function to as nearly 
a healthy standard as possible ; and as regards the effects of 
pregnancy in these cases, Case 3 would go to show, that the more 
formidable symptoms are at least kept in abeyance by it." 



Aet. 66» — Circumseribed Aneurism of the Walls of the Left 



By Dr. Wales, Surgeon U.S. Navy. 
(American Quarterly Jowmal of Medical Sdeneef July, 1863.) 

The patient in this case, Joseph Brown by name, an ordinary sea- 
man, was admitted into the Hospital at Portsmouth, Ya., comatose 
and well-nigh moribund, 24th December, 1863i The post-mortem 
examination was made 14 hours after death, and the state of the 
heart, the only point of special interest was found to be as follows : — 

" While in situ, this organ appeared of enormous size, and, grasped 
in the hand, conveyed the impression of its being double. Slitting 
up the pericardium gave issue to about two ounces yellowish serum, 
and displayed the heart with its cordiform aneurism in such a strik- 
ing manner, that the exclamation of some of the bystanders was, 
* The man has two hearts.* The coagula were removed from boUi, 
and the organ weighed 18 ounces avoird. Adipose tissue covered 
in the external surface of both ventricles, except at their apices, the 
muscular fibres beneath presenting a pale waxy appearance^ while 
those of the auricles were of a healthy reddish colour, and distinctly 
aggregated in strong bands. The pericardium adhered to the apical 
segment of the aneurism. 

''In the right ventricle yellowish filaments of fibrin entwined 
with the fieshy columns and the cords, and connected themselves 
with a large mass of the same material adherent to the columns 
camese. Loosely in its cavity were the almost black, post-mortem 
coagula. The tricuspid and pulmonary semilunar valves were per- 
fectly healthy, and accurately shut their respective orifices. Cada- 
veric coagula were also found in the right and left auricles, but noae 
of the yellowish deposit. The peculiar semi-organized yellow clots 
were found in the left ventricle, also adherent to the eolumna 
came8&.- 

" When the cavities of the heart were cleared of all these depodts, 
an incision was made from the left ventricle into the aneurism, ex- 

Sosing its cavity freely, and giving a good view of its mouth and the 
ypertrophied columnse carnea), which subtended it, dividing the 
area into an upper smaller segment, and a lower larger one. 

" The soft black cadaveric coagula were first turned out from its 
centre, then less dark granular matter, and lastly layer after layer 
of reddish-yellow, pinkish, or flesh-coloured fibrin was peeled out, 
like the lamin» of an onion can be separated after the removal of a 
section of it. It was distinctly organized ; and close to the outer 
rind I observed tender capillaries shooting into it. Outside of all 
this was a hard calcareous case, forming a complete widl for ths 



FBACnCAL MEDICINE, ETC. 141 

aneurism, except at its orifice and apex, where there were two round 
holea, the former 18 lines and the Litter nearly an inch in diameter 
in the shell ; there was also a holging of the extreme point some- 
what heyond the lower opening, making in this manner a small 
secondary carity. This limng had the thickness of two lines nearly 
everywhere over its surface, and was perforated at numerous parts 
by nnall holes. In its physical appearance, it resembled closely thin 
plates of the dense cortical substance of the thi^h bone; my micro- 
scope not being accessible, I am unable to give its minute structure. 
Outside of this was met the muscular structure of the heart, rather 
what was left, which only amounted to a thin layer of fibres, placed 
between the calcareous envelope and the pericardium, diminishing 
in thickness to the dilated apex that I have previously mentioned, 
where it ceased, the thickened pericardium forming witn the fibrous 
dots the only boundary of the aneurism in tliis direction and corre- 
BDonding to the lower opening of the inside crust. The thickness of 
these two lajrers permitted the rays of li^ht to pass through them 
in such quantities, when the heart was held between the eye and the 
gon^ as to constitute translucency. As I have said above, the heart 
was perfectly symmetrical, and if the aneurismal tumour had been 
cut m>m it, through its somewhat narrow neck, the organ would have 
been, pathologically, only concentrically hypertrophied and affected 
with fatty degeneration. The mitral and aortic semilunar valves, 
like their feUows on the opposite side, were in a normal condition, 
and performed their offices nealthily. I took the following measure- 
ments of the left ventricle walls : — 

At the base ....*. 9 lines 

middle 8 „ 

apex . . . . . 6 „ 
Sight Ventricle. At origin of pulmonary artery 2 „ 
lower down .... 3 „ 
ventricular septum between 7 and 8 „ everywhere. 

" Immediately under two of the aortic semilunar valves, and cor- 
zesponding to that part of the left wall of the right ventricle against 
which the inner segment of the tricuspid valves lay, when open, 
the partition was diaphanous, and resembled exactly in structure 
and thickness the membranous diaphragm of the foramen ovale of 
the auricles. 

Capacity of left ventricle 5J' 

" " right ventricle .... little less. 
« " right auricle little over . . . fjj. 

** " left auricle little under . . . • fjj* 

" The aneurismal pouch cleared out, as I have said, held exactly 
4 otmces of alcohol. 

" In regard to the walls of this cavity, I have already stated that 
at the point of it, the pericardium alone formed its wall. From this 
place the muscular tissue increased in thickness towards the base of 
the tumour, where it had attained six lines close to the margin of the 
ventricular orifice, which was surrounded bv a strong fibro-cartila- 
ginous ring seated about the middle of the left cardiac margin {margo 



142 FBACTICAL MEDICINB, ETC. 

obtmus) and a section of it presented a triangular shape inthits ba89 
outwards, and the two angles continuous either way with the parietatf 
of the Tentricle on the one hand, and that of the sac on the other, its 
apex bounding the orifice with a rounded margin. Between the 
first two angles there was a distance of 21 lines, and between ihm 
last and a point midway the base of the fibrous circlet 18 lines. 
From this orifice the walls of sac spread out behind to the yentri* 
cular fissures, and anteriorly midway between the anterior fissure 
and left border upwards to the base of the left auricle and inferior 
Tena cava, the apex projecting an inch and a half below that of the 
heart. From the situation of the communicating orifice its upper 
half must haye been covered by the mitral valves, when they flapped 
back in the ventricular diastole." 



Aet. 67. — Case of Embolus of the Puhnonart/ Artery. 

By Dr. Vanderpool, of Albany, U.S. 

(American Medical Times; and Dublin Medical Press, Sept. 80, 1863.) 

Case. — I was called to attend Mrs. O , on the 9th of ApriU She was 

about sixty years of age, and, while not corpulent, adipose tissue was full and 
well distributed. There were no constitutional symptoms or marked general 
disturbance, but she complained of slight neuralgic pains alternating in 
different parts of the body ; also, on attempting to rise, a sensation of great 
languor, and a feeling of lightness in the head. I noticed, while there was 
marked fairness and whiteness of the skin, there was no ansemia. I sap^ 
posed it a case where ifhtrition was perverted ; and though not decided 
fatty degeneration, still the molecular changes approximated that condition. 
Absolute rest was enjoined. She was directed to be raised only when 
necessary, and with care. A sustaining treatment, combined as neceflsarj 
with morphine, was adopted. Improvement was gradual but marked. At 
my morning visit some three weeks since she complained of an unpleasant 
feeling in the left arm, as also, that for an hour past it had been cold; she 
was obliged to keep it covered, and near a bottle of warm water. 

On examination, I found, while sensation was perfect, and motion no waj 
impaired, save a feebleness in the limb, the circulation had so far ceased 
that no pulsation was perceptible in any part. This feeble vitality remained 
for over two hours, when the obstruction gave way suddenly, and circula- 
tion in all respects was as in the opposite limb. During the period of the 
obstruction, I listened several times to determine whether any growths near 
the valves would, by floating off, cause the condition. Nothing abnormal 
could be detected. 

Her general health improved so far that she rose easily from the bed, 
walked to the adjoining room, and sat up for some time. It was after a com- 
fortable night, and, as she expressed it, ''a more natural feeling than she 
bad yet hstd," that she was seized with dyspnoea and prostration while 
walking into the adjacent room. I saw her very soon after: she was 
breathing very labouredly and rapidly ; a dusky pallor was upon the surbce; 
the heart was acting tumultuously, yet the capillary circulation was imper- 
fect, and the extremities cold. l)r. Hun visited her in consultation during 
the afternoon, and suggested that the embolus was probably in the 
pulmonary artery. She lived about nineteen hours firom the time of 



PIUCTIOAL HBDICUTE, ETC. 143 

Poit-mortem twelve Tiowa after death, — ^The contents of the thoraoic cayity 
(which was the only part examined) were removed entire. Upon opening 
tlM right ventricle of the heart a round, firm, fibrous band, about four lines 
in diameter, and some three inches in length, was found eztendiDg from the 
flashy columns of the ventricle to the semilunar valves, and terminated in a 
bulb of black, coagulated blood, just within the pulmonary artery. Upon 
duwlolly dividing the branch of the pulmonary artery leading to the left 
lung, a fibrous depodt of quite firm consistence, about one inch in length, 
and of the diameter of the artery, was found just at the first branching of 
t|ifi artery within the lung, completely plugging the artery, and sending pro- 
longations into the branches of the second size. The same condition was 
found upon dividing up the trunk leading to the right lung, save that the 
d^M>sit on the left arterial trunk was firmer than the right. 

The left ventricle contained a small amount of black coagulated blood ; 
the right was empty. The muscular tissue of the heart was easily torn, and 
its outer surface covered with rather more than the usual layer of fat. The 
arteries showed no atheromatous deposit; the lungs were healthy, and, 
though not exsanguined, contained a less amount of blood than is usually 
found in the capillaries of the lung after death. 

The microscopic appearance of Sie plug showed fibrillated fibrin, dense in 
stroctare, the meshes filled with haematine ; some portions were evidently 
of more recent formation than others. ' 



Art. 68. — On Dilatation of the Lacteals. 

"Bj Dr. T. Grainger Stewart, Pathologist to the Royal 

Infirmary, Edinburgh, &c. 

{Edinfmrgh Medical Journal, November, 1863.) 

The peculiar lesion described in this paper is one of such rarity 
that it is not mentioned in any English work on morbid ana- 
tomj, though it was referred to by Eokitanskjr in his last, edition. 
Pr. Stewart first describes the case in which it occurred, and then 
explains his view of its nature. 

Cabs. — S. M., a man set. 60, was examined August 28, 1863. The body 
was very oedematous, the heart was hypertrophied and fatty, the aortic 
valves much diseased, and covered with vegetations. The auriculo-ven- 
tricnlar orifices were dilated, and the valves diseased. 

The coronary arteries were tortuous and atheromatous. The aorta con- 
tained some calcareous plates and patches of atheroma. 

The plenrse were adherent — the adhesions very oedematous. The lungs 
were emphysematous in front, oedematous posteriorly, and contained some 
patches of pulmonary apoplexy. The liver was much congested, and some- 
what cirrhotic — the hepatic venous radicals were dilated : — it weighed 62 oz. 
The capsule of the spleen was thickened. The right kidney was natural, 
excepting an old cicatrix. The left contained several cysts, none of large 
lice. The two organs weighed 16 oz. The stomach was dilated. The 
moaonlar layer was hypertrophied in the neighbourhood of the pylorus. The 
mucous membrane was extremely congested, and in some parts ecchymosed. 
Towards the cardiac end there were patches of a yellowish colour, perhaps 
results of old extravasation. The intestine throughout its whole extent was 
congested. In many parts the small veins formed little prominences above 
the surface. There was a polypus in the ascending colon. Scattered 
throughout the whole small intestine was a number of whitish-yellow 



144 FBACTICAL MEDICINE, ETC. 

patches, yaryiag in size from that of a pin-head to that of a small bean. 
Some were granular on the surface, and evidently connected with the' 
mucous membrane ; others were smooth, rounded, and lobulated like little 
fatty tumours, and evidently lay in the submucous layer, for by a little 
careful dissection they could be separated from the mucous membrane on 
the one side, and from the muscular layer on the other ; a third set, again, 
much less frequent, consisted of a combination of the other two. On micro- 
scopic examination, those of the first kind were found to be made up of 
groups of villi greatly distended, as in the process of digestion — they 
were dark and opaque. On tearing them, a milk-like fluid escaped, 
which presented microscopically the characters of milk or chyle. The 
villus then collapsed, and there was no appearance of the bloodvessels 
having been distended ; and indeed it was obvious that the whole en- 
largements depended upon the presence of the milk-like fluid. As this 
is the matter naturally present in the lacteals during digestion, and as 
these take origin in the villi, we seem to be warranted in concluding that 
this class of patches results from the retention of chyle In the blind extremi- 
ties of the lacteal vessels of a number of adjacent villi. The whitish- 
yellow colour arose from the chyle shining through the coats of the villi, 
and the granular appearance of the surface from the patch being com- 
posed of numerous villi. Those of the second kind resembled small fatty 
tumours, and were situated between the mucous and muscular coats. Some 
consisted of a single lobule, others of several. On pricking any of them, a 
milk-like fluid, closely corresponding to that above described, but con- 
taining in addition cell-like aggregations of fatty granules, flowed out, and 
the walls of the pai-ticular lobule collapsed. I could not satisfy myself as to 
the structures of the bounding walls ; but some of the patches presented 
peculiar elongations from the main mass, like tails proceeding from the body, 
which evidently consisted of some tubular structure. But these did not 
pass into bloodvessels, nor did they seem to bear any special relation to 
them, and were therefore to be regarded as portions of lacteal vessels. On 
the whole, from the character of the contained fluid, the structure and ap- 
pearances, and the observations previously made, we may conclude that 
these patches consisted of dilatation of the small lacteal vessels. 

Commenting upon the ease, Dr. Stewart says : — " Only one 
theory as to the origin of this lesion occurs to me — namely, that the 
extreme backward pressure upon the blood, which arose from the 
disease of the heart and lungs and the general dropsy, acted upon 
the lymphatic vessels also in some unexplained way, and led to their 
distension at some points. This view is in accordance with all the 
facts observed, the chief of which were recapitulated in the account 
of the examination of the body. I regret that I neglected to 
ascertain the condition of the thoracic duct, the large lacteal 
vessels, and the mesenteric glands. It arose from my not havinff 
noticed the patches till the intestines were removed, nor suspected 
their nature until it was too late to investigate the other points." 

Dr. Stewart gives an abstract of a case closely corresponding to 
his own case, which is recorded in Rokitansky's Morhia Anatomy, 
and he refers to several cases of an analogous lesion, namely dilata- 
tion of the lymphatics. 



FBACnCAL MKDICm» SIC. 14S 

An. 69 — Om He I>ymile Pal^e amd DomiU H^art^uni^^ 

Bj P r ofc aaor Skooa. 
i4Vig. Wiem, Mtd. ZHi, rm. 1S63 ; and Mtd^Ctkr. Rninr, Jolr, ISiSl) 

The mtliar obserres thmt the redaplication of the pulse h not a 
j^tenomaum indicatiTe of miieh danger. It is not connected with 
the heart's moTementa. but is for the most part a local manifestatioii, 
moat likelj arising from a change in the fixed position of the arterj". 

Sednplieatioa of the heart's sounds is most readily explained oo 
the supposition that the elements of the sound {torn) on both sides of 
the heart are not contemporaneous, as thej ought to be, the aortio 
sound being produced at the end of the Tentrieular sound, so that 
between both of these a short period is perceptible, the sound being, 
as it were, split up (nerer properly redoubled) ; or if the sounds are 
doubled, the two rentricles do not contract at the same time, or the 
Ti^t one contracts twice while the left only contracts once. 

xhe reduplication of the second sound is ordinarily produced by 
the reflux in the aorta and pulmonary artery not being contempo- 
raneous ; and in most cases this is the result of an augmentation in 
the tension of the pulmonary artery, by which a division or splitting 
of the second sound is occasioned. Such a splitting also appears to 
he possible in a single artery (aorta or pulmonary artery), owing to 
an unequal eleration of the valve flaps. A reduplication of the second 
sound may be produced by the second sound in the ventricle and 
heart in the arteries not being contemporaneous ; the second sound, 
for example, being produced first in the pulmonary artery, and then 
in the ventricle. Another form of reduplication of the second 
sound may be produced by the heart's movements when exu- 
dation really exists in the pericardium, as in the beginning of 
pericarditis. 

(d) cokcebkino the alimentabt system. 

Abt. 70. — Cases of Throat Bi/scBsthesia, with Clinical 
Remarks, 

"Bj Dr. Handfield Jones, Physician to St. Mary's 

Hospital, &c. 

{Medical Times and Gazette, May 2, 1863.) 

" The following cases," says Dr. Handfield Jones, **are examples 
of an aflection which, as far as I knovr, is not noticed in standard 
works, and though not a life-perilling disorder, is one which causes 
no little distress, and for the cure of which patients are very grateful. 
I confess to a predilection for the study of these minor and more ma- 
nageable diseases rather than for those grave affections where there is 
room for diagnosis, — and little more. It seems a poor thing to 
know all about a disease except the most desirable kuowledu^e, viz., 
how to cure it. It is very possible to confound these affections 
with the so-called hysterical, from which, however, I consider that 

XXXVIII. 10 



146 PBACTICAL MEDICINE, ETC. 

they are positively differentiated by the results of treatment. The 
term hysteria or hysterical should be applied, I think, to no case 
■where there is really an honest desire on the part of the patient to 
get well, and where there is no morbid tendency to exaggerate the 
sufferings. A genuine specimen of hysteria will lead the unfor- 
tunate doctor a pretty dance of attendance on one symptom after 
another, and will be infinitely more benefited by moral discipline 
than by all the drugs that were ever invented. The patient is sick 
because she wills to be so, and sick she will be as long as it suits 
her, and no longer. There are doubtless examples common enough 
of a mixed kind, where, along with some real bodily disorder, there 
is more or less hysterical mental perversion. But there can be no 
question that the cases recorded below were not of this kind. 
Plainly and clearly the patients got well on a drug treatment that 
would have done small good to an hysteric. 

" As to the nature of the disorder, it seems plain that it was a 
pure neuralgic affection, as evidenced by the absence of visible 
disease, the remissions, the general state, and the juvantia. Now, 
the great rule to bear in mind in dealing with all neuralgia, which 
does not depend on some actual cause of irritation (as a decayed 
tooth), oi* on gouty or syphilitic poison, or the like, is, that in 99 
cases out of 100 it is either rheumatic or simple. The former it 
probably is if the urine is thick with lithates, the strength pretty 
good, and the patient has suffered previously from rheumatism ; the 
latter if the urine is pale, clear, of low sp. gr., if the patient is 
feeble, and gives no history of rheumatism. However, it is very 
common, as these cases exemplify, that the two affections run into 
each other in the same patient, and that the dyssesthesia at its outset is 
rheumatic, and afterwards becomes simple. In the rheumatic condition 
iodide of potassium and hydrochlorate of ammonia are the two 
remedies, the latter if muscular tissue seems to be specially involved. 
Alkalies should be given with the iodide as long as lithates are 
deposited. In the simple neuralgia, quinine, iron, and opium may 
be relied on, with rest, good diet, and pure air. It is often in 
doubtful cases good practice to begin with the treatment directed 
against rheumatism, replacing it if it fails, or proves inadequate to 
effect a complete cure, by the direct tonics. Not only in throat 
dyssesthesia, but in a multitude of disorders, like in nature, only 
rarying in situation, the above plain directions will lead to satisfac- 
tory results. . 

"Dr. Tiirck {Wien. Allg, Med, Zeitung, vii., 9, 1862) has de- 
scribed an affection which seems to be similar to, if not identical 
with, the one I am considerine^. He calls it neuralgia and hyper- 
SBSthesia of the entrance of tne throat, and describes pai'ticularlj 
its exact seat. His therapy consists in resection of a piece of the 
gustatory nerve, and application of lunar caustic. This, he says, 
has been successful ; but in my cases I am sure that the branches 
of the glosso-pharyngeal and sympathetic were much more involved 
than the gustatory nerve. In lingual neuralgia, on the other hand, 
which is a far more obstinate affection, division of the gustatory 
might, I think, be advisable." 



PBACnCAL HBDICINB, BTC. 14T 

'Cabb 1. — Simple Throat Neuralgia — Ben^t from Iron and Quinine, — 
Jane B., aged 35, admitted Oct. Ist. Had suffered a year with her throat. 
Tliere was no soreness in swallowing, nor any evidence of inflammation, 
bnt it was the seat of distressing constant aching pain, which came on first after 
a tooth bad been removed. The pain was not constant ; would come and go; 
»nd -Wsa increased by fatigue and causes of depression. She was exceed- 
ingly nervous, but showed no fussiness or hypersesthesia, and seemed to have 
a calm, well-ordered mind. She was of large, rather lax make She lived 
not far from a canal. She had occasionally not full power over her jaws. 
Often lost her voice, and said her throat felt weak. She had had the tonsils 
amputated without any benefit. Nov. I6th. — Has taken citrate of iron 
and quinine with benefit. The throat has been much relieved, but becomes 
again raw and tender when she takes any fresh cold. 

Case 2. — Th'oa^ Dysceathesia — Laryngeal and Pharyngeal Constrictive 
SjHums — Cure by Iodide of Potassium^ Iron, and Quinine, — M. B., aged 67, 
admitted Dec. 14th, 1857. She had been ill six months. She complained 
of feeling as if she should be choked; the phlegm "kept rising." At 
-times she had dysphagia, and was always hawking. She had not much 
cough. She referred her pain to the region of the os hyoides. There was 
nothing morbid to be felt externally, and internally the top of the epiglottis 
could be reached with the finger ; it seemed normal ; there was nothing 
wrong to be found in the throat. She had a sallow aspect. Tongue clean. 
Appetite very good. Bowels regular* Often suffered from frontal headache, 
"which '* took her sight away." An oesophagus bougie passed readily 'without 
pain. Had nausea and retching of a morning. Bt Potassii iodidi, gr. iij.; 
sodsB carb., gr. v.; infus. gent, co., 5j, ter die. ft Pil. hydr, gr. ss.; ext. rhei, 

S. ij. in pil. omni nocte. A blister to the front of the throat. 2 let. — 
nch better ; she can swallow better, and has not the heat and burning 
round the throat and mouth which she had. ft Potassii iodidi, gr. v.; 
tinct. cinchon., 3j'» infus. gent, co., 5j- ter die. 31st. — Has been much 
better, but is now for the last two days suffering in the same way. She 
complained of irritation about the throat, referred to the thyroid cartilage, 
with a sense of dryness. Bowels open ; urine normal. She now took for a 
week small doses of carbonate and sulphate of magnesia, with vinum 
oolchici and tincture of opium, but with little or no advantage. The 
dysse&thesia was absent occasionally. She was now ordered, on January 7 : 
B Ferri et quinss citratis, gr. v.; potassii iodidi, gr. j.; tinct. nucis 
Yomicse, ttix.; aquae, 5j» ter die ; pil. hydr. col., gr. v. alt. noct. 14th. — 
Throat and mouth much easier, though dry at times. 28th. — Has now 
scarce any of the old affection. She was now to take the iron and quinine 
without the iodide of potassium. On Feb. 11th she was discharged well. 

Casb 3. — Laryngeal and Pharyngeal Spasm cured by Hydrochlorate of 
Ammonia and Bark. — Hannah C, aged 20, was admitted October 18. She 
had been ill one week. She stated that she had been taken in the night with 
choking sensations in her throat ; '* her breath seemed to be leaving her." 
At the same time she had palpitation, lasting a quarter of an hour. Her 
tongue was much coated, and her appetite was bskd. Bowels open. Some 
menorrbagia. Pil. hydr. coloc., gr. v., alt. nocte. ft Spt. ammon. foetid., 
3(j. ; infus. valerian. 5^., ter die. 29th. — Food seems '^to stick in her 
throat" as before, ft Ammon. muriat., 9j. : mist, camph., 5j-) ter die; 
(pil. rhei co., gr. v, p. r. n.). Nov. 5th. — Throat much bettei-. ft Tinct. 
cinchonse, Sm. ; infus. gent, co., 5j-, ter die. 12th. — Much better. 19th. — 
Better. Discharged. 

Case 4. — Cranial Bkevmatismy Throat Dyscesthesia, Laryngeal Spasm 
dwed by Iodide of Potassium and Iron. — Charlotte H., aged 37, admitted 

10—3 



148 PBACTICAL MEDICINE, ETC. 

September 13. She had been ill eighteen months with great pain iu the top 
and sides of the head, with feelings of fright, and a tendency at night to 
jump out of the window, and to scream. She was rather feverish at night. 
Urine very clear. Bowels always relaxed. Loss of appetite. Pulse of fair 
force. Skin warm. She had lost four children : they aX\ died in the birth. 
No eruption was observed on them. She was ordered at first mistura 
ammonise acetatis, 5j-) ^tis boris, and an alum gargle. On the 18th this 
was changed — IV Potassii iodidi, gr. v; infus. gentiause co., 5j'> ter die; 
and pil. saponis co., gr. v., omni uocte. Oct. 9th. — She reported that her 
head was very much better, but she had choking sensations in her throat, 
so that at times she had to fight for her breath. This was mostly at night 
when she awoke. She felt as if she had something to bring up from the 
throat, which was a little inflamed. Urine very clear. Pulse steady. 
Pt. c. mist., ter die. Bt Ferri carb. saccharati, 3j.; ft. pulv. ter die. 
80th. — Throat quite well. Head a little queer at times. Pil. c. mist, et 
pulv. At the next visit, Nov. 6th, jshe was well. 

Cask 6. — Throat Dyscesthesia — Debility — Cure by Iodide of Potamum, 
IroUt and Quinine. — Eliza W., aged 36, admitted October 23. She had 
been ill one montli. She has a dreadful * ' worrited feeling " in her throaty 
whieh she said prevented her sleeping, and affected her eyesight ; when the 
feeling was bad it made her "violent," and caused her to scream. She 
could take no tea, coffee, or beer. Tea " made her throat bad directly." 
Pulse of fair force. IV Potassii iodidi, gr. iv. ; ammonise sesquicarb., gr. 
iv.; infus. gentianae co., 5j- ter. die. R Ferri carb. saccharati, Qj.; ft. 
pulv. ter die. Nov. 3rd. — Was much better ; sleeps weU at night. 
10th. — Going on well. Rep. pulv. Bt Quinse disulph., gr. iij. ; tinct. zingib., 
tnx. ; aquae 5j- ter die. Dec. Sth.^The ** worrited'* feeling in her 
throat is entirely gone ; she was able to sleep at- night ; speech was affected 
at times if she took tea or coffee. 29th. — She has had a severe shock from 
the death of her youngest child four days ago ; had not been able to sleep 
since. R' Ferri et quinse citratis, gr. x. ; tinct. nucis vomicae, ttix. ; aquae, 
5j.» ter die. Under this treatnient she continued to hold her ground 
&kirly well up to the present time, January 29, in spite of nursing a aick 
child. 



Art. 71. — On the Use of fyecacManha in the Treatment 

of Tropical Dysentery, 

By Dr. J. Ewart. 

(Indian Aimah of Medical Sciencet January, 1863.) 

The paper from which the following remarks are taken fonns 
part of an elaborate review of the treatment of tropical diseases. 
Commencing with a copious warm-water enema, ipecacuanha, Dr. 
Ewart thinks, is the main remedy. He says : — 

" After the operation of the enema, or immediately the patient 
presents himself suffering from any of the dysenteric conditions 
already mentioned, in those cases where no preliminary aperient is 
indicated, a turpentine epithem or mustard piaster should be applied 
to the epigastrium, and from half a drachm to a drachm of^the 
ipecacuanha powder, suspended in two drachms of syrup of orange- 
peel with four drachms of water, or in half an ounce of infusion of 
chamomile with ten grains of carbonate of soda, or five grains of the 
trisnitrate of bismutn, should be simultaneously administered. Eveij 



PSACnCAL KKDICnrS, ETC. 149 

minate gained in introducing the medicine into the stomach is an 
adrantage appreciated by cTery one who has largely used it in 
dysentery. To wait 20 minutes, until the counter-irritation is estab- 
luhed, is simply to give the disease so much advance as to time, and 
proportionately to diminish the chances of success. Moreorer, when 
the counter-irritant and ipecacuanha are both brought into action 
at the same time, the former almost invariably takes effect and pro- 
duces all the counter-irritation it is capable of, before the latter begins 
to cause the slightest feeling of nausea. 

"After the patient has swallowed the ipecacuanha, he should 
occupy the recumbent posture, with the head lying at a lower level 
than is customary. He should be directed to remin from drinking 
liquids for an hour or two. If, however, the desire to quench thirst 
prove irresistible, small pieces of ice may be sucked or swallowed, 
or, in localities where tms luxury is not procurable, cold water, in 
teaspoonsful, given at intervals, may be allowed. Vomiting should 
be resisted to the utmost. Nausea will probably occur ; perhaps, in 
some cases, retching and vomiting. But, as the vomiting is excep- 
tional, and, when it does occur, seldom happens before the lapse of 
an hour from the administration of the large dose ; and as no tepid 
water has been swallowed, so as to provoke and promote emesis, the 
vomited matter generally consists of small quantities of gastric and 
mucous secretion with or without a trace of the ipecacuanha. Hence 
the rule is that, when vomiting does happen, only an insignificant 
portion of the dose is actually rejected. If, however, the practitioner 
or nurse, after examination of the ejected matters, has reason to 
believe that the whole or the greater part of the drug has been ex- 
pelled, there should be no hesitation in repeating the dose, as 
soon as the stomach appears to be in a proper state for its re- 
ception. 

" Provided a full dose of the medicine has been retained, it is ad- 
visable to wait eight or ten hours before repeating the ipecacuanha, 
* — when ten, twenty, or thirty grains — usually a scruple — should be 
exhibited every four, six, or eight hours, according to the urgency of 
the case, or the manner in which the stomach tolerates its presence, 
^— until the tormina, tenesmus, sleeplessness, mucous, slimy, bloody 
stools and functional derangement of the whole digestive system are 
succeeded by relief from pain, refreshing sleep, feculent, or what are 
termed bilious evacuations, and a speedy restoration of the primary 
processes of assimilation. It will be found beneficial to time the 
large doses, so as to allow of 30 grains being given at bedtime, and 
a scruple in the morning, so long as their use is deemed necessary. 

" If no disorganization of the intestinal mucous membrane has 
taken place, the above changes frequently happen after the first or 
second large dose of ipecacuanha ; and even it* ulceration has set in, 
they are generally discerned on the second or third day after it has 
been commenced. In either case, it is necessary to discontinue the 
medicine, when the disappearance of tormina, tenesmus, the absence 
of mucus, blood and slime from the stools indicate that the cessation 
of the dysenteric process has been effected, and that the affected 
portions of bowel have been placed in the most favourable con- 



150 FBACTICAL MEDICINE, ETC. 

dition to undergo cure by ' resolution/ if the morbid action has not 
advanced to the stage of ulceration, or by the necessary proceeses of 
'granulation and cicatrization/ if sloughing or ulcerative destruction 
of the mucous membrane has already taken place. 

" In those cases where no ulceration exists, convalescence is speedy 
and complete in a few days, without any extraordinary care as to 
diet ; though it is well to caution the patient against all irregularities 
in this respect. When ulcers are to be healed up, ferruginous and 
bitter tonics, and an easily digestible and nutritious diet may be 
allowed. If required, the large intestine should be gently washed 
out by a tepid water enema. The direct application of astringent 
and stimulating remedies, in the form of enemata, should not be 
neglected, — particularly when the ulcers are situated in the rectum 
or sigmoid flexure. Should acute symptoms reappear, the large 
doses of ipecacuanha must be resumed and persisted in, until the 
re-excited dysenteric inflammation is checked, and the ulcers are dis- 
posed to granulate and cicatrize, when the conservative treatment 
and nutritious diet may be recommenced without delay. 

" Opium by the mouth is not necessary. It may be employed, in 
appropriate cases, in the form of small enemata or suppositories to 
alleviate the distress arising from tenesmus. When swallowed, it 
' locks up ' the secretions of the liver, pancreas, and alimentary 
mucous membrane, rather favouring than reducing the inflammation 
in the intestinal mucous membrane. — These bad efiects quite counter- 
balance the benefits derived from the sleep, diminution of peristaltic 
action, rest to the inflamed gut, and temporary decrease of tormina 
and tenesmus consequent on narcotism. This explains why the real 
character of the disease is often completely masked by opium, and 
why apparent amendment is taking place, whilst the destructive ul- 
ceration and sloughing of the mucous membrane is rapidly extend- 
ing. As ipecacuanha speedily brings about all the good, without 
any of the evil efiects of opium, this narcotic, in any form, with 
the exceptions adverted to, is not only superfluous, but in- 
jurious. 

'* There is less objection, however, to uniting the ipecacuanha 
with such remedies as are acknowledged to possess the power of 
lessening the irritability of the stomach and of increasing ita 
tolerance of the drug, without interfering with the functional activity 
of those organs whose secretions we are endeavouring to promote, 
with a view to rectify the disturbed balance of the portal circulation. 
On the contrary, medicines of this order may, perhaps, be associated 
with ipecacuanha with benefit — such as carbonate of soda, bismuth 
and, possibly, chloroform, camphor, and hyoscjramus. 

" The above outline of treatment is that which is usually applicable, 
but the dose and the repetition of the same must be regulated, ac* 
cording to circumstances, in special or exceptional cases. It mostt 
however, be borne in mind that all other remedies that have ever 
been recommended for the cure of dysentery- are of secondary im- 
portance compared with ipecacuanha, and that, during the con- 
gestive, exudative, and ulcerative stages of the acute form of that 
disorder, as well as in the acute relapses supervening upon chronic 



FBACTICAL MEDICINE, ETC. 151 

dysentery, every reasonable effort should be made to induce the 
stomach to tolerate and pass onwards the doses mentioned. 

** When dysentery occurs in pregnant women, largfe doses of ipe- 
cacuanha are not contra-indicated ; because, if the disease be allowed 
to proceed (which is more likely to happen under the old than the 
ipecacuanha treatment), abortion or premature labour is almost 
certain to follow ; and when such a complication supervenes, in the 
later months of gestation, the mortality almost surpasses that of 
any other disease. When the dysenteric inflammation is summarilj 
put a stop to by the ipecacuanha, abortion or premature labour is 

1>revented. Under the opiate method of management, premature 
abour is not averted, but, in the majority of cases, occurs at the 
acme of the disease, when the sloughs are being thrown off; and 
the woman succumbs to the conjoint shock to the system. In 
dysentery complicated with pregnancy, opiate enemata, to relieve 
irritation in the rectum, are more essential and permissible than 
under other circumstances. 

" In the acute dysentery of children, ipecacuanha is invaluable. 
For a child of six months, a grain, and for a child of one year two 
grains, should be given with an equal quantity of carbonate of soda, 
two or three times a day, until the tormina, tenesmus, slimy and 
bloody stools are replaced by freedom from pain and feculent eva- 
cuations. It will not always be necessary to continue the drug 
beyond two or three days at a time. But it should be recollected 
that the disease adheres with greater tenacity to children than 
adults ; and although we observe that ipecacuanha has an immedi- 
ately beneficial effect in diminishing the blood, mucus, slime and 
frequent stools, still we find that dysenteric or slimv motions with 
undigested food continue to pass. In that case, the ipecacuanha 
combined with chalk, bismuth, or carbonate of soda should be 
repeated, once or twice a day, for a certain period, till healthy eva- 
cuations are restored. In children, the gums must be lanced when 
necessary; turpentine liniment with fomentations, or turpentine 
stupes alone, may be applied to the abdomen ; weak chicken-broth or 
arrowroot should be substituted for milk ; and above all, food must 
be given, in small quantities at a time, and at regularly stated 
periods. From the age of one year, the dose is regulated by adding 
one grain for each additional year of age up to eighteen, when the 
doses already indicated for adults should be employed. In children, 
a full dose at night, and a smaller one in the morning, will often 
succeed in effecting a rapid cure. 

" In cases where evident malarious taint pervades the system and 
complicates acute dysentery, disulphate of quinine is indispensably 
necessary. A scruple of the antiperiodic will be most speedily ab- 
sorbed, if dissolved in water acidulated with sulphuric acid, and it 
may precede by an hour the first dose of ipecacuanha. Ten-grain 
doses should afterwards be given midway between the large doses of 
ipecacuanha, and, if possible, during abatement of any periodic 
febrile excitement which may exist, until the feverish symptoms 
have been subdued. Quinine here is as important as ipecacuanha, 
for until it has successfully checked the disturbing influence which 



152 FBAGTICAL MEDICIKE, ETC. 

xnalarioas poisoning exercises upon the capillaries of the portal and 
general circulatory systems, the ^ood effects which ipecacuanha pro- 
duces are only temporary and incomplete. The mildest febrile 
exacerbations of a miasmatic origin re-excite dysenteric action, and 
thus undo the good that the ipecacuanha has effected. Hence, the 
urgent necessity for removing, without delay, every vestige of 
masked or active malarious fever complicating the dysentery. No 
medicine enables us to accomplish this object so safely and so quickly 
as the disulphate of quinine in large doses. Z 

" In purely chronic dysentery, ipecacuanha cannot be expected to 
do the same amount of good, in acute attacks, however, super- 
vening upon chronic dysentery, it certainly appears to prove bene- 
ficial. 



Aet. 72. — On the Influence of a Long Course of Nitric Acid 
in Reducing the Enlargement of the Liver and Spleen 
which sometimes results from the Syphilitic Cachexy, 

By Dr. Budd, Physician to King's College Hospital. 

The attention of pathologists has for some years been directed to 
the enlargement of the liver ; or simultaneously of the liver and 
spleen ; or of the liver, spleen, and kidneys r of which Dr. Budd 
many years ago sketched the clinical history, under the heading 
** Scrofulous Enlargement of the Liver ;" but which, in consequence 
of the discovery since made, that some elements of the enlarged 
glands commonly exhibit the chemical reaction of starch, has 
recently been described as the " Amyloid Degeneration." 

This disease occurs under various circumstances, but especially in 
persons whose health has been long impaired by constitutional 
svphilis or scrofula. The most striking examples of it are seen in 
the victims of scrofulous or syphilitic caries. 

In such cases, after the disease of the bone has existed a consider- 
able time, it is found that, without pain, or tenderness, or other 
symptom specially directing attention to these organs, the liver and 
spleen are much enlarged. By-and-bye, the urine becomes albu- 
minous. 

Albumen continues to pass off in the urine ; the patient, often 
without much loss of flesh, grows paler and paler ; and, at length, 
death occurs — not from the disease of the hver or spleen, but from 
that of the kidneys. 

After death, it is found that the kidneys are enlarged, as well as 
the liver and the spleen, and that the three organs have undergone 
the same kind of morbid change. 

The object of this communication is not, however, to describe the 
course of the disease, or the characters of the morbid change ; but 
to make known that the nitric acid (or the nitro-muriatic acid), long 
continued, has, in certain circumstances, great remedial power over 
it. The nitro-muriatic acid has for many years been extensivelv 
used for its influence in modifying the nutrition of the liver ; and. 



FBlCnCAL MBDICIKB, BTO. 153 

in rery many instances, ander its lon^-continned nse, enlargement 
of the liver — presumably of the kind in question, occurring under 
different circumstances — ^has been found gradually to disappear. 

To illustrate this sequence of events, and the kind and degree of 
influence which, when the disease is of syphilitic origin, the nitric 
add exerts, Dr. Budd relates three cases. 

' Gasb 1. — A medical' graduate of Edinbui^h, of very temperate habits, 
during his studentship, towards the dose* of 1841, contracted a venereal 
sore, followed by enlarged inguinal glands. This malady was treated by 
local remedies only ; and at the end of a month or five weeks his health 
was re-established. He remained in good health till the autumn of 1853, 
when he had, for some weeks, ulcerated sore throat. 

In March, 1854) he had an attack of pneumonia, for which he took a 
large quantity of calomel; and before he had recovered from the debility 
which this ilkiess caused, the throat became ulcerated again ; the ulceration 
commencing in the sofl palate, and soon spreading to the uvula and tonsils. 

In July, a. piece of the- vomer came away. Subsequently, from time to 
time, small pieces of the nasal bones were detached, and, at length, the 
bridge of the nose sank. To <jheck this ulcerative process, iodide of potas- 
sium in very large doses, and a combination of the syrup of iodide of iron 
with ood-liver^oil, were taken, alternately, for some months. The ulcera- 
tion of the fauces was stopped by these remedies ; but the patient was left 
weak, and a puriform- discharge from the nostrils continued. 

In the autumn of 1859 — when the disease of the nasal and palate bones 
had existed between five and six years — he suffered considerably from 
acidity of the stomach, flirtulence, and other dyspeptic symptoms, and 
noticed an unnatural fulness and prominence of the epigastric region. 

On acoouRt of these ailments, he paid me a visit on December 24th, 1859. 
He was then pale and much emaciated^ weighing only nine stone seven 
pounds, though five feet eleven inches and a half in height. The skin was 
dry, and the tongue unnaturally red. 

The fulness and prominence of the epigastric region was found to be 
chiefly owing to enlargement of the -liver 7 the lower edge of which, from 
ihe thinness uf the abdominal walls, could be distinctly traced, reaching in 
the median-line as low as the umbilicus. The spleen was likewise enlarged, 
being plainly felt extending about the breadth of three fingers below the 
fedse ribs. 

The urine was voided more frequently than natural ; and, on examina- 
tion, was found to be of specific gravity 1012, and to contain a considerable 
quantity of albumen^. 

The fauces exhibited the scars of former ulcers, which had removed the 
uvula and much of the soft palate, but no actual ulceration was visible. 
There was still an abundant puriform di^icharge from the nostrils. 

The case was considered to be one in which disease of the liver, spleen, 
and kidneys, of the kind specified above, was consequent on protracted 
caries,* most probably of syphilitic origin ; and twenty minims of dilute 
nitric acid, with a dessertspoonful of the fluid extract of sarsaparilla, twice 
a day, and a generous diet, were prescribed. No change of residence or 
occupation was adopted. 

The medicines were taken continuously; and on the 28th of April, 1860 

* The condition of the liver is not exactly alike in all cases of this kind. 
In Pome cases it contains oil enough to add considerably to its bulk ; in 
others, scarcely any. 



154 FBACTICAIi MBDICIKB, ETC. 

— that is, after the lapse of four months — the patient had improved much 
in condition, and had gained a stone in weight. The liver and spleen were 
much reduced in size. The urine was of specific gravity 1010 ; clear, 
moderately acid, and contained only a very small amount of albumen. 

The diet since the preceding December had comprised solid animal food 
twice a day, at breakfast and dinner ; and, in addition, strong soup for 
lunch, and a pint of Guinness's porter daily, but no other alcoholic drinks. 

The patient was directed to continue taking the acid and sarsaparilla ; 
which, with only a fortnight's intermission, he did from this time to October 
12th, when I bad an opportunity of seeing him again. He was then stouter 
and stronger than before, and no perceptible enlargement of the liver or 
spleen existed. The urine was now free from albumen. The specimen 
examined was of specific gravity 1018, very slightly acid when just passed. 
There was still a puriform discharge from the nostril, but not one-tenth as 
much as on my first examination. 

On account of the persisting discharge from the nostril, and the absence 
of any discoverable ill effects from their use, the medicines wore continued 
to the beginning of April, 1861. On May 1st of that year, I examined 
the patient again. He then considered his health re-established. His 
weight was eleven stone one pound. The liver and spleen could not be felt 
beyond their usual limits. The urine was of specific gravity 10.10, barely 
acid when just passed, and, as at the prececUng examination, contained not 
a trace of albumen. 

The acid and sarsaparilla were thus taken more than fifteen months, with 
only a fortnight's intermission ; and the result was a gradual and progressive 
improvement of health. 

During this long course of nitric acid, with a highly animal diet, there 
had been no gravel or red sediments in the urine ; and from an early period 
of the course to its end, there had been no indications of undue acidity 
of the stomach, although, before the acid was taken, acidity of the 
stomach and flatulence had been among the symptoms most complained of. 

The effect of the plan of treatment appeared to be, a gradual amendment 
in the disease of the nostril ; a gradual diminution of albumen in the urine ; 
return of the liver and spieai to their natural size, and restoration of the 
general health. 

Ca8E 2. — On June 6th, 1862, I was called to a gentleman, of powerful 
frame, 35 years of age, who for several years had been grievously afiUcted 
with disease of the bones of the kind in question. 

As long ago as the year 1855, several pieces of necrosed bone, from the 
size of a shilling downwards, belonging to the outer table of the skull, had 
been removed from the forehead and top of the head. The left knee, in 
consequence of the long existence of ulcers near it, had been contracted, so 
that the foot could not be placed to the ground ; above the right knee was 
an ulcer still open, apparently connected with the femur ; on the forearm 
another open ulcer ; and the bones of the forearm, &iid the tibia on each 
side, were thickened in parts and uneven. 

For some months he had been confined to his bed and obair; and, from 
the shortening of one leg and general muscular debility, he was unable to 
stand. The liver was much enlarged ; the spleen could be felt projecting 
some inches below the ribs ; ihe urine contained « large amount of 
albumen. 

At this time, some diarrhoea existed, with occasional vomiting. These 
ailments were soon removed by attention to diet and by pills of creasote 
and opmm ; and twenty minims of dilute nitric acid were then ordered to be 
taken twice a day. Subsequently, the dose of the acid was increased to 



PSAcncAL MSDicnrB, iTC. 155 

twenty-fiye minims twice a day. A generous diet, which had heen pre- 
vionsly taken, was allowed. No change ¥ras made in the mode of life. 

Soon after I first saw the patient, he went to his usual country residence; 
and in the middle of Noyember, I received a report from his medical 
attendant, stating that he had improved in condition, and that the quantity 
of albumen in the urine had lessened. 

He continued to take the acid ; and in February, 1863, I saw him again. 
I found the liver reduced in siae ; the spleen scarcely to be felt ; and the 
general condition much improved. The amount of idbumen in the urine 
was less than in the preceding summer ; but was still considerable. 

As yet no attempt had been made to walk. Soon after this, an apparatus 
was contrived for the gradual extension of the contracted knee ; and, by the 
aid of crutches, he began to walk about the room. From twenty-five to 
forty minims of nitric acid, with eight minims of tincture of sesquicbloride 
of iron, were taken daily from this time till July 13th, when twenty- five 
minims of the acid were directed to be taken regularly twice a day ; and 
acid foot-baths were ordered in addition. 

^ On July 13th, the liver could be felt in the epigastric space, but on the 
right side did not extend below the false ribs. The spleen could no longer 
be felt. The sores were all healed. The urine, which was clear, and of 
natural colour, still, however, contained albimien. 

The acid has thus been taken continuously for thirteen months; and, 
though scarcely any bodily exercise has been possible, the result has been 
— reduction of the liver and spleen almost to their natural size ; diminu- 
tion in the amount of albumen in the urine ; healing of the sores ; and 
improvement in the general health. Notwithstanding the large quantity of 
acid taken, the urine, when tested, has never been more than modeiately 
acid, and no heartburn nor undue acidity of the stomach has ever been 
complained of. 

Case 3, — An officer in the army, of robust frame, Z5 years of age, had 
syphilis eleven years ago. This was followed by eore-throat. In less than 
twelve months from the time of infection, be began to have pains in the 
bones, worse at night. Subsequently, during the Crimean war, in which 
he was engaged, nodes formed on the shins and on the right radius. He 
continued to 8u£Eer, more or less, from pains in the bones for several years. 

Six years ago, abscesses formed on the right forearm and on both legs — 
aU, apparently, in connexion with the bones ; and, ultimately, in the arm, 
a piece of bone, as large as a shilling, exfoliated. The sore on the arm 
from which the ])iece of bone came remained open three or four years ; the 
other sores healed more quickly. 

Two years ago, after exfoliation of the piece of bone referred to, all the 
sores healed. Prom that time, his health was comparatively good for 
twelve months. Law proceedings in reference to some property then gave 
him, for several months, much anxiety. The pains in the bones recurred ; 
his sleep .became broken; his appetite impaired; and he began to suffer 
from thirst. 

These various ailments continued, notwithstanding the cessation of the 
mental disquiet to which he ascribed his relapse ; and when I first saw him, 
on Feb. 12th of the present year, he was pallid and cachectic, and so weak 
that he could not walk a quarter of a mile without fatigue. His weight, 
which in health was between thirteen and fourteen stone, was now eleven 
stone. He complained of pains in the bones, sleepless nights, and profuse 
morning perspirations. His appetite was much impaired ; he suffered from 
thirst ; and had occasional nausea. 

During the eleven years that had elapsed since the commencement of 



156 PBACTICAL MBDICINJK, ETC. 

illness, he had taken two or three courses of mercury and great quantities 
of iodide of potassium. The bones of the forearm and the tibia on each 
side were thickened in parts, so that their surface was rendered uneven ; 
and the skin above them was scarred by the former sores. The liver was 
much enlarged, reaching in the median line nearly to the umbilicus, and on 
the right side below that level. The urine contained albumen which, when 
coagulated in a test-tube and allowed to subside, rose to one-third of the 
height of the urine in the tube. Twenty minims of dilute nitric acid twice 
a day were prescribed. 

On March 6tb, the acid was directed to be taken three times a day ; and 
ten minims of liquor cinchonas were added to each dose. From the first^ 
there was a rapid improvement in the patient's condition ; the pains in the 
bones lessened ; appetite and sleep returned ; the excessive thirst abated. 

On June 15th — that is, after the acid had been taken rather more than 
four months — the patient had gained one- stone and four pounds in weight; 
could walk any reasonable distance without fatigue ; and had, indeed, little 
to complain of. The liver was found to be much reduced in size. The urine 
was of specific gravity 1016, and only faintly acid. It still contained 
albumen, but in very much less quantity than at firat. 

He continued to take the acid ; and on July 1st, when I last heard from 
him, he considered his health so far re-established that he was- indisposed to 
follow the advice I gave him, to decline joining his regiment, which was on 
foreign service. 

Here, the acid has been taken a very much shorter time than in the pre* 
ceding cases; but the result has been — reduction in the size of the liver; 
diminution in the quantity of albumen in the urine ;. and remarkable im- 
provement in the general^ health. 

The cases just related appear to warrant the following conclu- 
Bions : — 

" 1. That, when the liver and spleen have become diseased in the 
manner specified, in sequel to protracted syphilitic disease of the 
bones, nitric acid, long taken, has a remarkable influenee in gradually 
effecting the removal of the morbid deposit to which these organs 
owe their increased size, restoring the organs to a more healthy con- 
dition, and improving the general health. 

** 2. That, under such circumstances, there is unusual tolerance of 
the acid, which may be taken continuously for many months without 
inducing excessive acidity of the urine, or any inconvenience attri- 
butable to undue acidity of the stomach. 

*' The cases further afford a strong presumption that nitric acid, 
taken earlier, would prevent the disease of the abdominal glands, 
which, when established, it tends to remedy ; and they, perhaps, 
warrant the inference, that since the virtues of iodide of potassium 
were discovered, nitric acid has been too much neglected in the 
treatment of long-standing constitutional syphilis. 

" Nothing so quickens our perceptive faculties to discover diseases 
in their nascent state as knowledge of their causation. The know- 
ledge that the peculiar disease of the liver, spleen, and kidneys, that 
we have been considering, often results from the syphilitic or scro- 
fulous cachexy, more especially when the bones have been for some 
time affected, may, in many instances, enable us to anticipate its 
occurrence, or to detect it before it ia far advanced, and, conse- 
quently, to adopt preventive measures, if such there be; or, at least. 



FBACTICAIi MBDICINB, ETC. 157 

to apply what remedies we have before irremediable changes of 
stracture have occurred. 

" When, as in the cases related above, together with enlargement 
of the liver, there is albuminous urine, showing that the kidneys 
have become affected, the acid acts much more rapidly and certainly 
in reducing the size of the liver than in restoring the healthy action 
of the kidneys. 

" One reason of this is, that the healthy action of the kidney- 
requires a more perfect restoration of healthy structure than is 
implied by mere diminution of bulk ; and that changes of structure, 
which in the liver we are unable to detect, in the kidney are readily 
and plainly revealed by the presence of albumen in the urine. 

" It is probable, however, that when the acid is absorbed from the 
stomach, its remedial action is really much greater on the liver than 
on the kidney ; because it is carried to the liver directly in the portal 
blood, while it can only reach the kidney when it has passed in suc- 
cession through the capillary system of the liver and the lung, and 
has become distributed in the general arterial current ; and it is, 
therefore, possible that the acid, if taken in baths, when it would be 
absorbed by vessels that go directly to the lung, might have a more 
rapid and more powerful action on the kidney. 

" I need hardly remark, that it is only when the disease of the 
bone,* on which the enlargement of the liver, or of the liver and 
spleen, is consequent, can be arrested ; or when this peculiar change 
in the liver and spleen arises from other conditions that admit of re- 
moval, that such results as were witnessed in the preceding cases can 
be looked for. 

" When the enlargement of the liver and spleen are consequent 
on disease of bone which is irreparable ; or when, otherwise, the 
conditions which led to this enlargement remain in force, the malady, 
though even then its course may be retarded, usually makes pro- 
gress 5 and life, if not previously destroyed by some other affection, 
is at length cut short by disease of the kidney. 

" For reasons already stated, my remarks have been for the most 
part restricted to the enlargement of the liver and spleen consequent 
on the syphilitic cachexy ; but I should not have occupied the time 
of the meeting, were it not for the belief that the subject, when duly 
considered, will be found to have a much wider scope. 

** The enlargement of the liver and spleen, and the albuminuria 
in cases like those related above, though occurring in sequel to pro- 
tracted syphilitic disease, are not special syphilitic affections ; but 
are merely the result of the impairment of the general health which 
protracted syphilis occasions. 

" The remark was many years ago made by the late Dr. Graves, 
that long-continued syphilitic disease induces a state of constitution 
closely resembling, if not identical with, that to which the term 
scrofulous is commonly applied. The remark is quite true ; and it 

* The circamstance that the affection of the abdominal glands is espe- 
cially apt to occur in sequel to caries, suggests the question, whether pro- 
tracted suppuration tends to cause it ? 



15S PSAOTICAL MEDICIKE, ETC. 

serves, in some degree, to explain the circumstance, that persons 
of scrofuloas constitution, as a general rule, suffer much more from 
the effects of syphilis than persons in whom no scrofulous taint 
exists. Additional confirmation of the remark is furnished by the 
fact that long-continued scrofulous disease, more especially when 
the bones are affected, is often followed by disease of the liver, 
spleen, and kidneys, identical in its nature, as far as we can judge, 
with that which, in the preceding cases, was the remote effect of the 
syphilitic virus. 

" The disease of the liver, spleen, and kidneys, then, in cases like 
those related above, is not to be considered as a specific result of 
syphilis ; but as a result of the induced scrofula wnich protracted 
syphilitic disease so often occasions. 

" The effect of a long course of nitric acid in the cases related above 
is, therefore, suggestive of the question. What degree of influence does 
this agent possess in remedying, and, better still, in preventing the 
glandular enlargements, the slowly healing ulcers, and the other forms 
of disease that result from the more common variety of scrofula ? 

" I have been persuaded bjr long experience, that in tuberculous 
disease of the lung, nitro-muriatic acid, lon^ taken, tends to prevent 
the further deposit of tubercle ; and that, m scrofulous glandular 
enlargements, this acid and, still more, the nitric acid, has often a 
very beneficial effect. What is the degree of influence which the 
acid exerts in such cases, and what are the limitations to its use, 
further and more careful observation must determine.*' 



Aet. 73. — On the Physiological and Pathological Import of 
Cholesterine. 

By Dr. Austin Flint, Jun., of New York. 

{American Quarterly Journal of Medical SciencCj, October, 1863 ; 
and British Medical Journal, February 7, 1863.) 

Cholesterine is a product of the animal body regarding which, 
though it is found in sufBcient abundance, and the localities in which 
it exists are tolerably well determined, physiologists have as yet 
failed in ascertaining precisely where it arises, or what becomes of 
it, or whether it has any pathological importance beyond its frequent 
presence in gall-stones. Thus, Longet, writing in 1861, says that 
" it is one of the products destined to be expelled from the economy;" 
but in what manner he does not attempt to show. Robin and Verdeil 
fdso speak of its physiological import as altogether unknown ; and, 
not to quote more instances, our physiological treatises in general 
are equally deficient of information on more than the existence and 
locality of this substance. 

Dr. Flint has made some observations in order to clear up the 
unsettled points relating to this substance, and has publishcNl his 
researches in the paper under consideration. He has examined 
cholesterine in its relations with seroline, a substance found hitherto 
occasionally in small quantities in the blood, but which Dr. Flint 
discovers to exist normally in f»ces, and which he therefore calif 



PBACnCAL KXDICIHS, BTO. 159 

gtereorine. He holds that these two sabstances — cholesterine and 
seroline or stercorine— have a direct relation to each other ; that the 
knowledge of this relation is likely to be of great pathological as well 
as physiological importance ; that, in fact, " What the discovery of 
•tiie function of urea has done for diseases which now come under the 
head of ursemia, the discovery of the function of cholesterine may 
do for the obscure diseases which may hereafter be classed under 
the head of oholestersraiia." 

The general facts that cholesterine is found in the bile, liver, 
brain and nerves, and also in the crystalline lens, meconium, and 
(occasionally) fecal matter, and that it is eliminated by the liver, 
being recognised. Dr. Flint applies himself to the examination of the 

Suestion, Where is the substance formed P Its principal seats being 
tie liver and the nervous system, he has endeavoured first to deter- 
mine whether it is formed or merely deposited in the brain and 
nervous system, by making comparative analyses of arterial and of 
venous blood. His results, in six experiments on animals, show a 
marked increase of cholesterine in the blood of the internal jugular 
vein, and also an increase in the blood returning by the femoral 
vein, as compared with the blood of the carotid artery. He infers, 
hence, that the cholesterine is produced in the brain and absorbed 
there^om by the blood ; and, smce the increase in the blood of the 
jugular vein can only have come from the formation of cholesterine 
in the brain, he argues, supported by the known results of chemical 
analysis of the tissues, that the cholesterine found in the general 
venous system must be produced in the nerves. 

To further confirm this theory, he has analysed blood taken from 
each arm of three patients suffering from hemiplegia; the result 
being that on the sound side the blood yielded from 0'481 to 0*808 
parts of cholesterine per 1000 ; while on the paralysed side not a trace 
could be found. 

Dr. Flint has also made analyses of the blood of the portal and 
hepatic veins, as compared with that of the carotid artery. He finds 
in them proof that cnolesterine is eliminated by the liver ; and that, 
apparently, the diminution of cholesterine in the blood of the hepatio 
vem is nearly equal with the increase of this substance in the blood 
that has passed through the brain. Hence he sees in the bile two 
important elements having separate functions. 

'• 1. The bile contains the glycocholate and taurocholate of soda ; 
which are not found in the blood, are manufactured in the liver, are 
discharged mainly at a certain stage of the digestive progress, are 
destined to assist in some of the nutritive processes, are not dis- 
charged from the body, and, in fine, are products of secretion. 

"2. It contains cholesterine; which is formed in the blood, is 
merely separated from it by the liver, and not manufactured in 
this organ, is not destined to assist in any of the nutritive processes, 
but merely separated to be discharged from the body, and is a 
product of excretion." 

At this point, Dr. Flint takes up the examination of the hitherto 
undetermined question, What becomes of the cholesterine after it 
has been discharged from the liver P 



160 FBACTICAL MEDICINB, BTC. 

Cholesterine has been said by several anthors on pbysiology and 
physiological chemistry to be present in faeces. Dr. Marcet, how- 
ever, has noticed its absence ; and Dr. Flint's analyses lead him to 
the same conclusion. Convinced, however, that the substance most 
be discoverable in some shape, he has, by treating dried fsBces with 
ether and alcohol, <&c., obtained a substance in the iorm of delicate 
transparent needles, having all the characteristics of seroline. This 
substance being found in large quantities in the fssces, he terms 
stercorine. .It is not, according to him, the same substance as 
that which has been described by Dr. Marcet under the name of 
excretine. 

The observations which Dr. Flint has made in regard to stercorine 
are as yet incomplete ; but he brings forward the following evidence 
to show that it is a result of a change of the cholesterine during the 
digestive process. Cholesterine is found in the meconium, where 
stercorine is absent. This arises from the fact that bile is formed 
long before any food is taken into the alimentary canal, and before 
the intestines have had an opportunity of performing their digestive 
function. As soon, however, as digestion is established and the 
digestive fluids are secreted, the cholesterine is lost, and stercorine 
appears in the excrements. In hybernating animals also, cholesterine 
is found in the faeces during the period when no food is taken, but 
disappears when the animal awakes and takes food. Again, normal 
faeces do not contain cholesterine ; but, by examining the discharges 
of fasting animals, Dr. Flint has succeeded in finding small quantities 
of cholesterine in conjunction with the stercorine. Hence he infers 
that the change of cholesterine into stercorine is evidently connected 
with the digestive process. 

The effect of cutting off the supply of bile from the intestines or 
the presence of stercorine in the faeces has been noticed by Dr. 
Flint in the case of a patient who had jaundice from duodenitis. 
The faeces were clay -coloured for a time ; and, on examination, no 
cholesterine nor stercorine could be found in them. Nineteen days 
afterwards, when the faeces had regained their normal colour, they 
were again examined^ and 0*34 of a grain of stercorine was found in 
502 grains. 

Further, the theory of the conversion of cholesterine into stercorine 
is supported, according to Dr. Flint, by the fact that the amount 
of stercorine found in the faeces corresponds very nearly with the 
calculated average amount of cholesterine discharged from the 
liver. 

Regarding the pathological relations of cholesterine^ Dr Flint 
promises more complete observations than are contained in his pre- 
sent paper. So far, however, as his investigations have gone, he nas 
arrived at the conclusion that the retention of cholesterine in the 
blood is liable to produce a train of symptoms of blood-poisoning, 
which he designates cholestercemia. He explains in this way the 
difference in the gravity and fatality of the symptoms of two forms 
of jaundice ; one being attended only with vellowness of the skin, 
and dependent merely on the retention of the bile in the excretory 
passages, and the absorption of its colouring matter ; while in the 



PSACTICAL MEDICINE, ETC. 161 

other the cholesterine is retained in the blood. In the former ease, 
that of simple jaundice, such as that depending on duodenitis, the 
amount of cholesterine in the blood is not necessarily increased ; 
while in jaundice connected with structural change, ascirrhosis, the 
increase over the average maximum in healthy blood has been found 
by Dr. Flint as high as 146 parts in 1000. 

The morbid condition which Frerichs terms acholia is explained 
by Dr. Flint on the theory of the retention of cholesterine. In it 
there may or may not be jaundice ; but, as described by Frerichs, 
the patients may "become unconscious, and be afterwards seized 
with noisy delirium, from which they pass to deep coma, and in this 
gtate die." In one case observed by Frerichs, there was " spasmodic 
contraction of the muscles of the left side of the face." In such 
cases, attempts have been made to discover the elements of the bile 
—biliary acids and pigment — in the blood; it being argued that 
they ought to be accumulated in this fluid in the same way as urea 
in ur»mia. Yet, as has been shown by Frerichs and Moleschott, 
they have not been found. Dr. Flint suggests, however, that if 
sear^ had been made for cholesterine, the result would have been 
different. As regards this acute form of jaundice. Dr. Flint has not 
had an opportunity of actually determining the retention of clioles- 
terine; although the analogy of the symptoms referrible to the 
nervous system with those found in cases of cirrhosis, where the 
retention of cholesterine has been ascertained, is strongly marked. 

The degree to which cholesterine may be retained, and the 
quantity of stercorinein the fseces correspondingly diminished, varies 
in cases of cirrhosis with the amount ot structural disease. If the 
liver be but partially affected, the symptoms of cholesteramia may 
be slight or absent ; for the same reason that the function of the 
kidneys may be partially interrupted without producing symptoms 
of uraemia. 

These researches of Dr. Flint, of which we have given an outline, 
and which we hope he will extend, are apparently of considerable 
importance. They seem to show that, physiologically, cholesterine 
bears the same relation to the liver and bile as urea does to the 
kidneys and urine ; and that, pathologically, the retention of 
cholesterine in the blood produces a train of symptoms designated 
by Dr. Flint as cholestercemiay which may be compared with those 
resulting from the retention of urea — uraemia. Finally, as Dr. Flint 
observes: — 

" When we add to these conditions the cases of what is ordinarily 
called biliousness, attended with drowsiness, an indefinite feeling of 
malaise, constipation, &c. (and all this relieved by a simple mercurial 
purge, which is said to promote the secretion of the liver), cannot we 
tope that some light will be shed on their pathology by a knowledge 
that there is a condition called cholestersemia ? As yet this is but 
speculation ; but the discovery of the important function of choles- 
terine opens an almost boundless field of inquiry in this direction ; 
and ere long the physician may talk of ' biliousness ' and * liver- 
oomplaint * with some definite ideas of their pathology." 

xxxviii. 11 



162 FBACTICAL HEDICIKB, BTC. 

Art. 74}. — Observations on the Treatment of Tania, especially 
by the Use of Oil of Male- Fern. 

By Dr. Ogle, Assist. -Phys. to St. George's Hospital, <fea 
{British Medical Journal f March 14, 1863.) 

In this paper Dr. Ogle gives an epitome of twenty-four cases of 
tsenia in a tabular form, and then proceeds to say : — 

" As respects the action of the oil of male-fern, the table, I think, 
shows pretty well what may be expected of it. Out of the whole of 
the twenty-four cases in which it was given, in only two cases was 
there any doubt as regards its poisonous and expellent action on the 
intestinal worm ; and in one (Case 8), seeing that eight yards had 
been passed but a short time previously, it is not unlikely that there 
was no worm to be expelled. 

" As regards the period at which, after the male-fem oil had been 
swallowed, evacuation of the worm was produced, it appears that out 
of the twenty-four cases (excluding the two cases 4 and 8, before 
denominated as being doubtful as regards the action of the male- 
fern, and one case, 18, in which no information whatever upon this 
point was gathered from the patient), in twelve cases the worm was 
expelled within a short time after taking the remedy, and before the 
castor oil or other subsequent dose was given ; in one case (13), it 
brought away the worm in one hour and a half after having been 
swallowed ; in another case (18), in two hours afterwards ; in another 
case (23), in three hours. 

" Touching the action of the remedy upon the patient, irrespective 
of its vermicide and vermifuge properties, it wiU be seen that, in by 
far the majority of instances, this action was not in any degree or 
manner troublesome or disagreeable. In Case 10, the patient, aged 
21 years, was described as having been rendered * very ill * by the 
medicine ; in Case 11, as being made * ill all over,' * weak, and 
trembling*; in Case 23, a * good deal of pain* was complained of 
when the worm was voided ; and in Case 16, pain was experienced 
in the bowels about an hour after the male-fern had been taken. But, 
in by far the majority of the cases, it is expressly stated that no dis- 
comfort resulted from the medicine ; and m none other were any 
complaints of it made. In Case 11, that wherein so many unpleasant 
effects were experienced during the action of the drug, it is notice- 
able that the worm was only expelled after four doses had been 
taken. 

** Cases 1, 10, and 12 would appear to show as decided a supe- 
riority in the vermicide action of this medicine, compared with tur- 
pentine, as it is superior on the score of taste and agreement, &o. 

** Such are the results which may be elicited by a consideration of 
the table, regarding the utility of the oil of male-fem in the treat- 
ment of taenia. I hope to continue to give this remedy in such cases; 
taking care, if possible, to learn all particulars regarding the mode 
of life, kind of food used by patients, and specially with reference 
to the eating of raw meat, ham, bacon, sausages, &o. 1 shall also 



PRACTICAL XEDICnrS, ETC. 168 

take the precaation, which I would recommend to others (following 
the custom adopted with the nurses at Guy *8 Hospital), of promising 
a premium upon every ' root * or head of the worm brought to me by 
liie patient, so as the better to secure them ; and, when possible, to 
admit the patients as in-door patients for a day or two, for the pur- 
poses of ol^erration. 

" I will now pass on to make one or two obserrations which my 
notebook suggests respecting the uses of other remedies in tape- 
worm. Thus I find, amidst a great number of other cases of which 
I hare record (but so imperfect in various ways that I could not 
adduce them along with those placed in the table), that the oil of 
male-fern has certainly acted vigorously and abundantly in the 
destruction and expulsion of long lengths of the teenia when the 
kamsela (written also kamayla, kamala, and kamela) has failed. The 
form of kamftla which I used was the tincture, two drachms being 
the medium dose for an adult. In one case —a child, aged 4 years — 
after in vain trying the tincture of kamsela, forty drops of the 
maie-fem oil, in mucilage, syrup, and mint-water, caused the ex- 
pulsion of ten yards of the worm within three or four hours after the 
medicine had been administered. 

** I have also given the powder of the rottleria tinctoria, in about 
two-drachm doses, mixed with honey or mucilage, with the effect of 
expelling lengths of the tsenia. In this dose it has been longer, for 
the most part, before producing its specific action, than the male- 
fern oil. In one case in which I gave the rottleria tinctoria, it is not 
unworthy of remark that the patient complained that, when the tsenia 
caused intestinal irritation, in addition to a ' mistiness in eye-sight,' 
a gnawing pain at the upper part of the abdomen and pain in the 
forehead, he very frequently experienced * red blotches, to use his 
own expression, on the forehead and nose. In this case, I find from 
my notes that no sickness or uneasiness ensued on taking the rottleria 
tinctoria powder. In other cases, also, this drug has been noticed 
as acting without griping or discomfort of any kind. 

" Again, I have given the kousso in ample (half-ounce) doses, but 
with variable (in some cases quite unsatisfactory) results ; also the 
santonine, with, as yet, negative results. But I have reason to think 
that my doses of the latter drug have been too small for the purpose. 
I propose trying it in larger quantities. I believe it may be safely 
given in ten or fifteen grain doses. 

." On one occasion, I found that a two-drachm dose of the extract 
of taraxacum brought away a large number of the tsenia joints, the 
presence of which within the intestines had been unsuspected. It is 
possible that this vegetable may be rendered available, in suitable 
doses and form, for the expulsion of intestinal worms ; to which, 
indeed, all * bitters ' appear to be inimical. In another case, a tape- 
worm was expelled after a large quantity of very strong coffee had 
been drunk. 

*• There is another remedy of which I am about to try the effects, 
in consequence of its strong recommendation by Friedrich of Heidel- 
berg ; and that is the picronitrate of potash (£ali picronitricum), 

" X may remark, that it would appear that in certain cases there 
13— a 



164 PBAOTICAL MEDICINE, ETC. 

is an attempt on tbe part of the bowel to dislodge the wonn, apart 
from medicme exhibited. Thus I know of one, a private case, in 
which for many years the patient has had the tapeworm, and who, 
every few months, experiences violent griping, with nausea (never 
vomiting) and diarrhoea, for about half a day, with concomitant ex- 
pulsion of several yards of the worm. He has never found the root 
or head of the animal ; but he does not appear ever to have sought 
for it very systematically. In another case of which I have notes, 
the patient observed that, contrary to what is usually thought to be 
the case, he had had three worms of large size expelled within a 
short period of each other, in each of which the head was found. 
This observation, though stated honestly by the patient, may, of 
course, have been erroneous. 

" More than once I have found that the tsenia and the ascaris 
lumbricoides have existed in the human bowel at the same 
time. 

" With one more remark I will conclude, and it is one which may 
possibly have a practically beneficial effect ; and that is, that I think 
there may be reason for believing that the tsBuia may be communi- 
cated to infants and children from others, and in the following 
manner. In almost all cases, there is reason to think that a tsenia 
does not exist very long within the intestine without portions or 
joints being passed, not only by stool — i.e., with the faeces — but also 
by their ppontaneously working their way through the anus, and 
* skedaddling * (to use an expressive Scotch phrase) from the person, 
adhering to the garments, or falling on the ground. Now, I have 
known cases in which there is reason to think that these fragments, 
which soon desiccate, shrivel, and become reduced to a small brownish- 
coloured mass, may have been picked up by children, often crawling 
infants, who are ever ready to pounce upon and put in their mouth 
every crumb or crumblike substance which they can see, and thus 
have been introduced into the digestive organs. I have no certainty 
pf this ; but I think it is a point worthy of consideration and atten- 
tion, and one to be mentioned to parents in cases where the tsenia is 
known to exist in any members of a family." 



Art. 75. — Two Cases of Cancerous Disease of the Pancreas. 

By Dr. Wabd, Physician to the Seaman's IIc»spital, 

" Dreadnought." 

{Lancet, July 18, 1863.) 

Cancerous disease of the pancreas is unquestionably a rare affec- 
tion. There are but few recorded cases, and the two following only 
have occurred at the Seaman's Hospital for at least the last seven 
years. The liver, the stomach, the different parts of the intestinal 
canal, and the mesenteric and lymphatic glands, are frequently the 
seat of cancerous deposit ; but the pancreas, for some reason or other, 
seems to enjoy an inmiunity from it. 

The intimate anatomical relations of the pancreas with the stomaoht 



PSACnCAL MXDICINB, ETC. 165 

doodeniim, Tena porta, and, nnder enlargement, with the dnctoa 
oommanis eholedochus, render the diagnosis of its affections rery 
difficult. Indeed, on analysing the symptoms of the several reported 
eases, there is scarcely one thjEit would not be equally characteristic 
of disease of some one of the adjacent organs. In such cases as the 
subjoined, where the secreting structure of the gland has been 
destroyed, or its excretory duct constricted, we mi^ht have antici- 
pated assistance from functional symptoms. But the view of the 
emulsionizing action of the pancreatic juice upon fatty constituents 
of food has not received confirmation from pathological observation ; 
for, in the cased in which they have been looked for, fatty matters have 
not been found in the stools. The subjects of the following cases 
were of intemperate habits ; but in other cases such habits are not 
noticed. 

Persistent jaundice is a frequent symptom. The causes of this 
may be arranged under two heads — namely, those affecting the 
structure of the liver itself, and those implicating the parts external 
to it, as the gall duct, or ductus communis choledochus. These 
latter, again, may be subdivided into (1) internal, as permanently 
impacted gall-stones, and obliteration of duct from adhesive inflam- 
mation ; and (2) external, constricting the ducts by pressure from 
without, as the products of adhesive inflammation effused around 
them, enlarged lymphatic glands, cancerous or other tumours of the 
liver and pancreas. Affections of the latter organ can, however, 
only produce this result when its head is involved, and enlarged so 
as to embrace the excretory bUiary duct, as occurred in one of the 
imdermentioned and in one or two other recorded cases. The 
presence of this symptom of persistent jaundice, coupled with a 
history of paroxysmal pains, tended in Dr. Ward's case, as also in 
one reported by Frerichs, to increase the diflSculty of diagnosis ; and 
led to the supposition, at first, that there was occlusion of the ductus 
communis through impacted biliary concretions. 

A fixed, hard, circumscribed tumour, coupled with severe lancina- 
ting, paroxysmal pain, may be considered as in some measure 
characteristic of the disease, but would be equally so of scirrhus 
of the pylorus ; and the same also may be said of the attendant 
functional derangement of stomach and bowels. One fact worthy 
of notice in most of the recorded cases is, the insidious manner 
^in which the disease has become developed, and the comparatively 
short duration of the more formidable symptoms. In one of tho 
following cases the patient had been well until within a fortnight 
of his admission ; and in the other the symptoms had not lasted 
many weeks. In the first case recorded by Frerichs, the patient 
had been quite well up to within six months before admission, 
and then began to complain of short attacks of severe pain, ex- 
tending from the region of the gall-bladder to the epigastrium. 
Seven weeks before he came under Dr. Frerichs* treatment, he 
became gradually jaundiced. In a second case recorded by this 
pathologist there had been transient and scarcely noticeable pains in 
the upper part of the abdomen, and for three months gradually in- 
creasing and ultimately persistent jaundice. In a case of Dr. Hughes 



166 PBAOTICAL MEDICINE, ETC. 

Bennett's/ there had been for only four weeks pain in the lower part 
of the abdomen, with costiveness, and subsequently yomiting of 
food a few hours after taking it. In this case, as La the first of the 
following cases, the cancerous masses in the glands and lungs bore a 
close resemblance to tubercle. The treatment in these cases is 
evidently merely palliative. 

Case. — Cancerovs disease of the pancreas ; cancerous deposits in the liver ^ 
spleen, and lungs. — H. T , aged 27, admitted Oct. 22, 1862. An ill- 
nourished man, of a mulatto complexion. ConjunctivsB are of a deep yellow 
colour, and the skin generally of a tawny yellow tinge ; bowels relaxed, and 
stools deficient in colouring matter; urine abundant, of a deep yellow 
colour ; slight cough and expectoration ; pulse feeble ; he complains of 
severe paroxysmal pains in the epigastric region. He was taken ill eleven 
days before admission with severe pain in the epigastrium, vomiting, and 
constipation. Has been occasionally intemperate. Came last from New 
York. Never bad a similar attack. He was ordered a grain of podophyllin 
and half a grain of cannabis indica thrice a day. 

Oct. 26th. — Bowels relieved once since yesterday ; urine same as before ; 
pulse 90, weak ; tongue moist and flabby ; appetite good ; no mark of 
nepatic enlargement. To have two grains of mercury pill night and morning. 
27th. — Complains of pain in the episgastrium ; bowels freely opened; urine 
the same. To have dilute nitric acid in compound decoction of scoparium 
thrice a day. 80th. — Has sickness. To take two grains of oxalate of 
cerium at once, and also at bed-time. Next day an enema of turpentine 
was given. 

Nov. Ist. — Bowels relieved by the enema ; complains of constant pain in 
the course of the ascending colon, which seems much loaded ; for this he was 
oi-dered croton oil. 3rd. — Bowels freely relieved ; stools of a clayey colour; 
urine the same, contains no albumen ; the pains in the epigastric region 
still continue. A hard circumscribed nodulated mass can be felt in the epi- 
gastrium, a little to the right of the mesial line, just below the margin of 
the ribs ; it is somewhat tender to the touch. Ordered to take two grains 
of podophyllin and half a grain of cannabis indica twice a day. 5th to the 
7th. — Stools and urine remain the same ; tongue clean ; bowels open ; pain con- 
tinues; tumour can be felt lower in the abdomen, and there is gurgling just 
above it. 7th to the 20th. — The urine and stools remain the same. He 
has frequent sickness and paroxysms of excruciating pain, has .lost all 
inclination for food, and becomes rapidly weaker and more emaciated. 
Death took place on Nov. 20th. 

Post-mortem examination, — ^The head was not examined. The abdominal 
and thoracic organs were deeply biie-stained ; the pericardium contained a 
little dark fluid ; the heart was normal in size, and the texture of the valves 
healthy. Lungs : The left was slightly adherent at the apex ; underneath 
the pleura and throughout its substance were small semi-transparent deposits 
having the appearance of tubercle, and others much larger, opaque, yellowish, 
and soft in structure. At the apex of the left lung was a cavity as large m 
a bean, lined with a thick false membrane ; the lung-tissue was congested 
for some distance around it. 

Abdomen: Immediately below the pylorus, and embraced by the duo- 
denum, both of which were pushed very much forward, was a firm nodulated 
swelling, obviously occupying the position of the head of the pancreas ; it 
extended upwaixls behind the duodenum, completely surrounding the 
common bile-duct ; the coats of the duct were free from disease, and a 
probe could be passed along it into the duodenum ; the gall-bladder was 
largely distended, and contained several ounces of dark bile ; the lower end 



WRAcncAis xEDicnrB, XTC. 167 

€f the duodenum was oompletdy snrrounded by the tumour, but its owa 
costs were not implicsted ; the sorts, vena csts^ and right rensl vess^ 
were entirely imbedded in iMrge mssses sqpsrste £rom the tumonr above 
described, which s{>peared to repLuse the mesenteric and lumbar glands. On 
catting into the tomoor, it was seen to consist of greyish- white material, 
arranged in lobaks more or less isolated by areolar tissue, and easily broken 
down. The diseased glands were of a still softer consistence. Liver: 
Kearly normal in sise, snd dark in colour. Under the capsule were several 
deposits about as huge as a sixpence, of a wLite colour, with considerably 
depressed centres, separated from the liver-structure by a remarkably well* 
defined margin ; they were of a veiy soft consistence. Deposits of the same 
fluhstanoe, ^ various sixes, were scattered throughout the tissue of the 
oigan, which was otherwise normaL The spleen contained deposits similar 
to those in the fiver, and they showed a disposition to arrangement parallel 
with the trabecule. The kidneys contained no deposits, and were healthy, 
with the exception of a few small transparent cysts. Under the microscope 
the principal tumour and the secondary deposits both showed cells of various 
gizes and shapes containing large nuclei, many of them more than one. The 
prevailing shape was oval, while others were lengthened out so as to be 
fusiftHin or caudate. Both the transparent deposits above described in the 
lungs and the larger ones presented the same structure. 

Cancerous ditease of ike pancreas and liver. — ^Thos. T , aged 45, 

admitted Jan. 19, 186S. EEas been a hard drinker all his life, chiefly indulg- 
ing in gin. His last voyage was to China and back. He was attacked a 
few days before leaving Shanghai with diarrhoea, tenesmus, bloody stools, 
and other symptoms of dysentery, with constant pain over the liver. He 
continued work until within eighteen days of the ship's arrival in England, 
and subsequently spent, eleven days at a boarding-house, being successively 
under the care of three doctors, who all prescribed stimulants, of which he 
partook very freely. 

Symptoms on admission. — Aspect staring and anxious ; trembling of the 
hands and other symptoms of incipient delirium tremens ; no appetite, and 
sleeps very little ; the bowels are regular, and the pulse is small ; tongue 
furred. There appears to be considerable enlargement of the liver ; dulness 
on percussion, extending considerably over the leit side, and very low upon 
the right side. He was suffering from slight dysentery, passing, according 
to his own account, five or six stools each day. Ordered a mixture of dilute 
nitric acid in infusion of cusparia, and a morphia draught at bed-time, with 
diet of milk and beef- tea. 

Jan. 20th. — Has slept a little ; passed three stools ; but still complains of 
severe pains about the stomach and liver. To continue the mixture and 
anodyne ; blistering fluid to be applied to the hepatic region. 21st. — The 
blister appears to have given great relief ; there is much less pain ; the 
tongue is cleaner, and the stools are healthier. To have ordinary diet and 
six ounces of gin daily. 23rd.— All the symptoms have greatly subsided, 
and he now complains only of occasional griping pains, with some looseness 
of the bowels. A mixture of soda and rhubarb prescribed. 25th. — The 
diarrhoea still continues; but the motions, though fluid, do not contain 
blood. A pill of lead and opium was added to the last prescription, to be 
taken once a day. 

Feb. 2nd.— From the last date to this he has got up regularly, and with 
the exception of slight dyspeptic symptoms, appears tolerably free from dis- 
comfort, though weak, and with little appetite. Taking now a mixture of 
bismuth and bitartrate of soda in an infusion of calumba, with an occa- 
sional morphia draught at night. 6tb. — The pain has returned. To keep 



168 FBACTICAL MEDICINE, ETC. 

his bed, and have a blister applied to the epigastrium, with slop diet ; to 
discontinue the gin. 8th. — No appetite; the anxious aspect has returned ; 
he sleeps very little ; the bowels are regular, and evacuations healthy ; but 
the epigastric pain appears to increase, and he seems to lose flesh daily. 
12th. — No alteration of symptoms since last date. In addition to the 
mixture, a pill of opium was ordered to be given twice a day. 14th. — Very 
great pain ; fulness and tenderness in epigastrium. An emetic of sulphate 
of zinc appeared to give great relief. He was ordered arrowroot and eggs 
in addition to the slop diet. 17th. — Vomiting after food commenced to-diay. 
Ordered an efFei-vescing mixture, with soda-water and brandy. 18th. — ^The 
vomiting continued, and recurred at intervals. Creasote was given in 
addition to the mixture above mentioned, and simple enemata were used to 
relieve the bowels. The hardness and enlargement of liver appeared to 
have increased, but there was no sign of mateiial disease elsewhere. Chlo- 
rides in urine scarcely perceptible ; no albumen. 24th. — The vomiting still 
continued, and he has lately taken very little nouiishment except egg and 
brandy. He died in the night of the 25th, exhausted. 

Autopsy thirty-six hours after death. — Slight rigor mortis. Lungs healthy 
throughout. Heart healthy. Liver (weight, six pounds and three quarters) 
studded over its surface and throughout its substance with granular rounded 
masses, some hard, others consisting of a whitish cheesy matter, but forming 
collectively about one-third of the entire substance of the liver. Gall-bladder 
nearly full. Pancreas : The right half was, en masse, of stony hardness, 
and, when cut into, exhibited the same abnormalities of structure as those 
found in the liver ; and left half contained in many parts sinular masses of 
structure. Spleen small. Kidneys normal in size and weight ; much con- 
gested. Intestines contracted ; coats healthy ; no sign of tuberculous deposit 
in the mesenteric glands. The deposit in liver and pancreas was found, on 
microscopic examination, to contain characteristic cancer cells. 



Art. 76. — Case of Alscess of the Spleen Discharged into the 
left Lung, 

By Dr. A. A. Mantell, Bengal Medical Service. 
{Medical Times and Gazette, May 9, 1863.) 

Ca.se. — J. D., a European, and father of five healthy children, aged 62, 
and perfectly grey, was placed under my care on Jan. Slst of the current 
year. He had just arrived in a boat from the coast, where he was employed 
by Government as a superintendent of a lighthouse. He was accompanied 
by his wife, who gave the following history of his case: — 

She stated thjit during their thirty-seven years of married life he had 
always been a strong, healthy man ; that as a pilot he had seen much 
service, and that for many years he had been a very free liver, his favourite 
drink being rum. He had not been subject to fever, but had had a slight 
attack of ague before his present illness set in. As far as she could recollect, 
he had never had any affection of the chest, noi had he ever complained of 
pains in the loins or abdomen. His appetite was always good, and his 
bowels invariably regular. His present illness commenced five months ago 
with sore thi-oat and difficulty in swallowing ; he also complained of pain in 
the right side of his neck. 

The soreness of the throat and difficulty of swallowing continued to in- 
crease, and on Dec. 3lst last he became much worse ; on the following 
day he was unable to masticate his food, and his speech became thick. 



PBACTICAL MEDICINE, ETC. 169 

During the whole of this period his general health was good, hat he was 
imahle to take food in the solid form. 

. Od Jan. 25th he coughed up some dark-colouxed hlood and matter of a 
very offensive character. From this time hia hreathiug hecarae difficult, a 
hacking cough set in, and he daily expectorated small quantities of blood 
and matter. 

On the evening of the- 30th he was still worse, expectorating large 
quantities of the same kind of discharge, and unable to lie horizontally, in 
consequence of the extreme dyspncBa. During this night he had no sleep, 
and his wife did not expect hitu to live till morning. 

I saw him for the first time on the fallowing afternoon ; he was sitting in 
a bent posture ; his countenance, was- dusky^ and his lips livid ; he was at 
times delirious, and breathing with much noise and difficulty ; he had a 
slight but frequent coughj and with it expectorated aa offensive sanguineo- 
purulent fiuid, of a dark brick colour. 

He was free from fever, and had a tolerably strong pulse of 84. His 
tongue was clean <; he complained only of his throat,. and. pointed to it as 
the seat of pain ; nothing, liowever, abnormal could be felt externally, or 
seen internally ; there was partial paralysis of his tongue, which rendered 
his speech thick, and difficult to be understood.. His lungs gave no evidence 
of disease — resonance' was good on percussion, and the only abnormal sound 
present was a mucous r&le. No enkrgement of the liver or spleen could be 
detected ; and he did not complain of pain when his abdomen was examined 
by pn^ssure and percussion. Ordwed nourishing diet constantly, and a 
stimulant mixture. 

Feb. Ist. — He has passed a restless night, especially the early part of 
it. At times he was delirioiis, and on- several occasions it was feared he 
would be suffocated by the accumulation in his chest. This morning he 
appears somewhat better ; there is less delirium; his respiration is not so 
noisy ; and the expectoration has somewhat abated ; his pulse is 86, and 
firm ; he walks about the room occasionally, in spite of orders to remain 
quiet, and once nearly fainted in consequence of the exertion. He passed 
urine once during the night ; it was clear, and of a natural colour. His 
bowels not having been relieved for two days, he was ordered an aperient 
draught. 

2nd. — He appears much better this morning, as he has slept the greater 
part of the night ; his pulse is still 86, and of the same character. He can 
now lie in the horizontal position without much distress. From his im- 
proved condition prognosis more favourable. 2 p.m. — At this hour I was 
summoned suddenly tosee him^ and on arrival found tliat alarming haemo- 
ptysis had set in ; he had coughed up half a pint of pure blood. Nothing 
stopped the hsemorrhage, and in about twenty minutes he died. 

Inspection Twenty-one Hours after DeaUi. — Body pale, but well nourished 
considering his age. Brain not examined. On removing the trachea, 
pharynx, &c., the greater comu of the hyoid bone of the right side was 
lound in a state of caries, and the diseased part was surrounded by a small 
abscess, which had apparently burst into the upper part of the pharynx. 
The apex of the right lung was slightly adherent, and the bases of both 
lungs were firmly adherent to the diaphragm, especially the left ; their 
structure was healthy, but engorged with frothy blood and serum. Heart 
natural, with empty cavities. Liver smaller than usual, gall-bladder con- 
taining greenish bile, and one large black calculus. On endeavouring to 
remove the spleen, it was found adherent to the diaphragm, and so soft and 
pulpy that it broke to pieces under very slight pressure of the fingers ; the 
cause of this was an abscess which occupied its structure, and was now 



170 PRACTICAL MBDICINE, ETC. 

nearly empty ; the walls of it were thin, and what remained of the paren- 
chyma was infiltratdd with fetid matter and blood of a biick-red colour, 
similar to that which had been expectorated during life. The abscess had 
burst into the left lung, a communication being established between it and the 
spleen. The fatal haemorrhage was due to rupture of a branch of the left 
pulmonary artery. The left kidney was hypertrophied, and the right con- 
tained an abscess the size of a hen's egg, filled with yellow matter. The 
stomach was lined with a thin layer of coagulated blood, which had been 
swallowed during the fatal hemoptysis. The other viscera were healthy. 



Aet. 77. — Fatal Obstruction of tie Bowels /rom tAe Presence 
of an Hydatid Tumour springing from the Mesentery^ 

By Br. J. Sutherland. 

(Medical Record of Australia, Feb., 1868.) 

Case. — The patient, aged 48, enjoying general good health, except a 
feeling of fulness of the epigastrium, was suddenly seized with severe 
cutting pains around the umbilicus, and constant desire to go to stool with- 
out effect, succeeded by troublesome vomiting and tympanitis of the abdo- 
men. The pain continued, and tenderness on pressui-e came on, with fuiTed 
tongue, bounding pulse, and hot skin, &c. In spite of venesection and the 
use of leeches to the abdomen, &c., hiccough, subsultus tendinum, delirium, 
&nd coma came on, followed by death: On post-mortem examination, in- 
stead of invagination of the bowels or intussusception, which were expected, 
a very large oblong hydatid tumour (of the size of an adult human head, 
and weighing four pounds) was found in the left hypochondrium and um- 
bilical region, which compressed several folds of the ileum so closely as to 
prevent the possibility of the passage of the contents, inducing gangrene in 
the parts compressed, and intense peritoneal inflammation in the adjacent 
convolutions. The tumour was adherent by a small root or pedicle to the 
left side of the mesentery, having an artery and vein enclosed, and trace- 
able over the interior of the lining membrane of the sac or tumour. The 
reporter observes that had it been recognised during life, it could easily 
have been punctured and the fluid drawn off. 



(b) CONCERNiKO THE aENITO-URINARY GTYSTEM. 

Art. 78. — A Question as to the Pathological Distinctions 
in Cases of Diabetes. 

By Dr. Daniel Noble, of Manchester. 

(British Medical Journal, Jan. 17, 18&3.) 

Dr. Noble has been led to think that saccharine urine 3oea not 
constitute that very formidable question in disease which it is sup- 
posed to be — that, in fact, it is not to be regarded as the sure 
precursor of that particular diahetic condition which almost inya- 
riably has a fatal termination. As grounds for his opinion, he 
relates two cases of diahetes, representing the well-known features 
of the disease in their most aggravated form ; and, after these, two 



PBACTICAL MEDICINB, ETC. 171 

Other oases, the pathological significance of which, he thinks, is 
essentially different. He says : — 

** But there is another class, which I proceed very briefly to ex- 
emplify. A gentleman, between fifty and sixty years of age, of 
great mental endowment, one who had through life pursued a 
thoughtful and laborious career, had, for upwards of twenty years 
been accustomed to consult me when requiring medical aid; his 
ailments haying generally been some feverish cold, or a slight degree 
of gastro-enteric irritation that rendered his digestion habitually 
weak. For four or five years prior to the summer of 1860, he had 
been deeply engaged in labours demanding much brain-work, of a 
kind, moreover, that involved considerable worry and anxiety. 
About the period just specified, he became troubled with neuralgic 
pains about the head, with broken sleep and gastric irritation to an 
unwonted extent. I was constantly urging detachment from busi- 
ness-cares and labours, but this recommendation was but imperfectly 
carried out ; yet to the extent to which it was so, the symptoms 
were always relieved. Late in the autumn the ailment assumed 
severer features ; for great debility and some emaciation ensued. 
At this stage of affairs, the patient, having a demand for his pre- 
senee in London, asked if I would advise him whilst there to consult 
any one and whom, and I named to him a physician of well-earned 
distinction for his successful labours in pathological chemistry ; my 
recommendation was acted upon, and the physician in question was 
Been ; and, immediately on the patient's return home, my attendance 
was aj^ain requested. On inquiring if he had seen the London 

Ehysician, and if he had, what had been said, I was told that he 
ad done so and was glad of it, for the ailment had been found 
to be diabetes. I must confess, that upon hearing this statement 
I was somewhat startled, for there neither was nor had been any 
excessive discharge of urine, nor any dryness of skin, nor any 
voracity ; neither had the urine exhibited that greenish straw colour 
80 often suggestive of diabetes, but, on the contrary, had displayed 
the same superficial characters which I had noticed for years in 
connexion with disordered digestion — a somewhat higher colour 
than usual, and lithic deposits on cooling. However, I could not 
doubt, after what had been said, that tlie urine at this time con- 
tained sugar, and, having procured a specimen, I took it to an 
analytical chemist, that it might be quantitatively as well as qua- 
litatively examined. It was found to contain about eight per cent 
of sugar, and the specific gravity was 1031. I had already said to 
the patient that, although the urine should contain sugar, I did 
not think it quite correct that the case should be designated 
diabetes, if by the term was understood that grave form of it, 
which, undermining by degrees the forces of life, terminated in 
death by a sort of gradual decline ; and that, indeed, I wished him 
to rid his mind of such a notion, as being, at least in my judgment, 
not only not true, but calculated in itself to do him serious physical 
mischief. I had explained to him, moreover, that it had of late 
years been discovered that mental irritation, by its action on the 
brain, might give rise to saccharine urine, and that this phenomenon 



172 FBACTICAL MEDICINE, ETC. 

was not always of that momentous and fatal significance which the 
popular estimation of diabetes might lead him to think. However, 
ne had received from his metropolitan adviser both medicinal and 
dietetic prescriptions — all secundum artem, and these, I said, he 
must in fairness carry out au pied de la lettre; I let him understand, 
nevertheless, that I gave preference to my own practical views, 
which involved detachment from harassing oceupa»tion and thoughts, 
change of air and recreative amusement, with such medicines and 
diet as his own particular experienee might suggest to be the best 
calculated to restore the integrity of his digestive functions. After 
a trial of what 1 will call the systematic treatment for about a fort- 
night, he waa obliged to give it itp alike in its medicinal and dietetic 
items, for both appetite and digestion became still weaker; and, 
altogether, he was put more and more out of order ; but, all this 
time, neither the skin nor the quantity of urine gave any of the 
usual indications of advance in the direction of diabetes as ordi- 
narily understood. Early in 1861, all system of treatment was laid 
aside, my own more general views were carried out, and he began 
to improve ; the (Quantity of sugar in the urine and the specific 

fravity also were diminished, varying however from time tp time, 
n a few weeks the percentage of sugar was reduced to five, when, 
for what I deemed to be good and sufficient reasons, the urine ceased 
to be examined ; the patient had possessed himself of a urinometer 
and was in the habit of usini; ii himself; and in this way, I thought, 
he wafl exercising a prejudicial influence upon his physical condition 
by unduly fixing his attention upon it; therefore, subordinating 
my scientific interest in the case to anxiety for the patient's 
recovery, I ur^ed that he no longer notice the urine, that he forget 
it, and, so long as he continued to improve, neither make nor have 
made any more examinations of this excretion.. Through the 
spring the improvement went gradually on, appetite and digestion 
better, and the strength increased ; by the summer, he might 
almost be regarded as well. In the month of July, however, he 
had a most serious attack of summer-cholera, which, after some 
days very severe suffering, abated ;, I only saw him once during 
this illness, as it occurred upwards of forty miles from Manchester; 
but from what I did see, and from the account furnished by the 
local surgeon, I am enabled to describe it as most enervating in its 
effects, and he was for some time much shattered by it ; still, neither 
at the time, nor during the ensuing convalescence, was there any 
manifestation of the constitutional symptoms of diabetes. This 
gentleman, when sufficiently well, during the autumn went to 
Malvern, sanguine from what he had been told, that the water- 
treatment would invigorate him and perfect his cure ; and, for my 
own part, recognising the benefit to arise from this very mental pre- 
possession, I raised no objection ; and, certainly, on his return home, 
towards the end of the year, be appeared quite well. For reasons, 
however, already stated, I neither made nor procured any chemical 
examination of the urine. During the spring of the present year, 
the patient had another very severe break -down, in the old way and 
from the old causes — headlacke and functional disturbance of the 



PEACTIOAL MEDICINE, ETC. 173 

stomach from excessive brain-work and irregular diet ; still no sup- 
pression of perspiration, no excess in the quantity of urine, no 
voracity. Perfect recovery followed. At this time the gentleman 
is in excellent condition, looking perfectly well and cheerful, and 
is said by his friends to have a more healthful appearance than 
he has presented for some years. 

" A gentleman of my acquaintance, of high intellectual endow- 
ment, and, moreover, of great sensitiveness of disposition, has for 
the last seven or eight years had saccharine urine — a symptom 
which ensued upon much anxious mental effort. As he is a resi- 
dent at a considerable distance, I cannot exactly speak of this gen- 
tleman as my patient, although on several occasions I have had 
conversations with him on the subject of this particular derange- 
ment of his health. I think it was about the year 1854 or 1855 
that sugar was first discovered in the urine, but he had for many 
years had an imperfect digestion, evidenced very often by lithic 
deposits, and he had been a bad sleeper. In this case, there has 
been none of that steady progress in a downward direction so 
commonly happening when there is saccharine urine. From the 
time of its detection to the present there have been several attacks 
of illness, and on two occasions the patient had been all but given 
over. I saw him about three years ago labouring under irritable 
heart as the chief malady ; he was in bed and much exhausted, so 
much so, indeed, that his friends, having regard to the diabetes, 
scarcely expected that he would rally ; yet at this time the specific 
gravity of the urine was not high, below 1030, 1 think. The gloomy 
forebodings were not realized, and recovery took place, enabling 
him to fulfil important and responsible duties. In this instance, 
there was) for the most part, a somewhat inordinate appetite, but 
not any particular dryness of skin nor any great excess of urine. 
I select for illustration a case, with which I am but imperfectly 
acquainted however, mainly because the connexion in degree between 
mental wear and tear and saccharine urine was on several occasions 
quite notable ; for example, about four months ago, the patient was 
abroad accompanied by an intimate friend, from whom I had shortly 
afterwards the information that, during this absence from home, 
circumstances occurred to produce great stress of mind, breaking 
down the health for a brief period ; that, apparently in consequence, 
the diabetic symptoms became very much aggravated, the specific 
gravity of the urine running up to 1051 from 1025. On the enjoy- 
ment of quiet and the restoration of mental calm, the status quo 
was very speedily recovered ; and, since this occurrence, the patient 
has been better than for a long time before. Indeed, a gentleman 
well acquainted with him, writing about a month ago to me on 
another subject, refers to our common friend as follows : * He 
keeps well ; I suppose there never was known such a case.' 

" I think there can be no doubt that the class of facts, very im- 
perfectly exemplified by the preceding accounts, demands thejinference 
that some causal relation subsists between certain pathological 
states of the brain and the excretion of sugar by the kidneys ; 
showing, as it would appear, that mental perturbation is one of the 



174 FBACTICAL HBDICINE, ETC. 

first links in the chain of diabetic phenomena, and showing, more- 
over, that the degree of mischief exnibits some correspondence with 
the intensity of the presumed cause. Indeed, so obvious is the • 
relation in question, that it has been suggested by some, that 
diabetes mellitus is essentially of encephalic origin ; and, certainly, 
if pathological distinctions cannot be established, there is much evi- 
dence that may be cited in maintenance of some such thesis. The 
well-known experiments of Claude Bernard, repeated and confirmed 
by Dr. Pavy in this country, furnish no little plausibility to the 
doctrine ; they show that saccharine urine can be artificially pro- 
duced by mechanical irritation of the floor of the fourth cereoral 
ventricle. And other experimental lesions of the nervous system, 
moreover, have been found to produce diabetic symptoms since the 
one first practised by M. Bernard. Ordinary brain-disease will 
sometimes develop for a time a saccharine condition of the urine. 
The case of the late Mr. Hopwood, which attained so much noto- 
riety in the year 1855, on a trial affecting the validity of a will, 
supplies an excellent illustration of this position. In 1849, five 
years before this gentleman's death, it appeared from the evidence 
given on the trial by his very intelligent medical attendant, Mr. 
Abraham Wood, of Kochdale, that at the period mentioned he 
began to suffer in his head, complaining of pain, somnolence, and 
intolerance of light — symptoms attributed by Mr. Wood to con- 
gestion of the brain, and which later on were followed by paralysis 
and dementia ; * he had also another ailment,* said Mr. Wood, * an 
affection of the kidneys.' On cross-examination, he was told to 
say what this affection was, and he stated that it was ' diabetes 
mellitus,* and then that this was recovered from in ten days or a 
fortnight. Hereupon, Sir Fred. Thesiger, the cross-examining 
counsel, seemed to think that he had got hold of a good point for 
weakening the force of Mr. Wood's evidence, for, echoing the 
general popular impression concerning the necessary fatality of 
diabetes, he observed : * That (diabetes mellitujt) is the incurable 
kind, is it notP' To this interrogatory Mr. Wood very sensibly 
replied, *It depends upon the cause.' Sir Frederick, however, 
pursued the topic, resting upon the position that the ailment in 
question could never be recovered from, and that Mr. Wood did 
not know what he was about ; but that gentleman was quite a 
match for the clever counsel, stating that he had not merely been 
led to the diagnosis by the general symptoms, but that he had 
tested the urine and detected the presence of sugar. 

" Now, the Question which I would propose, and the question to 
which all that has preceded is introductory, is this : Is it possible to 
establish pathological distinctions in cases of diabetes, according to 
their origin, the course of the symptoms, and their curability — cha- 
racteristics which, under many circumstances, supply the oasis of 
such distinctions P In all these particulars, there would seem to 
be a wide difference between such instances as those last cited and 
those which I sketched in an earlier portion of this paper, the pre- 
sence of sugar in the urine being almost the only phenomenon 
common to the two sets. May we not expect that, m further pro- 



PBACTICAL MEDICINE, ETC. 175 

secution of our investigations in this direction, we may be enabled 
to determine distinctions in cases exhibiting sugar in the urine, just 
as now we can and do, but could not formerly, in the analogous 
instances of albumen in the urine P When Dr. Uritjht demonstrated 
the pathological connexion between granular kidney and albumi- 
nuria, it was for some time aflerwards regarded as constant ; and 
albuminous urine was consequently regarded as possessing a much 
graver significance in all cases than it is now known to have ifi 
many ; for, at the present day, this symptom is known to be ex- 
pressive of pathological states various in their kind, and involving 
great differences alike in their origin, course, and curability ; hence, 
we estimate the general character of albuminuria, not by the amount 
of albumen in the urine, but by the morbid causes which have 
brought this irregular excretion about. Is it not practicable, then, 
to ^establish, or to discover, in like manner, scientific as well as 
practical distinctions in cases of diabetes P I would venture, myself, 
to express the conviction that modern researches are tending in this 
direction ; and it is to stimulate attention to this view of the subject, 
that I have brought forward the question upon the present occasion, 
not, I need hardly say, in the form of a clinical contribution scien- 
tifically complete, but rather in that of an exposition of a course of 
thought initiated by the incidents of a casual experience." 



Art. 79. — Case of Diabetes Treated hy the Use of the 
Turkish Bath, 

By Br. K. H. Goolden, Physician to St. Thomas's Hospital. 
{British Medical Journal, September 12, 1863.) 

Cabb. — Wm. Spence, aged 21, farm-labourer, was admitted into Luke's 
"Ward, on February 10th, 1863. He had been ill five months, from his own 
account. He complained of great and increasing debihty, bo that he was 
obliged to give up work, becoming very much emaciated, and having intense 
thirst. The skin was dry and harsh. He passed large quantities of urine. 
He had good appetite ; no cough. The chest was well developed and healthy. 
Pulse Sl, feeble. The tongue was coated with dirty mucus, brown in the 
centre, and very red at the apex and edges. He had no headache ; no 
recollection of a blow on the head or accident; nor had he suffered from 
other illness. 

The emaciation and debility were excessive, so that he appeared to take 
little notice of what was passing about him ; and roused himself with difficulty 
to answer questions. The specific gravity of the mine was 1041; the 
quantity as yet was not determined. 

On admission, he had a warm bath ; and his hair was cut close. He was 
ordered five grains of calomel and five grains of Dover's powder at night, 
and a senna draught in the morning ; a drachm of sulphate of magnesia in 
peppermint- water three times a day. The urine, being measured, was 
found to be thirteen pints. 

Feb. 2l8t. — ^The quantity of urine was fifteen pints ; specific gravity, 
1043. He left off his medicine, and was ordered a Turkish bath on alternate 
days. 

Feb. 26th. — ^The amount of urine was ten pints; specific gravity, 1041. 
The diet of this patient was determined at this date as follows : — Mixed diet 



176 PBACTICAL MEDICINE, ETC. 

— Twelve ounces of bread, and three-fourths of an ounce of butter; one pint 
of tea with milk (no sugar) for breakfast ; and the same for tea ; milk, with 
rice, or bread-pudding. Alternately for dinner — Half- pint of milk; four 
ounces of roast meat when dressed, without bone. Extras : Greens ; half a 
pound of beefsteak ; a pint of porter ; two eggs ; and an unlimited supply 
of water, lemonade, and other hospital drinks. 

March 4th. — Urine of specific gravity, 1040; quantity under ten pints. 

March 11th. — Urine of specific gravity, 1037 ; quantity under ten pintg. 
He was very much more alive and cheerful, and increasing in strength. 

March 14th. — Urine of specific gravity, 1030 ; quantity under ten pints. 

March 21st. — Urine of specific gravity, 1037 ; quantity under nine pints. 

April Ist. — Urine of specific gravity, 1027 ; quantity under eight pints. 

April 4th. — Urine of specific gravity, 1030 ; quantity under seven pints. 

The specific gravity was less after coming from the bath. 

April 8th. — Urine of specific gravity, 1031 ; quantity under seven pints 
and a half. 

April 18th. — Urine : specific gravity of two portions, taken at different 
times in the day, 1041 and 1030 ; total quantity under seven pints and a 
half. He had been taking some sweetmeats, which accounted for the 
higher specific gravity. 

April 2oth. — Urine of specific gravity, 1030 ; quantity under seven 
pints. 

May 6th. — Urine of specific gravity, 1030 ; quantity under six pints. 

May 13th. — Urine of specific gravity, 1031 ; quantity under five pints 
and a half. 

The bath was omitted. 

May 20th. — Urine of specific gravity, 1032 ; quantity under six pints. 

May 30th. — Urine of specific gravity, 1032 ; quantity under six pints. 

June 3rd. — Urine of specific gravity, 1035 ; quantity under five pints. 

The bath was now resumed. 

June 6th. — Urine of specific gravity, 1030 ; quantity under five pints. 

June 13. — Urine of specific gravity, 1030 ; quantity under five pints. 

The pepsine was discontinued. 

June 27th. — Urine of specific gravity, 1031 ; quantity under five p'nts. 

July Ist. — Urine of specific gravity, 1028 ; quantity under five pints. 

July 15th. — Urine of specific gravity, 1030 ; quantity under five pints. 

July 18th. — Urine of specific gravity, 1028 ; quantity under five pints. 

Gluten bread was ordered as a substitute for hospital bread. 

July 22nd. — Urine of specific gravity, 1033 ; quantity under five pints. 

.Tuly 29th — Urine of specific gravity, 1035 ; quantity under five pints. 

Since taking the gluten-bread, he has suffered much dys^psia; and 
shows more sugar in urine. 

I will not offer any remarks upon this case, beyond the fact that it is un- 
complicated with remedies. Although not cured, and still under treatment, 
it shows that, in this particular instance at least, the bath is as powerful a 
remedial agent as any that we have tried. 

The sweat has been several times tested, and there is not a trace of sugar 
in it; but the usual quantity of urea and chloride of sodium; differing not 
at all from the results given in the perspiration of healthy persons. 

The skin has become soft and perspiring. He has increased in weight and 
muscular development; so that he has become capable of doing good work, 
and makes himself useful in the hospital. He is a very cheerful and in- 
telligent man for his station : in strong contrast to his first appearance. 

I was induced to try the Turkish bath in this, which I considered a hope* 
less case, because I had heard of a case (not very well authenticated) which 



7BACTICAL MEDICINK, UtO, 17{^ 

had been reUeved at one of the public baths. I was satisfied that, with 
proper care, very debilitated patients may be subjected to it without any 
fear ; and having the patients under our own control, we could stop them at 
any time. And, moreover, a number of cases (seven) of albuminuria with 
dropsy, and in some cases with heart-disease, have been subjected to the 
Turkish bath, without any inconvenience in any one case. Four of these 
oases have got entirely rid of albumen in the urine. All these cases have 
been relieved of the dropsy. When I have other cases of diabetes in the 
hospital (and I shall be glad to receive any, if sent from any part of the 
country by medical practitioners) I will report progress. 

Since the above report-, the quantity is reduced to four pints, and specific 
gravity from 1022 to 1030 ; and this improvement followed the application 
of ice to the cervical vertebra in an India-rubber bag, as suggested by Dr. 
Chapman. 



Art. 80. — Effects of Diet and Drugs in the Treatment of 
Biahetes Mellitiis, 

By Dr. Andrew Smart. 
{Medical Times and Gazette, February 14, 1863.) 

Dr. Smart gives the following results, obtained from a series of ob- 
servations — in two cases of diabetes mellitus treated by Dr. Lay cock, 
in the Eoyal Infirmary, Edinburgh — instituted with the object of 
determining the sugar-producing agency of certain articles of diet. 

The following articles are arranged in the order in which they 
were found to act as sugar producers : — 

" 1. Suaar (cane), whether used as an article of diet or medica- 
tion, besidfes undergoing transformation into grape sugar, acted as a 
fowerful diuretic and stimulant to the morbid production of sugar, 
t also greatly increased thirst. 

" 2. ^icey contrary to general belief, was next to sugar in its 
influence on the production of diabetic sugar and increase of urine. 
Its action in these respects was much greater than can be explained 
by reference to the proportion of starch and sugar which it contains. 

** 3. Potatoes were inferior to rice in their sugar and urine- 
producing powers, but exerted a markedly greater influence than the 
ordinary sorts of wheaten bread. 

** 4. Gluten Bread.— "We have not succeeded in ascertaining the 
exact composition of the bread usually sold under this name. It is 
decidedly sweet to the taste (but this saccharine quality does not 
depend on admixture with sugar). It is also very palatable, and 
preferred by diabetic patients to ordinary bread. It has been much 
recommended in diabetes, under the belief that, as an article of food, 
it operated more mildly in exciting and maintaining morbid action. 
This opinion was contra-indicated by repeated and careful trials, the 
results of which demonstrate that its influence as a sugar eliminator 
exceeds that of ordinary white and bran bread. 

" 5. White Bread, — The trials with this bread, as with the others, 
were extremely varied, but invariably with like results. It un- 
doubtedly produced less sugar than gluten bread, but was superior 

XXXVIII. 12 



178 PBACTIOAL MEDICIKB, ETC. 

ia that respect to brown bread and oatmeal. It is interesting to 
know that the amount of sugar found in the urine invariably main- 
tained a fixed relation to the combined proportions of sugar and 
starch contained in the bread, the proportion of diabetic sugar 
always exceeding that of the starch and sugar elements as two to 
one. Thus, for example, if the amount of bread taken in twenty- 
four hours contained, say 500 grains of combined sugar and starch, 
and no other substance interfered with the experiment, a careful 
analysis of the urine during the same period yielded, with remarkable 
uniformity, nearly double that amount — t. e,, somewhere about 1000 
grains. 

" 6. Bran Bread, — This bread differed in no important parti- 
cular, except in its milder action in the production of sugar. But 
this difference was trivial. 

" 7. OatmeaL — The influence of this cereal, when given weight 
for weight with the others, was so decidedly less that there can be 
no doubt in placing it last in the list now given. It diminished the 
amount of urine while rather heightening its density, but, as an 
article of diet, it was not relished by the patients. 

** 8. Eggs, — When thepatients were put on an exclusively egg diet, 
the amount of urine and sugar progressively diminished, and the 
latter would probably have disappeared entirely from the urine had it 
been possible so to restrict the diet for a sufficiently lengthened period. 

** 9. New Milk contains sugar, as sugar of milk ; but judging 
from all the trials which were made with it, we were led to infer 
that this constituent does not undergo glucose transformation. 
Under this, as in egg diet, the sugar progressively disappeared from 
the urine. But the great difficulty always experienced was, to con- 
fine the patient for some time to one or two kinds of food. 

" 10. Animal Diet. — When eggs, milk, fish, beef, mutton, and all 
other kinds of animal diet, were given either alone or in combination, 
the following results invariably followed : 1. Marked decrease in the 
elimination of sugar and secretion of urine, which was progressive 
with the continuance of the diet. 2. Sense of hunger and thirst 
greatly lessened. 3. Increased density of urine. 

" 11. Vegetables, such as cabbages and turnips, sensibly augmented 
the production of sugar, but to a much smaller amount than is 
generally supposed. They were also apt to derange the digestive 
system. Cabbage invariably produced diarrhoea in one of the 
patients, and in the other indigestion and flatus. 

" 12. Cod-liver Oil and Fats. — Their use was followed by the 
same results as were found in the animal diet trials ; but they could 
not be taken by the patients for some time, or in considerable quan- 
tity, without inducing nausea. 

** 13. Mixed Diet. — The production of sugar under this diet, of 
whatever substances it may be composed, was found to be invariably 
proportional to the amount of sugar and starch contained in the 
articles which were used.* 

♦ Porter and Ale. — It is generally supposed that all malt liquors very 
powerfully stimulate to the morbid production of sugar in diabetes mellitus ; 



FRACTIOAL HBDICINX, BTOj 179 

'* Series of Trials to Determine the Influence of Remedies on 
the Elimination of Diabetic Sugar, 

" 1. Permanganate ofFotash, allayed thirst, lowered the density, 
but increased the amount of the urine and also of the sugar. 

" 2. Sesquinitrate of Iron stimulated appetite for food ; did not 
allay the thirst ; did not materially in^uence the amount of urine, 
but increased that of the sugar. 

** 3. Glycerine markedly increased thirst and the amount of urine ; 
lowered density of urine, but total amount of sugar greatly in- 
creased. 

" 4. Chloroform. — This was exhibited by inhalation, which was 
repeated every two hours during the experiment. Quantity of 
unne greatly increased ; its density lowered, but total amount of 
sugar in twenty-four hours increased. Chloroform increases sugar 
simply by actiuir as a diuretic. 

" 6. Sulphuric and Chloric Ethers. — Both these agents operate 
as chloroform, but in a much less marked degree. 

" 6. Strychnia. — The experiments with this powerful agent were 
begun by administering -^Q^h of a grain thrice daily, and the dose 
progressively increased until its physiological action on the nervous 
system became incipiently apparent. 

" The result was a progressive and commensurate decrease in the 
amount of urine and sugar. The patients* diet during the course of 
this and the other trials of remedies was uniform. The patients' 
general health was good, and they gained weight.*' 



Art. 81.— ^0;^ the Excretion of Sugar and Urea under the 
Use of Benzoic Acid in Two Cases of Diabetes Mellitus, 

By Dr. Stockvis. 
{ffenle*8u, Meissner's Bericht; and Edinburgh Medical Journal^ Oct. 1863.) 

In two diabetic patients, Dr. Stockvis observed that in this dis- 
ease the benzoic acid administered associates itself in the liver with 
glycin, and appears in the urine as hippuric acid. In these two 
patients the sugar in the urine during tne use of benzoic acid was 
considerably less than previously and afterwards. A diminution of 
urea was also noted, as long as hippuric acid was excreted, and the 
increase of urea, when the benzoic acid was stopped, was remarkably 
apparent. In a third case, in which benzoic acid was given, no 
hippuric acid was found in the urine, nor was there a diminution of 
the sugar and urea. The author supposes that benzoic acid causes 
an increase of oxidation in the economy, so that more sugar is burnt. 

but the experiments made with ale and porter do not support that opinion. 
Their use, to the extent of twelve or twenty-four ounces daily, is attended 
with little more than an appreciable increase in the amount of sugar. The 
rate of increase, as in the other articles, was ascertained and recorded. 

12—2 



180 PBACTICAL MEDICINE, ETC. 

Art. 82. — A Case of Encephaloid Disease of the Bladder, 
with Remarks on the Semiotic Value and Treatment of 
Hcematuria, 

By Dr. Ranking, Physician to the Norfolk and Norwich 
Hospital, &C, 

(British Medical Journal, August 22, 1863.) 

Case. — The subject of the following case, which has recently proved fatal 
in the Norfolk and Norwich Hospital, first came under my notice as a 
private patient in consultation with Mr. Allen of Norwich. He was at that 
time 58 years of age, and lived in an ill-ventilated and low part of the city. 
He did not, however, appear to sufifer from the unfavourable hygienic con- 
ditions by which he was surrounded ; but with the exception of occasional 
rheumatic attacks, he had never had any serious illness, until the commence- 
ment of the formidable symptoms, which eventually proved fatal. Of these 
he was suddenly made aware, by finding that on attempting to empty his 
bladder, he passed a large quantity of blood. On this, he immediately 
placed himself under medical care, and it was after the failure of a judi- 
cious line of treatment by Mr. Allen, that I was requested to see 
him. 

On visiting him, I inquired minutely into his antecedents, more especially 
with the view of ascertaining the source of the haemorrhage, whether it was 
from the kidneys or from the bladder. To elucidate this important point, 
careful inquiries were made as to the prior existence of lumbar pain, and as 
to the fact of gravel or larger concretions having or not having been passed. 
T also inspected the urine as to the blood being intimately mixed with it, or 
whether the blood was passing either per se or in large quantities accompany- 
ing the discharge of urine rather than mixed with it. The discovery that 
the blood was passed under the latter conditions led me to the diagnosis, 
which was verified after death, of malignant disease of the bladder. 

At this stage of the disease, as no suspension of the hsBmorrhage took 
place, the man was made an in-patient in the Norfolk and Norwich Hos- 
pital, in October 1862. On admission, he was almost in a state of collapse, 
blanched to the greatest degree, and passing large quantities of dark blood, 
partly fluid, partly in clots, the passage of which caused much painful strain- 
ing. On some occasions the entire discharge was fluid blood, by which the 
bladder had become so distended as to call for its evacuation. On this oc- 
casion also, as well as his fainting condition would allow, I obtained from 
him a confirmation of his former history, and when reaction permitted, re- 
quested Mr. Williams to explore the bladder. The result of this operation 
was, that there was no stone, but simply a thickened and pulpy feel of the 
coats of the bladder as imparted by the instrument. This was, of course, 
another link in the chain of evidence as to the real nature of the disease, 
and a microscopic examination of the blood was the only further step 
necessary. This was also obligingly done by Mr. Williams, with the re- 
sult of finding cancer-cells, and thus settling the question definitively. 

Any prospect of curing or even materially alleviating the symptoms 
of the patient being now regarded as distant, it still became a matter of 
urgency to arrest the bleeding, which was rapidly exhausting his vital 
powers ; but as hitherto, all the medicines usually relied upon in such cases^ 
as gallic acid, matico, turpentine, and acetate of lead, &c., had failed, this 
was a result not very easy to be accomplished. I had, however, several 



FBACTICAL MEDICINE, ETC. 181 

times and in serious hsemorrhages from other sources, as the lungs, bowels, 
and uterus, seen the good effects of a secret remedy known as Ruspini's 
styptic, and therefore determined upon its employment. Its eflfect in 
moderating the hsBmorrhage was beyond expectation, three or four doses 
sufficing to make a marked change in the appearance of the urine, so that 
in three or four days all sanguineous colouration had disappeared. This 
might be thought by some to be a sequence, not a result; but further 
experience of the case proved cause and effect much more clearly than we 
are often able to establish with other medicines. In fact, from the ridi- 
culously extravagant price of this remedy, it became expedient in a chari- 
table institution to dispense with its use as speedily as possible, and it 
was accordingly suspended. But no sooner was this done, and gallic acid 
resumed, than copious bsemoirhage again appeared, and the styptic was a 
second time resorted to. This unlucky coincidence occurred again and again, 
till the persistence of the medicine was determined on, and with such good 
results in the mere absence of the sanguineous drain, that the patient 
gained so great an amount of strength as to induce him to return 
home. 

After this period, he made several appearances at the hospital on the out- 
patients* days, but each time exhibiting a further increase of the exhaustion 
and cachectic pallor of the skin. Asa matter of charity, therefore, he was 
readmitted on April 4th, in a state of great debility, but with the additional 
symptom of severe pubic pain, extending to the left testis and down the 
inner part of the left thigh. His bladder was now very irritable, acting pain- 
fully every hour ; his urine containing much albumen and an abundance of 
lithates, but no blood. The pubic region was so tender at this time th'^t he 
could scarcely bear the slightest pressure, but it was easy to discover the 
pr^ence of a rounded tumour extending nearly to the umbilicus, and per- 
fectly immovable. This tumour gradually enlarged, and after a few days 
of increased suffering, he appeared to sink from exhaustion, and died twenty- 
four days after readmission ; a suspension of the urinary secretion apparently 
having preceded the fatal termination. 

The autopsy revealed an emaciated frame, with a manifest prominence of 
the lower abdominal region. The lungs and heart were healthy ; the liver 
was of normal size, and on its diaphragmatic surface exhibited a large mass 
of encephaloid cancer, white and concave ; the rest of the organ was ap- 
parently healthy. Both kidneys were large and deeply congested, and the 
left had its pelvis and ureter largely dilated and distended with urine. The 
lower part of the abdomen was occupied by a large tumour of the size of a 
child's head, evidently the bladder converted into a solid mass, by the occu- 
pation of its left wall by encephaloid cancer, which had so much developed 
itself internally as nearly to obliterate the vesical cavity. The iliac glands 
were also cancerous, and the vesicular seminales and adjacent parts were 
agglutinated together into a large supplementary tumour. The whole mass 
weighed three pounds, and was made up of soft medullary cancer, much of 
it in a broken down condition. The explanation of the enormously dilated 
ureter was found in the obstruction of its vesical orifice in the immense can- 
eerous mass which had specially invaded that part of the organ. Underthe 
microscope were seen the compound cells of malignant disease with abundant 
cancer-cell nuclei, but no fibres. 

When the case was first seen, it was naturally enough diagnosed roughly 
as hceinaturia ; this term, however, is only descriptive of one objective 
symptom, not of the lesion from which the bleeding arises. In all these 
cases, therefore, it is necessary to turn over in our minds all the sources of 
bleeding from the urinary passages, not so much perhaps with reference to 



182 PBACTICAL HEDIOINX, ETC. 

the treatment of the particular symptom, hsemorrhage, but for the purpose of 
arriving at data for a correct prognosis, on which a medical reputation may 
depend in fatal cases, as much as on successful treatment in curable ones. 
In following up this inquiry, it is practically perbaps most convenient to put 
questions &'8t, having reference to the possible origin of the haemorrhage in 
the kidney. We must ascertain, for instance, whether the patient have ever 
bad gout, or whether his urine have been habitually highly coloured and 
charged with deposit, or more particularly if he have passed calculous con- 
cretions. If we elicit any affirmative evidence of this kind, associated with 
old standing lumbar pain, or with the history of an attack of nephritic colic, 
we may with some propriety regard the kidneys as the seat of the hemor- 
rhage, and this view will be confirmed, if the blood be intimately mixed with 
the urine instead of being passed per se, or in clots. 

If, however, on the other hand, there be no precise history of lumbar pain, 
but only complaints of pain or uneasiness confined to the pelvic region ; if 
the blood be passed pure and sometimes unmixed with urine, and more par* 
ticularly attended with straining for the passage of clots, we shall be justi- 
fied in suspecting the bladder rather than any other portion of the urinary 
tract. 

But, having thus ascertained that the blood comes from the bladder, we 
have still the further inquiry to make, On what condition of the bladder 
does it depend ? Is it caused mechanically by the wounding of the coats of 
the bladder by some foreign body, as a rough oxalate stone, for instance, or 
does it arise from some malignant disease of the bladder itself? This is an 
important question, for upon its solution depends not only our prognosis, 
but our treatment. In the case of a calculus, relief is obtainable by surgical 
measures ; but, in the case of malignant disease of the bladder, surgical 
explorations are injurious, and death may be looked upon as ultimately in- 
evitable. To make this diagnosis we have two sources of information to rely 
upon ; that afforded by the general symptoms, and that oU tactile evidence. 
For instance, in haemorrhage from calculus, the bleeding is seldom copious, 
is only an occasional phenomenon, following peihaps upon some accidentjU 
cause, as riding on horseback, or a sudden jolt or fall. The haemorrhage on 
the contrary, when arising from fungoid or cancerous disease is copious, 
passed pure as blood, and is accompanied by coagula ; and if checked, as in 
the present case, will return at close intervals. As in this case also, the 
peculiarly cachectic aspect of the patient will suggest the true nature of the 
disease. 

Respecting the treatment of haematuria. I need not say that where the 
loss of blood is slight, and apparently caused by congestion of the kidneys 
only, as after scarlatina, it is to be met by such means as are likely to 
remove the congestion, as warm baths, medicinal sudonfics, and in some 
cases by cupping over the loins ; but where the loss of blood by the urinary 
passages is in itself a formidable symptom, irrespective of its proximate 
cause, we shall find ourselves called upon to restrain it, at the urgent solici- 
tation of the patient, if not at the indication of stiict medical science. The 
drugs usually prescribed for this purpose are gallic acid in ten or twenty-grain 
doses, matico, and turpentine in from five to twenty drops. Each and all of 
these may succeed in individual cases of medium severity ; but it will some- 
times be found, where the loss of blood is more profuse, that in haemorrhage, 
whether from the lungs, &om the stomach, or kidneys, or still more so from 
a bleeding cancer of an internal organ, as in our case, none of these remedies 
can be depended upon ; and yet this profuse bleeding will be occasionally 
under the command of a medicine before mentioned, Ruspini's styptic. 

No friend to quackery in any shape, and indisposed as I am to the use of 



PBACnOAL UBDICINE, XTO. 188 

any medicine which is not openly made known to the profession, I confefls I 
have thought it my duty, where life was in the scale, to exhibit this prepa- 
ration in various alarming hsemorrhages. Such has been the case with the 
subject of this paper, who has repeatedly had all traces of blood vanish fW>m 
the urine after a few doses of it, to see the symptom as surely return when 
it was left off. I think you will allow this to be a sufficient justification for 
its exhibition. 

A few more words with regard to this poor patient's end. As I have 
said, he left the hospital to all appearance with the complete subsidence of 
the haemorrhage, the symptom which had most threatened his life. But 
the truce was fallacious ; the malignant disease no longer bled, but it deve- 
loped itself in the walls of the bladder with rapidity, until a tumour which 
/reached the umbilicus was formed in the course of a few weeks, blocking up 
the ureters, and causing him to die much in the mode which is seen in »tal 
retention of urine. 



184 



PAET II.— SUEGEET. 
SECT. I.— GENERAL QUESTIONS IN SURGERY. 



CONCEENINQ INFLAMMATION. 

Art. 88. — Observations on Pyaemia, 

By Mr. Richard Quain, Professor of Clinical Surgery in 

University College, London. 

(Medical Times and QazeUe^ July 11, 1868.) 

These observations, which are taken from a lecture on some cases 
of amputation occurring recently in University College Hospital, 
are well deserving of attention. Mr. Quain says : — 

" Four amputations were performed nearly at the same time, and 
the patients were in the hospital together. Two were attacked by 
pysemia and died ; two recovered without having been affected with 
that disease. Is there anything in the facts of the cases to account 
for the different results ? 

" The prevailing opinion is that there are certain circumstances 
which lead to the production of that pest of surgery — for so that may 
indeed be called which, as statistics show, destroys nearly half the 
cases of primary amputation. Nothing in connexion with pyaemia 
is of so much importance as the discovery of what the circumstances 
conducive to the disease really are, for to avoid the so-called 'pre- 
disposing causes* would be to prevent pyaemia. It is stated in 
treatises on general surgery that these causes may be looked for in 
the previous and present condition of the patient as to general 
health and strength, and in the circumstances in which the patient 
is placed after operation, a. The previous existence of ill-health, 
disease, or other source of debility, renders, it is asserted, the patient 
less able to resist the injurious influence of bad 'surrounding 
circumstances ;* which, in such cases, are said to be found in the 
impure air of a hospital crowded with patients, badly constructed, 
or unclean. Suppose we apply the seemingly reasonable statement 
as to the nature of the predisposing causes to some of our cases : — 
Two were healthy males, two unhealthy females. Only the latter 
two recovered. To make the comparison as close as possible, let us 
take the case of primary amputation of the upper limb. The male 



filTBGBBT. 185 

'(Case 3) was young, vigorous, and in perfect health ; he suffered 
nothing fromtiie ' shock ' either of the accident or of the amputation; 
nothing from the chloroform, or rather was so far from this, that he 
asked for, and took with relish, a good meal an hour after the 
operation. He had not one unfavourable symptom before the 
fourteenth day; his tongue was clean; his countenance and skin 
natural. Even after the fatal rigor, he continued for a week to 
take food welP, and to be interested in external circumstances, insa> 
much that he read a newspaper the dav before his death, and was at 
the same time free from indications of serious disease. Yet he had 
py»mia. And died. Now turn to the other picture. A female (Case 2), 
nabitually a drunkard, and subject to fits of delirium, deliberately, 
by a slow process, cut off her own hand ; she lost blood largely, was 
pale and bloodless in appearance, was delirious after the amputation 
(the surgical amputation), and mueh depressed for weeks, vomited 
frequently, took little food or sup{)ort of any kind except stimulants, 
yet the wound continued to heal without interruption, and the patient 
recovered. (Her health is now — June — as good as ever. — S. G.) 
So likewise in Case 1, the system was depressed by previous long- 
continued pain and illness, she vomited after every kind of food for 
more than three weeks after the operation, yet the stump went on 
meanwhile to heal prosperously. 

" So much for tne * personal condition ' of our patients ; now a 
word as to the * surrounding circumstances.* What was the state of 
the hospital at the time referred to ? You know from your own 
observation that very recently every part had been cleaned, painted, 
and washed : that the areas and ground around the hospital had 
been fully cleansed. The male patient, whose case has been dwelt 
on, was not in a crowded ward ;. in fact, he had a vtard to himself, a 
small one, certainly, but one intended for two patients, and venti- 
lated with a fireplace and two windows, as well as the door ; the 
same ward in which there is now a patient recovering from amputa- 
tion close to the shoulder-joint, who is in perfect health. The boy 
who died (Case 4) was in a ward exactly corresponding to that in 
which the Cases 1 and 2 were lodged. 

" In short, while the surrounding circumstances were favourable in 
all, there were present in Cases 3 and 4 all the conditions which 
enable the system to resist disease, yet both died ; and in Cases 1 
and 2 everything that favours the production of disease seemed to be 
present, yet both did well. 

" We should not leave these cases without noticing the history 
of a patient brought to the hospital while some of them were still 
with us. 

Case. — A delicate boy, aged 15, was admitted April 21 st, 1863. A 
fortnight before. admission he had received a blow just below the knee. This 
was Allowed by pain and swelling of the part injured, and in a few days 
by great general depression, vomiting, and delirium ; no rigors. On 
admission he was semi-comatose, and in a perfectly " typhoid condition." 
The leg was swollen and very tender. Both elbows and wrists became red 
and swollen. He died April 23rd, two days after admission. 

PM^morfew.— Periosteum of left tibia separated for nearly whole length, 



186 SUBGIBY. 

puriform matter being interposed between it and the bone. Both lungs 
were studded throughout with minute collections of matter. There were 
similar puriform spots in both kidneys. Liver healthy. 

" It was ascertained upon inquiry that this lad had been engaged 
in a trade which was not unhealthy — that of a goldsmith; that he 
was well lodged, sleeping in a room alone, and in a healthy district;* 

" Here is an example of pyaemia which arose neither in, a hospital 
nor after a surgical operation, but in the course of what there was 
evidence to show had been fair previous health, and among * sur- 
rounding circumstances* not conducive to disease. 

" With these cases, and such as these before us, surely it must be 
allowed that much still remains to be found out respecting the ' pre- 
•disposing causes ' of pyaemia, and the means to be taken to prevent 
it, or to lessen its amount. It prevails at one time much more than 
at another, and when it is known to prevail, operations which are not 
imperative to be performed at once, are deferred. It is to some 
atmospheric condition at present, unknown that I am disposed to 
look tor the solution of the difficulty. Practically we must advise 
cleanliness and other means of health ; for though the presence of 
all circumstances conducive to health will not, as we have seen, 
prevent occurrence of pyaemia, yet, because they are generally , 
conducive to health, they are always important. To the regulation 
of diet I attach much importance, more than to the administration 
of drugs. Patients lying in bed after operations do not seem to me 
to require to be largely fed ; waste does not go on to the same 
extent as when they are engaged in the business of life ; and by the 
amputation a part of what the food had to maintain has been taken 
away. Meat and stimulants together are not, in my opinion, neces- 
sary except in moderate quantities. The rule I would lay down is 
that when the patients can take meat, stimulants should be always 
sparingly used and often withheld, unless, indeed, there be a clear 
indication for their administration. Hospital patients ordinarily use 
stimulants as occasional luxuries, not as a common article of diet ; 
yet it is not easy to oppose the inclination for stimulants which such 
persons manifest when admitted into a hospital; they are best 
pleased when the dietary is liberal in beer, wine, or spirits. It is 
when food cannot be taken that stimulants give an important help 
towards sustaining the patient. Looking bacK to the cases detailed, 
you will see that it was not those who took food best that remained 
free from pyaemia and did the best in the end." 



Art. 84!. — On the Vie of Bromine in Hospital Erysipela^^ 8fc. 
By Dr. J. H. Brinton, Surgeon in the United States Army. 

(American Quarterly Journal of Medical Sciences, July, 1863.) 
Dr. Brinton, appointed by the Surgeon-General of the United 
States Army to investigate the character of hospital gangrene, 
pyaemia, and erysipelas prevailing in the U. S. hospital at Louisville, 
and the different modes of treatment there employed for those affec- 
tions, has made the following interesting report :— • 



SVBGEBT. 187 

" On my arriyal in Louisville, I called on Surgeon M. Goldsmith, 
U. S. v., the Medical Director of the Louisville Hospitals. In 
company with him I visited the principal military hospitals in the 
city andi vicinity, and careiuUy examined the various cases of hospital 
l^angrene and erysipelas therein contained. The type of the former 
affection at the period of my visit was somewhat similar to that 
which I had previously observed in U. S. A. General Hospitals at 
Annapolis, but, although of analogous form, the disease did not 
appear to me to be of so virulent a grade ; whether this was due to 
the original character of the affection or to the effect of the remedial 
measures employed, I am not prepared properly to decide. Nearly 
all the cases observed by me were in the stage of reparation, and 
but very few in the period of progress. The shape of the ulcers 
was characteristic, as was also the appearance of the grey slough, 
but the tendency of the sores to ourrow deeply, and to extend 
rapidly, was not well marked at the time I examined the cases, some 
thirty in number. 

" The treatment almost universally adopted in the Louisville 
hospitals is that originated and introduced by Surgeon Goldsmith, 
U. S. V. It consists in the direct local application of bromine, 
either pure or in solution, to the surfaces of the sloughing sore. 
iDue care is always taken first to remove as thoroughly as possible 
the sloughs, so that the agent may act on the living tissues, and 
permeate them to some extent. In cases in which the burrowing is 
90 extensive and deep-seated as to render the application of bromine 
difficult or incomplete. Dr. Goldsmith resorts to hypodermic injec- 
tions of bromine at the circumference of the sore. The punctures 
with the point of the syringe are made at intervals of from one-half 
to three-fourths of an inch, and one drop of pure bromine is thrown 
into the tissues at each application. The mode of dressing the 
surface of the sores with bromine was exhibited to me by Dr. 
Goldsmith. From my observation of the immediate effect of the 
reagent upon the diseased tissues, and of the conditions of the sores 
upon which it had been previously applied, I am inclined to look 
upon the remedy as one of great value, and well deserving of a fair 
and extended trial. 

** Surgeon Goldsmith declared to me that in forty-eight hours the 
specific character of any sore, the result of hospital gangrene, can 
be destroyed by a thorough use of the bromine. The arrest of the 
virulent process is at once evinced by the absence of the peculiar 
odour, and by the marked change for the hettev which immediately 
ensues in the constitutional symptoms. 

" From conversation with Surgeon Goldsmith I inferred that he 
regarded hospital gangrene as essentially a local affection, and that 
as soon as a decided local impression ts produced upon the sore all 
danger to life is averted. 

"The whole number of cases of hospital gangrene treated in the 
Louisville hospitals up to this time amounts to eighty-eight. But 
two deaths have occurred, and in these instances the disease was 
complicated with a very extensive infiammation of the cellular 
tissue. 



188 SUBGEBT. 

"I would remark that in the Louisyille hospitals but little 
tendency has been observed in the disease to spread from bed to 
bed, although isdation of the gangrenous patients has not been 
enforced. In my own judgment the absence of this tendency to 
infection tells strongly against the supposed virulence of the 
affection, and should even throw doubts on its true nature, at all 
events in some instances. Assuming the disease, however, to be the 
veritable hospital gangrene, the facta connected with its origin were 
peculiar. The disease occurred almost always in patients who had 
been wounded at the battle of Murfreesboro*, and who had been re- 
tained in crowded hospitals for some time previous to their transpor- 
tation to Louisville. I am informed by Surgeon Thurston, U. S. V., 
Medical Director of the Nashville hospitals, that no one upon whom 
the gangrene liad already appeared was ever sent from Nashville, 
and yet many were so infected when admitted to the Louisville 
hospitals. The development of this disease on the route seems to 
have been owing to the fact that the transportation of the wounded 
was eflfected by means of crowded and ill -ventilated boats, and that 
the trip by the Cumberland and Ohia E-ivers frequently occupied 
several days. During this time these patients, who had already 
undergone mueh suffering, were exposed to all the influences most 
apt to engender this disease. In contrast with this fact it was found 
that, as soon aa the Louisville and Nashville Eailroad was opened, 
BO that the wounded could be conveyed from city to city in one day, 
all importation of gangrenous sores into Louisville ceased. The 
development of hospital gangrene during the boat transportation is 
a noticeable fact, and i& strikingly analogous with the same 
phenomena observed among our paroled wounded prisoners from 
feichmond, received into the Annapolis Greneral Hospital some 
months since. 

** EryHpelas. — Two hospitals are especially set apart for this 
disease in Louisville (Nos. 19 and 20), both at some distance from 
the city, and originally country residences. These buildings are 
located on rising grounds, are well ventilated, and are tolerably well 
suited for their present purposes. All cases of erysipelas occurring 
in the city are at once sent thither, and strict isolation is enforced. 

" The whole number of cases of erysipelas treated at Louisville 
was 228; of these 97 were treated in Hospital No. 19, 100 in 
Hospital No. 20, and 31 cases in Hospitals Nos. 4, 8, and 10. Out 
of the whole number 51 died, and 177 recovered. 

" Treatment. — In the application of bromine to the treatment of 
erysipelas, two different methods were employed : first, by the action 
of the vapour of bromine in the affected part ; second, by a direct 
application to the erysipelatous surfaces of a solution of bromine of 
varying strength. In the first method the part affected was 
enveloped in a dry lint, a cloth saturated with pure bromine was 
then applied over this* and the whole dressing covered with a piece 
of oiled skin. The only objection to this treatment was the tendency 
of the bromine to blister the skin by soaking through the intervening 
layer of the lint. The other mode of using the bromine is to apply 
directly to the inflamed ^nteguments a solution of the bromine and 



STTBGEBY. 189 

bromide of potassium, of the strength of from fifteen to forty drops 
of the former to an ounce of water. An ample opportunity was 
afforded me to observe the results of this treatment in the disease in 
question, and I have no hesitation in pronouncing it one which, so 
Hur as I have seen, is of the greatest value. 

"Having finished my observations of erysipelas and hospital 
j^angrene in Louisville, I proceeded to Nashville, and placed myself 
m communication with Surgeon Thurston, U S .V., Medical Director 
of Hospitals in that city. vVith him I visited all of the principal 
hospitals, and among others the one appropriated to the reception of 
cases of erysipelas and hospital gangrene. I learned that the reports 
as to these diseases in Nashville had been much exaggerated. The 
whole number of cases of gangrene which had occurred since the 
battle of Murfreesboro* had not exceeded 20, and of these but 6 re- 
mained, all in progress of recovery. 

** The treatment followed in the Nashville hospitals consisted of 
applications of bromine, and the use of nitric acid in the ordinary 
manner. Dr. Thurston informed me that the latter treatment was 

? referred, and had, he thought, yielded the most successful results, 
t did not seem to me, however, that the bromine treatment, as 
practised in Nashville, was as thorough and effective as that pursued 
under the immediate supervision of Dr. Goldsmith. 

" JSrysipelas in Nashville. — The number of cases of erysipelas 
following the battle of Murfreesboro* averaged about 60 until 
recently. At the time of visit that number had fallen to twenty, 
and all were tending towards recovery. All cases of disease were 
isolated on their first appearance in a hospital set apart for the 

Surpose, under the charge of Assistant-surgeon Brown, U. S. A. 
'his building was clean, weU ventilated, and well managed. At 
the first out-break of the affection several deaths had occurred in 
patients severely wounded. 

" I was informed by the Medical Director that at present the 
disease was tractable and yielded readily to the therapeutic measures. 

"The treatment found most efficient, and which was almost 
universally adopted, was the local use of the bromine as already 
described; for constitutional remedies dependence was placed on 
iron, bark, tonics, full diet, &c. 

" Leaving Nashville, I proceeded to Murfreesboro*. The hospital 
gangrene, which at one time had been there rife and destructive, had 
almost disappeared ; but few cases remained, and were convales- 
cent. 

" The bromine treatment had been freely employed, but with 
varying results. I observed that its strongest advocates were those 
medical officers who had been previously stationed in Louisville, and 
who had been instructed in its use by Surgeon Goldsmith. 

" In conclusion, from a careful investigation of the cases in hos- 
pital at the time of my visit to the cities above mentioned I would 
remark : — 

** 1st.— That the external employment of bromine in the treatment 
of hospital gangrene has been attended in Louisville with the most 
marked and beneficent results. 



190 SUBGEBT. 

"2nd. — That I have not observed that any injurions consequences 
whatever have resulted from its application, but the contrary. 

" 3rd. — That all the medical officers with whom I have conversed ia 
Louisville, Nashville, and Murfreesboro*, unite in testimony as to 
the valuable therapeutic powers of bromine in the treatment of ery- 
sipelas ; my own observation fully confirms their views. 

**4ttk. — That as a disinfectant the use of bromine in hospital 
wards, and especially in hospitals intended for the reception of 
infectious disease, is to be recommended, and is eminently deserving 
of further trial. 

" It will be observed that in the above report I have not alluded 
to the subject of pysemia. In explanation I will state that I did not 
meet the disease in any of the hospitals I visited. I was informed 
that the pysBmic affection had not existed to any great extent ; at all 
events, to an extent unduly proportioned to the number and gravity 
of the wounds following the Murfreesboro* battle. Full reports, 
however, of the affection, as it did prevail, are in process of prepara- 
tion, and will be submitted to you when received." 



Art. 85. — On Periostitis and Osteomyelitis. 
By M. RosER. 
{V Union Mid, ; and Medico- Chii*urgical Review, October, 1863.) 
With the disease termed periostitis, osteomyelitis almost con- 
stantly exists. The inflammatory exudation into the medullary 
cavity gives rise to the remarkable result of forcing out the medulla 
through the pores of the bone, so that fluid fat, often in large quan- 
tity, is found behind the periosteum. As this fact has been doubted 
by Demme and others, tne author adduces the following proofs of 
its reality : 1. In a series of cases he has convinced himself by 
direct clinical observation, having found in recent periosteal ab- 
scesses drops of fat behind the periosteum. 2. In a patient, the 
subject of acute periostitis, and carried off during the first stage of 
inflammation of tne brain, fat was found a line in thickness between 
the bone and the periosteum. 3. In the year 1864, Dr. Andrea 
performed the following experiment, which is related in his thesis 
De Feriostitide. A piece of fresh tibia was laid in warm water for 
half an hour, in order that the fat might be rendered fluid. The 
diaphysis was sawn across at the upper part, and from its lower part 
a portion of the periosteum was removed. A rod, which did not 
entirely fill it (so that too great pressure might not be exerted), was 
passed into the medullary canal. Whenever strong and rapid 
pressure was induced by means of this rod, a flow of lat took place 
from the Haversian canals ; and when the pressure was but slow 
and gentle, the fat issued slowly, drop by drop. The experiment 
repeated with the other tibia furnished the same results. From 
these considerations the author is of opinion that many examples of 
inflammation and separation of the periosteum are only secondary 
to myelitis. Cases are met with in which myelitis has evidently- 
preceded, and periostitis, situated higher up the bone, has followed. 



STTBaBBT. 191 

Aet. 86. — On Tumours in Voluntary Muscles, with an Analysis 

of Sixty 'two Cases y and remarks on Treatment, 

"Bj Mr. Teevan, Snrgeon to the West London Hospital, &c. 

{Medteo-ChirurgicaZ Review, October, 1863.) 

Mr. Teevan has expeDded a good deal of labour upon this paper, 
and the result is an addition to our knowledge where information 
was decidedly wanting. He says : — 

" It will thus be seen that out of 62 eases the relative numbers of 
each growth were — cancerous, 21 ; fibrous, alone and in combina- 
tion, 16 ; cystic, 8 ; hydatid, 5 ; erectile, 5 ; osseous and osteoid, 3 ; 
doubtful nature, 3 ; myeloid, 1. The cancerous tumours were the 
most numerous, being rather more than one-third of the whole ; 
but, from an examination of the other cases that I have excluded, 
I am convinced that their proportion is very much greater than 
this. It would also appear that the tumours affected the muscles of 
the lower extremity almost as often as they do those of the upper 
limb ; but with this difference, that in the latter they are almost 
entirely confined to the pectoralis major, deltoid, and biceps, 
whereas in the former they are very equally distributed. The 
muscles of the trunk, and head, and neck were rarely the seat of 
tumours, with the exception of the rectus abdominalis, which would 
appear very subject to them.'* 

Speaking of the treatment of cancer in muscle, Mr. Teevan 
says :— 

** Whenever practicable, a cancerous tumour in a muscle should 
not only be excised, but the muscle in which it originated ought to 
be cut out from its origin to its insertion. But if the cancer be of 
large size, or if the skin be affected, or if the wound resulting from 
the excision of the muscle would be of great extent, then the limb 
ought to be amputated, and the remainder of the muscle in the 
stump excised. 

•* I have thus ventured to propose an operation which is founded 
on definite principles, is supported by analogy, and is in unison 
with the views of some of the most original thinkers of our time." 



Art. 87. — On the Banger of Temporizing too much with 
Encysted Tumours. 

By M. Fleury. 

(Qaz, M6d, de Paris, No. 16 and 17, 1863.) 

M. Fleury, surgeon of the Hotel Dieu at Clermont, in this paper 
observes that these tumours are generally regarded as slight affec- 
tions, and, as they frequently for years long occasion little incon- 
venience, patients feel indisposed to undergo the pain of their 
removal. Many practitioners also advise expectation, while others 
still have faith in topical applications or absorbent medicines. If 
the progress of such tumours were always gradual and progressive,- 



192 BUBGEBT. 

expectation mi^ht indeed be advised until a given moment, but, 
unfortunately, this is not always the case. Thus a tumour which 
has remained stationary for years will sometimes in a few weeks, or 
even a few days, double or triple its size j while in another case it 
may undergo a degeneration leading to a general infection of the 
economy. Such conversions into cancerous tissue are, however, 
rare, and the author has only met with one example, and in this case 
the patient died before there was time for the general system to 
become affected. In some cases, the changes which the internal 
membrane of the cyst may undergo have been confounded with 
cancerous alteration. In some tumours the membrane will remain 
as thin as paper, while in others it acquires enormous thickness. 
Some of the tumours dilate at the same time that their walls aug- 
ment in density ; and such are the most dangerous for treatment, 
as large surfaces have to be exposed, leading to severe inflammation, 
not unfrequently ending in gangrene. Sometimes, after acquiring 
a large size, the tumour spontaneously bursts, and secondary cysts 
form around the aperture which has given issue to the liquid con- 
tents. 

The wisest course is not to wait too long, and to caution patients 
as to the possible consequences of too long temporization. The 
accidents are of two kinds. The modifications which the membrane 
of the cyst may undergo have their perils ; but those accruing from 
the great increase of its cavity are still greater. The larger tumours 
are not always those which are most prone to undergo these trans- 
formations. Patients not unfrequently present themselves with 
cysts situated on the knee, which, after existing for years without 
attaining a large size, burst externally without obvious cause, and 
project a soft, reddish mass, offering some analogy to softened en- 
cepnaloid, and soon furnishing an enfeebling arterial haemorrhage. 
On cutting into such a tumour, a fleshy membrane is found, formed 
by a velvety, fungoid tissue, whence the slightest pressure causes 
an abundant escape of blood. Touching this membrane with charpie 
imbibed in perchloride of iron, or its removal with the bistoury, 
induces the cessation of this bloody oozing. Its non-malignant 
nature is proved by the fact that there is no tendency to reproduc- 
tion. Cysts are sometimes met with, distended with fiorinous 
coagula, presenting great analogy with those found in aneurisms ; 
and arterial blood escapes with great facility after operations upon 
cystic goitres. This blood is due to the presence of a spongy tissue, 
which is not found exclusively in cystic goitre, but also m cystic 
tumours of other tissues of a less vascular structure. 

Not only is there danger produced by delay in the case of cystic 
tumours from the production of this vascular texture, but also from 
the supervention of severe inflammation after operation, having a 
great tendency to terminate in gangrene or give rise to purulent 
mfection. The author has operated many times in these cases, and 
the mode which he has found most successful has been to divide 
the tumour along its mesian Ime, not meddling with the membrane 
of the cyst if very thin, but excising it when much thickened. He 
then induces inflammation by Ailing the cavity which contained the 



SITBaBBT. 193 

fluid with dry cbarpie. At the end of four or five days the inner- 
most layers have become dead and exfoliate, leaving behind a gra- 
nulated membrane, which forms the point of departure in the 
formation of a healthy cicatrix. The edges of the wound are then 
brought together by strapping. Under any mode of operation, 
however, a fatal issue in advanced cases is not rare ; and *M. Fleury 
concludes his paper by again pointing out the necessity of removing 
these tumours at an earlier period of their appearance. 



Art. 88. — On the Importance of Tapping Joints Distended 
with Fluid, 

Bj Prof. Inzani, of Parma. 

{Dublin Medical Prets, May 27, 1863.) 

A paper on this subject, in OmodeVs Annali, begins by assert- 
ing the perfect harmlessness of puncturing a distended joint, even 
during the progress of acute inflammation. The fear of bad conse- 
quences following from the wound of the tendinous structures is a 
mere imagination of the ancients ; nor does the air ever appear to 
make its entrance. The puncture may be made with a trocar or a 
lancet, the latter being preierable for superficial joints. The author 
has operated very frequently on the knee, several times on the elbow, 
occasionally on the carpus and ankle, and once only on the hip ; no 
bad consequences ever following. Pressure by means of a starched 
bandage should be made, and when the synovial sac refills, it should 
be again punctured before the distension has advanced too far. In 
this way a radical cure may be obtained. Examples are given in 
which large joints, principally the knee, were openea for effusions of 
blood, of serum in acute inflammation, of serum in chronic inflam* 
mation, and of pus — ^usually with a successful result. But para- 
centesis should be avoided where the skin is much thinned, and 
ulceration seems pending. In the synovial bursse, paracentesis has 
given equally good results. The examples which are given are those 
of efl*usion in the sheaths of tendons after accident (as the peronei in 
sprains of the foot, the extensors of the thumb in falls on the baud), 
in which a puncture will give exit to synovial fluid mixed with blood, 
with much relief to the pain and abbreviation to the course of the 
disease. The author beUeves that by these punctures chronic 
synovitis may often be arrested in cases which, treated by ordinary 
methods, would end in ** white swelling," and that in dropsy of the 
joint the treatment by repeated puncture and pressure is as effectual 
and more safe than by injections. 



XXXVIII. 13 



194 SUBGBBT. 

Art. 89. — On the Efficacy of Villate's Lotion for the Cure 
of Caries and Sinus, 

By M. NoTTA, Surgeon to the Lisieux Hospital 

(V Union Midicale ; and Joum, de Mid, et Chir, Prat., JuiUet, 1863.) 

M. Notta relates several cases of caries in which great benefit 
was experienced by injections performed with the mixture known to 
veterinary surgeons as Yillate's lotion. Its composition is as 
follows : — 

9> Liq. plumbi acetatis, 5J. ; 
Cupris Bulphatis cryst., ) ^ 
Zinci sulphatis cryst., ) ^ '* 
Aceti, Jvij. 

The salts are dissolved in vinegar, and the acetate of lead poured 
slowly into the solution. The result is the formation of acetates of 
zinc and copper, and of a precipitate of sulphate of lead. Vinegar 
and sulphates of zinc and copper remain in excess. An exploring 
trocar is in the first place inserted as deeply as possible into the 
tract, and the fiuid, previously shaken, is injected. Considerable 
pain follows the operation, and inflammation and copious suppuration 
are induced, which require the application of poultices. In a case 
of caries of a rib of twelve months* duration, M. Notta performed an 
injection every morning for a week; no further treatment was 
required, and a complete cure followed in the space of twenty days. 
In another instance of the same kind twenty-four injections and four 
months and a half were necessary to efiect a cure. But the patient 
was affected with tuberculosis, a circumstance which, in M. Notta's 
opinion, affords additional evidence of the efficacy of Villate's fiuid. 
M. Boinet says that caries of a rib has never yet yielded to iodine 
injections. In cases of this kind therefore, and in diseases of the 
bones of the metatarsu)? or phalanges, with abscesses and sinuses, 
surgeons are fully justified in following M. Notta's example. 



Art. 90. — On the Efficacy of Artificial and Mineral Tar in 
the Treatment of Biphtheria^ Ulcers, and Cutaneous 
Affections. 

By M. BoucHUT. 

(DMin Medical Press, July, 1863.) 

Of late, M. Bouchut has been in the habit of prescribing mineral 
and vegetable tar in unhealthy ulcers, cutaneous diseases, and diph- 
theria m children. In twelve cases observed at the Hospital of the 
B/Ue de Sevres, herpes circinatus of the scalp, a highly contagious 
disease, was cured in eight or ten days by the application, morning 
and evening, to the patches of eruption of the following solutions : — 
B) Picis liquidse, 3j. ; aquae, Jiv. ^ Picis liquidse, 9ij. ; aquse, Jiv. 
M. The weaker solution was first used, and subsequently the 
Btrongest. Coal-tar and wood-tar, the action of which is the same, 



STTBaEBT. 195 

hsve yielded very satisfkctory results in pityriasis of the scalp, in 
eczema impeti^odes of the face, and in common ringworm. Tinea 
favosa, although not removed by the application of tar, is improved 
by this treatment, and the pporules are thus prevented from flying 
aoout and propagating the disease — a consideration of some impor- 
tance in hospital wards. 

M. Bouchut in these various cases employed different preparations. 
In some cases he has recourse to a mixture of glycerine and 
starch : — 5> Glycerine, Jj. ; amyli, 5J- ; picis purif. 388-5J. In other 
instances he substituted lard for glycerine. The selection of the 
preparation varying according to the requirements of each case. In 
unhealthy phagedenic sores coal-tar is most serviceable; and M. 
Bouchut has tested the effects of the remedy in diphtheria. A little 
girl was admitted into the wards for diphtheritic sore throat ; the 
tonsils were touched night and morning with a brush dipped into 
the following solution: — Jl Pi^is ^q., 3j. ; aquae, s'lj. 

In the course of twenty-four hours the patches disappeared. With- 
out drawing from a single case any absolute inference as to the 
efficacjr of the application, it is plain, that this result is of an en- 
couraging nature. Moreover, in cutaneous diphtheria, in which 
no doubt can be entertained as to the true nature of the disease, 
the good effects of coal-tar are remarkable. In the same ward as 
the patient just alluded to, was noticed a little girl who had under- 
gone tracheotomy for the treatment of croup. False membranes 
•were rejected; others formed on the surface of the wound, and 
an eczematous eruption which existed behind the ears became 
covered with a pseudo-membranous secretion. Wood-tar was also 
resorted to locally in this case, and in a few days a perfect cure was 
effected. 



Abt. 91. — Certain Consequences oftTie Bite of a Viper 

reappearing periodically for Thirty -nine Years, 

By M. Demeueet. 

{Qaz, Hehd. de Mid, et Chir,, November 6, 1863.) 

Case. — ^The patient, is a woman, about 65 years of age, well formed 
and nourished, the wife of a peasant in a healthy part of the country. 
On the 25th of May, 1824, whUe in a wood, she was bitten by a viper 
on the inside of the fore- arm, near the wrist. Immediately afterwards 
the arm became swollen, red, livid, almost purple ; and with these local 
symptoms were extreme anxiety, headache, vomiting, and shiverings. In the 
course of a few hours a large bulla, with a dull-red base, had developed 
itself over the wound. Afterwards (the time is not mentioned;, bullae of 
the same description made their appearance all over the body, even on the 
face, the intermediate space being red and swollen. When ruptured, a very' 
large quantity of turbid serum escaped. This eruption continued from 2^ 
May, 1824, to Nov. 1825. On the 28th May, 1826, the same phenome^ 
appeared ; the eruption beginning at the seat of the bite, and caxitmiy 
November of the same year. And every year, from 1826 to 18^ 
tory of the patient ban been the same — the symptoms beginning' 
of May with lassitude, anxiety, nausea, headache, &e, : ^ 

13— a 



196 8UB0EBY. 

eight days of these introdactory troubles, the cicatrix becoming red and 
painful ; then tingling and swelling of the arm ; then the development of 
DuUsB exactly as in 1824, the only difference being that the eruption disap- 
pears in five or six weeks, instead of continuing for five or six months as at 
first. In the interval the patient is apparently quite well, and a white faint 
cicatrix is the only visible remains of her troubles. 

Before the accident, M. Demeuret tells us, the patient had never suffered 
from any cutaneous affection, not even the mildest. 



Art. 92. — New Instruments for Discovering the Presence of 
a Ball or other Metallic Body within a Wound — viz,y 
Nelaton's Porcelain Probe , and Favre's Galvanic Probe. 

By Mr. . 

{Medical Times (md Gazette^ December 13, 1862.) 

The diflSculties which have attended the diagnosis of General 
Garibaldi's wound, and the contradictions of surgical opinion, have 
had the good effect of stimulating ingenuity for the devising of new* 
and more certain methods of physical exploration. It will oe recol- 
lected that the positive opinion of the presence of the ball in 
Garibaldi's wound given by M. Nelaton was based upon the dull 
character of the sound elicited when the probe struck against the 
hard substance at the bottom, which was very different in his expe- 
rience from the clear sound elicited from a piece of necrosed bone 
under similar circumstances, and also upon the sensation imparted 
to the hand, which bore no resemblance to that imparted by the 
rough surface of a carious bone. On his return to Paris, he devised, 
in conjunction with M. Em. Rousseau, a contrivance by which a 
portion of the ball might actually be brought away, so as to convince 
those who differed from him in opinion. This instrument consisted 
of a probe, furnished at the extremity with a little sphere of un- 
glazed porcelain or biscuit-ware, about the size of a small pea. On 
bringing this sphere in contact with a leaden ball, and exercising a 
little rotatory iriction, it acquires a stain of the metal, which subse- 
quent contact of the soft parts and morbid secretions fails to remove. 
There is this additional advantage, that the portion of metal thus 
removed may be dissolved off, and made the subject of chemical 
tests. It was bv the use of this little instrument that Dr. Zanetti 
convinced himself of the presence of the ball with sufficient certainty 
to lead to a determination to extract it. The credit of another con- 
trivance, more coniplicated but not less ingenious, is due to the 
fertile brain of M. Favre, Professor of Chemistry to the Faculty of 
Sciences of Marseilles. The principle involved is the different con- 
ducting power for electricity between a metallic substance, on the 
one hand, and the fluids and tissues of the bod^, on the other. Thus 
it happens, that if the conducting wire of a feeble galvanic circuit 
connected with a galvanometer be broken, and a bullet or other 
metallic body be interposed, on the completion of the circuit the 
needle will be strongly deflected. This would not be the case on 
interposing the ordinary tissues of the body. With the assistance 



8UB0EBY. 197 

of M. Favre, Dr. Fontan, a military surgeon at Marseilles, has 
made experiments to test the efficiency of the plan proposed by the 
former. The apparatus used was as follows : 1. A Smee's battery 
of a single pair of plates, so feeble as to be unable to produce any 
sensible amount of electrolysis with the animal tissues. 2, A 
{^galvanometer. 3. A probe, consisting of two parts, one of which 
IS received into the other, which forms thus an outer casing. 
The internal portion, or galvanic portion, is a straight metalho 
probe, through the length of which pass, packed in silk, two 
metallic wires, each terminating in a steel needle, and isolated 
and firmly fixed beyond the extremity of the probe by means 
of a little cone of ivory. These wires are intended to conduct 
the galvanic current, the galvanometer being placed in the course 
of the intended circuit. For this inner probe, there is provided 
an external metallic casing, so constructed as to permit the 
galvanic probe to be slid within it, and perforated at its extremity 
with two holes, through which the needle-points of the conducting 
wires can be protruded. There are various little arrangements of 
grooves, slits, and a screw to insure accuracy of adaptation between 
the galvanic probe and its case. In using the instrument, the inter- 
nal probe is retracted and fixed by the little screw, and the instru- 
ment is then employed in the ordinary way as a probe. On the 
solid substance being arrived at, the screw is loosened, the needle- 
points protruded, and brought into contact with it, by sliding down 
the internal probe. If the substance be metallic the circuit is esta- 
blished, and the galvanometer deflected. The first experiments 
were made with wires unprovided with needle-points, the addition 
of which were found essential to success, inasmuch as they readily 
penetrated any soft tissues or adventitious substances, pieces of 
clothing, leather, &c., which might chance to be interposed and also 
overcame the difficulty likely to result from oxidation of the surface 
of the metallic substance, &c. The use of a little friction with the 
point of the sound, or a gentle percussion upon it, never failed to 
establish the galvanic current. M. Fontan suggests that, by modi- 
fication of this probe, the principle involved might be applied to 
other purposes of diagnosis, as where the presence of metallic 
bodies in the canals or mucous cavities of the body was to be 
detected. 



Art. 93. — A Case of Traumatic Tetanus in which a Nerve 
was Divided with seemingly Satisfactory Results, 

By Dr. Fayrer, of Calcutta. 

{Indian Annala of Medical Science^ No. xvi., 1863.) 

Case. — A young Brahmin, aged 22, was admitted into the Calcutta 
Hospital on Nov. 3rd. A week previously, he ran some splinters of bamboo 
into the left hand at the root of the thumb ; they broke off, and remained 
lodged in the band just by the ball of the thumb. Suppuration followed, 
and was attended with much pain. The patient, during the three days 
before admission, had been able to close the fingers of the injured hand^ 



198 SUBOBBT. 

but when he opened them they became spasmodically contracted and twisted ; 
the thumb and the three fingers supplied by the median nerve were impli- 
cated. He had no spasm of the arm, but pain in the left shoulder, and 
partial closure of the mouth, which could be opened sufficiently to introduce 
the handle of a table-knife. He was in good spirits, and seemed to have 
had good health before the accident. Dr. Fayrer made an incision into the 
palm of the hand, and removed a splinter an inch in length. An enema of 
castor-oil and turpentine was ordered ; also two grains of opium, to be taken 
immediately. The next day, the spasms continued in the band, and he had 
frequent spasms in the back, and some rigidity of the jaw. The slightest 
touch produced spasm of the arm, back, and jaw. He was ordered to have 
tincture of Indian hemp and chloroform ; enemata of oil and turpentine ; 
opiate poultices to the wound ; and, as diet, milk and sago, or whatever he 
would eat. 

Dr. Fayrer removed another small splinter. As the splinters were im- 
pacted just where the median nerve divides into its digital branches, the 
patient was put under the influence of chloroform, and Dr. Fayrer divided 
the median nerve just above the annular ligament. Very little effect was 
. produced at the time. Six hours afterwards, he said that the fingers were 
somewhat benumbed ; that he had pain in the hand and arm ; but that the 
contractions of the arm were much less frequent and violent. 

On the following day (Nov. 6th), there was no rigidity in the neck and 
jaws. The spasms in the arm and hand continued, but were less violent 
and persistent. The Indian hemp, opium, and chloroform, were continued 
up to Nov. 9th. On Nov. 12th, matter having formed in the hand, incisions 
were made and another splinter was removed. The spasms had ceased, but 
the fingers continued bent into the palm, though less rigidly than before. 
The hand remained for some time contracted, long after spasm had ceased. 
When he left the hospital on Nov. 28th, he could with slight effort straighten 
the fingers, and was regaining the use of them. 

Dr. Fayrer believes that the anest of the tetanic symptoms was due 
rather to the division of the nerve than to the internal remedies which were 
employed. The operation was done soon after the tetanic symptoms set in. 



SECT. II.— SPECIAL QUESTIONS IN SURGERY. 

(a) CONCEBNINa THE HEAD AND NECK. 

Art. 94. — On Iridectomy in Destructive Ulceration of the 
Cornea. 

By Mr. R. Brudenell Carter, of Stroud. 
{Medical Times and Gazette, May 16, 1863.) 

The value of iridectomy in destructive ulceration of the cornea, 
although long since established by Von Graefe, and fully recognised 
on the Continent, has not, Mr. Carter thinks, in this country, 
received the attention that is its due. The operation is certainly not 
performed often enough by surgeons in general practice, and, even 
m some ophthalmic hospitals, it does not hold the position to which 
it is entitled. The following case affords an illustration of its ad- 
vantages : — 

Case. — G. R., a farm labourer, aged 53, applied to me on Feb. 5th, on 
luscount of an injury to his right eye. He is a feeble^ decrepit-looking man. 



SUBGEBT. 199 

grey, and partially bald, who might pass for ten or fifteen years more tlian 
the age he acknowledges. 

On Jan. 28th (eight days previously) he received a blow on the eye from a 
twig. With the apathy characteristic of his class, he continued to work, in 
spite of loss of vision and increasing pain, until his employer sent him to 
seek assistance. 

I found the conjunctiva of the right eye so much injected, that a pterygium 
of long standing on the nasal side, could scarcely be distinguished from tho 
surrounding vascularity. The cornea was nearly perforated by a grey, 
sloughing ulcer, about three lines in diameter, surrounded by a zone of 
dense opacity. The ulcer not being perfectly concentric with cornea, but 
situated somewhat towards its outer and lower margin, the zone of opacity 
reached the margin in this direction ; while, on the upper and inner side, 
above the pupil, it left a crescentic portion, which, although steamy and 
tnrbid, retained sufficient transparency to show the dark brown colour of 
the iris, but not to show its fibrous structure. There were no vessels pro- 
ceeding to the ulcer, nor (except at the pterygium) encroaching upon any 
part of the corneal margin. Vision was limited to a dim quantitative per- 
ception of light, the patient perceiving the direction of the window, but not 
its outline, nor its sash-bars. There was severe pain, with nocturnal 
exacerbation, a feeble, quick pulse, and a worn, suffering aspect. The 
tension of the globe was not at all, or only very slightly, increased, and was 
certainly not greater than in the left eye, which, however, was already 
showing traces of sympathetic initation. The injured organ had been 
covered by a folded handkerchief, but not treated in any way whatever. 

Prior to experience of the good effects of iridectomy, it would have 
appeared to roe certain, under \he conditions I have described, that the im- 
pending perforation would be followed by iritis, probably passing on to 
complete disorganization of the eye, and involving great likelihood of 
sympathetic destruction of its fellow. 

I placed the patient upon a couch, and made an immediate iridectomy, 
removing the superior sixth of the iris. The pain of the operation was very 
acute ; and, after applying Arlt's compress, I directed the patient to wait 
until the pain subsided. It was my intention to see him again, to prescribe 
an active tonic and sedative treatment, and to give him some general 
directions. As soon, however, as he became somewhat more easy, he left 
the house without my knowledge, and did not return until the following 
Sunday, the 8th of February. He then stated that all pain had ceased 
three hours after the operation, that be went back to work in the afternoon, 
and that he had deferred visiting me until Sunday, in order not to lose time. 
The compress had remained undisturbed, and, on removing it, I found the 
conjunctival injection much diminished, the section healed, the turbid 
crescentic portion of cornea cleared, the zone of opacity naiTower and less 
dense, the ulcer receiving red vessels from below, and nearly filled up by 
plastic lymph. Perception of light had become qualitative, the patient 
being able to see a sheet of white paper. 

As the case had done so well without medication, I re-applied the com- 
press, and sent the man back to his work. On the 11th, the improvement 
being confirmed, and the patient able to count fingers, the compress was left 
off, and a band substituted for it. On the 22nd, there remained very little 
conjunctiva] injection, the vessels that repaired the ulcer had dwindled away ; 
the place of actual excavation was marked by a well-defined dense cicatrix, 
its upper border just reaching to the centre of the natural pupil, and the 
rest of the cornea had regained perfect transparency. The patient could 
read Ko. 16 of Jager s test-types without assistance, or No. 14 by the aid 



2C0 SVBaEBT. 

of a ten-inch bi-convez lens, and I found that he could do very little more 
with the uninjured eye. Such a degree of amblyopia is not uncommon 
among elderly agricultural labourers, who, even when able to decipher 
simple words, never read, and who have never been accustomed to exercise 
their eyes about small objects of any kind. Their wives are preserved from a 
similar condition by using their eyes about needlework. 

The patient was directed to discard all coverings from the eye, and to 
apply a mild astringent lotion (arg. nit., gr. ij., ad. 5j«) ^or the removal of 
the remaining conjunctival vascularity. 

" This case," says Mr. Carter, " is only singular from the absence, 
at first accidental, of medical treatment ; and, this feature excepted, 
my note-book would furnish several of similar import. In all of 
them, however, iridectomy was followed by the administration of 

?[uinine, or bark, and ammonia, with or without opium, and by the 
ocal application of atropine and poultices, so that I was unable to 
determine the precise curative influence of the operation itself. Still, 
the operation has been the turning-point of every case, and the in- 
variable precursor of rapid recovery. Before I practised it, I used 
to see occasional destruction of the cornea ; but such a result has 
never followed its performance. 

" It must be confessed, I think, that we do not understand the 
modus operandi of iridectomy. In these corneal cases there is 
seldom increased tension, and there can hardly be (as suggested by 
Dr. Moore, in iritis) any retention of morbid matters behind the iris. 
A very complete division of the radiating fibres of the ciliary 
muscle is effected when the section for iridectomy is properly made — 
that is, when it is sufficiently far back, although the circular fibres 
are left intact. Is it possible that this division may produce a 
salutary change in the ocular circulation? The surgeons who 
practise division of the ciliary muscle by puncture seem to think 
that their procedure exerts some such influence. I tried it in a case 
of irido-choroiditis with marked, but very temporary benefit, and its 
repetition was not only useless, but a source of irritation. Shortly 
afterwards, I saw a patient in whom division of the ciliary muscle, by 
another surgeon, had been followed by extensive detachment of the 
retina — a result that the operation is obviously well calculated to pro- 
duce. It is easy to conceive that the point or edge of the knife may itself 
detach and push inwards the retina in some cases, and that in others 
hsBmorrhage or effusion under the choroid may produce the same 
effect. Since then I have entirely abandoned the operation, 
believing it to be, at the best, a very uncertain and imperfect substi- 
tute for iridectomy, and to be beset with many disadvantages and 
dangers from which iridectomy is wholly free. 

" The method of performing iridectomy is worthy of a passin^^r 
notice. Mr. Bowman has sanctioned, by the great weight of his 
precept and example, such a rapid withdrawal of the knife as may 
produce a gush of aqueous humour, and a probable prolapse of the 
iris. Mr. Ernest Hart has recently advocated the same way of 
withdrawing the cutting-needle after the smaller incision required 
for artificial pupil. There is, however, among many operators of 
large experience a growing opinion that this gush of aqueous 



SUEOBBT. 201 

Iramoiir, and tluB prolapse of the ins, bj tiie nudden shock to, and 
displaoemeot of, the lens that they produce, are fertile sources of 
cataract after the operation, even where the anterior capsule has 
remained perfectly intact. Until this opinion be disproved, it will 
be safest to withdraw the knife with extreme caution, and to seize 
tiie iris by the introduction of proper forceps within the anterior 
chamber. This manosuTre is* to say the least, perfectly unobjection- 
able ; it avoids- a risk that may be actual, and that we cannot at 
present call chimerical, and it is perhaps more sur^^ical than the 
more hurried and less careful method of procedure." 



Art. 95. — Clinieal Bata respecting Amauroshy more espe^ 
eiallj^ respecting that form of it supposed to be Induced 
by Tobacco, 

By Mr. Jonathah Hutchiksoit, Surgeon to the London 
Hospital, Assistant-Surgeon to the Royal Loudon Ophthal- 
mic Hospital, kc. 

{Medical Circular, November 11, 1863.) 

Mr. Hutchinson has collected together all the cases of true 
cerebral amaurosis of which he has taken notes during the past 
four years. 5hese cases, which are 65 in number, are arranged in 
three groups : — First, cases in which both eyes are affected and the 
patients are adults (47) ; secondly, cases in which both eyes are 
affected and the patients are children (11) ; and, thirdly, cases of 
amaurosisof only one eye (7). The subjoined table will show the 
relative proportion of the two sexes in each group : — 

Series L — Symmetrical, and in Adults : Males. Females, 

Cerebral amaurosis, uncomplicated (idiopathic) 37 . . 3 

Ditto, probably complicated or secondary . . 3 . . 4 

Series, II. — Symmetrical, and in Children : 

Cerebral amaurosis, uncomplicated (idiopathic). 3 . . 7 

Ditto, probably complicated or secondary . . . . 1 

Series 111. — Unsymmetrical (all ages) 3 . . 4 

In this table, all the cases- in which there is good reason to suspect 
that the amaurosis was secondary to other disease are considered as 
complicated ; in the others (idiopathic) Mr. Hutchinson has been 
unable, on careful inquiry, to discover any satisfaetory explanation 
of the disease. It must be noted that a most remarkable difference 
in the relative proportion of the two sexes existed in the idiopathic 
class of the first series, and that this discrepancy is not found m the 
other groups. Mr. Hutchinson then proceeds to inquire as to how 
this great disproportion (37 men to 3 women) could be explained. 
The possible influence, let, of different occupations ; 2nd, of intem- 
perance ;.3rd, of sexual irregularities r 4th, of venereal diseases ; 6th, 
of injuries ; and lastly, of tobacco, are severally examined. That 
occupation has not much to do with it seems clear from tlie fact that 
the patients had followed most various callings; and as to syphilis 



202 SUBGEBT. 

and intemperance, to neither of these is the male sex ex])Osed in 
sufficiently disproportionate degree to account for the very different 
numbers. In only 4 of the whole number of cases is there any 
history of injury to the head ; and in 2 only of these could it be 
reasonably inferred that the injury has been the exciting cause of 
the disease. There remained then the possible influence of tobacco- 
smoking and of sexual excesses. The author states strongly his 
conviction that the real explanation of the mtjority of cases of this 
form of amaurosis would be found in one or other of these two. 
Whether tobacco had any share, or whether all should be attributed 
to the former, he cannot say. He wiphes to abstain for the present 
from any positive opinion, and simply begs to call attention to the 
clinical facts. It might possibly {>rove that, after all, this dispro- 
portion in the sexes is a mere coincidence, and that a larger collec- 
tion of cases would show it to be such. 

Amongst the conclusions obtained by analysis of the series of 
eases, the following are the more important : — In 23 of the 37 cases, 
it was recorded that the patients had smoked ; whilst in 2 it was 
expressly «tated that they had never done so ; and in 12 there was 
no information. In 10 the patients had been intemperate. In only 
2 could it be ascertained that the patients had had constitutional 
syphilis. In 4 instances the sufferers attributed their disease to 
anxiety. The disease had progressed to absolute blindness in 15 
instances ; in 5 it appeared to have been arrested ; 'and in most of 
the others it was either progressive at the last date of notes or the 
patient had ceased to attend. 

With regard to the probability of sexual excesses having anything 
to do with the causation of the disease in question, the author states 
that in not a few he has obtained the history of failure of sexual 
power. He has also found that varicocele was a frequent concomi- 
tant of this form of amaurosis. Still, on the other hand, in many 
instances the patients were healthy, robust men, who ailed nothing 
whatever excepting the loss of sight. In no single instance in the 
series was there any strong reason for attributing the disease to 
masturbation. Even if it were proved that varicocele, wasted testes, 
and loss of generative function were usual concomitants of this 
form of amaurosis in the male, still the tobacco hypothesis would 
not be wholly set aside, since the two classes of symptoms might 
both be due to one common cause. It was remarkable that in 
almost all the few oases in which the disease occurred idiopathically 
in females, there was the history of very decided disturbance of 
menstruation. 

Although he feels that there are great difficulties in the way of 
belief in the tobacco hypothesis — such, for instance, that many of 
those affected had smoked only quite moderately ; that many had 
smoked for a long series of years before the amaurosis supervened; 
that thousands and thousands smoked to great excess without ever 
suff*ering from amaurosis ; that it was not easy to understand how 
the tobacco poison could act on one single nervous ganglion alone, 
the other parts of the nervous system escaping — still the author 
thinks that there is enough of suspicion in the clinical facts to make 



8X7B&BBT. 208 

it the duty of ophthalmic surgeons to insist on the disuse of tohaoco 
in all cases in which the premonitory symptoms of this disease 
were presented. The subject is one well worthy of prolonged in- 
vestigation, and no doubt it will soon be set at rest one way or the 
other. 

In concluding his paper Mr. Hutchinson mentions the following 
desiderata : — 

1. A much more extended series of cases. 

2. More detailed information as to the use of tobacco by those 
affected by this form of amaurosis. 

3. Information as to whether there may not be a considerable 
proportion of men affected by it who have never used tobacco. 

4. Information as to the co-existence or otherwise of varicocele 
irith this form of amaurosis. 

6. Information as to whether it ever occurs in women who have 
smoked. In some countries where smoking is more common amongst 
women than it is here, valuable information on this head might 
be obtained. 

6. Better knowledge as to whether the course of the disease can 
in any considerable number of cases be suspended — Ist, by makinff 
the patient give up smoking; or, 2nd, by regulation of sexual 
habits. 



Art. 96. — On Smoking as a Cause of Optic Atrophy ^ 8fc. 

By Mr. Ernest Hart, Ophthalmic Surgeon to 

St. Mary's Hospital, &c. 

(Lancet, August 1, 1863.) 

In a short letter upon this subject, Mr. Hart says : — ** Since I have 
learnt that Mr. Wordsworth was indined to connect a definite lesion 
of the eyeball with the habit of smoking, I have given attention to the 
question. The results at which I have been able to arrive are, how- 
ever, much opposed to the views which he last week enunciated, I 
hope that, for the purposes of this inquiry, we may be allowed to dis- 
card the term ** amaurosis " which has been imported into it. That is 
a phrase orip;inating in .the darker ages of ophthalmic science, and has 
been well defined as describing a condition in which the patient saw 
nothing, and the surgeon just as little. It included all those " ob- 
scure diseases *' of the fundus of the eye in which the existence of 
disease was inferred from the loss of sight, but was beyond the 
reach of diagnosis. 

" Fortunately the fundus of the eyeball is no longer concealed 
from inspection, but with the aid of the means which modern physi- 
cists have placed at our disposal we can examine the optic papilla, 
the retina, the cJioroid, and vitreous as reaHily as the cornea, and 
c&n. read off their pathological changes. When, therefore, authors 
apeak now of * tobacco as a cause of amaurosis,* we may expect that 
they will be good enough to define the form of disease to which they 



204 8VBGBBY. 

apply that very indefinite term. Mr. Wordsworth, when speakinji^ 
of amaurosis as the consequence of smoking, is of opinion that 
tobacco produces white atrophy of the optic nerve. 

" I have been unable to trace the connexion in any case of white 
atrophy which has come under my notice, and I cannot see that he 
supplies any satisfactory evidence which can be considered to support 
that view. 

" It will be observed that the tobacco disease of which he speaks 
in the clinical histories is in. no way distinguishable from ordinary 
white atrophy; it seems, indeed, to be avowedly identical with that 
condition. Now, in the first place, to those who wiU think over the 
pathology of that affection, itvwill not seem a very probable sugges- 
tion that tobacco-smokin^ should produce this specific degeneration, 
without first veri/ serioualy affecting the other parts of the nervous 
system^ on which it undoubtedly acts more powerfully and directly. 

" Among the known eausea of white atrophy of the optic nerve 
are, cerebral, efiusion, tumours of the brain, struetural changes of 
the thalami and corpora strata, &c. In order to ascertain whether 
tobacco-smoking has any claim to be ranked among the unknown, 
causes, I have been examining with the ophthalmoscope all the in- 
veterate smokers on whom I. could lay handa among my patients 
and in a considerable acquaintance. I have not in any case found the 
least trace of or tendency to white atrophy. On the other hand, 
white atrophy is found in children and females as well as in adults 
and males. Of the six cases which have come under my notice re- 
cently, and in which I have investigated the question, not one was a 
regular or 'considerable smoker ; two did not smoke at all. In a very 
distressing case of double white atrophy now under my care, in 
which .the disease is gradually approaching its last stage and the 
sight nearly extinguished, the patient has been a very moderate 
smoker, on\y- smoking when a friend. dropped in. He has- not de- 
rived any benefit from total abstinence. I invite Mr. Wordsworth 
to reconsider. this question, and I believe that a further review of 
clinical evidence will lead him to the same conclusion as myself." 



Art.. 9Z.— ©» a Lesion of the Conjmiciwa coinciding 
with Ilemeralo^ia.^ 

By M. Bitot. 

(BulL de VAcad, de M^d,, No. 14, 1363 ; and Medico-GhtTwrgital Review^ 
J:uiy,1863.) 
In a recent report on hemeralopia, M. Gosselin noticed the fact 
of slight blepharitis or conjunctival catarrh being connected with 
the night-blindness, as assisting to explain its epidemic character, its 
persistence in the same regiments, and its recurrence in the same 
men. In the present paper, M. Bitot indicates the coincidence of 
hemeralopia with a lesion of the conjunctiva, occupying not the lids, 
but the globe of the eye, and not exiiibited by signs of inflammation, 
but by an assemblage of shining white spots, producing a pearly or 
silvery spot by the side of the cornea. The author has made his 



8T7BOEBY. 205 

observations in twenty-nine cases occnrring in the Bordeaux 
Children*s Hos^tal, nineteen beinfir males and ten females ; the ages 
varying from nine to nineteen years, these children being employed 
as tailors, shoemakers, and dressmakers. The lesion has been always 
found near the lateral part of the cornea, generally on the external 
side. The spot, of a pearly or silvery appearance, seems constituted 
of an aggregate of minute points, and may vary in form not only in 
different individuals, but in the tvro eyes of the same person. In 
general, it is triangular, having its somewhat concave base turned 
towards the cornea. The form is susceptible of undergoing change 
when pressure is made on the eyelids, the parts constituting the 
spot being simply in juxtaposition. The extent of this spot is propor- 
tionate to the completeness of the hemeralopia, and at the commence- 
ment of the disease only a few pearly points are visible. In some 
cases these have furnished the first indication of the approaching 
hemeralopia, the patients not being aware then of any disturbance 
of their vision. The course of the spot follows that of the hemera- 
lopia, increasing in size as this becomes more complete, and diminish- 
ing slowly or rapidly, according to the rapidity of the cure. Not a 
trace of tne spot remains visible when the normal vision has become 
restored. The existence and duration of the spot thus becomes a 
measure of the principal disease ; but before concluding this to be 
the case, M. Bitot examined the other children of the establishment, 
in order to ascertain whether its presence might not be a mere co- 
incidence due to the lymphatic or scrofulous constitution so prevalent 
there. On examination, however, the subjects of hemeralopia were 
found to be some of the most healthy children, while cases which 
e:idhibited marked scrofula, independently of hemeralopia, never 
manifested the spots in question. These spots cannot be detached 
by the finger-nail, but seem to consist of epithelial layers. The con- 
junctiva situated between them and the external an^le of the eye, 
loses its normfd characters. It is less moint, soft, shining, and pliable, 
and pressure made by means of the eyelids, exhibits a very clear line 
of demarcation between its changed and healthy portions. 

M. Villemin, an army-surgeon, states, without having been 
aware of M. Bitot's investigations, that he met with this white spot 
in an epidemic of hemeralopia occurring in a battalion stationed at 
Strasbourg in 1860. 



Art. 98. — On the Treatment of Strabismus at the Royal 
Ophthalmic Hospital^ Moorfields, 

By Mr. George Lawson, Assistant-Surgeon to the Royal 
London Ophthalmic Hospital, <&c. 

{Lancet, July, 4, 1863.) 

It is often stated that some of the objections to the subconjuncti- 
val operation are, that the plica semilunaris is interfered with, and 
that the result is a shrinking and retraction of the caruncle. Again» 



206 SUBOBBY. 

it is urged tliat suppuration and large growths of granulations follow 
the operation, ana add considerably to the after deformity. 

**To such statements," says Mr. Lawson, "I can only say that 
the writer of them either could never have seen the subconjunctival 
operation properly performed, or else must have witnessed results 
very different from those which are obtained at Moorfields. 

" I would preface the remarks I have to make on this operation 
by stating that the plica semilunaris ought never to be interfered 
with ; that the falling back of the caruncle is an exceedingly rare 
occurrence after the operation, and cannot follow it unless improperly 
performed ; and that suppuration of the wound and the after-forma- 
tion of granulations in the site of the cut in the conjunctiva never occur. 
" I will now briefly describe the operation as performed at Moor« 
fields. 

** The lids are kept apart by the ordinary wire speculum. The 
surgeon then makes a small opening in the conjunctiva with scissors 
over the lower edge of the insertion of the rectus tendon, taking hold of 
the membrane, and often of the deep fascia at the same time, with 
the forceps, which, if the eye be turned inwards, may be slided 
(closed) along the surface from the edge of ihe cornea till they reach 
the proper spot for the opening : thus the eye need not be held by 
an assistant. The fascia being opened, the lower edge of the tendon 
is exposed close to its insertion. If the fascia has not been opened 
at the first snip, it is in its turn seized by the forceps at the same 
point and divided, without interference with any other structure ; 
the object being simply to divide the tendon on the ocular side of 
the hook ai its insertion. The blunt hook is now passed through 
the aperture in the subconjunctival fascia, and behind the tendon, 
which it renders tense by being made to draw on it slightly forwards 
and outwards. The next step is the introduction of the scissors. 
Mr. Bowman insists on the propriety of carefully introducing the 
points of the scissors, not much separated — one along the hook be- 
hind the tendon, the other in front of the tendon, and between it 
and the conjunctiva, and of dividing the tendon by successive snipt 
from the lower to the upper edge. If the tendon is divided by one 
cut the operation is more roughly executed, for, as the blades have 
to be opened more widely, the opening in the conjunctiva and fascia 
must be larger ; vessels of a larger size may be divided, and the 
tendon may be pushed off the hook before the points of the scissors : 
if this happen, of course the hook must be re-introduced. The 
surgeon completes the operation by making a small counter-puncture 
by bulging the conjunctiva on the end of the hook in the situation of 
the upper border of the tendoi^ after its division, and by then snip- 
ping it with the scissors ; the object being to allow any of the 
effused blood immediately to escape, instead of diffusing itself over 
the sclerotic. The subsequent ecchymosis then never need extend 
beyond the seat of the operation, and should disappear within a few 
days. 

" The results of this operation, when properly performed, are so 
satisfactory that I feel any new method must possess very strong 
claims to justify its preference. 



SXTBaBBY. 207 

" Before operating on a patient for strabismns, that Tisnal con- 
dition of the two eyes is to be ascertained, and the relative strength 
of the internal and external recti muscles made out. Mr. Bowman 
is very decided in urging the necessity of carefully estimating the 
comparative strength of these muscles in both eyes, as according to 
their relative power he determines upon the necessity of operating 
on one or both eyes. He has adopted a set of symbols which indi- 
cate accurately their comparative state. The patient is made to look 
at a near object held at the extreme outer limit of his field of vision, 
first on one side, then on the other, and the extreme limit of move- 
ment of each eye inwards and outwards is then noted, with refer- 
ence respectively to the lower punctum and the outer canthus : the 
pupil being the part of the eye used to mark the movement inwards ; 
the outer edge of the cornea the movement outwards. In noting 
the case on paper, the diagrams of the positions of the two eyes 
■ should be placed on the same line, as if facing the observer ; that of 
the right eye on the left-hand side. The following may be taken as 
an example : — 

<|; •" ■' >| 

a b c d 

o, b. "Right eye. e, d. Left eye. 

a. Extreme range outwards ; the outer edge of the cornea fails bo reach 
the canthus. b. Extreme raofi^e inwards ; the pupil passes beyond 
the punctum. e. Extreme range inwards ; the pupil does not reach 
the punctum. d. Extreme range outwards ; the outer edge of the 
cornea passes beyond the cuithui. 

" In each case the exact distance admits of being recorded. In 
this manner the relative strength of the internal and external recti 
of the two eyes may be estimated, and the result marked down in a 
single line, so as to show at a glance in which eye the preponderance 
of power of either muscle exists. After the operation another ex- 
ammation is made, and the result again marked down. We are thus 
enabled accurately to record on paper the amount of power the one 
muscle has gained and the loss the other has sustained by the opera- 
tion, and this at successive periods in the history of each case." 



Abt. 99. — Double Vision with each and both Eyes. 

By Dr. Bethune. 

{Boston Medical and Surgical Journal, Feb. 12, 1863.) 

Cask.— Mrs. , aged 37, the wife of a physician, and who had formerly 

taught in one of the highest of our private schools, consulted me first ob the 
10th of March, 1862. Naturally far-sighted, and without previous trouble 
in the eyes, eighteen months ago, after unusual exertion in studying, she 
was seized with double vision with each and both eyes. She suffers no paiD, 



208 SUBOEBY. 

photophobia, or other subjective symptom. This diplopia does not extend to 
very near objects, the nearest point being from four to five feet. The new 
moon she describes as seeing with four horns. The false image seems ad ways 
to the leftf except in the case of horizontal lines, as, for instance, a telegraph 
wire, when it appears below. The appearances are the same with either eye 
covered. By bending the head, she thinks to the lefty the two images coin- 
cide. She thinks there has been no variation in the double vision since she 
first observed it, when the circumstances are the same. She observes it 
more when looking towards the sky, and in clear light, than when the light 
is weaker. 

She is rather a delicate-looking person, though her general health is good. 
Her hands and feet are apt to be cold. A bout six months ago she was 
attacked with tinnitus of both ears, which still continues. 

On examination, the only abnormal appearance in the eyes is a little tinea 
ciliaris. She was advised to rest the eyes, to apply a lotion of acetate of lead 
to them, and a stimulating lotion to the spine. To take sherry wine, and 
exercise in the open air up to her strength. 

Jan. 17th, 1863. — Was again seen to-day. No change in eyes. Other things 
as above, except that the tinnitus has diminished. The left pupil was dilat^ 
with atropine, and the eye examined with Burow's ophthalmoscope. 
Nothing ahnoi^mal seen. Two repetitions of this examination, on different 
days, were made with the same result. 



Art. 100. — On the Diagnosis and Treatment of Syphilitic 
Tubercle of the Eyelid, 

By Mr. J. Vose Solomon, Surgeon to the Birminghain 
and Midland Eye Hospital. 

{British Medical Joumaly April 18, 1863.) 

A disease for which the common tarsal tumour — the grando or 
chalazion of technologists — may be mistaken, is syphilitic tubercle 
of the lid. 

The tarsal border in this affection becomes the seat of a well 
defined and hard tumour, in the centre and free border of which a 
yellowish spot is apparent. At this stage, the tubercle bears a rude 
resemblance to hordeolum or stye. 

The yellow spot sooner or later ulcerates; and if the molecular 
changes be not controlled by mercury, a deep notch is made in the 
border of the eyelid, and remains as a permanent deformity. The 
ulcer is at first superficial and of a dusky yellow colour, and the lid- 
tissue* around is widened out by a circumscribed and dense exudation, 
as in the Hunterian chancre. 

Case 1 . — My introduction to this form of syphilis of the lid was made many 
years ago, in the case of a married lady, who consulted me respecting a 
tumour such as I have described. One of her eyelids was disfigured by 
a notch, which she told me marked the site of a tumour similar to the 
one which now concerned her, and which had run a natural course. The 
disease was not ** tarsal tumour," for this never ulcerates or suppurates 
at the free margin of the tarsus. The chronicity of the disease and ap- 
pearance of the yellow spot forbad the idea of its being hordeolum. On 
calling upon the surgeon who attended the family, I learned from him 



8I7BGEBT. 209 

that the patient had been infected with syphilis by her husband two years 
ago, and had been treated for secondary symptoms. 

The following case affords a good clinical picture of the early stage of 
syphilitic tubercle. 

Case 2. — A young woman, aged 20 (married) applied at the Eye Hos- 

Sitalon Oct 21st, 1856, with a hard tubercle on the edge of the right upper 
d close to the outer canthus, and a similar tumour on the correspond- 
ing situation of the left lower lid. They were not inflamed ; but pre* 
sented, upon the integument at its line of union with the muco-cutaneous 
surface of the tarsus, an excoriated ulcer, of small size and oval shape. 
The ulcer on the right side was covered by a sticky secretion of yellowish 
colour. 

The face of the patient was disfigured by syphilitic papulae. 

The velum palati was oedemat-ous, the tonsils foul and deeply ulcerated, 
and one side of the tongue presented a blanched patch, in the centre of 
which was an ulcer. Plummer's pill was ordered. 

In three days (Oct. 24th), the right lid was much inflamed and swollen. 
The ulcers had extended; they were oval, and covered by a dirty gray 
crust (epithelial scales), on the removal of which a tawny surface was 
exposed. 

Treatment was now directed to the relief of the inflammation of the 
integument; and gray powder in combination with the extract of conium 
was substituted for the Plummer's pill, which did not appear to agree. 
Bt Hydrargyri cum cretA, ext. conii, aa gr. v. 
Fiant pilulse ij ter in die sumendse. 

The importance of abstinence from alcoholic stimulants, the necessity 
of a nutritious diet, and of keeping the body warm, were fully explained 
to the patient. 

My notes for Oct. 28th state: — "There is less inflammation of the lid, 
the tubercles are smaller and softer, but the ulcers remain unchanged. 
The woman looks better, and says she feels so.'* 

In six days afterwards (Nov. 3rd), the thirteenth of the treatment, the 
ulcers had cicatrised, and the surrounding hardness had disappeared. The 
appetite was good, and the complexion wore the aspect of health. It was 
a long time, the poor woman said, since she had felt so well as now. 
She remained under observation for a time, taking small doses of the 
mercury and iodide of potash. There was no relapse. 

For the cure of this disease, all that is needed is a course of mercury 
adapted to the constitutional power and idiosyncrasy of the patient. The 
supervention of inflammation is to be met by the application of such 
remedies as would be appropriate if there were no syphilitic complication. 

The inflammation should not be considered as belonging to the venereal 
complaint, but as an independent disease; hence a leech or two and an 
evaporating lotion may be necessary in addition to the mercury. 

In syphilis of the eyelid I have not been able to satisfy myself of the value 
of yellow or black wash as a topical application. The occasional touching 
of the sore with a crayon of nitrate of silver, in combination with nitrate of 
potash, is useful. A solution of nitrate of silver in distilled water, to which 
so much glycerine has been added as will give a coating to the ulcer, is a 
good form of application. 

I have encountered a difficulty in the administration of mercury in two 
cases. Both were females: one was phthisical; the other suffered from 
tertiary osseous symptoms, and was old and feeble. 

Cancer of the eyelid is to be distinguished from syphilitic tubercle by its 
history, the absence of secondary symptoms ; by the accompanying tume- 
XXXYIII. 14i 



210 * SUBGEBT. 

faction being less, and of a different feel when manipulated ; by the in- 
efficiency of mercury ; and by the results of a microscopic examination of 
the diseased structure. I have not laid stress on the generally more advanced 
age of cancer patients, because I have seen a fiat syphilitic tubercle on the 
integument of the eyelid of a woman who was nearly 60 years of age, and 
which rapidly disappeared under mercurial treatment ; nor upon slight en- 
largement and tenderness of the preauricular gland, as they are common to 
syphilis, cancer, and hordeolum. 

Case 8. — A woman, aged 25 years (married to a policeman), of strumous 
diathesis, complexion rather white, moderately plump, presented herself on 
March 17th, 1863, with a red swelling of the lid, situated very near to the 
right tear- sac, and was prescribed for by Mr. Bowen, our intelligent house- 
surgeon. 

On March 20th, I saw her for the first time, and noted the following 
symptoms. The integument of the inner half of the right lower lid is shiny 
and of a slightly coppery hue ; and its surface slightly uneven. On taking 
the lid between the finger and thumb, a swelling occupying nearly one-half 
of the lid, of soft cartilaginous feel and slightly lobulated in front, is dis- 
covered; to the touch it closely resembles the remains of a large Hunterian 
chancre of the prepuce, for which mercury has been somewhat recently ad- 
ministered with effect. The margin of the swelling can without difficulty 
be clearly defined, there is no sort of blending with the surrounding 
tissue. 

The voice of the patient is " veiled." In the base of the uvula is a small 
hole with a sharply defined and rounded edge ; there is no secretion from 
it ; the velum palati is white, and chronically oedematous; the right pillars 
of the fauces are in the same condition, and there is a little notch in the 
centre of the free margin of the anterior pillar, marking the seat of a cica- 
trised ulcer. These parts present a diffused pale pink shade. 

The patient denies all knowledge of a primary sore of the genitals, and the 
existence at any time of leucorrhoea or ardor urinso. The throat has been 
affected upwards of six months, and the eyelid about three months and a 
half. She has had medical treatment, which does not appear to have 
included mercury in any form, or specific treatment of any sort. 

The disease commenced at the inner end of the lid, and was believed to be 
a stye, but it never suppurated. It was at one time inflamed, and became 
of a large size ; a leech was applied with great relief, and the swelling dimi- 
nished much. At the present time, the part is not inflamed or tender, and 
the conjunctiva is healthy. She was ordered to take every night a pill con- 
taining hydrargyrum cum cret& and extract of conium, two and a half grains 
of each ; and a drachm of syrup of iodide of iron in a cup of milk three 
times daily. 

March 31st. — The tumour is nearly gone; the copper-coloured stain 
continues, as on , the 20th, well marked. The patient is looking more 
healthy; she says she feels better than she has done for five years, and 
that her appetite is now excellent. Four pills only have been taken. 

The preceding case affords an example of tertiary syphilis, of the same 
nature as the indolent nodes (lumps ?) thai sometimes form in the skin of the 
arms or its subjacent cellular tissue, and which are much benefited by prepa- 
rations of iodine and sea-air. 



SUBGEBT. 211 

Art. 101. — An JJndescribed Lesion of the Coniunctiva, 
associated with Night -Blindness. 

By M. Bitot, of Bourdeaux. 
ifiaz. Mid, de Paris, Juillet 4, 1863.) 

M. Bitot, in a communication to the Academy of Medicine, has 
called attention to what he believes to be a hitherto undescribed 
affection of the eye attending night-blindness, and consisting of an 
assemblage of glistening white points on the cornea, giving the ap- 
pearance of a pearly or silvery spot. His observations were made 
on twenty-nine cases of night-blindness which came under his notice 
in the Foundling Hospital at Bourdeaux. Of these, 19 were males, 
and 10 females. The night-blindness appeared between the ages of 
9 and 17 in boys; between 10 and 19 in girls. The weakest 
children were free from it ; it was most common in those who ap- 
peared to have the best constitutions. 

The conjunctival lesion presents the following characters. It is 
always seated on the part of the eye which is exposed, during the 
waking state, to the action of the air. Its situation is generally to 
the outer side of the cornea; M. Bitot has never seen it above or 
below this membrane. It is readily distinguished by standing in 
front of the patient, and desiring him to direct the eye inwards. 
The spot is of a pearly silvery colour ; it may be described as an 
aggregation of small points or delicate short lines. The colour varies 
little; but is more or less intense in different subjects, and accord- 
ing to the time when the spot is observed. When it is about to 
disappear, the whiteness loses its glistening appearance. 

Tne form of the spot differs, not only in different subjects, but 
also even in the two eyes of the same individual. In general, it is 
triangular, with the apex turned outwards, and the base slightly 
concave, lying next the cornea. In some cases, it was circular or 
oval ; in others, simply linear. Most usually, the particles com- 
posing it are agglomerated, so as to produce a dotted surface; 
sometimes they are disposed in parallel wavy lines, giving the spot 
an undulated or corrugated appearance. These forms may be 
modified by pressing on the eyelids with one or two fingers ; and 
the change in form depends on the fact that the constituent parts of 
the spots do not appear to be connected, but simply in juxtaposition 
and capable of a certain amount of displacement. 

The extent of the spot is in proportion to the mtensity of the 
night-blindness. It was very large in tvro of M. Bitot's patients, 
who were absolutely incapable of distinguishing objects after sunset. 
It was never so large in persons who could see in the evening, 
although confusedly. At the commencement of the disease, the 
spots scarcely exist; they are represented by some pearly points, 
the first seat of which is always to the outer side of the cornea ; 
these points multiply and extend as the night-blindness increases. 
In a general inspection of the eyes of the children of the hospital in 
1861, M. Bitot found three in whom no affection of the sight was 
Bospected, bat who presented the spots in an early stage ; he pre- 

14—2 



212 SUBGEBY. 

dieted that they would be affected with night-blindness, and the 
event soon confirmed his prediction. 

The spots, which increase during the progress of night-blindness, 
and even encroach on the intracorneal portion of the conjunctiva, 
decrease as soon as the sight becomes stronger ; and the decrease is 
rapid or slow, in proportion as the recovery of the sis;ht takes place 
quickly or only by insensible degrees. When the sight has regained 
its normal condition, not a vestige of (he spots remains. 

M. Bitot has examined into the question whether these spots may 
be mere coincidences with night-blindness, and be tjonneeted with 
scrofula. So far from this being the case, he has found tbat, 
although scrofula was very common among the children in the 
hospital, the general health of those who had night-blindness was 
generally very good — two only of the twenty-nine being scrofulous. 
On the other hand, among the numerous rickety and scrofulous 
children, none presented any appearance of the conjunctival spots ; 
and M. Bitot is not aware that such a lesion has been described as 
connected with scrofula. In 1862, he examined the eyes of such of 
the night-blind patients of the preceding year as had not quitted the 
hospital, and in none of these was there any reappearance of the 
spots. 

As to the nature of these spots, M. Bitot has found, by scraping 
them with the nail and by microscopic examination, that they are 
produced by a special desquamation of the epithelium or the con- 
junctiva. Around the spots, especially to the outer side and as far 
as the palpebral commissure, the conjunctiva of the bulb does not 
present its normal characters. It has lost its moisture, softness, and 
brilliancy; and resembles parchment. Pressure on the eyelids 
accurately determines the limit between the disordered and the 
healthy portions. 



Art. 102. — The Fibrous Tunic of the Eyeball, or " Ocular 
Tunic f^ and its Relations and Bearings in Ophthalmic 
Practice, 

By Mr. Haynes Walton, Surgeon to St. Mary's Hospital, <kc. 

(British Medical Journal.) 

The remarks which follow were made in the course of clinical in- 
struction at the Central London Ophthalmic Hospital. Mr. Walton 
says :— 

" It may seem strange to say that, till lately, the anatomy of the 
ocular appendages was not correctly taught. An extensive and im- 
portant membrane about the eyeball, concerned alike with opera- 
tions and in the discrimination of disease, was not recognised in 
orbital dissections, but disregarded and taken away as so much 
cellular tissue to be cleared out, in order to render evident other 
anatomical relations. 

" Knowing how little this structure is understood, how scarcely 
it has been alluded to either by anatomical writers or surgical 



817BGSBT. 213 

teachers, and seeing the importance of it, I shall make it the sub- 
ject of a short lecture, describing the anatomy, and pointing out the 
influence it has in actual practice. 

"So long ago as the year 1804, Tenon demonstrated this ocular 
tunic, and called it the tunic of the eye. Like, however, many 
Taluable hints in anatomy and surgery, it was forgotten for a long 
series of years, till a later recog^nition of it was declared a new dis- 
covery. Drs. OTerrall and Bonnet were the next to treat of it, 
each claiming the merit of originality. The former made his views 
known in 1841, in the Dublin Journal of Medical Science, and to 
him indisputably is due the merit of surgical and pathological appli- 
cation. Bonnet's notice appeared a year later. 

** I shall now give a description of this tunic, which has been also 
called tunica vaginalis oculi, cellular capsule, Bonnet's capsule, 
cellular sheath of eye, fibrous sheath. 

" It is a distinct tunic of a white colour and fibrous consistence, 
continuous in front with the posterior margins of the tarsal car- 
tilages, and, extending backwards, adheres to the optic nerve as 
this penetrates into the sclerotica. With the sharp end of a probe, 
or of^a director, it may be separated from the eyeball, by breaking 
the fine cellular tissue which connects them. Within, it is smooth, 
facilitating the ocular movements ; externally, it is loose and cellular. 
The muscular portions of the recti muscles lie at the outside, so that 
it insulates and protects the eyeball in the most perfect manner 
possible. Half an inch posterior to its front margin are six well- 
defined openings, through wiiich the tendons of the muscles pass to 
their insertions in the sclerotic coat, and over which they play as 
through a pulley, and get their force properly directed, securing 
rotation, and opposing retraction, which would otherwise pre- 
dominate. 

" The readiest way of exposing the tunic is to cut through the 
palpebrse vertically, to turn back the separated parts, and to divide 
the conjunctiva at its angles of reflection from the internal surfaces 
of the eyelids to the ball of the eye. 

"How different all this is from the usually received opinion of 
the orbital muscles being in contact with the eyeball. 

" The first beneficial result of a proper knowledge of the tunic 
was the present improved manner of extirpating the eyeball, in 
•which the conjunctiva is cut through close to the cornea, the recti 
and oblique muscles divided at their sclerotic attachment, and the 
optic nerve severed within the tunic; so that the orbit is, as it 
were, left sealed in front by the membrane. This contrasts greatly 
with the old operation of dissecting away the whole of the orbital 
fat and cellular tissue, when it was desirable only to get away the 
eyeball, and not any of the appendages, an act that can scarcely be 
justifiable, except in the somewhat doubtful measure of clearing out 
the orbit for a cancerous growth. The difference in the severity 
between the two processes and the after effects is great indeed. In 
the one, there is no shock to the system, and the patient is 
scarcely invalided, and the effect passes off quickly in one or two 
days. The orbital vessels and nerves are left intact, and there can 



214 SUBGEBY. 

scarcely be any bleeding. The extent of the other, the haemorrhage, 
the general bodily disturbance, and the somewhat risk, are well 
known. 

" The better result in the operation for internal squint is also to 
be ascribed to the recognition of the ocular tunic. Formerly a very 
free dissection made at the inner corner of the eye, and unfrequently 
the tunic detached from its connexion under the supposition of 
being 'adhesions' that needed disconnexion. The common issue 
of such mal-operating being frightful eversion of the eyeball with 
prominence. We now know how essential it is, in order to secure 
the correct ocular movements, that the divided muscle should ac- 
quire an attachment as near the natural spot as possible, through 
one or other of the four or five processes that j^a^^-wor^em inspection 
has revealed to us, and which is beyond the range of possibility, if 
the paits in connexion, especially the tunic, be much cut and dis- 
placed. I think that prominence scarcely, if ever, occurs to any 
marked degree, when the tunic is not interfered with.. 

*' Another addition arising out of this knowledge, is the greater 
facility and accuracy afforded in the removal of orbital tumours. 
Suffice it to say, that it greatly furthers the execution of such 
operation, whether the growth be solid, or encysted. On many 
occasions, I have been able to proceed with more confidence, better 
to avoid parts not involved in the disease, and to get superior results. 
It should be the object of the operator, in every instance, to pre- 
serve the tunic as intact as possible. On one occasion, while re- 
moving a fibrous tumour from the upper part of the orbit that had 
cellular connexions to the vestment, I was enabled by slow and 
careful scratching with the point of the scalpel, rather than cutting, 
to get the whole away without damaging it. 

** The position of abscesses in the orbit, and their relation to the 
eyeball, can be better understood, and therefore, the evacuation of 
the pus more surely accomplished. When a student, I was taught 
always to keep the instrument, used for such a purpose, towards 
the wall of the orbit, lest the eyeball should be wounded. But if 
this be adhered to, how is the abscess to be got at when it is within 
the tunic. With the commonest care when here, it may be evacuated 
without the least risk. I have relieved several patients after other 
Burgeons, not cognisant with the anatomical matter in question, 
have failed to find the pus. 

" To Dr. O'Eerrall is due, too, the credit of recognising rheumatic 
inflammation of the ocular tunic ; and, with his accustomed inge- 
nuity and accuracy, he makes the anatomy of the eyelid available in 
the diagnosis. He shows that under the orbicularis muscle is a 
distinct layer of fascia, and that this is the first element of the eyelid 
that enters the orbit ; that there is another layer of fascia beneath 
the levator palpebrss, which also enters it, and uniting with that 
above, forms a sheath for the accommodation and support of the 
muscle ; and he points out the attachment of the ocular tunic to the 
orbital margin of the tarsal cartilages. This anatomical arrangement 
he then traces on the outer surface of the eyelid in the two portions 
separated by the natural fold of the skin, the upper portion consti- 



SCXGSBT. 21S 

totiii^ about one-third of the surface of the lid, the lower the i^ 
mainin^ two-thirds. From these he makes the patholot^ical deduc- 
tion, that eertain forms of disease within the orbit that are seated in* 
or internal to, the motor apparatus — that is, the substance of, or 
within the caritj of the ocular tunic, extend their effects to the 
lower portion of the eyelid, with which they are continuous, and 
liiat certain other aflfections situated external to the motor apparatus 
^which is that part of the orbit containing the fat — will show them- 
selres by inflammation or other changes in the upper division of the 



" The last subject to be noticed in connexion with the ocular 
tunic, ia the greater light that Dr. OTerrall has been able to throw 
on the causes that protrude the eyeball. Inflammation of the 
ocular tunic will in itself cause ocular prominence. This is chieflr 
through e&^ion into the cellular memDrane connecting it to the baU 
of the eye. The infiltration iii apparent where the conjunctiva ia 
reflected from the eyelid to the eyeball, just where this membrane 
eloses up the ocular tunic in front. Here it receives the pressure of 
the effused serum, and becomes separated from the sclerotic coat by 
the extension of the infiltration. The amber-coloured chemosis 
originating in inflammation of the conjunctiTa, is distinguished from 
it by redness as well as serous infiltration." 



Art. 103. — On Affections of the Tympanum, and their 
Danger to Life, 

By Dr. Von Troeltsch. 
{Deuitcke Klinik, No. 37,1862; and Med, Times and Gazette, July 11, 1863.) 

The delicate lining of the cavity of the tympanum does not admit 
of its being separated into mucous membrane and periosteum ; and 
the membrane commonly called the mucous is also the supporter of 
the vessels of the bone, thus fulfilling the function of the periosteum. 
This duplex condition is of great importance, as long-continued or 
intense disease of the mucous membrane influences the nutrition of 
the bones constituting the tympanum. Every inflammation of the 
mucous membrane becomes a periostitis, if the inflammation is 
chronic there is thickening of the mucous membrane and hyper- 
trophy of the bones ; while, when acute, the membrane becomes 
ulcerated, and the periostitis oftener leads to atrophy of the bone 
and superficial canes. With increasing experience the author has 
become more and more convinced that caries of the petrous bone ia 
infinitely more frequently due to neglected inflammation of the soft 
parts of the outer and middle ear than to any primary disease of the 
Done itself. We have only to consider the parts wliicli surround the 
inflamed tympanum to learu how easily the aflection may spread to 
these. The frequency of consequent perforation of the membrana 
tympani is well known ; and the researches of Leber t and Gull 
confirm the conclusions arrived at by the author, that the extension 
of the inflammation through the roof of the cavity to the meninges 



214 SFBGEBY. 

scarcely be any bleeding. The extent of the other, the haemorrhage, 
the general bodily disturbance, and the somewhat risk, are well 
known. 

" The better result in the operation for internal squint is also to 
be ascribed to the recognition of the ocular tunic. Formerly a very 
free dissection made at the inner corner of the eye, and unfrequently 
the tunic detached from its connexion under the supposition of 
being 'adhesions' that needed disconnexion. The common issue 
of such mal-operating being frightful eversion of the eyeball with 
prominence. We now know how essential it is, in order to secure 
the correct ocular movements, that the divided muscle should ac- 
quire an attachment as near the natural spot as possible, through 
one or other of the four or five processes that j^o^^-jwor^em inspection 
has revealed to us, and which is beyond the range of possibility, if 
the par ts in connexion, especially the tunic, be much cut and dis- 
placed. I think that prominence scarcely, if ever, occurs to any 
marked degree, when the tunic is not interfered with.. 

" Another addition arising out of this knowledge, is the greater 
facility and accuracy afforded in the removal of orbital tumours. 
Suffice it to say, that it greatly furthers the execution of such 
operation, whether the growth be solid, or encysted. On many 
occasions, I have been able to proceed with more confidence, better 
to avoid parts not involved in the disease, and to get superior results. 
It should be the object of the operator, in every instance, to pre- 
serve the tunic as intact as possible. On one occasion, while re- 
moving a fibrous tumour from the upper part of the orbit that had 
cellular connexions to the vestment, I was enabled by slow and 
careful scratching with the point of the scalpel, rather than cutting, 
to get the whole away without damaging it. 

** The position of abscesses in the orbit, and their relation to the 
eyeball, can be better understood, and therefore, the evacuation of 
the pus more surely accomplished. When a student, I was taught 
always to keep the instrument, used for such a purpose, towards 
the wall of the orbit, lest the eyeball should be wounded. But if 
this be adhered to, how is the abscess to be got at when it is within 
the tunic. With the commonest care when here, it may be evacuated 
without the least risk. I have relieved several patients after other 
surgeons, not cognisant with the anatomical matter in question, 
have failed to find the pus. 

" To Dr. O'Ferrall is due, too, the credit of recognising rheumatic 
inflammation of the ocular tunic ; and, with his accustomed inge- 
nuity and accuracy, he makes the anatomy of the eyelid available in 
the diagnosis. He shows that under the orbicularis muscle is a 
distinct layer of fascia, and that this is the first element of the eyelid 
that enters the orbit ; that there is another layer of fascia beneath 
the levator palpebrsB, which also enters it, and uniting with that 
above, forms a sheath for the accommodation and support of the 
muscle ; and he points out the attachment of the ocular tunic to the 
orbital margin of the tarsal cartilages. This anatomical arrangement 
he then traces on the outer surface of the eyelid in the two portions 
separated by the natural fold of the skin, the upper portion consti- 



SUBGSBT. 215 

tntin^ about one-third of the surface of the lid, the lower the re- 
maining two-thirds. From these he makes the pathological deduc- 
tion, that certain forms of disease within the orbit that are seated in, 
or internal to, the motor apparatus — that is, the substance of, or 
within the cavity of the ocular tunic, extend their effects to the 
lower portion of the eyelid, with which they are continuous, and 
that certain other affections situated external to the motor apparatus 
—which is that part of the orbit containing the fat — will show them- 
selves by inflammation or other clianges in the upper division of fhe 
same. 

" The last subject to be noticed in connexion with the ocular 
tunic, is the greater light that Dr. O'Ferrall has been able to throw 
on the causes that protrude the eyeball. Inflammation of the 
ocular tunic will in itself cause ocular prominence. This is chiefly 
through effusion into the cellular membrane connecting it to the ball 
of the eye. The infiltration is apparent where the conjunctiva is 
reflectea from the eyelid to the eyeball, just where this membrane 
closes up the ocular tunic in front. Here it receives the pressure of 
the effused serum, and becomes separated from the sclerotic coat by 
the extension of the infiltration. The amber-coloured chemosis 
originating in inflammation of the conjunctiva, is distinguished from 
it by redness as well as serous infiltration." 



Art. 103. — On Affections of the Tympanum, and their 
Banger to Life, 

By Dr. Von Troeltsch. 

{DeuUche Klinik, No. 37, 1862 : and Med, Times and Gazette, July 11, 1863.) 

The delicate lining of the cavity of the tympanum does not admit 
of its being separated into mucous membrane and periosteum ; and 
the membrane commonly called the mucous is also the supporter of 
the vessels of the bone, thus fulfilling the function of the periosteum. 
This duplex condition is of great importance, as long-continued or 
intense disease of the mucous membrane influences the nutrition of 
the bones constituting the tympanum. Every inflammation of the 
mucous membrane becomes a periostitis, if the inflammation is 
chronic there is thickening of the mucous membrane and hyper- 
trophy of the bones ; while, when acute, the membrane becomes 
ulcerated, and the periostitis oftener leads to atrophy of the bone 
and superficial caries. With increasing experience the author has 
become more and more convinced that caries of the petrous bone is 
infinitely more frequently due to neglected inflammation of the soft 
parts of the outer and middle ear than to any primary disease of the 
oone itself. We have only to consider the parts which surround the 
inflamed tympanum to learn how easily the affection may spread to 
these. The frequency of consequent perforation of the membrana 
tympani is well known; and the researches of Lebert and Gull 
confirm the conclusions arrived at by the author, that the extension 
of the inflammation through the roof of the cavity to the meninges 



216 SUBGhBBT. 

and the brain, and the production of abscess of the brain, is, indeed, 
no very rare occurrence. Important is the fact, that the diseases of 
the tympanum are taking place in the vicinity of many diploetie 
spaces, into which the inflammation is easily propagated in the form 
of osteophlebitis. This favours the formation of thrombus, which 
takes place the more readily from the propinquity of sinuses to the 
tympanum. Lebert has the merit of pointing out how frequently 
inflammation of these sinuses is due to otitis, and the fact, that the 
cerebral, typhoid, or pysemic symptoms hence arising are commonly 
misunderstood. Then, again, how near the floor of the tympanum is 
to the jugular vein ; and if the ill effects of collections of matter in 
the cavity have been little observed in this direction, this arises less 
from the rarity of the occurrence than the fact of these parts not 
being examined after death. The vein, as also the internal carotid 
artery, is only separated from the cavity by a thin, transparent plate 
of bone, which is often defective, and there is always danger of the 
caries extending in this direction. Finally, the labyrinth or the 
facial nerve may participate in the inflammation, and suppuration 
may take place within the porus acousticus internus, leading to puru- 
lent meningitis. 

When we consider all these dangerous surroundings of the tym- 
panum, we cannot but feel astonished at the indifference with which 
inflammation and suppuration of this portion of the ear have been 
hitherto treated, not only by the public, but by the medical practi- 
tioners themselves. Yet, it is in the cavity of the tympanum that 
accumulation and decomposition of secretions take place so easily, 
inasmuch as such secretions are usually of firm consistence, the walls 
of the cavity are full of depressions and sinuosities, and its floor is 
below the level rf the passage by which these products might be dis- 
charged externally. As the lower edge of the membrana tympani 
does not extend to the floor of the cavity, even when this membrane 
is totally destroyed there is still no free issue of the discharges by 
the meatus. The narrow cavity of the Eustachian tube, the mucous 
membrane of which usually in these cases becomes tumefied, soon 
becomes obstructed with secretions, so that a discharge of these into 
the throat takes place much seldomer than is generally supposed. 
By the passage of the discharges into the cells of the mastoid process 
nothing is gained, unless it serve to arouse the practitioner's atten- 
tion to the threatening danger. Although in the great majority of 
cases, when dangerous otitis interna exists, purulent discharges and 
perforation of the membrane are present, these conditions are not 
essential accompaniments. The membrane sometimes acquires great 
power of resistance from the thickening it has undergone during the 
early stages of the inflammatory process ; while, in other cases, the 
otitis runs its course so rapidly as to terminate in a fatal issue before 
the membrane has yielded. Still, the cases on record in which 
death has taken place without perforation are few in number. The 
author believes the profession and public in England are far more 
alive to the dangers of chronic otorrhoea than they are in Germany, 
judging from the numerous preparations contained in the hospital 
museums, the cases recorded, and the fact, that life-assurance is 



0TTBOXBY. !217 

effeeted with difSonlty when this affection exists. He believes, 
judging from his own experience, that could an exact statistical 
mcoount of the ayerage duration of life of individuals suffering from 
chronic otorrhoea be procured, very surprising results would be 
obtained. It is true that there are numbers of persons having puru- 
lent discharges from the ear, who remain entirely well, and who, 
possibly, after a long course of years, succumb, so far as our know- 
ledge goes, to some disease having no relation to the affection of 
ihe ear. But Dr. Von Troeltsch, who for many years has had the 
opportunity of watching a considerable number of individuals suffer- 
ing from chronic affections of the ear, has been struck with tlie 
large proportion of these cases, mostly men in the prime of life, 
who have died somewhat suddenly, the subjects of acute tuber- 
culosis of the meninges, the lungs, or the intestinal canal, exhibiting 
symptoms of a septic infection of the blood. He has long since put 
to himself the question, whether some forms of rapid tuberculosis 
may not be explained by an infection of the blood, due to some 
purulent collection. Professor Buhl, of Munich, has proved by 
facts that acute miliary tuberculosis may thus originate. What 
more likely to serve as such source of infection than pus accumu- 
lated in the middle ear and its cellular communications, and there 
imdergoing caseous metamorphosis P 



Art. 104. — On a Peculiar form of Otitis and Deafness 
Induced hy the Immoderate Use of Tobacco and Fermented 
Liquids, 

By M. Triquet. 

(Jownal of Practical Medicine and Surgery ; and Medical Circular^ 
May 18, 1863.) 

Persons addicted to intemperance, or the immoderate use of 
tobacco or snuff, are liable to a peculiar kind of otitis, which, 
according to M. Triquet, promptly induces obstinate deafness. 
This affection of the ear is unaccompanied by puriform discharge, 
accumulation of mucus in the drum or Eustachian passages, or 
thickening of the membrana tympani, but is connected with that 
m^bid condition of the system which follow s the protracted action 
of injurious substances, and especially of alcohol and tobacco, what- 
ever be the form in which either may have been indulged in. 

The leading characteristics of the disease are a sort of torpor of 
the ear, with a sensation of refrigeration of the organ ; no pain 
exists, the ceruminous secretion is absent, no alteration can be 
detected in the ossicula or membrana tympani, which is not preter- 
naturally vascular; and the pharynx, nasal fossae. Eustachian tubes, 
and middle ear, are drier than in health. Both ears may be simul- 
taneously affected, the hardness of hearing, at first slight, soon 
becomes inconvenient, and tinnitus exists from the beginning, with 
a peculiar hissing intonation. 

This otitis, induced by the abuse of fermented liquids, snuff, or 
tobacco, was formerly confounded with nervous deafness, resulting 



218 SUBOEBY. 

from unknown causes. For a long time, M. Triquet acknowledges 
that he fell into the same error, a mistake difficult to avoid, on 
account of the close resemblance of the anatomical and physiological 
signs in both instances, and because the discrimination chiefly 
reposes on a knowledge of the cause {alcoholism, excesswe addiction 
to the use of tobacco), and also on certain symptoms of a subjective 
character, which in many cases prove deceitful. A careful inquiry 
into the history of the patients will, hawever, generally lead to a 
correct diagnosis at an early stage of the affection^ before what M. 
Triquet denominates the paralytic period, has set in» 

The progress of the disease may be divided into three periods. 
The first is marked by local excitement, intolerance of sound, and 
sharp, sibilant tinnitus. In the second, the irritation is followed by 
corresponding depression ; tinnitus, and singing in the ears have 
departed, and the paiient experiences a sort of craving for acute 
intonations ; and the third is characterised by paralysis of the 
auditory nerve and destruction of its function. 

The symptoms of each stage deserve peculiar attention, and were 
described by M.. Triquet as follows: — 

A person long addicted to habits of intemperance or to the immo- 
derate use of tobacco or anuff, is in general suddenly disturbed at 
night by a sibilant sound in both ears, analogous to metallic tink- 
ling. This phenomenon decreases in the course of the day, but 
returns after meals, especially in the evening, and uninterruptedly 
persists throughout the night. The slightest noise causes pain, and 
even the suppressed murmur af conversation is distressing, and the 
patient stops hia ears with cotton, or with the tips of his fingers, 
not only in the street, but at honie, in the midst of persons whose 
voices have long been familiar. This condition may last a few daya 
or weeks, a month op two at most, and is immediately followed by 
the symptonis of the second stage, that of depression. 

The subject congratulates himself at first upon what seems to be 
an improvement. The tinnitus has much diminished, and may even, 
have entirely ceased. The (distress occasioned by noise and sharp 
sounds is replaced by an opposite condition. The patient now seeks 
loud conversation, and complains that he is addressed in too low a 
tone. This deceitful amelioration lasts, however, but a short time, 
the last period of the disease is at hand, and sometimes suddenly, 
in the course of a night, the patient, to the surprise of all his 
frieniis, becomes stone-deaf. 

This third or paralytic stage is the longest and most distressing, 
and with some few exceptional cases in which, by timely medical 
interposition, some amendment is effected, the more or less com- 
plete abolition of the sense of hearing, which is the leading symp- 
tom, obstinately persists with all its evil consequences, cutting 
off* the patient from all social intercourse, and inducing a state oi 
melancholy which occasionally leads to self-destruction. 

This kind of deafness is not unfrequcntly accompanied by de- 
bility or perversion of some other or^an of special sensation. Thus 
M. Triquet has often met in such oases with congestive ambliopy, 
with marked vajBcularity of the retina and optic disc;, althougli 



8UBGEBT. 219 

Tision is not impaired in the same degree as hearing, it has, even 
in the young, lost a considerable amount of its power. Olfaction 
is also more or less obtuse, a fact to be accounted for by the 
numerous communications existing between the nerves of these 
yarious organs. In some few instances^ a marked diminution of 
the intellect, and vacillating movements in walking, indicate the 
propagation of the injurious effects of tobacco and alcohol to the 
brain and spinal cord. 

As- w« have stated, the otitis which induces the succession of 
phenomena above described, is to be referred to the immoderate 
use of tobacco or alcohol. The presence of this cause, and of the 
r^mptoms we have enumerated, are suflficient for the purposes of 
diagnosis ; M. Triquet, however, attributes pathognomonic value to 
the purple redness of the fauces, with minute granulations, which 
impart a shagreened appearance to the mucous membrane. Where 
this sign coincides with the others, no doubt whatever can subsist 
that the otitis and deafness are the result of the abuse of tobacco 
or alcohol. 

The prognosis of the third stage is most unfavourable ; medicine 
is of no avail but in the first and second periods of the disease, and 
incurable deafness supervenes. With every new remedy the deaf- 
ness seems to increase, especially if the treatment be of a stimu- 
lating nature, such as electricity or galvanism. With these desperate 
noli me tcmgere cases, M. Triquet conceives it best not to interfere. 
Palliatives and the waters of Saint-Sauveur may be prescribed. 

It is unnecessary to say, that in all stages of the afiection, the 
first measure to be adopted is the suppression of the injurious 
habit in which it has originated. 

During the first, or congestive stage, cupping behind the ears, 
leeches to the seat, in persons who have a tendency to piles, will 
be found advantageous. The regularity of the catameniat function 
will also require attention. 

In the second period, M. Triquet has derived much benefit from 
fumigations with the acetate of ammonia; but he considers the 
injections- of verAtrine as especially applicable in this variety of 
otitis. . 



Art. 10.5. — On Syphilitic Disease of the Mouth. 

By Professor Sigmund, of Vienna. 

(Wiener. Med, Wochenschr, ; and BritUh MedicalJournal, Oct. 3, 1863.) 

Professor Sigmund, one of the most eminent syphilologists of the 
present day, has for some time past been publishing in the Wiener 
Medizinisnhe Wbckensckrift, a series of articles on syphilitic disease 
afiectiuj^ the mucous membrane of the lips and mouth. He has been 
led to this by having lately met with^ both in hospital and in private 
practice, an unusually large number of cases or this kind ; and a 
similar occurrence took place in 1850, when the patients attributed 
the disease — erroneously, as Dr. Sigmund has been led to think — to 
the use of cigars.. He treats . first o£ primary and afterwards of 



220 SITBGEBT. 

secondary syphilitic disease of the mouth. On the present occasion, 
we give a somewhat condensed translation of his remarks on the 
primary syphilitic affection of this part. 

Primary Syphilis affecting the Lips, — Most of the cases that 
came under Dr. Sigmund's notice were in males. The most frequent 
seat of the disease was the upper lip ; and here, as well as on the 
lower lip, the centre was usually aflPected, the disease being more 
frequent and more extensive on the exposed red surface than on the 
surface next the gums. Primary chancres were rarely seen at the 
angles of the mouth, and were always confined to one angle. As on 
the genital organs, the disease first appeared as a simple infiltration 
of the skin and cellular tissue, with or without the formation of an. 
ulcer. 

The indurated chancre, unattended with ulceration and suppura- 
tion, appears first as a mere abrasion of the epithelium, with slight 
swelling of the cerium, which presents also fissures of greater or less 
extent, that sometimes bleed. At a later period, a dead white, 
yellowish, or brownish, generally firmly adherent scab, is formed of 
the epithelial dShris, serum, and blood. The infiltration frequently 
extends inwards beyond thedenudated part: the diseased portion of 
integument, however, acquires the appearance of havmg been 
burned or scalded by a cautery. The ed^es and base of the infiltra- 
tion are at first moderately hard ; but the hardness increases in the 
course of the disease, as may be proved by comparison with the 
healthy surrounding parts. The hardness extends itself either 
superficially into the skin and upper layer of areolar tissue, or deeply 
in the form of a roundish knob. In the further progress of the dis- 
ease, the scab becomes separated, and the corium projects and is 
observed to be overlaid with epithelial debris and pus. A well- 
defined, sometimes channeled, border denotes the limit of the 
epithelial abrasion. New epithelium is gradually formed at the 
edge of the abraded part; it has a pale white appearance, and 
gradually covers the part, so that a new integument is in time 
formed. The new skin is smooth, very tender, is easily torn, often 
desquamates anew, and is not safe from lesion until the induration 
has disappeared, and the ordinary softness and elasticity of the 
mucous membrane have been regained. The characters of the 
normal tissue of the part become so perfectly restored, that not even 
the practised eye can discern a trace of the chancre. The extent of 
the disease varies from the breadth of a lentil-seed to that of a 
finger-nail ; the infiltration is almost always confined to one spot. 
The disease is never produced in the sound lip by the contact of the 
diseased one. 

Indurated chancre with ulceration is developed in a different 
manner. If the infection be accompanied by a wound or fissure in 
the part, or if this occur at a later period in the infiltrated part, a 
portion of the affected tissue becomes purulent : this may be pro- 
duced through the destruction of the tissue by the chemical action 
of fluids, or by other irritating articles, such as tobacco and caustics, 
and by decomposed animal fluids, such as blood and pus. While 
several of these causes operate on the genital organs, so as to 



BITBGEBY. 221 

produce frequent and great destruction of tissue, it is only through 
great neglect of cleanliness that any great mischief can be produced 
by their action on the lips ; and when they act, it is most frequently 
at the angles of the mouth. The observation so often made in 
regard to the genital organs, that the disease commences with a 
purulent ulcer within the first twenty-four or forty-eight hours after 
infection, while the induration is not observed until the second or 
third week, can yery seldom be made in regard to the lips. If the 
disease occur in an anaemic or cachectic constitution, and the patient 
be exposed to deleterious'influences, such as cold, damp, impure air, 
or have improper diet, those well known obstinate ulcerations occur 
which are frequently enough met with on the genital organs, but 
seldom on the lips. The process of repair of the lost tissue in such 
cases is always imperfect, and even for years the cicatrix is dis- 
tinctly risible. The edges and base of these ulcers remain long 
indurated; and it is only gradually that the extensibility and 
pliability of the tissue of the lips is able to obliterate any observable 
traces of the disease. 

Venereal non-indurated sores appear so very seldom on the lips, 
that up to a recent time their occurrence liere (or on any part of the 
head) has been denied. But Dr. Sigmund has no doubt of their 
occasional occurrence, although it be very rare. 

The communication of infection from the diseased to the healthy, 
may be either direct or indirect. 

The direct communication of syphilis takes place most frequently 
through the contact of the lips of a diseased person. The infectious 
matter is furnished from tne mucous membrane of the cheeks, 
palate, throat, and tongue, mixed with mucus, saliva, pus, and serum. 
The inoculation of blood alone is sufficient. The infecting matter, 
however, does not affect the healthy person unless it rest on a surface 
denuded of skin. The knowledge of this fact, in combination with 
that of the long incubation and mode of development of syphilis, 
explains those occurrences for which very exceptional explanations 
have been offered, and which often have appeared to admit of none ; 
it especially explains the fact, not unfrequently observed, that an 
individual may communicate a perfectly characteristic chancre to 
another, and yet may present no appearance of syphilis on the part 
with which he has touched him. It explains also how the com- 
munication of syphilis by the mouth is comparatively so in- 
frequent, although the custom of kissing is so very common even 
among men ; for the infecting material takes effect only when it 
comes into contact with parts denuded of skin. Infection sometimes 
occurs through contact of the genital organs with the lips, through 
a disgusting practice (coitus viri cum labiis oris feminse). No case 
has occurred to Dr. Sigmund in which the communication of syphilis 
could be referred to the sucking of the wound made in circumcision. 
Doubtful instances of this kind have been frequently related to him ; 
but it has not been proved either that the children were syphilitic, 
or that the circumciser may not have become infected from some 
other source. On the other hand, the communication of syphilis to 
the finger, and thence to the lips, has been repeatedly noticed. A 



222 STJBGEBY« 

case of this kind, which Dr. Si^mund has observ^ed lately, was that 
of a midwife who was supposed to have a whitlow on the right fore- 
finger, but in whom the appearance of secondary symptoms (the 
genital organs and other parts of the body exhibiting no trace of 
primary disease) showed that the finger was affected with primary 
syphilis. The skin of the ungual phalanx around the nail was in* 
filtrated, of a deep red colour, and peeled off; and there were bleed- 
ing fissures at the fold of the nail. The child under her care con- 
tracted a chancre at the right angle of the mouth, and afterwards 
had constitutional syphilis. The midwife had nine weeks previously 
attended in confinement a woman who had papular syphilitic erup- 
tion. 

Indirect infection most frequently occurs in persons who use in- 
struments which may have been introduced between the lips of 
patients affected with syphilis of the mouth. Musicians who play 
on wind-instruments, and workmen who use blowpipes (as glass- 
blowers) are most frequently affected in this way. A very interest- 
ing case of this kind occurred in two chemists, who were accustomed 
frequently to work in their laboratory with the blowpipe. One of 
them had secondary syphilis and desquamated papules on the 
mucous membranes of the lips, mouth, and tongue. One blowpipe 
was in common use with them. His colleague contracted a chancre 
on the upper lip, without showing any other primary symptom, and 
without having been in contact with any other source of infection. 
A similar case was also observed six years ago in a chemical labora- 
tory, where two healthy persons were affected in rapid succession by 
the same diseased individual. Communication of syphilis throui^n 
smoking takes place most frequently where pipes are more used than 
cigars. Dr. Sigmund has observed very few cases of this kind; 
and the idea entertained in 1850 and 1851, that the syphilitic affec- 
tions of the lips then prevalent were due to the use of infected 
cigars, was proved incorrect by an accurate inquiry into the source 
of the disease in twenty-seven cases. Examination of the persons 
employed in cigar manufactories — almost all women and girls — 
proves the comparatively great rarity of syphilis among them ; and 
the exemplary cleanliness observed in the manufacture renders it 
almost incredible that the cigars can be charged with infecting 
matter. 

The experience of Dr. Sigmund has afforded him an opportunity 
of observing an unusually great number of ways in which syphilis 
may be indirectly transmitted. Many of the data of such cases fall 
to the ground on unprejudiced consideration, and still more on con- 
tinued observation of tne alleged facts ; and hence some deny alto- 
gether the mediate communication of syphilis. Unprejudiced and 
sufficiently extensive and accurate observation must, however, esta- 
blish more certainly the extent and frequency of mediate transmission. 
If traces of primary infection be not found on the genital organs or 
anus, the mucous membrane of the lips, mouth, and fauces should 
be the more carefully examined. Whenever many men, collected 
together, use in their common occupation instruments by which in- 
fection may be conveyed, especially such as are applied to the mouth, 



SUBOEBY. 223 

careful attention should be directed to this source of infection ; and 
the diagnosis and etiology should not be grounded merely on the 
history given by the patient, but on what has been observed by the 
medical man himself. 

Dr. Sigmund believes it very probable that many cases of syphilis 
in children, which are attributed to other causes, are traceable both 
to suckling and to artificial feeding, as from a bottle. He refers to 
a case in which vaccination was blamed as the cause, althougli no- 
thing abnormal was observed in the development of the vaccine 
pustule, and it was not until three months afterwards that a chancre 
appeared at the angle of the mouth. The wet-nurse and a servant 
in the house both had syphilis ; the child was suckled by the first, 
and was artificially fed by both. 

Primary syphilis has never been observed by Dr. Sigmund on 
the inner surface of the lips and cheeks, on the gums, or on the 
hard palate ; while secondary disease is not un-frequently met with 
on these parts, especially on the lips, cheeks, and tongue; the same 
observation is applicable to the soft palate and tonsils. He has, 
however, observed cases in which limited circular infiltrations with 
epithelial desquamation were met with on the tongue, tonsils, aiid 
soft palate, without any syphilitic disease being discoverable on the 
lips, genital organs, or any other parts of the body. It was extremely 
probable that the infecting matter had been applied directly to the 
parts affected ; and this view was confirmed by the observation of 
the further extension of the disease from these points. 

It is most frequently in sucking children and in those fed arti- 
ficially, that several infected spots are observed in the mucous mem- 
brane of the mouth. From the often imperfect observation made by 
those who have the care of such children, it is not strange that the 
first manifestations of the disease should be overlooked ; since, as 
is frequently the case, they consist of simple infiltration with more 
or less desquamation and fissures in the mucous membrane, and 
gradually heal without proceeding further ; giving place, however, 
to a host of constitutional symptoms, the primary source of which 
is often traced with great difficulty, frequently not at all. 

The course of chancre on the lips does not differ essentially from 
that on the genital organs. Abrasions and local destruction of the 
integument are favoured by friction, bruisinji:, biting, and by the 
action of the fluids of the mouth ; if it be protected from these in- 
fluences, the diseased part becomes gradually skinned over, and re- 
mains indurated for a longer or shorter time, according to the con- 
stitution and habits of the patient, and the treatment to which he is 
subjected. Even during the continuance of very moderate indura- 
tion or thickening, new desquamations or destructions of tissue are 
very easily produced, as is observed also on the genital organs. 
The lymphatic glands in immediate connexion with the diseased 
parts are at the same time infiltrated, and gradually those which are 
more distant; first the glands beneath the lower jaw, then the 
upper and posterior cervical glands, and then the axillary and re- 
maining cervical glands ; even the inguinal glands may become in- 
Yolved. Blotches are formed on the external skin; but, being 



224 SUBGEBT. 

usually of short duration, are not always observ^ed ; and accompany- 
ing and following these appear scattered papules, usually in small 
numbers, partly on the face and hairy scalp, partly on the neck, to 
which they gradually extend from the head. In a number of cases, 
however, all these appearances affecting the external skin are not 
produced, or are very scanty and limited in extent ; while the palate 
and tonsils, both together or in succession, more frequently the latter, 
are the seat of sharply defined swelling, redness, and infiltration, 
which is soon followed by desquamation of the epithelium and folli- 
cular infiammation of the tonsils. The secretion from these, united 
with the muco-pus from neighbouring parts, forms often a more or 
less copious yellowish discharge. All the patients do not suflfer from 
dryness, heat, burning, or difficulty in swallowing, breathing, speak- 
ing and coughing, which might be assumed to be the necessary 
results of such disease ; on the other hand, changes in the voice, 
even amounting to its loss, are constantly observed ; and in persons 
whose voice was known to Dr. Sigmund before they become diseased, 
he has observed this change to be produced in the slightest cases. 
The disease of the palate and tonsils appears first after the chancre 
of the lips has lasted some time, and simultaneously with the affec- 
tion of the glands. That the infiltration of the cervical glands is 
not a mere consequence of the disease of the palate and fauces, is 
proved by the fact that in some patients these parts remain un- 
affected, and yet the glands become infiltrated. Certainly, the 
swelling is increased in several, as the anterior cervical and submaxil* 
lary lymphatic glands, as soon as the mucous membrane between 
the jaws and on the palatine arches and tonsils becomes affected. 

The time within which secondary or constitutional symptoms are 
developed from the local or primary disease, is the same here as in 
the genital organs. Two or three weeks, seldom later, after the first 
appearance of the disease on the lips, the glands become diseased — 
t. e, from the sixth to the seventh week after the first inoculation, 
as the incubation-period of syphilis is of two or three weeks' dura- 
tion. An apparent exception occurs when the contagion is imparted 
at the same time from a soft venereal ulcer (chancroid). An ulcer 
then generally appears in from twenty-four to forty -eight hours, the 
edges and base of which become indurated at a later period, even in 
the second or third week. Even here, also, the induration which 
occurs from the second to the third week, with the gradually de- 
veloped affection of the lymphatic glands, is characteristic of syphilis ; 
and we observe the same course followed as in " mixed " chancre of 
the genital organs, and the usual results of this. Acute inflamma- 
tion of the nearest submaxillary lymphatic glands sometimes even 
appears, leading to suppuration, as in the soft contagious sore of the 
genital organs. This combination of the contagious ulcer with the 
infectious infiltration affords an opportunity for the extension of the 
disease to neighbouring parts, and gives rise to the production of 
numerous and extensive purulent discharges followed by slow cica- 
trization ; while the syphilitic infiltration (induration) once developed 
does not allow the transmission of the disease in the same individual, 
even to the adjacent parts or to those with which it comes into contact. 



sirsGBST. 225 

The treatment of'clumcre of the lips differa from that of the 
genital organs only in the adaptation of the remedies to the special 
condition of the part. As local applications. Dr. Sigmund recom- 
mends corrosive sublimate (one part in eight of spirit) ; sulphate of 
copper and nitrate of silver (in substance, or one part in six of 
water). Solutions of caustics in glycerine are useful, on account of 
their not drying too rapidly. Calomel, corrosive sublimate, sulphate 
of copper, or white precipitate, may also be advantageously com- 
bined with diachylon plaster in cases where it has been the custom 
to use Vigo's plaster. In the application of the remedies, the sur- 
geon should take care to carefully cleanse and dry the diseased spots, 
and to apply the remedy in very small quantity— in the fluid state, 
•with a brush, is preferable ; this is to be repeated daily until the 
spots are perfectly covered with skin. If considerable reaction 
follow the use of the stimulant applications, the surgeon must with- 
hold them for thirty-six or forty-eight hours. If firmly adherent 
scabs be formed, an attempt should be made to remove them with- 
out injuring the skin, after first oiling them. If the scabs adhere 
firmly, and no fluid be concealed beneath them, the formation of skin 
goes on, and the scabs gradually scale off* and leave the new epider- 
mis, somewhat thinner and paler than that in the vicinity. The in- 
duration, however, remains for a long time ; in some otherwise 
unhealthy persons, from six to nine months. The formation of new 
skin and the removal of the induration and of the secondary symp- 
toms are hastened by the combination of local with general treatment. 
The object is soonest gained by inunction with blue ointment ; other 
mercurial preparations, as corrosive sublimate, calomel, protiodide of 
mercury, &c., are more tedious in their action. The most thorough 
cleansing of the mouth and fauces is always necessary. From the 
commencement of the treatment, lotions and gargles, consisting of 
solution of chlorate of potassa, borax, alum, sulphate of zinc, tannin, 
&c., according to the individual state of the mucous membrane, 
must be frequently used. The teeth and gums must be kept clean 
by means of charcoal ; and if the tonsils be swollen, some of the 
above-named solutions may be inhaled through the nose or injected 
on them by the mouth. 

Art. 106. — A Case of Pneumatocele of the Skull folloioing 
Fracture of the Petrous BonCj in which the Patient 
Recovered.' 

By M. Chevance, of Wassy. 

(BvU. de Thir,, Aodt 30, 1863 ; and British Medical Journal, 

Oct. lU, 1863.) 

Emphysematous tumours of the cranial region do not seem to be 

common. One has been recorded by M. Jarjavay; and another by 

M. Balassa of Pesth, in the Archives GSnerales de Medecine for 1853. 

To these, M. Chavance adds the following : — 

Case. — A miner, aged 44, of good constitution, fell, in 1850, from a height 
of five mHres (nearly five yards and a half) on his feet; and immediately felt a 
xxxviii. 16 



226 SUBGBST. 

very intense fixed pain at the back of his headj on thel^ft side, with dazzlings 
of the eyes, slight giddiness, and singing in the ears ; he felt stupified abo 
for half an hour, but did not lose consciousness. He said afterwards that he 
several times beard a crackling sound at the back of his head, in the situation 
of the pain. There was no wound, nor any escape of blood or of any fluid 
by the ears, nose, or mouth. The symptoms which followed were, pain at 
a distance of five centimetres behind the left external auditory meatus, and 
difficulty of swallowing on this side. No treatment was pursued. Six weeks 
afterwards, there was difficulty of hearing, and constant troublesome buzzing 
noises in the left ear. At the same time, there appeared at the painfhl spot 
a small tumour, which remained stationary eight months, and then increased 
rapidly in size, so as to occupy the left posterior half of the head and almost 
the whole of the occipital region. Two punctures were made in it by a 
medical man; but air only escaped. At this time, seventeen months 
after the receipt of the injury, the patient entered the hospital at Wassy. 
At this time, the tumour commenced four centimetres from the ear, had a 
transverse extent of fifteen centimetres, and extended from the neck to the 
back of the head, forming a curve of twenty centimetres in extent on the left 
side and eighteen on the right. It was painless, elastic, resistant to pressure, 
without heat or any trace of inflammation, and gave a tympanitic sound on 
percussion. There was no pulsation nor fluctuation. On being punctured 
with a trocar, it gave issue to gas alone, which, on being collected under 
water and tested, presented all the characters of atmospheric air. After its 
removal, there were found, a little above and behind the mastoid process, 
about four or six centimetres from the left auditory meatus, two hard, bony, 
unequal projections, between which a depression was felt ; it was in this 
situation exclusively that the patient had always complained of pain. When 
the man made a strong expiration, the nose and mouth being closed, the air 
escaped with a hissing sound through the left ear. When the swelling was 
compressed with the hand, it collapsed, and gradually shrivelled, producing, 
the patient said, a crackling sound in the left ear. The membraua tympani 
was tern. 

M. Chevance concluded that the case was one of fracture of the petrous 
bone by contrecoup, producing a communication between the tympanic cavity 
and the areolar tissue lying beneath the scalp ; and in this way he explained 
the gradual formation of the pneumatocele. In order to produce a radical 
cure, be determined on provoking adhesive inflammation on the walls of the 
tumour. A seton was therefore introduced, by which violent inflammation 
was set up ; and on the third day, there was an abscess which, on being 
opened, discharged 500 grammes of pus. In a month, the adhesion of the 
skin appeared complete. But, two months afterwards, the tumour again 
formed, being attended with the same symptoms. An abscess was, therefore, 
again evicted by the introduction of another seton ; and on this occasion the 
cure was permanent. In M. Ballassa's case, also, the cure was completed by 
the excitation of inflammation so as to produce adhesion of Ihe integuments. 



Art. 107. — A Symptom of Fracture of the Base of the Skull. 

By M. DoLBEAU. 

(Presse Mid, Belg.f Avril 27, 1863 ; and British Medical Journal, 
June 7, 1863.) 

In a comTnunication made to the Surgical Society of Paris, M. 
Dolbeau has called attention to the presence of eccnymosis of the 



SUSGEST. 227 

pharynx at its upper part as a sign of fractnre of tlie base of the 
skull. In a case admitted into the Bicdtre, where death took place 
twelve d&jB after the receipt of the injury, the patient complained, 
when sensible, of pain in swallowing. On exammation after death, 
the base of the skull was found fractured ; and there was infiltration 
of blood behind the pharynx, from the occipital bone to the second 
cervical vertebra ; the mucous membrane of the pharynx was also 
evidently ecchymosed. In two other cases in which the symptoms 
pointed to injury of the base of the skull — contusion in one, and 
fracture in the other — and in which recovery took place, pain in 
deglutition was complained of ; and, on examination, in each case 
there was found to be ecchymosis of the posterior wall of the pharynx. 
The portion of the pharynx in which the ecchymosis occurs is rather 
difficult to be seen ; it is limited by the bone of the skull above and 
the velum palati below, by the vertebral column behind, and the 
posterior orifice of the nares in front. 



Art. 108. — A Specimen of Fractnre of the Odontoid, Process 
of the Axis, with Perfect Anchylosis of its Apex with the 
Occipital Bone, and Partial Luxation forwards of the 
Atlas. 

By Mr. Philip Bevan. 

(Dublin Medical Press^ February 18, 1863.) 

This important specimen, which was exhibited at a meeting of 
the Surgical Society of Ireland, was discovered accidentally while 
making a dissection of the ligaments of the spine. On opening the 
spinal canal, and removing the dura mater, the perpendicular liga- 
ment or apparatus ligamentus colli was normal in size and strength, 
but on removing it, the apex of the odontoid process of the axis was 
found to be connected by perfect bony union to the anterior margin 
of the foramen magnum of the occipital bone, whilst its neck was 
attached to the body of the bone by a fibrous substance, about 
three-quarters of an inch long, of great strength and thickness, 
which closely resembled that which ordinarily unites the fragments 
of a broken patella. On cuttinoj into this substance, the transverse 
ligament was found of its natural strength and thickness, retaining 
its normal cohnexion to the atlas on either side, but completely 
altered in its relations and position ; for instead of passing behind 
the odontoid process, with a concave surface covered with cartilage 
and synovial membrane, directed towards that process, it now lay 
between the broken-off point of the odontoid process and the body 
of the axis, with flat surtaces upwards and downwards. It still pre- 
sented its usual glossy appearance when dissected from the fibrous 
tissue in which it was imbedded, and was fully as strong as in the 
natural state ; but the smooth, articular surface and synovial mem- 
brane were removed from its anterior surface. Not a vestige of 
either the moderator or suspensory ligaments remained. Having 

15—3 



228 8UB0BBY, 

dissected the anterior surface of the spine, the upper articular pro- 
cesses of the atlas retained the normal relations to the occipital con- 
dyles ; but the lower ones were thrown forwards, considerably in 
front of their natural position on the dentata, and were supported 
there by a bony growth from the anterior margin of its articular 
processes ; in fact, the atlas was partially luxated forwards, for want 
of the support of the odontoid process, and the axis was modelled 
80 as to support that vertebra in its new position. 

The anterior atlanto-axoidal ligament was very strong, and must 
have served to prevent further displacement of the atlas. 

On examining the bones the following changes were found to have 
taken place: — The occipital foramen magnum was completely 
changed in shape, being heart-shaped, instead of oval, owing to the 
attachment of the apex of the odontoid to the centre of its anterior 
margin. 

Its transverse diameter is greater than the antero-posterior, the 
former being one inch and a quarter, whilst the latter is only ten- 
twelfths of an inch. 

The most normal size is the reverse of the above. 

The apex of the odontoid is so completely incorporated with the 
occipital bone, that, but for a slight crack on the right side, no ap- 
pearance of the line of union would be perceptible ; the base of it 
18 smooth as if cut with a knife, where it was attached by a fibrous 
tissue to the body of the axis. The occipital condyle of the right 
side is unaltered, but that of the left side is changed in shape, axis, 
and direction, being flat, circular, and directed downwards and out- 
wards ; transversely larger than natural ; about three-fourths of an 
inch in diameter ; smooth and covered with cartilage on its surface, 
but rough and irregular round the margin. The inner surfaces of 
the condyles are quite smooth, instead of being rough, for the attach- 
ments of the moderator ligaments. 

The upper articulating surfaces of the atlas are not much altered ; 
the left one is more round than oval, and not contracted in the 
centre, as in the normal state. The lower articular processes, on 
the other hand, are much altered, being rough and irregular on the 
surface, surrounded by a bony growth, as in cases of chronic rheu- 
matic a rthritis, and much larger than natural, especially in the antero- 
posterio r diameter ; but the chief alteration has taken place in the 
anterior ring of the bone ; it is contracted inferiorly by irregular 
growths from the lower articular processes. The posterior surface 
of the ring is prominent and rather rough (instead of being smooth 
and lined witi cartilage and synovial membrane) ; it was here firmly 
united to the fibrous tissue, which united the apex to the base of 
the odontoid p rocess. The lower surface of this ring is thick and 
broad, where it iay on the upper surface of a process of bony growth 
from the anterior margin of the odontoid process. 

The axis is also much altered ; the body of the bone terminates 
above, in the base of odontoid, from which the apex has been 
broken; from the front of this a bony mass has grown in a groove, 
on the top of which rested the anterior ring of the atlas, with which 
it was connected by the above-mentioned mass of fibro-cartilage i 



8UBGBBT. 229 

the npper articnlar processes are on different planes, the left being 
lower than the right, both of them are much enlarged by bony 
growth from their anterior margin, which overhangs the body of the 
bone to the extent of a quarter of an inch. This served as a sup- 
port for the luxated articular processes of the atlas. The surfaces 
are rough and were covered by a very imperfect cartilage ; the right 
is convex ; the left concave. 

The remains of the base of the odontoid is rough and very convex 
towards the vertebral canal; its upper surface is very irregular, 
bein^ grooved transversely in front for the anterior ring of the atlas 
and behind for the attachment to the fibro-cartilage. It is much 
enlarged bj the bony growths above described, being about two 
inches in circumference at the part corresponding to the neck of 
the process, and is so rough and irregular as to give it much the 
appearance of the bone represented in Mr. Adams* book, " On 
Rheumatic Arthritis." 

" I am not aware," says Mr. Bevan, " of any case similar to the 
above. E^okitansky says that, * in a few cases, fracture of the odon- 
toid process has not only not proved fatal, but has existed for a 
considerable time without union of the fragments. A specimen of 
this kind is contained in the Vienna Museum.* 

" 11 e gives no particulars concerning it, says nothing of the state 
of the moderator ligaments, or whether the point of the odontoid 
was anchylosed to the occiput ; nor does he mention the partial 
luxation of the atlas. 

" The specimen was taken from a woman, aged about 40, who 
died of dysentery in one of the Dublin unions ; all her bones were 
healthy and strong. 

" Althouj^h it is impossible to obtain a history of such a case, yet 
I had sufficient evidence that she never had anything remarkable 
about the motions of her neck ; nor had she ever complained of pain 
or stiffness. Indeed an examination of the preparation would prove 
that she must have had considerable power of moving the neck, as 
the fibrous tissue, which united the base and apex of the dentatus, 
although very strong, would permit a considerable amount of 
twisting, which with the ordinary circumduction of the remaining 
cervical vertebrae would be sufficient for all ordinary purposes, and 
the nodding motions could not have been interfered with. 

" It was, till lately, a generally received opinion that both luxa- 
tions and fractures of the odontoid process were necessarily fatal. 
Thus Chelius says, * that if fractures occur with luxation above the 
third vertebra, death speedily ensues.* Samuel Cooper savs, * that 
whenever the processus dentatus is suddenly displaced or fractured, 
the effects on the medulla spinalis must be immediately fatal.* Sir 
A. Cooper, Boyer, and Dupuytren, all declare that such cases are 
necessarily fataj. This opinion can no longer be admitted as regards 
fractures of the odontoid process, although I believe it is correct as 
regards luxations of that bone ; for I cannot find any case of 
recovery where this process was proved by dissection to have been 
luxated without fracture. Two cases of supposed reduction of lux- 
ations of the axis are given in Malgaigne, but in both the diagnosis 



230 BUBGBBr. 

was very doubtful j in the first, the only important symptom was, 
that the head was bent forwards, so that the chin rested on the 
sternum. This might have been a luxation of auy other cervical 
vertebra ; and, in the second, although the constitutional symptoms 
were more important, and the head was thrown backwards, and to 
the right side, still it was equally doubtful which vertebra was lux- 
ated, or indeed whether any vertebra was luxated. The interesting 
cases given by Dupuytren in his work * On Fractures,' prove that 
it is extremely diflicult to diagnose between severe contusions of the 
muscles and ligaments of the neck, and luxation of the cervical ver- 
tebras. In one of these eases the head rested on the left shoulder, 
could not be straightened, was accompanied with violent pain in the 
opposite side of the neck, numbness of the corresponding arm and 
cheek, difficulty of deglutition, and inability to turn the head without 
the body ; in fact, all the symptoms of luxation were present, and a 
luxation was supposed to exist ; yet, in a few days, all these symp- 
toms were removed by mere leeching and stuping. It is difficult to 
believe that a luxation of the odontoid process without fracture 
could occur without death supervening, if we recollect that either 
the transverse ligament must be broken, or the point of the process 
must pass under that ligament, which cannot occur vrithout lacera- 
tion of both the moderator and perpendicular ligaments, and that, 
in either case, the process must directly press upon the medulla 
. oblongata, on the slightest motion of the head forwards. 

" But although luxations of the odontoid process must be fatal 
from pressure on the medulla, fractures of that process are by no 
means necessarily so. No doubt most of these must be fatal, either 
from the fearful shock to the system caused by such an amount of 
violence as is required to break that bone, or from the extravasation 
of blood on the medulla ; but should the patient escape those 
dangers, there is no necessity for him to die of pressure of either of 
the fragments on the cord ; in fact, the apex will be kept in situ by 
the moderator and transverse ligaments, whilst the base is retained 
by the powerful* apparatus ligamentosus colli. In experiments on 
this subject, having first cut across the odontoid process with a fine 
saw, without injuring the ligaments, in attempting to force the spine 
forcibly forwards, I found that the bones themselves gave way before 
any considerable amount of pressure was made on the medulla by 
the bodv of the axis, owing to the great strength of this ligament. 

" Malgaigne has collected three cases of this fracture of the odon- 
toid with luxation of the atlas ; in one, the patient lived seventeen 
days ; in the second, he lived for one month and six days ; and, in 
the third, he lived for four months. 

" Whilst a still more interesting case is given by Dr. Parker, of 
New York, where the patient walked about on the fifth day after 
the accident ; on the ninth day resumed ordinary occupations ; con- 
tinued at his work, notwithstanding constant pain in the head and 
neck, for five months, when he suddenly became paralysed and died; 

* This ligament is so strong that it has heen divided into three layers by 
Dr. Humphrey in his excellent work, ''On the Bones." 



BUBOBST. 231 

yet the odontoid process was broken off, and its lower extremity was 
pressing on the cord at the time of his death. 

" This specimen proves, not only that a patient may live for 
months but for many years, as there can be little doubt that the 
accident happened in very early life. Indeed, that it occurred before 
the union of the epiphysis was consolidated to the body of the bone 
is rendered extremely probable, by the anchylosis of its apex to the 
occiput, as it is well known that the point of that process is the 
last part ossified, and would, therefore, be more likely to become 
adherent at that time than after the process of ossification had been 
completed. The alteration in the shape of the anterior ring of the 
atlas, and the smoothness of the surfaces of the occipital condyles, 
where the moderator ligaments were attached, would lead to a 
similar conclusion. 

** In order to produce the accident, the neck must have been first 
violently twisted, so as to tear away the moderator ligaments, and 
then the neck must have been flexed backwards or forwards to break 
the odontoid process. The only practical deduction to be drawn 
irom these cases is the necessity that perfect rest should be observed, 
and that a long time should elapse oefore a patient, who has re- 
ceived an obscure injury of the cervical region, should be permitted 
to support the weight of the head on the spine. Had Dr. Parker's 
case submitted to restraint it is quite possible the broken bone 
might have united, and the patient Uvea as long as in the present 



Art. 109. — Otim, Simple Mode of Removing Foreign Bodies 
from the Gullet. 

By Mr. . 

{Medical Record of AmtraUa, April 30, 1863.) 

The plan proposed by our anonymous writer may be said to be 
the same as that adopted for extracting pieces of cork from bottles, 
the only difference being that the ends of the wire are bent outward 
and upwards, instead of bemg turned in, and in place of a wire ring 
to compress the prongs, a large sized catheter is passed down to their 
extremities, which, when the wires are passed beyond the obstruc- 
tion, is drawn up to allow the prongs to expand. Th^ instrument is 
made in the following manner : — Three or four pieces of elastic wire, 
from 20 to 24 inches long, are twisted together down to within half 
an inch of their extremities, the extreme ends of which are curved 
outwards and upwards, and carefully filed down to prevent them 
injuring the coats of the canal ; a piece of large-sized catheter of the 
same length is passed down, to prevent the prongs expanding, the 
extremities fitting well over the end of the catheter, to admit of the 
instrument readily passing beyond the obstruction, without driving 
it deeper into the walls of the canal. If catheter tubing cannot be 
obtained of sufficient length, a piece of string may be attached to its 
upper extremity, to allow of its being drawn up, to allow the prongs 



232 SUBGBBT. 

to expand. The instrument, with the prongs closed, is passed down 
tlie gullet, well beyond the piece of bone or money ; the tube is then 
drawn up, and the instrument with the prongs expanded, withdrawn, 
bringing with it the foreign body. Some difficulty may be expe- 
rienced with fine, long fish-bones, from the extremities of the prongs 
not being able to obtain sufficient hold upon them to loosen them 
from their attachment to the mucous membrane, but if floss silk is 
passed loosely from the extremity of one prong to the other, this will 
be overcome. The following cases will illustrate the action of the 
instrument : — 

Case 1. — A servant girl swallowed a piece of the rib of a small cod fish in 
a spoonful of mashed potatoes. She felt something stick in her throat, and 
made several efforts to bring it up, but without effect. She then swallowed 
a large quantity of water, with the efilsct of carrying it lower down.. She 
experienced pain of a pricking character, which was greatly aggra\ ated by 
attempts to swallow either liquids or solids — the latter, she said, drove the 
bone deeper and caused her severe pain. The sensation was so severe, 
during the night, that she was unable to sleep. At one p.m., on the second 
day, twenty hours after the bone was swallowed-, sh© was unable to swal- 
low a tea-spoonful of water, and the effort to swallow the saliva caused 
^reat pain, and there was considerable tenderness deep in the neek behind 
the trachea, and redness of the fauces.. Efforts had been made, several hours 
before, to introduce a probang and force the obstruction down, but with no 
other effect than to increase her sufferings. The pharynx and oesophagus 
seemed to be in a state of spasm and inflammation. She was highly hys- 
terical, the hysteria possessing something of an hydrophobic character — 
being excited by the noises in the street, and by the efforts to swallow a tea- 
spoonful of water. The attempt to introduce the instrument excited severe 
spasm of the muscles of the pharynx, she was therefore brought under the ' 
influence of chloroform. The instrument was passed down several times, 
but without being able to catch the bone ; some floss silk was then passed 
loosely from the extremity of one prong to the extremity of the other, and 
on its being again introduced, the piece of bone was caught and brou^iht up. 

Case 2. — A man between 40 and 50 years of age, swallowed a piece of 
bone in a spoonful of soup. He first felt it in the lower part of the pharynx, 
but it descended to opposite the second rib before it was arrested. He said 
that he could feel it pricking when he drew a deep breath and swallowed his 
saliva. Beyond a sense of uneasiness, this was the only inconvenience. H© 
was seen within an hour of the accident. The instrument was passed down 
to the bone, which could be easily felt, lying across the canal ; with some 
little difficulty and pain, it was passed between it and the canal and then 
opened, and the piece of bone, which was of the diameter of sixpence, with 
two spine-like projectures, making it about an inch in length, was readily 
brought away. 

Tliere is an advantage in doing without chloroform, as the surgeon has 
then the sensation of the paiient to guide him in passing the instrument. 
"When chloroform is used, there is risk, particularly when fish bones are 
impacted, in driving them deeper into the walls of the canal. In tlie first 
case, this seems to have taken place, and had the floss silk not been thought 
of, the bone would have been obliged to have been left, and the patient 
exposed to abscess of the walls of the canal, and, perhaps, also of the lung. 

Case 3. — A little girl had swallowed a curtain ring two days before the 
case was brought under our notice by a mediciil friend. Emetics had beeu 
^iven, without effect, and an attempt had been made to pass a probang, but 



suBaBBT. 233 

the cries and struggles of the child had prevented it. It was doubtful 
whether the ring had really been swallowed, the only evidence of the 
existence of an obstruction was an inability to swallow solids. ''They 
returned," the mother stated, "as they were swallowed." She was placed 
under the influence of chloroform. When the instrument was passing down, 
a slight tick was heard opposite the upper border of the sternum. It was 
passed a short distance further, then opened, and withdrawn, and the ring 
was brought into the mouth. 



Art. 110. — On the Normal Pvsition of the EpigloUia as 
determined hy tlie Laryngoscope. 

By Dr. GiBBj Assistant-Physician to the Westminster 

Hospital, <kc. 

(BeMs Archives of Medicine, Na 13^ 1863.) 

This paper is based upon a laryngoscopic examination of 520 
healthy persons. " In the course of my investigations," Dr. Gibb 
says, " I discovered that there were individuals whose epiglottis was 
not elevated, but naturally depressed, and had been so from birth. 
In other words, that it was an abnormal physiological condition, so 
to speak, for there was really no evidence to prove the existence of 
any disease past or present giving rise to it, and the interior of the 
larynx could not be seen but with great ditBculty, from the absence 
of the erect position of this fibro-cartilage. Very probably if this 
condition has been noticed by otliers in the healthy, it has been set 
down to relaxation of the proper ligaments of the epiglottis, or to 
some state allied to disease; In the large number of healthy persons 
examined, I satisfied myself that it was not so. Many of my inspec- 
tions were sometimes made on single individuals, at others on a 
number in the presence of a company of persons taking all indis- 
criminately. In this way, I have examined parties of from six to 
ten and twenty persons on single occasions. Tliey included several 
young children of both sexe.s, and persons as old as sixty, and a few 
upwards to the age of ninety-two. I have seen the larynx in 
children at the first examination, and it is astonishing how well they 
comport themselves under the influence of example; and I may 
state that the vocal apparatus in the chil<i is one of the most beauti- 
ful objects that can come under the notice of the physiolojjjist. 

"A certain proportion of the 520, that is to say, eleven per 
cent., had an absence of the erect position of the epiglottis, and I 
was enabled to determine in a few that it actually was congenital, 
for whilst the parent had this condition, so had the child, and yet 
in neither had any inconvenience that I could determine, been ex- 
perienced. 

" Although I have frequently examined the epijjlottis in the dead 
as well as the living, I was not aware of the circumstance, until I 
read it in Dr. Tiirck's book on the Laryngoscope (French edition), 
that in the dead the epiglottis projects backward more than in 
the living, and the plates publish 3d in his work illustrate this, 
for they were taken from the dead. Dr. Tiirck considers it neces- 



^34 8USGEST. 

sary to remind the reader of his book that it is important fof 
him to remember, that in the living individual, the epiglottis 
seems less strongly projected backwards, and that in consequence, 
the interior of the larynx can be seen more readily than in the dead ; 
and this he had confirmed by numerous laryngoscopic observations 
made upon the dead. 

** This fact renders my own observations only the more important, 
for the depressed condition of the epiglottis occurring as a natural 
state, produces such alterations in phonation, and such inconve- 
niences in the event of disease, together with rendering the indivi- 
dual so circumstanced predisposed to incur serious pathological 
changes, that an early examination of the larynx in the young, 
should be a matter of necessity, as a guard against future evils, as 
much 80 indeed, as vaccination is a preventive or modifier of small- 
pox. 

" The physiological modification of phonation, the result of back- 
ward epiglottic prqieotion, is an absence of clear intonation, so 
usually heard in young persons. Vocal utterance is thicker, deeper, 
and more guttural in character, and as far as I could make out, the 
persons thus placed were not singers, unless to a moderate degree. 
One lady who had her epiglottis placed in the manner described, 
and who was not aware of it, until I discovered and explained it to 
her, assured me she* always enjoyed fair health, but tnat »t times 
her throat felt tired. Her daughter, a girl of 16, with her epiglottis 
precisely in the same position, was delicate when young, but Icould 
not ascertain whether she ever had any throat derangement. 

" The condition of the epiglottis in the 520 persons examined, 
varied much according to age and sex ; when vertical it possessed 
the natural shape and colour in nearly all, being modified in regard 
to the former in the young and the male sex, and in females «p to 
30, and a few upwards. Whilst in elderly, in some it was thinner, 
curled laterally forwards, and in colour somewhat altered to grey or 
drab. As an invariable rule, the interior of the larynx could be seen 
with greater facility in the elderly than in the young. In those 
again m whom the vertical position was absent, the cartilage was 
thinner, much thinner, fiatter, and broader, and in some it appeared 
to excite a constant secretion of mucus between it and the sides of 
the glottis, with which it was in contact. As compared with the 
vertical, even in the young, it had not the plump and thick appear- 
ance which is so striking in the vertical, in one instance of nearly 
horizontal position in a lad of 18, who was the subject of fissure 
through the soft and hard palate, it possessed the natural appear- 
ance and thickness, and was itself slightly fissured. 

" The attenuation of the epiglottis in these cases is, I think, suffi- 
ciently explained by its exposed poflition, and arrest of action ; it 
resembles a muscle that has become wasted from the want of use, or 
the absence of any power to excite it to contraction ; and in the 
event of disease, we can imagine the further risk to which it is ex- 
posed, not to say that from injudicious topical medication. 

"We will suppose, for an instant, that a person is being treated 
for a throat malady, with the epiglottis lying almost flat upon the 
glottis, and that without makmg an inspection of the parts, a 



8VBOBBT. 285 

sponge pTobang is introduced with the intention of passing into the 
larynx. What would be the effect of such a proceeding upon the 
person undergoing the operation? The glottis would be almost 
completely closed by the pressure of the sponge upon what is here 
the upper surface of the epiglottis, and suffocation is for a short time 
imminent. Ot seyeral instances which have come under my im- 
mediate observation for diagnosis, this condition of the epiglottis 
obtained, and the sponge probang had been introduced several 
times before the persons came to me, whose glottis had never been 
inspected by the laryngeal mirror, and their sufferings during and 
after the operation were described as being severe in the extreme. 
I^ot only is their misery au^^mented in undergoing this infliction, 
but the upper or interior surface of the mucous membrane covering 
the cartilage, and most likely the cartilage itself, is severely injured. 

" My present belief is, that if this position of tbe epiglottis has 
resulted hrom disease, there is a possibility of rectifying it, but if it 
is a normal congenital peculiarity, then I am afraid it is almost 
irremediable, as the ligaments and muscles attached to it are so ar- 
ranged that it is next to an impossibility to alter them, until further 
light has been thrown upon the subject." 

Dr. Gibb's general conclusions are these : — 

"1. Physiologically speaking, the epiglottis is vertical in the 
great majority of mankmd ; in a certain proportion it is oblique 
or transverse. 

" 2. The evils likely to arise from the latter at present appear to 
be so inconvenient, that it would be desirable that an inspection of 
the glottis should be made in every child where practicable, between 
the ages of four and ten years, &)r the purpose of ascertaining its 
correct position. 

" 3. If it is found to be not vertical, a knowledge of the fact will 
prove beneficial through life in guarding against evils likely to arise 
during the prevalence of epidemic sore- throat, or other diseases 
likely to involve the larynx. 

"4. No interference with the throat or larynx should ever be 
permitted without the aid of laryngoscopic inspection. 

" 6. Whilst any imperfection in the voice or speech may be ex- 
plained by the position of the epiglottis, independently of the 
vocal cords, a chance for the improvement of both is hela out, by 
adopting some means that shall render this valve more oblique in 
direction than transverse, or possibly (but at present very doubtful) 
restore it to a vertical position." 

Art. 111. — On the Treatment of Hoarseness and Loss of 
Voice by the Direct Amplication of Galvanism to the 
Focal Cords. 

By Dr. Morell Mackenzie, Physician to the Dispensary 

for Diseases of the Throat. 

{British Medical Jowrncd, September 23, 1863.) 

For the purpose of applying galvanism directly to the vocal cords, 

Dr. Mackenzie has contrived a very simple and efficient instrument^ 



^6 



JSUBOEBT. 



and with its assistance he has several times succeeded in cnrini; 

cases of long-standing aphonia which had obsti- 

^^ nateljr resisted the ordinary external mode of 

^Hi^^ applying galvanism. In his paper he gives the 

U ^^^^ particulars of sixteen of these cases. 

^^ "The operation," says Dr. Mackenzie, "re- 

quires but little skill on the part of the operator, 
and still less fortitude on the side of the patient. 
Whether m?.gnetic or chemical electricity be 
employed is not a matter of any importance. 

** To employ nmgnetic electricity properly, an 
assistant is required to turn the electric machine 
with one hand, and with the other to hold one 
sponge against the side of the neck, either over 
the situation of the pneumogastric nerves, or 
directly on the thyroid cartilage. The operator 
should hold the laryngeal mirror with the left 
hand, and with the right introduce the laryngeal 
galvanizer below the epiglottis. He now touchefl 
the spring on the upper part of the instrument 
with his index finger, and the current passes 
directly to the cords. 

" The woodcut shows the instrument very 
weU ; and it can be seen that the current does not 
pass beyond the metal ring (b) till the operator 
touches the ivory handle (i), when the spring 
(s) connects the two rings (a and b) ; and the 
current then passes on to its destination. The 
irritation of a foreign body in the larynx causes 
the vocal cords ta become tightly approximated, 
■ and thus it renders it easy to touch their upper 
surfaces. By placing the point of the laryngeal 
galvanizer on the arytenoid cartilages, both 
branches of the pneumogastric may receive the 
electric impression. 

" In conclusion, I may observe that I have 
employed galvanism to the larynx in more than 
thirty cases, and that no baa effect has ever 
followed its use. Most patients feel the electric 
action more acutely externally than in the 
larynx, though some have told me that they 
felt an agreeable sensation of warmth passing 
down from the larynx to the scrobiculus cordis. 
Others, again, have described a choking and 
pricking sensation in the throat. 

"The success attending the application of 
galvanism to the cords in aphonia will depend 
entirely on the proper selection of cases suitable 
for treatment. The absence of any structural 
disease or inflammatory changes, on the one 
hand, and a state of impaired innervation ouihe other, are of oourae 




SUBGEBT. 237 

the features which promise the most satisfactory results from this 
method of treatment." 

We give one case in illustration : — 

Ca&e.— Loss of Voice, of Three Years* standing, cured hy Eight Applica- 
tions of Oalvanism internally ; a hoarse Voice returning after tite Fourth 
Application. — Miss Kate H., aged 26, consulted me in March, 1863, for 
loss of voice. The young lady Ijoked rather delicate, if not sickly ; but did 
not complain of weakness. She was of a cheerful disposition, and did not 
appear in the least degree hysterical. She informed me that, in April, 1860, 
she took cold, had an ulcerated sore- throat, and lost her voice. She after- 
wards wrote me a more detailed account of her aphonia, which I shall give 
as far as possible in her own words. " After recovery from the sore- throat, 
the voice did not return ; and in October, 1860, her regular medical at- 
tendant applied caustic twice to the throat, but without any effect." Sh« 
then consulted some of the leading London physicians, and, among others, 
Dr. Walshe, who clearly recognised the nervous character of the disease, 
and "recommended galvanism to be applied, first by one of Pulvermacher's 
chains, and afterwards, if that did not succeed, by means of a battery. 
Neither produced any effect." This distinguished physician then " strongly 
urged her to leave it to nature, which she did till April, 1862, when she had 
the throat painted with iodine, with no other result than making it very 
sore on the outside." In May, another eminent physician prescribed 
^ zinc pills, which were taken three times a day for a month, without any 
result. In June, 1862, Dr. Blandford met Dr. Czermak, to examine the 
throat with the laryngoscope. Galvanic shocks were strongly advised ;'* 
and, in the following November, Miss H. placed herself under a physician 
who has paid especial attention to medical electricity. **He applied 
galvanism every day with a metallic brush, and afterwards in a stronger 
form for a fortnight. All this time there was not the least return of the 
voice." 

Miss H. applied to me in March, 1863; and, in making a laryngoscopic 
examination, the vocal cords were seen to be very pale and narrow, as if 
atrophied. On attempted phonation, they approximated well, but still were 
distinctly relaxed ; and the upward bulging towards their centres was quite 
perceptible. 

I at once applied galvanism to the cords, by means of my ** laryngeal 
galvanizer.'* The operation was repeated every two or three days ; and, 
after the fourth application of the electro-magnetic current, the voice re- 
turned. It was very gruff at first, and "came and went ;" so that, though 
the young lady recovered her voice one evening, when she came to tell m© 
of her good fortune the next day, she was unable to produce a sound. 
Gradually the voice became more constant, though its monotony was very 
striking ; every syllable and every sentence was produced in the same tone, 
with an entire absence of expression. After the larynx had been galvanized 
altogether eight times, the voice was completely restored, and perfect as 
regards modulation. The laryngoscopic evidence of relaxation of the cords 
disappeared after the third application of galvanism. 

Many people would consider this case an example of hysterical aphonia ; 
but I must again repeat, that the patient never showed a single hysterical 
Bymptom. Being anxious to investigate the case thoroughly, 1 wrote to Dr. 
Alfred Tapson (of Gloucester Gardens), the regular professional adviser of 
the young lady, and he kindly replied as follows : — '* Miss Kate H. has been 
a patient of mine for a good many years, and I well recollect her illness in 
1860. She suffered from intense headache, a remarkably quick pulse, and 
tptal loss of appetite, attended with great prostration, emaciation, and loss 



238 6UBOEBT. 

of voice. She had no hysterical symptoms. Dr. Todd saw her Beveral 
timcR, and was quite puzzled what to make of her symptoms. We both had 
some suspicions that she might be going to have tubercle in the brain or 
elsewhere. She gradually recovered her health and strength, but never her 
voice (though I and a good many others tried all we could think of.) She 
gave everything a fair trial, being most anxious to regain her voice.** 

I have entered somewhat minutely into the history of this case, because 
I was anxious to show that it was entirely free from hysteria, and that the 
aphonia was dependent on profound disturbance of the nervous system. 
There were, as Dr. Tapson says, ** intense headache, a remarkably quick 
pulse, and total loss of appetite, with great prostration and emaciation.** 
It is scarcely necessary to observe that such symptoms imply impaired in- 
nervation of the most extreme form. 

Galvanism was clearly indicated in this case. Dr. Walshe from general 
investigation, and Dr. Czermak from special examination of the larynx, 
both recommended electricity. External electricity was vigorously employed 
by an experienced galvanist, "without the least return of the voice." 
Electricity applied directly to the vocal cords succeeded rapidly in restoring 
the voice, which had been completely lost for three years. No comment on 
the superiority of the internal method of employing galvanism is required. 



Art. 112. — On the Performance of Tracheotomy in Children. 

By M. GiRALDES. 

{BvlL de Thir. ; and Medico- Chirwgical Review^ July, 1863.) 

M. Giraldes is of opinion that the rules laid down for this operation 
in surgical treatises are not explicit, and that the great variety of 
instruments which have been proposed tends rather to increase than 
to remove diflBculties, and to confuse the mind of the operator. In- 
genious in their construction, they seem capable of fulfilling every 
indication, and of enabling hands, however inexperienced, to perform 
the operation without much difficulty. Most of these inventions 
testify rather to the ingenuity than to the experience of their con- 
structors. For its rapid execution, tracheotomy requires none of 
these special instruments — a convex bistoury, slightly pointed, a 
dilating forceps, and two blunt hooks, constituting all the necessary- 
apparatus. The canula in croup is indispensable. The following 
rules for the operator may be laid down :— 

1. The position of the patient and assistants, -^ThS!& is a very 
important preliminary, embarrassment and difficulties sometimes 
resulting from the faulty manner in which the patient has been 
placed and maintained. The child should be laid on a mattress placed 
upon a table, having his neck supported by a bolster, and his head 
thrown forcibly backwards, an assistant kneeling down behind, sup- 
porting it firmly in this position by placing his hands over the jaws. 
Another assistant should fix the shoulders so as to prevent the slightest 
movement. The patient is thus maintained immovable, and there 
are none of the oscillations of the trachea which various instruments 
have been contrived to prevent. 

2. The operation. — The operator, standing on the right of the 
patient, carries his incision three or four millimetres in length firom 



SITBGBBT. 239 

the cricoid cartilai^e, rapidly, but without precipitation, as deep as 
the thyroid gland before it becomes necessary to stop and sponge 
away the venous blood. The forefinger is then passed into the wound 
and fixes the trachea, its nail senrin^ as a conductor to the bistoury 
with which the puncture in the trachea is made. Without removing? 
his nail from the wound in the trachea, the operator slides in the 
dilating forceps along it, and by a slight pressure secures enoue:h 
dilatation for the admission of the canula. The child should now be 
set upright, in order to facilitate the expulsion of false membrane or 
bloocl from the air-passages. The end of the canula should be carried 
directly to the bottom of the wound, in order to prevent its sliding 
off in front of the trachea. Before securing it, the fact of its entrance 
into the air-passages must be carefully ascertained. The aperture 
in the trachea ou^ht not to be of too large an extent, and even if it 
be made too small it may be easily enlarged by means of a probe- 
pointed bistoury. During the operation the child should be well 
covered, and carefully protected from all chills. 

3. Accidents during the operation, — The sliding of the canula in 
front of the trachea has already been adverted to. Haemorrhage 
usually ceases when normal respiration has become established 
naturally or hj artificial means, such as frictions or taps of the 
thorax, made with the view of regularizing the play of the respi- 
ratory muscles. The haraorrhage almost always proceeds from veins, 
which are sometimes numerous and distended ; and when the incision 
has been carried to a great extent, so as to approach the sternal 
Jburchetie, there is a great probability that numerous and voluminous 
venous trunks may have been opened. If the bleeding persist, 
rounds of agaric, dipped in Commander's balsam, should be applied. 

When the blood bubbles up by the side of the canula, the wound 
of the trachea has been made too large, so that the blood gets 
entrance during inspiration. A larger canula should at once be sub- 
stituted. When the operation has been a laborious one, emphysema 
of the neck, sometimes extending to some distance, may be met with. 
It usually results from a want of parallelism between the cutaneous 
and the tracheal wounds. Ill-repressed movements of the child may 
have displaced the trachea, or too great a delay in the introduction 
of the catheter may have favoured the passage of the air into the 
cellular tissue. The same result may occur from the tracheal wound 
being too large or the canula too small. Frictions and shampooing 
the emphysematous region should be employed. 



(b) conceening the chest and abdomen. 

Art, 113. — Operation /or Compression of the Sjnnal Cord. 

By Dr. H. A. Potter, of Geneva, N. Y. 

{Am€Tic(m Medical Times, January 10, 1863.) 

Case. — A. M. Salsbury, of Phelps, Ontario County, New York, while 
engaged in gathering walnuts, in October, 1 859, fell from a tree, a distance 
of twenty feet, and fractured certain vertebrae in the inferior cervical region. 



240 STT^GEBY. 

Three days after the accident I was called in consultation. The patient was 
perfectly conBcious, but was unable to wove any part of the body or ex- 
tremities, except the hands, which he could slightly raise, but which would 
fall upon reaching a certain point, without the least control of the will over 
them. Sensation was as imperfect as the motion. The patient being a 
fleshy man, it was difficult to determine the exact point of injury. 

It was decided I should operate, which I did, Oct. 9tb, 1869. I found the 
spinous process of the sixth vertebra fractured and displaced, and the arch of 
the fifth crushed in upon the spinal cord, nearly separating it longitudinally. 
"With some difficulty I removed ail that portion comprised in the lamina and 
spinous process of the fifth and the spinous process of the sixth cervical ver- 
tebrae. Tiie sheath of the spinal cord was entire, but, as before stated, the 
cord itself was much injured. 

I did not see the patient again until the following January, at which time 
the wound was nearly healed, and he was as comfortable as could be ex- 
pected; he could sit in an easy chair, could readily move his head, and 
could converse as freely as any one. He had gained very little from the 
operation — sensation and motion being as imperfect as when first injured, 
except that he could use his left hand a little more freely than before. He 
remained in this unhappy condition until Nov. 29th, 1862, when I was 
again called to see if something might be done to relieve him. During the 
past three years there had been some spasmodic action of the lower ex- 
tremities, and thinking that some compression might still exist — which, 
from the stout and fleshy condition of the neck, had escaped detection in 
my first examination — and as the situation of the patient could not be made 
worse, I determined upon another operation, which was made in the presence 
and with the assistance of Dr. Dox, of Geneva, and Dr. Carpenter, of 
Phelps. 

I removed the fourth, sixth, and seventh cervical vertebrae, which left the 
portion of the spinal cord covered by the four inferior cervical vertebrae en- 
tirely exposed. The cord had not united, but at the point of the first ope- 
ration it was well protected by a th'ck substance, resembling the coat of a 
large artery. At least an inch of the superior portion of the exposed part 
was much flattened and thinned, but the sheath was entire. At the con- 
nexion of the first dorsal vertebra the cord was full, and, to all appearance, 
in a normal condition. There was no pulsation at any point exposed, but 
there had been at the first operation; and, in my judgment, the pulsation of 
the cord will determine very correctly the diagnosis as to the extent of the 
injury. In two cases upon which I had previously operated, the cord could 
not be only felt, but the pulsation could be distinctly seen. In both cases it 
was simply the yoking in, as it were, of the arch of the vertebra upon the 
spinal cord — the cord not being in the least separated. The first case was 
of five months' standing, and was the most perfect instance of paralysis and 
loss of sensation I have ever seen. A report of the same may be found in 
the Journal of Medicine and Collat. Sciences for March, 1844. It was, I 
believe, before the time of chloroform, and sensation returned instanta- 
neously upon removing the compression, and a perfect recovery was effected. 
The other case I did not report. The patient was a coloured man by the 
name of Susey. The operation was performed at Geneva, New York. I 
removed the posterior portion of the three inferior cei*vical vertebrae, and 
found the cord had simply been pressed against the body of the spinal 
column ; the cord was not separated, and pulsated freely. I had great hopes 
of his recovery, but he died the fourth day. An autopsy showed fracture 
of the left parietal and occipital bone. A large clot of blood was also 
found around the foramen magnum, which was beyond doubt the cause of 
his death. 



SUBGEBY. 241 

Tlie last operation upon M. Salsbury ban as yet proved of no benefit to 
bim, and it probably never will, as nearly all connexion with the bram is 
obliterated. 

There are two points I wish to call the attention of the profession to in 
connexion with this class of injuries. The first is, that, in all cases which 
have come under my notice, and I have seen eight, wkeii blood is taken from 
a vein of the arm it is arterial. This being true, the change from arterial 
to venous blood must be dependent upon the cerebro- spinal action of the 
nervous system, and it is not absolutely necessary for the change to take 
place in the passage through the system. 

The second point is, that, immediately after the receipt of the injury, the 
patient begins to lose flesh, and during the first few weeks becomes much 
emaciated. Arriving at a certain point the recuperative powers of the 
system seem to rally, and nutrition appears perfect — the patients gain flesh 
in about the same propoi*tion as it was lost. 

Why is this, and what is the cause of the suspension and restoration of 
nutrition ? My own opinion is, that suspension of nutrition is in consequence 
of the loss of the nervous action. 

But what restores it ? It cannot come from its original source, for the 
cause is not removed, and there is no sensation or motion below the injury, 
and no direct communication with the brain. 



Art. 114. — Recovery after Transfixion of the Thorax hy an 
Iron Bar, 

By Dr. C. W. Hoyland, Surgeon-Superintendent of the 

British Seaman's Hospital, Constantinople. 

{British Medical JournaZy December 13, 1862.) 

Case. — Macknesky Leon, aged 25, a Pole, was employed in the hold of 
the Liverpool steamship Sicilian, discharging bar iron ; and while he was 
in a stooping position preparing to sling a bundle for hoisting on deck, a bar 
from the one preceding slipped from the slings, and, descending end on, 
pinned him to the flooring of the hold, penetrating the wood to the extent 
of three inches, and requiring the united efforts of three men to extract it. 
The bar was of angular iron, an inch and a half square, and about fifteen 
feet long. The wounds were dressed by the captain, who simply applied 
pledgets of lint, steeped in compound tincture of benzoin, to the sites of in- 
jury anteriorly and posteriorly, and a roller round the chest. It was re- 
ported that considerable haemorrhage took place at the time. On reception 
at the hospital about an hour after the accident, Mr. Hoylaud found the patient 
much depressed ; he had a feeble, quick pulse, aud some dyspnoea ; no 
cough. The dressings were not disturbed. Depression gradually subsided, 
and the reliction was moderate, no inflammatory or other unpleasant symp- 
toms following. The patient was kept in a large ward, with the windows 
open night and day ; and cold applications of a strong infusion of matico, 
in which a little chlorate of potash was dissolved, were employed. He did 
not micturate for the first twenty-four hours, and the bladder appeared quite 
empty. The bowels did not act until the fourth day, although castor oil 
and injections were administered freely. On the fourth day the bowels were 
evacuated freely once, and the kidneys acted regularly. On the fifth day, in 
the presence of Mr. J. Murphy, surgeon of Her Majesty's ship Gannett 
Mr. HoyUnd removed the drewungs, found the wounds discharg ng freely 

ZZZYIII. ^« 



242 SUBGEBT. 

and j^nulating kindly. The same treatment was continued — viz,, pledgets 
saturated as above. The iron bad entered posteriorly between the ninth 
and tenth rib, on the left side, a little before the angle, traversing the thorax 
in an upward and slightly outward direction, and coming out anteriorly be- 
tween the fifth and sixth ribs about an inch below, and slightly outwards of 
the nipple. There was only slight constitutional disturbance for the first 
few days, with slight cough, but no dyspnoea. This yielded to the anti- 
phlogistic regimen and saline draughts, the bowels throughout being gently 
relaxed. He was discharged quite well on the 8th of September. 



Art. 115. — Treatment of Gunshot and Penetrating Wounds 
of Chest and Abdomen hy Hermetically Sealing. 

By Dr. B. Howard, Surgeon-in-Chief, Artillery Brigade, 

Army of the Potomac. 

{American Medical Times; and Dublin Medical Press, October 26, 1863.) 

The operation recommended by Dr. Howard is as follows: — 
" All accessible foreijjn bodies having been removed, introduce the 
point of a sharp-pointed bistoury perpendicularly to the surface just 
beyond the contused portion, and with a sawing motion pare the 
entire circumference of the wound, converting it into a simple 
incised wound of an elliptical form ; dissect away all the injured 
parts down to the ribs, then bring the edges of the wound together 
with silver sutures deeply inserted, at not more than a quarter of an 
inch apart ; secure them by twisting the ends, which are then cut off 
short and turned down out of the way. Carefully dry the surface, 
and with a camel's hair pencil apply a free coating of collodion over 
the wound; let it dry, and repeat it at discretion. For greater 
security shreds of charpie may now be arrayed crosswise over the 
wound after the manner of warp and woof — saturate it with collodion, 
and when dry repeat the process until the wound is securely ce- 
mented over : as a still greater protection a dossil of lint may then 
be placed over the part and retamed with adhesive straps. 

" If there be a tendency to undue heat in the part it may be kept 
down with cold affusion ; should any loosening of the dressing occur 
an additional coating of collodion may be applied. The sutures must 
not be removed until healing by first intention is complete. Should 
suppuration occur so as to occasion distressing dyspnoea, proceed to 
treat it in all respects as a case of empyema, introducing the trocar 
at the most dependent point, and taking special care to avoid the 
admission of air." 

The advantages of the operation are said to be these s — 
** 1st. HsBmorrhage is controlled. At the worst the amount of 
blood lost after the operation cannot be more than would sufiice to 
fill up the unoccupied space remaining in the pleural cavity; the 
elastic clot resulting, furnishing a styptic par excellence for the 
wounded vessels of the yielding lung. 

** 2nd. Dyspnoea is immediately relieved upon removal of the 
iitmospheric pressure, and the restoration of the parts approximately 
to their normal condition. The inclosed volume of air being absorbea. 



SUBOBBY. 243 

the Inng is again at liberty to expand with its usual freedom, limited 
only in proportion to the size of the clot which may happen to be in 
the pleural cavity. 

"3rd. Suppuration, if not prevented, is greatly diminished by 
shutting out the constantly renewed currents of atmospheric air, and 
its character is very favourably modified. Indeed, if the wound were 
closed soon enough, I deem it possible that the slough of the track 
through the lung, with the limited amount of attendant pus, might 
be entirely disposed of by absorption and expectoration. The 
operation which I practise is by hermetically sealmg." 

As to results. Dr. Howard says : — 

" My first experiment in hermetically sealing was in a bayonet 
wound of the abdomen in a private of the 18th U.S. Infantry in 1861, 
which was followed by the best results. Since then I have deemed 
it the most eligible treatment for gunshot and penetrating; wounds of 
closed cavities when not contra-indicated by serious complication. In 
incised or punctured wounds the paring process is of course dispensed 
with. 

" Practically the immediate results have been very remarkable, 
and I think unprecedented. The moat painful eases of dyspnoea have 
been promptly relieved, the patient usually falling into a quiet 
slumber in about an hour after the operation. The subsequent 
results, also, so far as I have been able to continue the treatment, 
have never disappointed my expectations. I have obtained healing 
by first intention, and removed the sutures within five days after the 
operation." 

Art. 116. — Case in which the Sac of a Spina Bifida was 
Successfully Removed hy Operation, 

By Dr. Wilson, of Clay Cross. 

{Proceedings of the Pathological Society of London ; and Medical Times and 
Gazette, January 17, 1863.) 

The following account was read, and the sac exhibited, at a meet- 
ing of the Pathological Society. The case is the first successful one 
of its kind in English practice, all others, and these not a few, having 
ended fatally. In fact, the operation is so pregnant with danger, that 
this case is not here put on record with a view to recommending its 
adoption in other cases : — 

"The child from whom the sac was taken was a fine, and, in 
other respects, well-formed boy, the first child of young parents. 
Qlie tumour was pyriform, the size and shape of a ten-ounce necked 
cupping-glass. It hung from the upper dorsal region of the spine, 
was flaccid, and only partly filled with fluid; the integuments over 
it were very thin, indeed, translucent, and over the most prominent 
part of the swelling were two small excoriations. At the base of the 
tumour could be felt a deflciency in the bones beneath, correspond- 
ing with the third and fourth dorsal vertebrae. There was no 
paralysis or other symptom of deficiency of nervous power. From 

16 — 2 



244 strsaBBT. 

the time of birth Dr. Wilson applied pressure to the base of the 
tumour, so as to isolate it from the spinal canal as far as possible. 
To relieve the tension of the integuments which had become extreme, 
on the twentieth day after birth it was punctured, and eight ounces 
of fluid were drawn off. During the next twelve days it was tapped 
four times, each time about two ounces of fluid being drawn offt A 
steel clamp was applied to the base for Ave days before removal, and, 
on the thirty-third day, the sac and integuments were shaved off at 
the base of the tumour, which was grasped by a pair of circumcision 
forceps. The cut edges of the spinal membrane were lightly touched 
with a red-hot needle, sutures were applied to the wound, and 
pressure to the base of the tumour. Twenty days after the operation 
the wound had entirely healed. Two months after the operation the 
chink in the vertebrce was found to be closed by a solid mass which 
projected somewhat beyond the neii^hbouring spines, and appeared 
to be formed of bone. The sac, as Dr. Wilson sajrs, consists of thin 
integuments cohering the dura mater, to which it is unadherent ; 
this is lined internally by a layer of epithelium resting on a basement 
membrane, coated on its free surface by a more or less organized 
exudation of lymph. The dura mater ia quite an independent coat in 
this tumour, and is in no way connected with the integuments : the 
sac contains no nerves. The fluid in this case was situated in the sac 
of the arachnoid, and not, as is usually the case, in the sub-arachnoid 
space. The tumour was examined by Dr. Cornelius Black, of 
dhesterfield, by Mr. Savory, and by himself, and all coincided with 
Dr. Wilson in his account of its structure and connexions with the 
spinal membranes." 



Aet. 117. — Case in tohich a BreasUpin was Swallowed by a 
Child, and passed hy Stool Twenty Hours after. 

By Mr. Thomas Annandale. 

(Edinburgh Medical Journal, May, 1863.) 

Case. — One day in the month of January, 1863, a respectable trades- 
man in Newcastle, came to my father in great consternation about bis son, 
who had just swallowed a breast-pin. It appeared that the child, three 
years of ag€, had suddenly begun to cry, and the father's attention being 
directed to the boy's throat, he saw the sharp point of the pin sticking up 
&om between the fauces. The father made an attempt to seize it with his 
fingers, but failed, and the pin passed down out of sight, and caused no fur- 
ther inconvenience. The accident happened immediately after the child's 
dinner at twelve o'clock. The child had bad for his dinner one or two 
mouthfuls of roast beef, and had partaken freely of a rice pudding. The 
parents were advised to keep the patient quiet, and carefully watch his 
stools. The child suffered no inconvenience, and next morning, about half- 
past nine o'clock (twenty hours after the accident happened), he had amotion 
from the bowels without any pain. In this stool the pin was found. 



BUBGEBT. 246 

Aet. 118. — Description of a Ne%o Instrument for the Relief 
of Retention of Urine in Cases of Tight Strictures of the 
Urethra, 

Bj Dr. Patrick Heron Watson, Surgeon to the Royal 

Infirmary, Edinburgh, <fec. 

(Edinburgh Medical Journal^ July, 1863.) 

To any one conversant with the success which has in recent times 
attended the efforts of surgeons to relieve retention, in cases of 
stricture, by the employment of the common silver catheter, a 
proposal to increase the armamentarium of surgery by the addition 
to it of a new instrument, may appear very uncalled for. No doubt, 
the silver catheter, varying in scale from the size of a fine knitting- 
wire upwards is well suited in most cases to enable the practitioner 
to overcome the difficulties so far as the diminished capacity of the 
urethra at the seat of stricture is concerned ; and when contrasted 
with the gum catheter affords a facility of manipulation to which the 
latter instrument cannot pretend, feigidity of material is thus 
obviously a matter of moment, conferring as it does a command over 
the extremity of the instrument ; so that delicacy of manipulation, 
combined with the requisite amount of power, is certainly attained. 
This rigidity in the case of the silver instrument is, however, only 
comparative, and becomes less and less as the size diminishes, till at 
length in the smallest catheter, No. \ or No. 1 of the Edinburgh 
scale, the condition of flexibility is almost attained. Nos. 2, 3, and 4 
are certainly less pliant, but still they are less easily introduced than 
the more rigid bougies of the same size which are made of solid 
German-silver or steel. This fact has long been recognised, and has 
led generally to the use of bougies of those sizes in preference 
to catheters in the treatment of stricture by dilatation. While the 
advantage to be obtained by the use of a very small instrument, which 
possesses as great an amount of rigidity as possible, has led, in the 
Edinburgh Infirmary, for many years, to the employment of a probe- 
pointed German- silver bougie, made in its stem of the size of No. 3, 
out tapering at its point to an extremity not larger than that of 
a common probe. Such an instrument is more easily introduced 
into the bladder where a tight stricture exists than even a No. 1 
bougie of uniform size, the tapering point enabling the instrument 
to be guided through the constricted portion with precision ; and 
thus to permit the thicker part of the stem with the greatest facility 
to follow up the slender extremity. When introduced it dilates the 
stricture, so that a No. 2 or 3 will easily pass without experiencing 
any obstruction. I have therefore on many occasions found it 
preferable, when foiled in the first attempt to pass the small-sized 
catheter in cases of retention with stricture, to resort to the passage 
of the probe-pointed bougie as a preliminary measure, following it up 
with a No. 2 or 3 catheter, and thus securing the relief of the patient 
with less delay and with much less risk of injury to the mucous 
membrane of the urethra than by oft-repeated eflforts with a small 
catheter. In such cases, too, especially when there has been much 



246 StTBaEBT. 

thickening in the perinfienm, to secure a still greater degree of rigidity. 
Dr. Watson has found that Mr. Syme's stricture- staff, of the smallest 
size, Dras better suited to dilate the canal, as a preliminary to the 
introduction of the catheter, than the probe-pointed German-silver 
bougie. In a case of tight stricture with retention, he has very 
frequently, however, felt, after having introduced this probe-pointed 
bougie with no little difficulty, that, were it only hollow, and capable 
of acting as a catheter, a great deal of trouble to the practitioner and 
pain to the patient might be avoided. Following out this idea, Dr. 
Watson had constructed a probe-pointed stricture catheter of highly 
tempered steel, and of exactly the same dimensions as the German- 
silver stricture bougie in common use. The whole length of the 
instrument is lOJ inches ; its stem is hollow from the handle up to 
about li inch from the top, where there is an orifice : a silver wire 
occupies the interior of the instrument, and occludes the orifice, so 
as to prevent blood or mucus obstructing the channel during its 
introduction. 

" I have now," says Dr. Watson, ** used this instrument for more 
than a year, restricting its employment to those cases where either 
others or myself had previously been foiled in the introduction of a 
small-sized catheter, and where formerly I should have resorted to 
the use of the probe-pointed bougie as a pioneer to the common 
catheter. In every such instance I have found that the steel probe- 
pointed catheter was introduced with facility, and afforded the 
requisite relief completely, — though, of course, slowly, from the small 
size of the channel through which the water flowed. This instrument, 
I may mention, has also been employed by several friends, and in 
their experience has been found signally serviceable. There is but 
one objection to the instrument — that is, the liability of steel instru- 
ments to rust ; and more particularly this might be expected to hold 
good with respect to the channel of a steel catheter. I can only say 
in reply, that during the period I have employed the instrument, 1 
have had no reason to complain of it on this score. The only 
precaution I have thought it necessary to employ has been to wasn 
it after use, and then to pass the silver wire dipped in oil along the 
channel. Should, however, the risk of rust appear to be a serious 
objection to its general usefulness — as it might in a warm climate- 
then the instrument may be electro gilt, so as thoroughly to protect 
the steel surface. 

" In introducing the catheter to relieve retention, from the position 
of the eye of the instrument, the operator must take care that this 
aperture, and not merely the laoint of the catheter, is lodged in 
the bladder ; else the water will come away in a very tiny and 
unsatisfactory stream. By passing the finger up the rectum the 
position of the point of the instrument can easily be determined, and 
when it is once in the bladder the catheter may then with perfect 
safety be pushed onwards, stretching the stricture by its graaually- 
increasing calibre till at least an inch and a half more of the stem 
has passed within the canal of the urethra. If the silver wire is now- 
withdrawn, the urine will escape in a continuous free stream ; and 
ii tne patient is then placed in the erect posture or sitting upon the 



STTBGSBT. 247 

edge of the bed, the bladder will gradually empty itself without the 
assistance of any pressure over the pubes. 

*' The advantages to be obtained from> the employment of this steel 
probe-pointed catheter are : — 

•* 1st, That in it we have an instrument which, being made of 
steel, is thoroughly rigid, and therefore under the control of the 
operator ; 

" 2ad, An instrument which, to relieve retention, possesses all the 
excellence of the smallest catheter, with, from its probe-pointed 
extremity, all the facility of introduction presented by the probe- 
pointed bougie." 

Art. 119. — On the Successful Treatment of Severe Stricture 
of the Urethra hy Gradual Distension at a Single Sitting, 

By Mr. Henry Thompson, Surgeon to University 

College Hospital. 

(Proceedings of the Royal Medico- Chirurgical Society ^ April 14, 1863. ) 

It is the author's object to illustrate and explain a new method of 
treating severe and obstinate strictures of the urethra. This term 
is intended to denote those which are little benefited by dilatation. 
The distinction which constitutes its novelty does not consist in the 
mere production of some iJteration or improvement in existing me- 
chanical contrivances, but in the adoption of a mode of action on 
the stricture itself, which is different from those which characterize 
any of the other systems of treatment pursued at the present day. 
The author shows in what it differs from dilatation, simple and 
continuous; from rupture, or "instantaneous treatment;" from 
cauterisation ; and from incisions. He illustrates the proceeding, 
which he distinguishes by the term "gradual distension," and 
describes the instrument employed to accomplish it. By the process 
in question, the strictured part of the urethra only is acted upon, 
and this is not to a degree short of, but up to or even beyond, the 
natural calibre of the canal, wherever the stricture may be situated. 
All this is accomplished at one sittmg, but with gentleness and 
' slowness, so as to avoid unnecessary rupture ; the degree of 
distension being regulated with absolute certainty, and its extent 
indicated with extreme accuracy, by apparatus in the handle of the 
instrument employed- The object of the operator is not to rupture, 
but to over-distend the fibrous tissue which constitutes the stricture, 
80 as to destroy, or, at all events, to impair its natural tendency to 
contract. He aims at attaining that result which occurs from the 
practice of over-distending vital tissues elsewhere — viz., to impair 
or destroy their contractility. This is known to happen after the 
application of over- distension to both healthy and morbid tissues, and 
is turned to account by the surgeon for that purpose. The class of 
patients for which this proceeding appears to be best adapted is de- 
scribed, and illustrative cases are appended. The instrument con- 
sists of two long and narrow steel rods, aocurately applied through- 
out their entire length by the single plane surfaoe which each possesses. 



248 8UBGBBT. 

The external surface of each rod is conyez, so that together they 
form a nearly cylindrical instrument, but tapering towards the 
lower extremity, where they, are closely united. At the opposite or 
upper end they are also united, and are surmounted by a handle 
resembling that of an ordinary sound. This handle ia attached to a 
screw with a very fine thread, which being turned causes the two 
rods to diverge very slowly and very gradually from each other at a 
given spot, about six inches from the handle. When the separation 
of the blades is efiected, an index placed near the upper end, and 
connected with some numerals on a disc, shows the exact degree of 
extension made by pointing out that number of the catheter scale to 
which the distension existing at that moment is equivalent. The 
general form and contour of the instrument is that of a slightly 
curved catheter. When the screw handle is turned, the two rods 
separate, so as to form a long oval or spindle-shaped figure, the long 
diameter being about three inches and a half or four inches in length, 
and the short diameter corresponding to the number of turns given 
to the screw, and varying between the slightest possible separation 
of the rods and an interval of about three-eighths of an inch, or 
even more. 1 he stem of the instrument has marked on it a gradua- 
tion in inches, which commences one-quarter of an inch below the 
point of maximum distension or centre of the spindle-shaped figure 
produced by the separated rods. It is that point which will corre- 
spond with the stricture when the instrument is placed in the urethra, 
so that the contracted portion of the canal undergoes the greatest 
amount of distension which it can be desired to produce, while the 
rest remains wholly unaffected. The mode of applying the instru- 
ment is as follows : — A medium or full-sized bougie or catheter is first 
passed as far as to the stricture, and the distance from it in inches to 
the external meatus carefully noted. Suppose it to be five inches, 
the operator, taking the distending instrument, places the little blue 
steel collar which slides on its shaft opposite to the figure 5, and 
passes the instrument through the stricture until the collar arrives 
at the meatus of the urethra, and prevents the instrument from 
entering further. The maximum point of distending power must 
therefore correspond with the narrowest part of the stricture. The 
act of distension is now commenced by making two or three turns of 
the screw- handle, and is continued by slowly turning it once every 
half minute, taking care at the same time to prevent the instrument 
from shifting its position, by observing that tne collar remains oppo- 
site the external meatus. In a short time the index, gradually 
rising, shows that the calibre is reaching Nos. 10, 11, 12, and so on, 
until in a few minutes No. 14 or 16 has been reached, which latter 
limit is usually quite sufficient. The screw-handle is now slowly 
turned backwards, not the whole way, but until the index has re- 
treated to about No. 8 or 9, when the instrument is withdrawn. 
The operator next passes a full-sized gum catheter into the bladder, 
and fastens it there, leaving it in place for about twenty-four hours. 
It is then removed altogether. All that remains to be done is to 
pass a full-sized metallic instrument every second day for a week, 
and after that at increasing intervals for a week or two longer. 



8UBOEBT. 249 

Art. 120. — On the Treatment of Incontinence of Urine, 
By Mr. Robert Johns. 

(Dublin Medical Press, April 29, 1863.) 

The point of interest in these cases is the fact that the disorder 
yielded to very simple surgical treatment, after persistent resistance 
to all medical treatment. 

Case 1. — Some years since a medical friend sought my assistance under 
the following circumstances : Mrs. £. sent for him, and stated that she 
should be obliged to get rid of her housemaid, whom she highly prized, 
unless he could cure her of an infirmity from which she had been suffering 
for upwards of a year, which was not only highly detrimental to her 
property, but most distressing to the girl herself. She was a strong, 
robust, healthy country girl, aged 25 years, of a plethoric habit, and was 
unable to retain her urine at night, which commenced to flow off in- 
voluntarily as soon as she became warm in bed, and continued to do so 
incessantly until she rose in the morning. My friend employed assiduously 
for two months every known treatment, but without the least benefit to his 
patient. He could not assign any cause for her malady, none of those laid 
down by writers having existed. However, on inquiring more particularly 
from herself, I discovered that about fourteen months previously she had 
had a bad fever, during which, on several occasions, her urine was retained, 
and on each was passed off by means of warm fomentation, but that the 
retention had eventuated in her then present complaint. I then recom- 
mended that a metallic catheter should be introduced each night into the 
bladder, and there retained for a quarter of an hour. At the expiration of 
a week from my visit, the doctor informed me that his patient was quite 
-well, the carheterratn having removed the incontinence, some benefit having 
resulted to her after the first introduction of the instrument. 

Case 2.— During the winter of 1861, Mrs. B., aged 30 years, of a 
strumous diathesis, called upon me, and stated that she could not retain 
her water for a minute, but that she was* always worse at night, when she 
became warm in bed. She was the mother of one cliild (a male), which was 
still-born after a very tedious labour, requiring the use of destructive 
instruments for its completion. About the fourth day after the birth of her 
child her water began to pa8S off involuntarily, and had continued to do so 
for some years, but that about six months before her visit, to me she had 
been cured of a very bad vesico- vaginal fistula (after six plastic operations) 
which had originated the incontinence. Having found on examination per 
vaginam and by the catheter, that the urethra and neck of the bladder 
"Were rough and highly irritable, every second day for three weeks I passed 
a metallic instrument into *he bladder, and retained it thereon each occasion 
for from ten to fifteen minutes, at the same time giving her each night a pill 
containing half a ^ain of extract of belladonna and four gr^bins of dried soda. 
Under this treatment her distressing complaint was removed, and at the 
termination of the period just stated she was able to retain her urine as well 
as ever she did at any time of her life. 

Case 3. — On the 23th of December, 1362, I was brought some distance 
from town to see Miss M., a young lady, 13 J years old, who had only a 
few days returned from school, and had caught cold in travelling. I found 
the pulse quick^ weak, and compressible ; the tongue foul, covered with a 
whitish fur; the tonsils swollen, inflamed, and of a brick colour, with specks 
of diphtheritic exudation here and there on them, as well as on the soft 
palate. For a couple* of dayn previously she had been complain ing of chills 
and other feverish symptoms. At this visit she was also suffering very 



250 StTBGESY. 

much from scalding and soreness of the genitals, consequent upon a 
dribbling away of her nrine, which she had been unable to retain for a 
minute during the five preceding days. Her person and room were strongly 
impregnated with the urinous smell so common in such cases, and which 
obtained in the two former. Her throat was then well washed over with a 
strong solution of nitrate of silver, a gargle, consisting of dilute muriatio 
acid, chlorate of potash, honey of borax, and decoction of barley, was 
frequently used, the vapour of boiling water with vinegar was inhaled, and 
a mixture of infusion of bark, chlorate of potash, and tincture of the sesqni- 
chloride of iron was given every third hour, together with a liberal 
allowance of beef- tea and wine. For the soreness of the genitals fomenta- 
tions of chamomile flowers with poppy-heads were employed, and followed 
by a lotion of subacetate of lead, at the same time strict attention to 
cleanliness being enjoined. Under this treatment the affection of the throat 
was removed, and the irritation at the vulva was lessened ; but as the in- 
continence still persisted, the tonic mixture was continued, and cold bath- 
ing was ordered. On the 7th of January, pb she exhibited some signs of 
incipient pertussis, from which her sisters and brothers were then suffering, 
she was ordered a stimulating embrocation for the chest, and an expectorant 
mixture, with the addition of liquor potassse and extract of belladonna, the 
former treatment having been suspended. After a few days she fancied the 
incontinence was somewhat less, yet, although the medicine was given more 
frequently, no real benefit accrued. On the 22nd, as the pertussis was 
^ly established, which increased very much the annoyance from the urinary 
complication, her mixture was changed for one consisting of tincture of 
cantharides, camphorated tincture of opium, syrup of "bark, and syrup of 
orange-peel, but the liniment was repeated. On the 8th of February I was 
hurriedly summoned to see her, as she was suffering great pain in ^e 
genitals, which, on examination, I found to have been caused by an abscess 
in the right labia, which was at once opened with a lancet, and healed in a 
few days hy linseed-meal poultices. Although the pertussis had been com- 
pletely removed, yet, as the incontinence still obstinately remained, the bark 
and cantharides were given more frequently, and a blister was applied over 
the bladder, but without any better effect. On the 11th, having found that 
matters had not in any way improved, I passed a small-sized silver catheter 
into the bladder, and kept it there for ten minutes, when it, together with 
about an ounce of urine, was expelled with force into the bed-pan. On the 
following day she expressed herself as being much better; however, the 
catheter was again employed as before, and with the same happy results. 
On visiting her on the next day, she said she was quite well, and could 
retain her water for any length of time, and as well as she did at any period 
of her life, which salutary condition has continued up to the present. In 
the following way, according to her own statement, this distressing complaint 
■originated : Having been at school about 100 niiles from Dubhn, she left 
for home for the Christmas vacation very early in the morning of the 23rd 
of December, and did not arrive at her father's house until vei7 late that 
-evening, not having passed water during the entire day, although on several 
occasions having had a desire to do so ; but as she was unaccompanied by a 
female friend, she was ignorant how to act, and after some time all the 
inclination to micturate passed off. On her arrival in Dublin she essayed 
to empty the bladder, but without success; yet, after several trials, she 
effected her object at the end of two hours. On the following day on rising 
she first l)ecanie sensible of the incontinence, which had been continuing 
during the night, and which persisted, as already stated, up to the 12th of 
February, 



SDBOSST. 251 

Abt. 121. — On Tui&reular DUease of tie Urinary Organs. 
Bj Dr. KussMAUL. 

(WurAwrger Med.Zeii9d^^ Bd. !▼. Heftl ; and Brki$k MedieaL Jowmtd, 
Mardi 21, 1863.) 

Taberculoflis of the urinary apparatus. Dr. Kussraaul observes, 
may occur as a part of general tuberculosis, manifested either in the 
acute or in the ordinary chronic form. In general, the deposit is 
limited to the cortical substance of the kidneys ; the secreting 
tissue being capable of performing its function, and becoming only 
hypersmic and ecchymosed ^ hen a copious tubercular deposit sud- 
denly takes place ; the affection being attended by catarrh of the 
urinary passages. In very rare cases, the tubercular deposits become 
confluent, and form, by softening, small caverns in the substance of 
the kidney ; and still more rarely, the morbid process extends to the 
urinary passages, causing ulceration and thickening. 

Of greater clinical importance than the manifestation of urinary 
tuberculosis as a part of a general affection, is a class of cases, much 
more rare, in which tuberculosis of the mucous membrane of the 
urinary passages appears either as a primary affection, or extends 
to the bladder and urethra, generally from the seminal passages, but 
in exceptional eases from the prostate. 

Tubercle of the male genital organs is generally primary, and its 
extension to the urinary organs is either limited to the bladder or 
to the bladder and urethra, or extends on one or both sides to the 
ureter and pelvis and calices of the kidney, sometimes even attacking 
the renal structure itself. In primary tubercle of the urinary 
passages, on the other hand, the degeneration generally proceeds 
from the calices of the kiiiney to the bladder ; but both the renal 
calices and the bladder may be independently. affected ; or the blad- 
der may be the starting point of the degeneration. 

In women, the combination of tubercular disease of the urinary 
passages with tnbercle of the genital organs is as rare as it is fre- 
quent in men. Dittrich, in forty-five cases of tubercle of the genital 
organs in women, observed it once to be combined with tubercle of 
the urinary apparatus. In this exceptional case, there was extensive 
tubercular ulceration of the urethra — perhaps, Professor Xussmaul 
thinks, the only recorded instance of tuberculosis of the female 
urethra. As a rule, then, tubercle of the urinary passages in women 
is primary, while in men it has generally first appeared in the 
genital organs. 

Phthisis of the urinary passages seldom attacks the entire urinary 
apparatus, but is generally limited to particular points. As has 
been shown by B,ayer and J. F. Meckel, one kidney may be exten- 
sively diseased, while the other, with its ureter, is quite or nearly 
free from tubercle and performs it function. This explains tlie 
infrequency of uraemia in phthisis of the urinary organs. 

The kidney may be so wr destroyed by the confluence and soften- 
ing of tuberculous deposits, and the tuberculization of the products 
of diffuse nephritis may advance so far, that scarcely any part of 
the gland remains beyond the thickened capsule. 



SUBGBBT. 

The tubercular kidney is generally enlarged ; sometimes it is of 
its normal size, or even smaller. Professor Kussmaul has seen a case 
in which it was as large as a child's head ; the patient was a female 
servant. Such a ^reat enlargement always arises from the disten- 
sion of the kidney and its pelvis and capsule by retained urine and 
pus, if the ureter be narrow or frequently and for a lonjf time ob- 
structed. Moderate enlargement may be ascribed to inflammation 
of the parenchyma of the organ, preceding the deposits of tubercle. 

As more rare conditions under which tubercle of the urinary pas- 
sages is met with. Dr. Kussmaul refers to the following. I)r. 
Basham saw, in one ease, a fistulous communication between the 
bladder and rectum. Lundberg has described a case in which the 
renal purulent collection broke into the abdominal cavity. Passa- 
vant describes an instance where the trigone of the bladder was 
destroyed by tubercular ulceration. 

Phthisis of the urinary passat^es is a very rare disease. Willigk 
has arranged in order^ according to the frequency in which the 
disease waa found in them, the organs in which tubercle was observed 
in 1317 cases. The order is as follows : lungs, intestines, mesenteric 
glands, larynx, lymphatic glands, peritoneum, spleen, kidneys, 
pleura, liver, air- passages, bones, genital organs, brain, cerebral 
membranes, urinary/ passages, pericardium, stomach, tonsils, skin, 
muscles, tongue, pharynx, oesophagus, pancreas, and heart. The 
kidneys thus occupy the eighth, and the urinary passages the six- 
teenth place. Among the 1317 cases of tubercle, the kidneys were 
affected in 74, or 6*6 per cent. — riz., in 44» (or 5*8 per cent.) of the 
men, and in 30 (or 6*3 per cent.) of the women ; while the urinary 
passages were tuberculous in 12, cases only, or 00, per cent.— viz., in 
7 men and 5 women. 

Tubercular disease of the urinary passages is observed at all ages ; 
but rarely before the tenth or after the sixtieth year. Ammon. saw- 
it in a female child aged 3^ years, the left kidney being enormously 
enlarged; and Dittrich saw a man aged 71 with tubercle of the 
bladder, ureters, and kidneys, the disease having extended from the 
genital apparatus. 

The diaunosis of the disease, according to Dr. Kussmaul, depends 
on the following phenomena and circumstances :r— 

1. The patients become rapidly emaciated. This erftaciatioa de- 
pends on hectic fever; on the discharge of pus and frequently also 
of blood with the urine; on nightsweats ;.on disturbances of the 
digestive function ; and occasionally on diarrhoea, which does not 
necessarily depend on tubercle of the intestines. 

2. There are symptoms of chronic inflammation and ulceration of 
the urinary passages. Among these, as direct results of inflamma- 
tion and ulceration, are burning, heavy, and dragging pains, gene- 
rally severe, but varying in intensity in the bladder, in the course of 
one of the ureters, and in one or the other loin, corresponding 
with the extent of the tuberculous inflammation. Pressure on the 
vesical region, or below the false ribs according to Christensen, may 
increase the pain. The pain in the inflamed bladder is increased in 
micturition; there is urgent desire to pass urine^ and sometimes 



SUBOEBT. 253 

even incontinence. Ammon noticed pain in the leg of the affected 
side in a lad aged 19 ; Konig has noticed numbness of the thij<h. 

Another symptom is the discharge of blood and especially pus 
"with the urine. Sometimes the discharge of blood appears first, 
and that of pus at a later period. Frequently a purulent deposit 
only is observed ; and in a case described oy Rayer, blood alone was 
discharged by a patient suffering from tubercle of the gen i to- urinary 
apparatus. In a case described by Chriatensen, the urine at the 
commencement of the disease was dear, but contained albumen. 
The urine has been observed to be sometimes acid, sometimes alka- 
line. The fluid may remain clear in spite of ulceration of one 
kidney, if its ureter be obstructed by any cause, and the mucous 
membrane below the obstruction remain healthy. 

The epithelium of the bladder may be thrown off extensively, and 
discharged either in single scales or in large flakes. Epithelial casts 
of the renal tubules may also be occasionally discharged with the 
pus. 

Elastic fibres, granular detritus, and shreds of cellular tissue may 
be discharged with the urine. This discharge denotes deep-seated 
loss of substance of the mucous membrane, but does not absolutely 
denote tuberculous ulceration, unless it be of long duration. 

The presence, to the naked eye, of larger or smaller cheesy- 
looking deposits, together with the discovery by the microscope of 
tubercle-corpuscles insoluble in acetic acid, with granular detritus 
and elastic fibres, render the existence of tubercle very probable, 
inasmuch as these cheesy -looking products are rarely observed ex- 
cept in tubercular ulceration. 

As more indirect results of the chronic infl&mmation and ulcera- 
tion there have been observed diminution of the urinary secretion, 
and .the presence of a swelling in the region of the kidney. The 
urine may be dimmished by destruction of the secreting apparatus 
or by obstruction of the urinary passages. Dr. Kussraaul believes, 
that the retention of urine on the pelvis of the kidney by the 
blocking-up of the ureter throuj^h the impaction of tuberculous 
masses or shreds of tissue increases the lumbar pain, which again 
decreases when the impacted mass is carried away. The absence of 
urea and urinary salts, observed in one case by E.igler, is to be 
ascribed to the destruction of the secretory apparatus. Signs of a 
renal tumour have been observed by Ammon, Rayer, Konig, and 
others, sometimes on the left, sometimes on the right side ; but they 
are generally absent. In one case, recorded by Lundberg, the renal 
abscess opened into the abdominal cavity. The pus became en- 
closed in a cyst, which was punctured, after whicn the patient (a 
female) lived half a year. 

3. The diagnosis is further aided by the exclusion of other causes 
which may give rise to chronic inflammation and ulceration of the 
urinary passages. In none of the cases collected and compared by 
Dr. Kussmaul was there gravel, calculous deposit, or echinococci in 
the urine, or any of the colicky pain which is observed in cases of 
calculous pyelitis and sometimes in hydatid disease of the uriuary 
passages. The diagnosis is further grounded on the absence of 



254 SUfiGBfiY. 

ramified fibres or of cells from the urine, denoting the non-existence 
of cancer ; as well as on the absence of any tumour projecting? from 
the wall of the bladder into its interior. If a tumour be observed 
in this situation, the larger it is, the more likely is it to be cancerous. 
Another point in diagnosis is, the absence of urethral stricture or of 
enlargement of the so-called third lobe of the prostate, which may 
be attended by chronic inflammation of the urinary passages. 

4. There is heteditary predisposition to tubercle, or evident tuber- 
cular deposit in other organs, in the lung or testicles. Tubercular 
degeneration of the testicles, from which in the male sex tubercle of 
the genito- urinary apparatus usually extends, is readily recognised. 
When no positive signs are elicited by examination of the testes, an 
exploration per anum is indispensable, as the disease may have been 
developed from the prostate and vesiculse seminales. In many cases, 
pulmonary tubercle appears at an early or a late stage of tubercu- 
losis of the urinary organs ; sometimes, however, no signs of it 
can be discovered, even on post mortem examination. 

Tubercular disease of the urinary passages rarely continues more 
than one or two years. Death is usually brought about by maras- 
mus, terminating in diarrhoea, pneumonia, &c. ; more rarely there is 
uraemia. Sometimes death occurs from pyaemia ; or the concomi- 
tant tubercular disease of other organs. 

The treatment of tuberculosis of the urinary organs is altogether 
oonflned to symptomatic and palliative measures. 



Art. 122. — On a New Application of Mastic Bands in 

the Treatment of Strangulated Hernia. 

By M. Maisonneuve. 

(Jowm. de Mid. et Chir. Prat., October 25, 1863.) 

In a recent communication to the Academy of Sciences at Paris, 
M. Maisonneuve cites eight cases in illustration of this procedure, 
of which cases we select two. 

"On the 16th of July, 1863," says M. Maisonneuve, "the 
director of the Hotel-Dieu summoned me at one o'clock in the 
morning, to the assistance of the lamp-lighter of the hospital, who 
was affected with strangulated hernia. I was informed that the 
patient, a man aged thirty-four, had for several years borne reducible 
inguinal hernia on the left side, for which he wore a truss. 

** The truss, however, was worn out, and for a month the hernia 
had not been kept properly reduced, and in the evening of the 14th, 
during an effort, strangulation took place. 

"The entire night of the 14th passed without N calling in 

any assistance; he trusted that the horizontal attitude alone would 
be sufficient to cause the return of the protruded bowel into the ab- 
domen. The pain, however, persisted throughout the night, nausea 
and vomiting made their appearance, and the tumour acquired the 
size of the fist. M. Jobert then prescribed a bath of two hours* 
duration, to be followed by attempts at taxis, which proved entirely 
unavailing. 



SUBCIBBY. 255 

" The attempts were a^in repeated after the application of ice 
over the tumour, but without any better result. In the course of the 
evening, the symptoms became extremely urgent, the hernia was 
hard and painful, and vomiting recurred, every half hour, with 
intense suffering. ^J'he house-surgeons on duty opined that kelotomy 
could not with safety be further delayed, and I was requested to visit 
the patient. 

" The history of the case was then related to me, and I found that 
the tumour was hard, renitent, and had assumed a purple aspect. I 
inspected the matter rejected from the stomach, inquired into the 
state of the pulse and the condition of the abdomen, and satisfied 
myself that the case was one of scrotal entero-epiplocele, that in- 
carceration was present, that the constriction was too intense to 
yield to the usual means of reduction, and that two measures only 
afforded any chance of preserving life — viz., operation with the knife, 
or elastic pressure with the India-rubber band. My experience of 
the latter method, which for seven years I have invariably found 
successful in inguinal hernia, induced me to resort to it in preference 
to the other alternative, and I immediately applied it in the presence 
of the internes of the hospital. 

** The patient was placed on a trestle-bed, and a linen bandage 
was rolled round the body. To this was secured the extremity of a 
long India-rubber band, four rings of which were tightly applied 
round the pedicle of the tumour. The hernia was then more loosely 
covered with the elastic roller, the compressive power being increased 
by the number of its turns. 

" Scarcely was the operation concluded when a gurgling sound 
was heard, indicative of the return into the abdomen of a portion of 
the contents of the tumour. The latter became immediately softer, 
and the band having been removed, the hernia was reduced with 
ease. A new truss was applied, and the patient has since resumed 
his duties in the hospital." 

In six other instances of inguinal or umbilical hernia a similar 
satisfactory result was obtained. In femoral hernia, however, the 
local condition of the protrusion is very different. M. Maisonneuve 
proceeded as follows in the case of a woman aged fhirty-six, who was 
admitted into his wards on the 23rd of last July, for crural hernia, 
occupying the left side ; incarceration had taken place twenty-four 
hours before, and all attempts at reduction had entirely failed. 

The tumour was hard, small, and from its shape, but ill- adapted 
to the application of the band, and the professor therefore modified 
his usual modus operandi, A thick pad of compresses was in the 
first place laid over the hernia, and with the India-rubber roller, 
applied as tightly as possible, the kind of bandage termed spica 
inguinis was speedily constructed ; the pressure was permitted to 
last for five or six minutes, and was then quickly removed ; the 
hernia though not reduced was found soft and flaccid. A very 
trifling amount of manipulation completed the reduction, and no 
relapse has since taken place. 

To effect the reduction of small hernise, the base of which cannot 
easily be surrounded by the band, M. Maisonneuve employs in ad- 



256 sufiGisT. 

dition to the elastic roller, a kind of compressor consistinir of two 
parts — riz., 1, a lumbar metallic plate, and 2, a pad supplied with i 
Bcrew. 

The lumbar-plate, lined in an appropriate manner, resemblea those 
in use iu the construction of hypogastric belts ; it is strong and 
sufficiently wide to rest on the small of the back, and at either ex- 
tremity presents a hook, to which the caoutchouc band can be 
secured. 

The pad is analogous to that of Petit's tourniquet, slightly con- 
cave, and pupplied with an endless screw shaped like a cylindrical 
pin, on which runs a strong metallic rod, eight inches in length, and 
hooked at the extremities. 

In order to use the instrument, the lumbar-plate is, in the fir«t 

flace, applied to the loins, and the pad adapted to the hernia. An 
ndia-nibber band is then secured to each of the hooks of the pos- 
terior plate, and is brought forward and turned over the correspond- 
in;^ hooks of the rod attached to the pad, a procedure which is 
repeated as often as may be necessary to produce the required 
amount of pressure, the pad being at the same time carefully adapted 
to the tumour. The surgeon can regulate and increase at will the com- 
pressive action, by turning the screw, which causes the rod slowly to 
recede from the pad, and stretches the band in a correspondinjj degree. 
This instrument, M. Maisonneuve believes, is susceptible of mani- 
fold and important applications — in the treatment of aneurism for 
instance, of erectile tumours, &c., but he looks upon it as more 
especially calculated to be useful in incarcerated hernia. 

Art. 123. — Case of Inguinal Hernia Treated Successfully 
hy Professor Chisholm^s Method, 

By Mr. James J. Dickinson, Assistant-Surgeon, Bengal 

Medical Service. 

{Dublin Medical Press, August 19, 1863.) 

Case. —The man who was operated upon was a Bhelstee, aged 30, and 
his history is as follows : — He was ruptured in the cold season of 1856, in 
consequence of slipping while descending a steep hill near Cashmere. Im- 
mediately he felt as if something had given way, and on placing his hand 
over his right groin, discovered a small tumour there. This gradually in- 
creased in size, took a downward direction, and ultimately descended into 
the scrotum. He states that from the day of the accident till within a few- 
days of having the operation performed he has regularly pursued his avo- 
cation, and that, with the exception of one or two obstinate attacks of con- 
stipation, he has enjoyed uninterrupted good health. 

When he first presented himself to me in April last, I lost no time in 
writing off to my friend, Dr. Bourne, to get me a needle constructed similar 
to the one described by Professor Chisholm ; but from the time it necessarily 
takes to get anything made in India as compared with England, some slight 
delay occurred, and we were ordered to march from Segoolee to Gwalior, a 
distance of 500 miles. The man, however, was so anxious to have the ope- 
ration performed, that he marched the whole of the way with us ! 

On examining him, I found he had a large inguinal hernia of the right 
side, which completely filled the scrotum. With gentle pressure the wholo 



susoBST. 257 

of tlie gut could be easily returned ; and on pushing the flabby scrotum up 
before the forefinger, it could be passed through the tendinous aperture, 
more than an inch in diameter, into the abdomen, and the pillars of the 
external ring could be distinctly felt. The man himself was a spare man, 
though in good condition ; and J mention the fact because I am of opinion 
th&t pari passu with stoutness, so will the difficulty of the operation be en- 
hanced, and so will needles of various sizes and curves be required. 

On the 27th of May I performed the operation, having on the previous 
day given him a dose of castor- oil. After the case had been carefully ex- 
amined by my friends, Assistant-Surgeon Jackson, of H.M. 13th Light In- 
fantry, and Dr. Caird, of the Camel Corps, by both of whom I was ably 
assisted, I proceeded to operate, the patient being under the influence of 
chloroform. The mode of operating is as follows : — " The scrotum having 
been invaginated upon the finger, as the only mode of guiding the needle in 
its passage, a long strong curved needle, fixed firmly in a handle and armed 
with silver wire, guided by the finger, transfixes the scrotum at the apex of 
the invaginated portion, passes through the internal column, and appears 
through the skin of the abdomen, when one end of the wire is drawn out. 
The point of the needle is then drawn backwards, and disappears again in 
the canal. Its direction is then changed. Whilst still imbedded in the 
scrotum and guided upon the finger, its point is made to traverse the ex- 
ternal column of the ring near Poupart's ligament, lifting the skin of the ab- 
domen. By gliding the skin upon the needle, the point appears through the 
small puncture made by the fii-st passage of the needle, when the other end 
of the wire is seized, and the needle is unarmed and withdrawn through the 
scrotum. The finger is now removed from the canal, and the two ends of 
the wire being drawn upon the loop, it dissects the cellular tissue up to the 
columns, which it hugs closely. By twisting the ends of the wu:e the 
columns are felt approaching, until they are brought into such close appo- 
sition as to allow nothing to pass between them ; the spermatic cord in its 
exit filling up all the available space remaining of the ring. When the ring 
is felt closed, the twisted wire is drawn firmly outwards, and clipped oflf as 
close as possible to the skin, so that when traction on the skin of the abdomen 
is removed, the gliding back of the integuments to their normal positions 
conceals completely the ends of the small loop of silver wire." This is the 
description of the operation as given by Professor Chisholm. The operation 
which I performed was, but with one slight modification, precisely similar. 
Those who witnessed the operation were much struck, on passing their fore- 
fingers up the canal, to find how very distinctly the pillars could be felt 
approximating as the wire was being tightened; and when it was tied, and 
the ends cut ofl", a perfect plug could be felt, presenting an impassable barrier 
to the egress of any portion of gut. 

The progress of the case was everything that could be desired. For the 
first two days there was slight pain over the abdomen, which was subdued 
by small doses of opium ; and there was also a good deal of thickening of 
the cord, which subsided after a time. The small wounds healed slowly ; 
nor need this surprise us when we remember that the thermometer stood at 
105° in the house. 

On the thirteenth day after the operation he was able to rise from his bed 
and obey the calls of nature ; and on the twenty-fifth day he walked from the 
hospital to my house and back again, a distance of a mile and a quarter, 
without suflfering much fatigue. On the 20th of June (twenty-four days 
after the operation) he was discharged, being at that time able to draw as 
much water from the well as he required for his own use. 

XXXVIII. 17 



258 STBGEST. 

Art. 124. — On KizmorTliage from the Rectum. 

By Mr. Syme, Professor of Clinical Surgery in the University 

of Edinburgh. 

(Canada Lancet, October 15, 1868.) 

" Internal hffimoirhoids," says Mr. Syme, " are so generally the 
source of bleeding from the rectum, that hardly any others appear 
to have been noticed by writers on the subject. "But having fire- 
auently met with the most profuse and obstinate haemorrhage, when 
tnere was not the slif^htest trace of internal piles, I think it is very 
important that attention should be directed to the morbid states of 
a different kind which may give rise to this occurrence. Of these, 
the one most frequently concerned, is that of external hsemorrhoids. 

" That pendulous flaps of skin hanging round the anus, should 
fiive rise to a serious flow of blood, seems in the highest degree 
improbable, and might indeed be deemed altop;ether incredible, were 
it not proved beyond the possibility of question, by well-ascertained 
facts. It is now more than thirty years since I became aware that 
external piles, independently of any other morbid condition, might 
be the cause of bleeding, through the observation of a case in which, 
although the patient had been rendered almost exsanguine, the 
most careful examination failed to detect any other derangement, 
and complete relief was afforded by its removal. Since then, both in 
public and private practice, I have had very many opportunities of 
observing similar facts, and of those may select the two following as 
sufficiently illustrative for the purpose : — 

Mr, Craig of Ratho, to Mr. Syme, 
** Sir, — The operation performed on Mr. D., in July, 1845, was 
most successful : he was then 47 years of age, and looked quite 
anaemic, having for many weeks lost a large quantity of blood 
at stool ; the amount had daily increased, but the most careful ex- 
amination of the anus and rectum revealed nothing more than a 
quantity of loose skin external to the orifice. When he sat upon 
the stool in our presence, pure blood to the amount of several 
ounces was speedily discharged, and formed a cake of coagulum in 
the utensil. You merely removed the whole of the loose skin by 
scissors, saying that you had reason to beUeve this would prove 
sufficient, and the result was a complete and permanent cure, as the 
patient never passed any more blood, and is still in good health. 

Yours, &c., 
Rathoy 1861. James Cbaio.' 

" Dear Sib, — The Eev. Mr. laboured under large and ex- 
hausting discharges of blood from the rectum, which had been going 
on for years. As there were some external hsemorrhoids, you con- 
sidered that these were most likely the cause of the heemorrhage. 
They were accordingly removed ; since when there has been no 
bleeding whatever ; and nearly six months have now elapsed since 
the operation. Yours, &c., 

BOBEST PaTEBSON. 
LeUh, 81#t May, 1861, 



STTBaBSY. 



" How the presence of external piles causes bleeding from the 
howel, or how their removal prevents it, I am quite unable to ex- 
plain ; but do not, on this account, regard these facts as of less im- 
portance in practice. If their occurrence were extremely rare, 
they would be of less consequence, but happening so frequently, as 
I have had occasion to see, their recognition is obviously a matter 
of no small practical importance. 

"Another source of haemorrhage from the rectum, which could not 
have been readily suspected or anticipated, is spasmodic stricture of 
the anus. The fissures and ulcers, which are so frequently con- 
nected with this condition, usually discharge a little blood, although 
hardly in such quantity as to constitute a prominent feature of the 
case; but, independently of any such complication, a mere con- 
tracted state of the sphincter may occasion the most profuse and 
serious bleeding. As an instance of this effect, I may mention a 
very remarkable case that was presented to me not long ago, by a 
medical student of great talent and diligence. He complained of 
bleeding at stool, but, on examination, was found so perfectly free 
from heemorrhoidal disease, that I supposed he must labour under a 
delusion. Some time afterwards, remarking that he had become ex- 
tremely pale and emaciated, I was led to make further inquiry, and 
then learned from a companion who resideii in the same house with 
him, that there really w as a copious discharge of blood which issued 
in a fluid state, and then coagulated. On making another examina- 
tion, I found that the external part of the sphincter was tightly con- 
tracted, and knowing that this might be the cause of bleeding, made 
a division of the tight muscular fibres. No blood was subsequently 
discharged, and the patient soon regained his healthy aspect. 

" There is still another source of hsemorrhage from the rectum of 
which I have met with only one example. The patient was a young 
lady whom I saw along with the late Dr. Graham, the professor of 
botany. She had lost so much blood as to excite attention by her 
altered appearance, and was brought from the country in quest of 
relief. 1 could not detect any hsemorrhoidal disease, or any other 
recognised derangement ; but observed, that when expulsive efforts 
were made, the blood issued from a small round orifice, apparently 
seated in a varicose vein. To this point I applied a ligature with the 
effect of affording complete relief." 



Art. 125. — A New Method of Treating Infiammation of the 
Testicle. 

By Mr. Beany, Surgeon to the Melbourne Hospital. 

{Australian Medical Record j June, 1863.) 

** My plan of treating all stages of acute inflammation of the 
testicle and its coverings," says Mr. Beany, ** is by evacuating as 
early as possible the eftused fluid contained in the tunica vaginalis 
by means of a small trocar and canula. I was formerly in the habit 
of using a small silk seton, which was allowed to remain in forty- 

17-2 



260 SUEGBBT. 

eight hours, and then withdrawn, but the trocar and canula seem to 
me to fulfil all the requirements of the surgeon. 

" When called to a patient suffering from orchitis, and complaining 
of intolerable pain, I direct him to stand erect, and grasping the 
organ, as I would in a case of hydrocele, I plunge a trocar and 
canula into the tunica vaginalis at the most depending part of the 
scrotum, and completely evacuate it. I then direct him to keep his 
bed, and employ a lotion of acetate of lead and opium ; this generally 
effects a cure in six or seven days. 

** This plan of treatment I find has never been practised before ; 
the only record we have of the employment of operative measures in 
the treatment of the acute form of orchitis is the barbarous and 
unnecessary one originally proposed by J. L. Petit — namely, that of 
cutting with a bistoury through the scrotum down to the testicle, and 
dividing freely the tunica albuginea. This practice was subsequently 
revived and practised by M. Vidal de Cassis, and more recently by 
American practitioners, but as yet it has found no favour at the 
hands of British surgeons. 

" When serving with the British army in the Mediterranean, I 
had an opportunity of examining about twenty cases of acute orchitis, 
immediately after death, in the bodies of soldiers who had died from 
cholera whilst under special treatment, with the following results : — 
The tunica vaginalis was in a state of inflammation, and distended 
with turbid serum ; the epididymis was enlarged at its lower part, 
and very much thickened and indurated ; the testes were slightly 
enlarged, and their vessels considerably injected. We have hitherto 
been taught to regard the disease under consideration as an inflam- 
matory affection of the parenchymatous texture of the testicle, the 
pain being attributed to the strangulation of the inflamed organ by 
the unyielding nature of the tunica albuginea, but, from what I have 
learned of the pathology of this affection, I am inclined to consider 
that it is the serous covering of the testicle — the tunica vaginalis 
propria— that is primarily affected, the vascular condition of the 
testes being merely a secondary lesion. My views on this subject 
are more fully confirmed by the fact that immediately an outlet 
is made for the escape of the effused fluid the pain in the testicle at 
once subsides, and it will be found but very slightly enlarged. 

" I therefore look upon the disease hitherto termed * orchitis* as an 
acute inflammation of the vaginal tunic, exhibiting the same pheno- 
mena as inflammation of serous textures in other situations ; thus, the 
redness of the skin, the hardness and swelling, together with the 
sickening pain felt in the testicle, are only symptoms of the distended 
condition of the serous investment of the testicle. 

** Although I am far from expecting that puncturing the tunica 
vaginalis \iill meet with the same opposition as cutting into tlie knee- 
joint, still it is to be presumed that my theory of the nature of acute 
orchitis, *as suggested by the pathological condition,' will necessarily 
provoke discussion, and thereby elicit a diversity of opinion ; be that 
as it may, the successful issue of the cases which have been submitted 
to the proposed method of treatment will tend in a great measure to 
settle most conclusively the qtusstio vexata. 



SUBGESY. 261 

" The pathological sequence of acute inflammation of the tunica 
vaffinalis testis are — first, effusion of serum, which is usually turbid, 
ana may contain flakes of lymph and blood corpuscles ; it may also 
become purulent. Secondly, inflammation of the epididymis, involving 
the spermatic cord ; and, lastly, the testicle, and tunica albuginea, 
in a more or less degree. At first I was in the habit of strictly 
enjoining rest in the horizontal position for a period of seven days 
aft«r the evacuation of the effused fluid, but I may here observe 
that I only employ this plan in the acute stage of the affection, and 
not in the sub-acute or relapsing form. In the treatment of the 
latter variety I am in the habit of strapping the testicle imme- 
diately after tapping, and allow the patient to follow his accustomed 
avocation." 

Case 1. — Mr. W., a clerk, aged 25, in December last, after rowing on the river 
on a very hot day, got chilled. This was soon followed by pain in the back 
and limbs. A warm bath and some colchicum and iodide of potassium was 
ordered, and in a few days he was well. As soon as he began to move about, 
pain with swelling set in, in the left testicle, which increased in intensity, 
and compelled him to keep his bed. When seen, the testicle was very much 
enlarged and very painful, and if it were allowed to hang down, vomiting 
was excited. I introduced a fine trocar and canula, and evacuated about 
five drachms of turbid serum, with immediate relief to the symptoms. 
Acetate of lead lotion was ordered to be kept constantly applied, and a dose 
of extract of acetate of colchicum, with blue pill and extract of henbane, to 
be taken. With the exception of a little pain in the side, and which lasted 
for about two hours after the operation, he was not troubled with any 
unpleasant symptoms. In seven days he returned to his office quite well. 

Case 2. — Mr. L., aged 22, whilst climbing over some bales of goods 
bruised one of his testicles ; the pain caused thereby soon subsided, and he 
took no further notice of it until a few days alter the occurrence, when he 
felt great pain in the testicle, with well-marked enlargement of the organ. 
He consulted me immediately, and I ordered him a suspensory bandage, a 
saline aperient, and a pill containing morphine and blue pill at bedtime. A 
few days after this I was asked to visit him, as he was unable to leave his 
bed ; 1 found him suffering from all the symptoms of ** Orchitis," and at once 
emptied the tunica vaginalis, drawing off about half an ounce of bloody 
serum. The after-treatment, the same as in the last case, was attentively 
observed, and in seven days he was pronounced cured ; he, however, started 
on a tour in the interior, riding on horseback a good deal over a rough part 
of the country, and before he reached Melbourne he found his former com- 

Elaint returning. He applied again to me, when I found the swelling was 
irger than when I saw him previously. The testicle felt very heavy, but 
the pain was not so excruciating as it was during the acute attack. On this 
occasion I drew off nearly an ounce of serous fluid, and tightly strapped the 
testicle immediately y and permitted him to go to his business. There was 
very slight enlargement of the gland left, and this disappeared in about three 
days. It was again strapped at the end of this time, and instructions given 
to him not to call on me again until the adhesive plaster became loose. 
In a fortnight he came, and I i-emoved the straps, and found him quite cured, 
but advised him to wear a suspensory bandage for a short time. 

Case 3. — F. G., setat. 28, has suffered from stricture of the urethra for 
seven years, the cause of which he attributes to his having used a strong 
injection of nitrate of silver (12 grs. to the ounce). He came under my care 
in January last, and has been treated by progressive dilatation. About a 



262 SUBGEST. 

fortnight since I dilated his urethra, which gave him considerable pain, and 
two days subsequently be called at my house complaining of great pain and 
swelling of the right testicle ; he was directed to take a warm bath, some 
.aperient medicine, and to keep the organ suspended, with directions to call 
again if the swelling and pain persisted. He sent for me the next day, and 
told me be was much worse, the pain was considerably aggravated, and the 
swelling had increased. I at once introduced the trocar and canula, and 
emptied the tunica vaginalis, which contained about 3^ drachms of bloody 
serum ; lead and opium lotion was kept constantly applied, and in four days 
he was able to go to his office, saying he felt quite well. 

Case 4. — W. H., setat. 22, a short time since contracted gonorrhoea^ 
during the treatment of which he suffered from an acute attack of orchitis ; 
he was leeched, and hot fomentations were applied, and as soon as the 
inflammatory symptoms had subsided, his testicle was " strapped," but this 
gave him such an amount of intolerable pain that the plasters were removed ; 
he wore a suspender, and the testicle remained large, but free from pain. 
After a smart gallop across country be was seized with violent pain in the 
testicle, which continuing unabated for three days, he sent for me. I found 
him in a high state of fever, with great pain, and swelling of tbe left testicle. 
As he was of a highly nervous temperament, I administered chloroform, 
tapped the tunica vaginalis, and drew off about six drachms of turbid serum. 
I then strapped tbe organ very titjbtly, suspended the scrotum, and per- 
mitted him to go to his office. He called in five days, and pronounced 
himself well. 



Ab-X, 126. — A Simplified Apparatus /or tie Radical Cure of 
Varicocele, 

By Dr. Packard. 
(American Medical Times; and Dublin Medical Presa^ May 20, 1863.) 

"This plan," says Dr. Packard, '* is merely a modification of that 
proposed by Eicord, or rather a simplification of the apparatus 
described by him. My experience with if in a number of cases has 
been so successful as to induce me to offer it for the consideration of 
other surgeons. 

"The apparatus employed by me consists of a needle, a fine 
annealed iron wire, and a piece of sheet-lead. The needle is rather 
slender, two and a half inches in length, slightly curved near the 
point ; its eye is near the point, and it is either set in a handle or 
neaded so as to be firmly grasped with a pair of forceps. The lead 
plate is about an inch and a quarter in length, by half an inch in 
width ; it has a hole bored through it near each end. 

• * Having isolated the swollen veins in the usual way, I pass the 
nee die, armed with the wire, behind them, and slip it back along one 
end of the wire, leaving the loop. Cutting off the long end oi the 
wire, I now arm the needle again, and pass it in the opposite direc- 
tion, in front of the mass of veins, through th^ same openings in the 
skin ; it is then withdrawn as before, again leaving the loop. Each 
pair of ends is now passed through the other loop, when the mass of 



STBGEST. 263 

veins will be enclosed between the two doable wires. Now, taking 
the lead plate, I pass the ends through the holes in it, draw them 
rather tight, and gradually twist them aU together over the middle 
of the plate. 

" Bjr twisting the collected ends of the wires once or twice every 
half-minute or so, there may be gradually effected a most forcible 
eonstriction of the diseased vessels ; the twisting may be suspended 
vrhen the pain caused becomes severe, or when the operator feels 
satisfied that the tissues must be cut by the wire if the pressure be 
further increased. Half-a-dozen additional turns, or more, may be 
daily made until the loops of wire have come together, which will be 
known by their looseness in the sinus formed by their passage. 
Now, by simply dividing them near one opening they may be drawn 
out by pulling on the longer end. So slight is the pain caused by 
this operation that I have not yet found it necessary to resort to 
ansesthesia for its performance. But the point I particularly wish 
to draw attention to is the cheapness, efficiency, and simplicity of 
the apparatus as compared with that of Eicord. The security given 
by the twisting of the ends of wire, and the power it affords of 
gradually tightening the loop in any case, seem to me to be among 
the great advantages of metallic over other sutures." 



Abt. 127. — On the Means of Controlling Hemorrhage in the 
Removal of Scrotal Tumours. 

By Dr. J. Fayeeb, Senior Surgeon to the Medical College 
Hospital, Calcutta. 

(Medical Times and Gazette, May 16, 1863.) 

" Dr. Quinlan, of Dublin," writes Dr. Fayrer, " alluding to the 
removal of scrotal tumours, remarks, that recent operators nave not 
acknowledged Dr. 0'Ferrall*s method of controlling hsemorrhage, 
though they have had recourse to it in these operations. He also 
remarks, * that since the publication of Dr. O'Ferrall's plan of ele- 
yating the scrotum to drain it of blood, a complete change has oc- 
curred in these operations.' 

"Dr. Quinlan is, perhaps^ not aware that they are of almost 
weekly occurrence in Calcutta, that the tumour is invariably ele- 
vated to drain it of part of its blood before it is removed, and that 
such has been the case for many years— long before 1844 or 1845, 
when Dr. O'Ferrall's plan was made known. 

" The late Mr. Brett, of the Hon. E.I. Co.'s Service, in his work 
on ' Surgery in India,' printed in Calcutta in 1840, mentions eleva- 
tion of the tumour to drain it as one of the preliminary steps of the 
operation. Vide page 94 : — * The tumour should be turnea over on 
the abdomen to allow of the veins being somewhat emptied of their 
contents.' 

"We now use a clamp, of which I enclose a sketch of my own 



264 SUSGEBT. 

desi^, or a running cord with a brass rinjir, a suggestion for which 
we are indebted to Dr. Mactier, B. M.S., and we have comparatively 
little dread of haemorrhage, which, I must add, in my experience of 
these operations, is more formidable in its arterial than venous form. 
** I have no desire to detract from the originality of Dr. O'Ferrairs 
invention, but I and my colleague, Mr. Partridge, have frequently 
had recourse to this proceeding, unaware that it was claimed as an 
original invention, or was anything beyond what the circumstances 
of these cases naturally suggested." 



Steel Claiip. 



Front View. 

The neck of the tamoar 
is compressed with this 
clamp, which can be 
relaxed at a moment's 
notice, as it is only held 
and compressed by the 
assistant s hand. 




Side View, 

Carved to fit weU into 
the perinenm. 



8UBOEST. 




A cord, strong and twisted, like those of window sashes in England, 
ranning tnreagh a brass ring (R), and enclosing the neck of the 
tumour. It is fitted with a handle at each end, lu:e that of a cork- 
screw, to pull tightly on. This is a most efficacious tourniquet. 



Art. 128. — Observations on Sterility in Man. 

By Mr. Curling, Surgeon to the London Hospital, &c. 

(Proceedings of the. Royal Medico- Chirtirgical Society, June 23, 1863.) 

The object of this communication is to show that a want of 
aptitude to impregnate may coexist with the capacity for sexual 
intercourse ; or, in other words, that man is subject to sterility 
independently of viriUty, 

The author states that sterility in man may arise from the follow- 
ing causes :— 

1. Malposition of the testicles. 

2. Obstructions in the excretory ducts of the testicles. 

3. Impediments to the escape of the seminal fluid. 

1. Sterility from Malposition of the Testicles. — The opinion of 
John Hunter, " that when one or both testicles remain through life 
in the belly they are exceedingly imperfect, and probably incapable 
of performing their natural functions," was corroborated in a re- 
markable manner by the facts adduced in this paper. After 
describing the condition of detained testicles, the author stated that 
the question to be considered was whether a testicle that had not 
passed into the scrotum can secrete a fertilizing fluid. He assumed 
as quite established, that to possess this property the semen must 
contain zoosperms. 

Having refeiTed to the observations of Professor Grobaux on 
horses, and to those of MM. Follin and Godard on man, the author 
remarks that the iprooh adduced by these observers are not suf- 



266 SUBGEBT. 

ficiently cogent and numerous to establish the law that cryptorchics 
are infertile ; and it could not be expected that assent snould be 
given to results so remarkable and unexpected without evidence of 
the most convincing character. Opposite opinions continued to be 
entertained, and had recently been avowed by Dr. Alfred Taylor. 

The author gives the particulars of two cases of double detained 
testicle in married men (cryptorchics) without children ; and also 
two cases of single detained testicle, the second testicle, in one case, 
being completely atrophied, and in the other having been removed 
by operation. In all four cases the copulative powers were satis- 
factory ; but the eiaculated semen was destitute of spermatozoa. 
He gives a table, which included these four cases and five others ; 
three described by Godard, one by Puech, and one by the President 
of the Society, making nine in alC in which the fluid ejaculated by 
men with retained testicles was submitted to examination, and found 
to be destitute of spermatozoa. In confirmation of the results 
obtained in these cases, he deduces some observations made upon 
the lower animals by MM. Gobaux, Follin, and Godard ; and he 
furnished a table of eight eases in which the fluid found after death 
in the substance of a retained testicle — in the epididymis or vas 
deferens, or in the vesicula seminalis on the side corresponding to 
the misplaced gland — had been examined and found destitute of 
ppermatozoa. They had not been discovered after death in the 
spermatic ways of a detained testicle in any one instance that he^ 
knew of. 

The facts brought forward as opposed to the conclusion that 
cryptorchics are sterile, are chiefly instances in which they were 
reputed to have procreated children. Three cases are cited ; one 
recorded by Mr. Poland, another by Mr. Cock, and a third by Mr. 
Durham. The author feels no little hesitation in calling in question 
the claims to paternity in these cases ; but remarked that as yet no 
case had been found in which a retained testicle had been fully 
proved to be capable of secreting a fertilizing fluid. The observations 
collected in the paper seem sufficient to show that, as a rule, they do 
not ; and though there appears to be no valid reason why there 
should not be exceptions, still the evidence was wanting to establish 
the exception in either of the instances of reputed paternity which 
had been mentioned. 

2. Sterility/ from Obstructions in the Excretory duds of the 
Testicles. — After giving a brief account of Gosselin's researches, ia 
which he shows that after attacks of gonorrhoea! epididymitis the 
channel for the semen is temporarily and sometimes even per- 
manently obstructed, causing, when the epididymitis is double, 
sterility, the author relates three cases occurring in his own practice, 
of permanent obstruction in the epididymis of both testicles in 
married men whose wives were barren. In all three the patients 
had vigorous powers ; but there was a total absence of spermatozoa 
in the ejaculated fluid. The author insists on the importance of 
careful and prolonged treatment in cases of epididymitis, to obtain 
the removal of inflammatory effusions. 

The author remarks that the passage of the semen from the 



8T7BGBBY. 267 

testicle might be prevented by congenital absence of the vas deferens, 
which, if double, would occasion sterility. A case of the kind, 
n which the testicles were sound, had been observed by John 
Hunter. 

The excretory duct of the testicles is liable also to be interrupted 
by tubercular deposits in the epididymis. It is well ascertained 
that this part is much more frequently the seat of tubercle than the 
body of the gland, and is often extensively diseased, whilst the 
substance of the testicle remains sound. The author gives a case in 
point, in which the semen wa4 destitute of spermatozoa. 

3. Sterility from Impediments to the Escape of the Seminal Fluid, 
—A close stricture in the urethra so completely interrupts the 
passage of the seminal fluid, that in the ejaculation it regurgitates 
into the bladder, where it mixes with the urine. In erection of the 
penis, the urethra becomes narrowed, so that a stricture which offers 
but a slight obstacle to the flow of urine may under congestion be 
sufficient to impede the emission of semen. The author has grounds 
for concluding that sterility from chronic stricture in the urethra 
exists to a greater extent than is commonly supposed. As the con- 
dition was one which is in most cases remediable, it was only 
necessary to call particular attention to it as not an unconmion 
source of infertility. 

The author alludes also to a case in which he had reason to 
conclude that sterility was consequent upon inflammation and 
abscesses near the prostate gland, occasioning obliteration of the 
ejaculatory canals. 

Two important and delicate questions arose out of these inquiries. 

1. Whether a man who has the inclination and power to copulate, 
but who is nevertheless sterile, is justified in contracting marriage P 

2. Whether his condition is a sufficient ground for a divorce P 
That a man who is unable to fulfll the command, " to be fruitful 

and multiply " is right in disappointing the hopes and periling the 
happiness and perhaps health of a woman, could not, the author 
thought, be maintained by any casuist ; and in some of the cases 
related in the paper he had felt it his duty to give advice in accord- 
ance with this opinion. 

It could not be doubted that, in women ready for conception, 
frequent sexual excitement without impregnation was very likely to 
prove injurious to health ; and the author showed from the writings 
of Dr. West that diseases of the ovaries and uterus originate from 
this cause. 

The second question is one upon which a surgeon was scarcely 
called upon to pronounce an opinion. But the author remarked 
that, as sterility in women is not considered an adequate cause for 
divorce, so the man ought not to pay such a penalty for unsuspected 
nnfruitfulness. 



268 ST7BaEBY. 

(C) CONCEENINa THE TTPPEB EXTEEMITIE8. 

Art. 129. — An Easy Means of Reducing a Dislocated 

Humerus, 

By Dr. Gabms. 

{Archiv des HeiUk., No. 2, 1863 ; and Medico-Ckvrurgical Review, Jufy, 1863.) 

Dr. Garms describes the followipg modification of Cooper's pro- 
cedure. The patient is laid upon the floor^ not on his back, but on 
his belly, some cushions intervening. A towel is attached to the 
humerus above the elbow, and another, passed round the upper 
part of the humerus, is given into the hands « of the assistant, 
standing on the side of the dislocated arm. The operator, sittini^ 
down on the floor, on the same side, lays hold of the lower towel, 
and applies the heel of the foot lying nearest the patient to the 
axilla. He makes extension backwards and downwards, while the 
assistant draws laterally. The dislocation is thus reduced with 
surprising facility, the agency of chloroform not being required. 
The advantage of this modification is that extension backwards 
may be far more easily executed than when the patient is in the 
supine position; and this is the direction required in dislocation 
forwards, which prevails in the .great majority of cases. For 
dislocation backwards^ which is very rare, Cooper's procedure Ib 
the besL 



(d) CONOEENING THE INFEEIOB EXTBEMITT. 

Art. 130. — A Case of Elephantiasis Arahum of the Loioev 
Extremity Successfully Treated by Tying the Femoral 
Artery. 

By Dr. Rich.^ G. Butcher, Surgeon to Mercer's Hospital, 

Dublin. 

{Dublin Quarterly Journal of Medical Science^ May, 1863.) 

This is the second case in which this operation has been per- 
formed, the first being one in which the operator was Professor 
Carnochan, of New York {v. Abstract XVII., p. 178). 

Case. — The patient, a woman, aet. 44, was admitted into Mercer^s Hos- 
pital, Nov. 6th, 1861. The disease, which was well marked, had beea 
gaining ground steadily for eighteen years. The operation was perfonned 
on Nov. 25th, 1861. 

In an hour after the operation the limb fell remarkably in temperature^ 
and a good deal of pain was complained of about the knee and ham, when, 
in addition to the flannel bandage, the limb was wrapped up in cotton wad- 
ding, and heated jars placed along its sides, and also to the sole of the foot; 
a large opiate, with wine, was given, and repeated in two hours. 

4 o'clock, P.M. — Heat perfectly restored throughout the limb, from one 
extremity of it to the other, and the pain considerably diminished. The 
patient had some sleep at intervals. Opiate and wine repeated. 



8UB6ESY. 269 

9, P.M. — ^Heat of Hmb considefrablj iDcreaaed, so reraoved the entire of 
the cotton wadding, leaving the toes only covered by it. The patient now 
free from all pain. The opiate to be repeated twice in the night. 

Nov. 26th. — Slept occasionally through the night. Pulse 98 ; steady in 
its beat. Complains of some nervous pains about the knee and ham ; no 
tenderness in the wound, which looks most satisfactory. She referred some 
spasmodic pains to the abdomen, such as she was frequently in the habit of 
experiencing before the operation. Now, as formeiiy, they yielded to very 
hot turpentine stupes. 

On stripping the limb, it was observed by all the students how warm and 
natural was its temperature ; and when tested by the thermometer it proved 
equal to the sound one, while the most striking characteristic of all was 
evidenced in the diminution of its bulk, the integuments in some places 
being absolutely flaccid. I again carefully rolled the foot and leg with a 
flannel bandage, to above the knee, gently and with a very equable support, 
then rested it throughout upon the pillows as before, slightly flexed at the 
knee, and somewhat rotated outwards. The opiates to be continued through 
the day. 

4, P.M. — Going on most favourably, the nervous pains sometimes absent 
altogether. Expresses herself as deriving the greatest cOmfort from the 
increased pressure eflected by the readjustment of the bandage. Tempera- 
ture of the limb excellent. 

9, P.M. — No pain, and inclined to sleep quietly. 

Nov. 27th.— Slept for lengthened periods uninterruptedly; no pain of 
any amount. Bandage slackened ; yet I did not wish to disturb the limb, 
even by lifting it, so soon again, for fear of interfering with or interrupting 
the reparative process in the wounded artery. Opiates freely ; four ounces 
of wine, and beef tea. 

9, P.M. — Has spent a quiet day ; scarcely any nervous pain. 

Nov. 28th. — Slept well ; took some breakfast with appetite ; limb free 
from pain. Beadjusted the pillows. No tenderness or uneasiness about 
the wound ; foot and leg preserving their natural temperature. To have 
beef tea, four ounces of wine, and full opiate at night. 

Nov. 29th. — Slept well ; pulse 98. No pain in either wound or limb. 
Bemoved the bandage ; limb reduced as to bulk in a most remarkable way, 
and its natural temperature perfect. Another very important change has 
been brought about — the absence of the acute sufferings which the patient 
experienced in the ulcerated and eaten-away toes. I dressed them to-day 
without pain, though hitherto she experienced the greatest agony on their 
being touched. New skin is forming in many parts, whilst in others cica- 
trization and healing is established — the excess of vascular action being 
removed, which, according to my views, killed and perished them, as parts 
die from excess of inflammation. To continue full opiate at night, four 
ounces of wine, beef tea, and bread. 

Nov. 30th.— Complained of great sensitiveness and pain in the wound 
this morning. On examination, parts were reddish, and evidently pus pent 
up ; 80 I clipped, with a scissors, the adhesive straps, and cut two of the 
wire sutures and withdrew them. Matter appeared at the centre of the 
incision. No undue pressure of any kind was exerted upon it, and the 
tender, sensitive w«und was covered with a soft linseed-meal poultice, half- 
an-hour after which all pain dispersed. Took her food at the regular 
hours, as usual. 

3, P.M. — Free from pain ; opiate repeated. 

Dec. 1st. — Pain absent during the entire night, and she slept quietly. 
The wound looks well, matter oozing up from the vicinity and around the 



270 8UBGEBY. 

ligature. All redness and puffioess gone. Temperature of the limb admi- 
rable. Poultice continued, and full opiates repeated every third hour, so as 
to quiet the whole system, and so act as a guard against haemorrhage. 

Dec. 2. — No pain ; wound suppurating ; tenderness all gone ; limb 
greatly diminished in bulk ; wine, four ounces ; beef tea ; and full opiates 
every third hour ; poultice still continued to the wound. 

Dec. 3rd. — Wound suppurating kindly ; to continue the opium. 

Dec. 6th. — No pain whatever ; wound flaccid ; no redness ; ligature lies 
quiet ; limb gradually diminishing ; and ulcers on the toes just healed. 

Dec. 12th. — Wound all healed except where ligature comes out. 

Dec. 15th. — Wound quite firmly united, except the immediate point 
where the ligature comes out. The cord has been most carefully protected, 
all through, lest any sudden drag or violence should be offered to it. 
The diminution of the bulk of the limb is still progressing in a very remark- 
able way. 

Dec. 22nd. — A most striking change has taken place in the cuticular 
covering of the limb, all the scales have dropped off, leaving the skin 
smooth and even on the surface ; the patient has now the power of moving 
the toes quite freely, and they, too, are greatly reduced in volume. Liga- 
ture still in its place, the slightest trace of purulent matter along its track ; 
no attempt whatever made to hasten its detachment by that reprehensible 
practice of pulling gently upon it from time to time. 

Dec. 26 th. — I cannot express the satisfaction which I felt this day at 
finding the ligature safely cast off, and lying on the cicatrix, 31 days exactly 
after its application. Limb remarkably reduced since last adjustment of 
the bandage ; applied one with greater firmness than before. 

Dec. 28th. — Wound all healed now, the track of the ligature being 
sealed up. 

Jan. 6th. — Diminution progressive of the limb ; administered mercury 
so as slightly to bring the system under its influence, and had the limb freely 
anointed with iodide of lead and iodide of potash ointment ; frictions with 
this application were had recourse to morning and evening, caution being 
observed that no breach of surface might be occasioned, yet at the same 
time, pressure of a moderate and steady kind was insured, and the dressings 
so saturated with the compound that the absorbents were stimulated and 
assisted in their action as far as could be accomplished. For four months 
this treatment was energetically aod strenuously carried out, and so like- 
Tvise gradually absorption was promoted. Soon the motions of the ankle- 
joint were moderately permitted ; but as the great, massive, dense welts of 
morbid tissue above and below the angle of flexure were removed, so like- 
wise the movements became more extensive, and, as time passed on, were 
at length gradually perfected. The motions of the great toe — which, toge- 
ther with the four others were locked, as it were quite removed from under 
control by the massive preponderance of new material — to a certain extent 
participated in the same marvellous change. I have qualified the amount 
of restoration ; for two of them, the second and third toes, had growa 
together, were matted into each other by early ulceration, granulated sur- 
faces side by side, pressed closely to each other and cicatrized. However, 
the most important portion of this part of the foot, the great toe, became 
perfectly loosed — its actions perfect. At this time the patient regained full 
control over the motions of the foot, evidenced by complete flexion and 
extension, without the slightest pain. To so great an extent was the limb 
reduced, and so soft and pliable had the tegumentary covering become, that 
the tendons and muscles could be traced in their course, as they started out 
in action, when performing their movements; altogether the size of the limb 



SUEOBET. 271 

was but little larger tlian its fellow. At the end of the sixth month the 
patient was able to walk well upon the limb, without pain or uneasiness ; 
she expressed herself as feeling an indescribable relief from the burden 
which had so oppres9ed her for years. Though moving about and walking 
through the wards all day, no additional swelling followed, and never a 
return of pain. Shortly after this the patieut left the hospital and resumed 
her occupation as a laundress ; frequently since I have heard the most satis- 
factory reports as to her condition, and the ability with which she is able to 
pursue her laborious business throughout the whole day, standing nearly the 
entire time, yet neither swelling, fatigue, or pain is occasioned by her doing 
so ; the precautionary application of a bandage is never dispensed with. 
So &r as the history now goes, the case has, I would say, been eminently 
successful ; as to the permanent nature of the cure, time has not yet suffi- 
citmtly passed by so as to afford a practical answer. 



Art. 131. — On Excision of the Knee- Joint. 

By Mr. R G. H. Butcher, Surgeon to Mercer's Hospital, 
. DubliD. 
{Dublin Medical Press, February 11, 1863.) 

In a communication to the Surgical Society of Ireland, Mr. 
Batcher makes some interesting remarks on this operation, usingj as 
a text the case of a lad of 19, in which the operation had been 
perfectly successful. This case is the fourth in which Mr. Butcher 
nad operated with a like result. 

Mr. Butcher says : — " It seems abundantly clear, from the facts 
collected by Dr. Hodges, as well as from the practice of Langenbeck, 
that gross carelessness and recklessness have been adopted in the 
selection of cases for the operation. What must we think of resec- 
tion of the knee-joint performed for malignant disease of the patella P 
or what think of resection undertaken for acute abscess of tne joint 
when pyeemia had already commenced P On resection performed on 
children, four years of age, who die of caries of the spine before the 
wound has had time to heal, notwithstanding, however great the 
authority or reputation of the surgeon that adopts such a line of 

gractice, I deliberately state that he is open to grave censure ; he 
as mistaken altogether the nature and applicability of the operation, 
and has afforded examples of what ought to be avoided, and of a 
reckless style of operating, which tends greatly to retard the science, 
the art, and the progress of surgery. 

•* I never looked upon the operation of excision of the knee-joint 
but as a severe and terrible measure, not to be undertaken lightly or 
without grave consideration as to its applicability." 

Mr. Butcher lays down the following directions to be adhered to 
in this operation : — 

1. l%e judicious selection of the case. — The bones not being 
diseased far beyond their articular surfaces, while if upon section 
found to be a little more than had been expected, the part should be 
gouged out, or an additional thin slice removed ; but if to a greater 
extent, amputation should be at once resorted to, and, as recorded in 
my first memoir, with a hope of excellent success (First Memoir on 



272 8UBGEBY. 

Excision of the Knee-Joini, page 64). Again, the report goes on to 
show that amputation may be performed some days after excision 
should any unfortunate circumstance in the management of the case 
have arisen to demand it In this same paper seven instances are 
recorded of amputation of the thigh, and all made rapid recovery 
save one (page 65). 

2. The JOT incision should he preferred. — The perpendicular 
strokes placed well back so as to allow all fluids and discharges to 
drain on — far more effective and safer than any opening made in the 
popliteal space. No portion of the flaps to be curtailed, though 
they may be thinned of any thickened fibrinous matter or diseased 
synovial membrane ; the latter, particularly, should be clipped away 
with a strong scissors ; all ligamentous fibres, both around and 
within the joint, should be cut through, and the extremities of the 
knees fairly freed and exposed. 

3. The patella should be taken away in all cases, whether diseased 
or not, and then the section of the bones well thrust out in front 
should be made with " Butcher's saw," from behind forward, due 
attention being paid to the axis of the thigh bone at the time of its 
division. 

4. All bleeding vessels should be tied, or any that have sprung 
and retracted should he drawn out and secured, so as to guard 
against intermediary hsemorrhage. 

5. While the patient is yet on the operating-table, the limb should he 
placed in the horizontal position, either by gentle and steady traction, 

combined with pressure of the cut surfaces of the hones backwards, 
or, if necessary, the division of the hamstring tendons. Their 
support behind, in every case, I look upon as of great value ; there- 
fore, their section must be looked upon as a last expedient towards 
straightening the limb. 

6. During the adjustment of the hones, great caution should he 
exercised that their surfaces he throughout their extent in contact, 
and that no soft parts intervene. The flaps should be then laid down 
and connected by suture closely throughout their transverse division, 
while the lateral incisions should be brought together only at their 
extremities by one or two points, and the central portion of each, 
that corresponding to the division of the bones, should not be 
brought in contact, but dressed lightly with lint soaked in oil, thus 
securing a ready outlet for the escape of fluids. The extremity 
should next be cautiously laid upon ** JButcher's box splint," padded 
to the natural configuration of the limb, its sides elevated, foot- 
board applied, suitable pads introduced, and tlien the anterior splint 
laid on, taking the place of the assistant's hand, which from the 
first restrained the femur from projecting forward ; then the 
straps buckled, the waist-band applied, and the patient may with 
safety be removed to his bed. The bed should be prepared in this 
way, and consist of a couple of hair mattresses, laid one upon the 
other, evenly supported, and intervening between the upper one and 
the sheet ; a folded blanket, feather pillows for supportmg the head 
and shoulders ; the bed should be likewise moderately warmed so as 
to prevent the patient being chilled when put into it. 



susaEBY. 273 

7. The limb should not he disturbed for several days, the length 
of time depending a good deal on the season of the year when the 
operation is performed, whether it be in the heat of summer or the 
cold of winter. After five or six days it may be necessary to let 
down the sides of the box splint, to sap up discharge, change lateral 
pads and soiled dressings, &c. By tne apparatus named the 
facilities for cleansing the limb are so efficient that it may not be 
requisite to lift the member from its support for even so long a 

Seriod as five weeks, as evidenced in my own practice. Should, 
owever, it be considered expedient to change all the dressings, the 
anterior splint should be steadily held back by all assistants, and the 
limb pressed up to it, thus guarding against any starting of the 
femur forwards or displacement laterally when lifted from its bed. 
When the box is prepared, freshly arranged, the limb controlled after 
the manner mentioned, should be laid down, the side-splints elevated, 
foot board secured, and the straps over the anterior splint first 
tightened, so as to maintain it in that position, from which it was 
never suffered to change. I would impress the advice still further, 
if the straps be unloosed for any purpose, the hand of an assistant 
should steadily keep the anterior splint in its position and well 
pressed back, until the artificial support is again brought to bear 
upon it and fastened. 

8. In cases where large abscesses form in the vicinity of the excised 
joint, or up along the thigh, Chassaignacs drainage tubes may be 
used with the best hopes of success. (See Butcher's Reports on 
Operative Surgery, Dublin Quarterly Journal, February, 1859.) 

9. The free administration of stimulants and sedatives impc' 
ratively demanded i7i all cases of excision, regulated to a certain 
extent by age, sex, temperament and habit. 



Abt. 132. — Luxation of the Head of the Fibula, 

"By Dr. Jos. G. Richardson, Resident Physician to the 

Pennsylvania Hospital. 

(Americcm Quarterly Journal of Medical Science, April, 1863.) 

The following example of this accident is interesting from its 
rarity, there being but three cases of it on record, one by Sir A. 
Cooper, another by Malgaigne, and a third by Sanson : — 

Case. — John Dixon, a schoolboy, aet. 9, was admitted into the Pennsyl- 
vania Hospital on the evening of December 26, with an injury to the knee. 
In the absence of my colleagues, being called to the case, 1 found the child 
extended upon his back, with the left leg in a semi-flexed posture, and 
the foot slightly everted, apparently suffering considerable pain, and unable 
to completely flex or extend the Umb. When questioned in regard to the 
accident, he referred the uneasiness to the outside of his knee, and stated 
that it was the result of a fall of about five feet from the top of a fence, and 
that he had struck that part of his leg against something in his descent. On 
examination, a protuberance was observed on the outer back part of the leg, 
about three- fourths of an inch behind the head of the fibula. The tendon of 
the biceps flexor, rendered prominent by spasmodic contractions of that 

XXXYIII. 18 



274 8VBOBBT. 

muscle oocnrring at short intervals, was distinctly felt attached to ibis pro- 
minence. After a careful scrutiny of the joint and surrounding portions, ia 
which no other lesion was discoverable, the diagnosis of luxation of the bead 
of the fibula backwards was formed, and an attempt made to reduce H by 
insinuating the tips of the fingers beneath the fibula, so as to make some 
traction outwardly, at the same time the head of the bone was drawn 
forwards to the articulating surface on the tibia. In this way the dis- 
placement was overcome with but little difficulty, and the boy enabled 
to resume the natural movements of the limb. To guard against a re- 
currence of the luxation from muscular spasm or otherwise, a compress 
was placed behind the fibula, a firm banchige applied to the leg, and the 
patient directed to remain in bed with the limb partly flexed until 
further orders. No tendency to redislocation being observed, howeTer, 
after a few days a cautious resumption of the usual functions of the Kmb 
was permitted. 



AuT. 133. — On CJiopart^s Operation. 

By Mr. Hancock, Surgeon to the Charing Cross Hospital, &c. 

{Lancet, Jan. 81, 1863.) 

In a paper on the anperiority of Chopart's operation and of excision 
of the ankle in all cases admitting of their performance, Mr. Han- 
cock speaks as follows npon a former operation : — 

" Chopart's operation, I need scarcely remark, is that whereby the 
anterior portion of the foot is removed at the joint extending be- 
tween the calcis and cuboid and the astragalus and navicular bones, 
preserving the calcis and astragalus in their normal positions, and 
the ankle-joint intact. The objection, however, made against this 
operation is, that the extensor muscles of the ankle, having lost 
their opposing forces, and acting through the tendo-Achillis, draw 
up the heel, and direct the cicatrix towards the ground, whereby 
the patient, obliged to bear his weight upon the tender cicatrix, is 
prevented walking by the agony induced, and suffers so much that 
he willingly undergoes secondary amputation. Mr. Syme, who per- 
formed secondary amputation at the ankle-joint in three cases, 
remarks : * You will observe that, as in all other cases of the same 
kind.anchyloflis has taken place between the astragalus and calcis, 
whilst the latter has been previously drawn up by the action of the 
gastrocnemius, eo as to prevent the patient from resting on the 
proper part of the stump.* 

'* In other cases, again, ulceration and exfoliation of the bone 
have occurred from tension of the flaps, necessitating the same 
untoward results. 

" Instances are also recorded in which, after this contraction had 
taken place, the tendo-Achillis was divided, in the hope of remedy- 
ing the mischief, but with so little success that Syme*s operation 
•was subsequently performed. Mr. Fergusson relates a case of this 
character. 

" Nevertheless, I still advocate Chopart's operation wherever the 
disease is located anteriorly to the os calcis and astragalus, and where 
an adequate flap can be obtained. I have now performed this ope- 



.917BQSST. 275 

ration four times, with the best results, and I attribute this success 
to the following mode of proceeding : — 

" Making the unper dap at least an inch long, and carrying the 
under or plantar nap well on to the under surface of the toes, 
whereby, when there is much thickening, very nearly an additional 
inch is gained in that direction, and the junction of the flaps is 
brought to the centre of the stump instead of the upper margin, to 
which the principal stress is referred. The flaps, moreover, being 
full and free, danger of sloughing is avoided ; whilst, if required, 
they provide a sufficient covering for the whole or a portion of the 
navicular bone, which, when possible, should always be preserved, as 
by these means we not only obviate the necessity of opening into the 
Lurge synovial cavity of the astragalo-navicular joint, but we at the 
same time preserve the attachment of the calcaneo-scaphoid liga^ 
ment, and consequently the natural and firm support to the head of 
the astragalus, whilst we also make the stump more full and even. 
Again dividing the tendo-Achiliis at the time of operation, and not 
waiting to do so until contraction has already taken place, when such 
division is useless, as the parts have now become adherent and fixed^ 
and it is too late to remedy the mischief. 

" The success, moreover, is greatly influenced by the situation at 
which the tendon is divided. When this is done near to the oa 
calcis, where the fascia extending from the tendo-Achillis on either 
side to the malleoli is dense and strong, and when the inability of 
the patient to rest his heel or foot on the ground during the ante- 
cedent disease has already induced a considerable amount of contrac- 
tion, the consequent separation of the divided tendon is so slight that 
it quickly reunites, and the result is not to be relied upon. I always, 
therefore, select a point as near to the body of the muscle as prac- 
ticable, where the fascia is less dense, and where the tendon is more 
under the influence of the muscular fibres. 

" Chopart's operation, performed in accordance with these sug- 
gestions, will prove as successful as any in surgery." 



Art. 134. — On the Treatment of the Early Stages of 
Hip- Joint Disease in Children, 

By Dr. Wm. Price. 

{British Medical Jov/maly July 4, 1863.) 

The object of this paper is not to advocate a new method of 
treatment, but to direct attention to the supposed superiority of 
one plan of treating the earlier stages of morbus coxae over all others: 
viz., the continued employment of the long splint. 

** Many provincial surgeons now discard the long splint altogether 
in the early stages of hip-joint disease, giving preference to splints 
made of gutta percha, leather, or pasteboard ; carefully moulded over 
the buttock, reaching somewhat above the ilium, and extending 
down the upper half or two-thirds of the femur. They argue that 
the patient is thereby enabled to take early out-door exercise oa. 

18—3 



276 SUBGEBT. 

crutches, and is saved a strict confinement to the wards of a hospital 
which the lon^ splint necessarily entails. That much henent is 
derived from the gntta percha and leather splints during a more 
advanced stage of the disease, no one will deny. But how, it may 
reasonably be questioned, can perfect immobility of a hip-joint be 
maintained by means of a splint which does not equally prevent 
movement of the knee and ankle-joints of the same limb ? 

" The long splint should reach from midway between the axilla and 
crest of the ilium to a few inches beyond the external ankle. It is 
best adapted while the patient is under chloroform ; and, no matter 
how severe the previous pain or muscular contraction about the joint, 
speedy diminution of the more urgent symptoms, as a rule, ensues. 
The length of time required for its employment must necessarily vary 
in each particular case. I have now in the infirmary two children, 
side by side, one having worn a long splint for nineteen weeks, the 
other but five weeks; in neither case does any trace of original 
mischief now exist. 

''In many old-standing cases of hip-disease coming under my 
notice, I observe marks of previous severe counter-irritation, produced 
by moxas, issues, and the like. I have long ago satisfied myself that 
these measures are not productive of any appreciable benefit, and in 
my own practice abstain from any external application save the actual 
cautery. This invaluable agent, applied repeatedly by dotting over 
the integument of the buttock and surrounding parts (not allowing, 
however, the heated iron to remain suflBciently long upon the surface 
to produce an eschar or slough), cannot be too highly extolled, more 
especially as a means for relieving the pain dependent upon com- 
mencing ulceration of the cartilages ; the relief thus afibrded being 
singularly marked. 

" The happy results attending the above plan of treatment in my 
hands induce me to believe that an earlier discrimination of the first 
symptoms of hip-joint, disease (as a rule, not diflBcult to recognise), 
the sedulous employment of a long splint, together with strict 
attention to a well-selected diet, would go far to diminish, if not 
the mortality, at least the deformities, resulting from advanced 
stages of a malady so common at all ages and amongst all classes of 
society." 



Art. 135. — Curious Reunion of an Amputated Toe, 

By Dr. Richard W. Day. 

(Jhihlin QtMrterly Journal of Medical Science, August, 1863.) 

Case. — I was standing in the Royal Victoria Dockyard (passenger) one 
morning, and was nervously watching a " young hand" drabbing. He was 
handling the adze so awkwardly, that I cautioned him about it. I had 
hardly done so when he exclaimed, " I am cut." On going over to him, I 
found the upper leather of his right boot cut across the toes and instep. I 
had it immediately taken off, and the stocking carefully removed ; as this was 
slipping off, he cried out that '* his toe was in his stocking.*^ I found the 
second toe literally amputated. The adze had cut obliquely, passing in the 



SUBGEBT. 277 

direction through the phalangeal articulation. The thinnest bridle of skin 
from the sole of the foot prevented its complete separation. I wish it to be 
clearly understood that this connecting medium was so thin that it did not 
include a muscular /fire, it was in fact nothing more than a thin shaving of 
the thickened cuticle v'f the sole. There was much haemorrhage. 

Being, as I said, a witness of the occurrence, and thinking that if there 
was any virtue in " Conservative Surgery " this was the time to test it, I 
brought the paHs into apposition, and kept them so by two lateral sutures. 
A foot-splint and a roller steadied the toes and prevented muscular jerking ; 
and a poultice, changed night and morning, was the only treatment in the 
progress of the case I found necessary. 

During the first week the separated toe appeared as if its circulation was 
in abeyance ; it was livid, cold, and had no sensibility. On the ninth day I 
was encouraged to persevere by my patient telling me that he felt a slight 
** tingling" in it. This sensation continued until the fifth week, when 
perfect union was established, and the toe had become nearly as strong as 
ever. 



278 



PAET III.— MIDWIFEET. 



MIDWIFEEY AND DISEASES OF WOMEN AND 
€HILDEEN. 



(a) CONCEBNINa PEKaNANCT AND PAETTTEITION. 

Art. 136. — Spontaneous Uterine and Extra-uterine Gestation 
Proceeding to the Full Term, 

By Mr. C. R Cooke. 
(Proceedings of the Obstetrical Society of London^ June 3, 1863.) 

Case. — E. R , aged 39 yeara, who had had three previous natural 

deliveries, was taken in labour on December 8, 1862. She had suffered no 
very unusual amount of inconvenience during her pregnancy beyond 
dragging pains, and an unusual sense of weight in the abdomen. On ex- 
ternal examination, the abdominal swelling was found to differ from its 
normal characteristics, in having its greatest prominence considerably to the 
left side, and about on a level with the umbilicus; the whole tumour being 
also more circumscribed, well defined, and spherical in form than usual. The 
limbs of a foetus were distinctly traceable through the abdominal walls, and 
a placental souffle was audible over a large portion of the tumour. A 
vaginal examination showed the canal much elongated, its rugae obliterated, 
and the os uteri drawn up beyond reach of the fingers. Suspecting, there- 
fore, an abnormal gestation, Mr. Cooke requested Mr. Spencer Wells to see 
the patient with him, and he attended with Dr. Kuman, of Vienna. It was 
thought there were two sets of foetal heart-sounds, while the extensive sur- 
face over which the placental bruit was heard gave a suspicion of two 
placentae. Whether the foetuses were both intra- uterine, or an ovarian 
tumour present also, was uncertain. At this time the pains were so slight 
and at such long intervals, that the patient was left, the bladder having been 
emptied, and a grain of opium administered, instructions being given to 
send for Mr. Cooke on the occurrence of expulsive pains or of any change 
in the patient. 

She passed a good night, and the uterine pains had been gradually re- 
established during the next day. At six o'clock, p.m., Mr. Cooke was sent 
for, and found her in strong labour. Making an immediate examination, the 
sacral concavity was now found occupied by a firm, resisting, rounded 
tumour, presenting no trace of fluctuation, and immovable under a very 
considerable degree of force employed between the pains. Its presence 
reduced the outer posterior dimension of the inlet to less than two fingers* 



MIPWI7EBY, BTC. 279 

breadUi, through which no os uteri was discoverable ; but resting on and 
anterior to the symphysis pubis, a small portion of the convex cranial sur- 
face of a foetus was to be felt. 

Dr. Greenhalgh and Mr. Meates, of Chester-square, saw the patient. The 
diagnosis was still a matter of doubt, because the tumour was not traceable 
abdominally, the uterus being in front more or less; and examined per 
vaginam, it might equally have been taken for a solid tumour or a 
pedunculated fibrous outgrowth from the uterus. The obvious indication 
was to deliver the woman as speedily as possible, as the severity and 
frequency of the pain threatened rapid exhaustion of her strength, if not 
rupture of the uterus. Perforation of the head of the foetus was considered 
inadmissible from the almost impossibility of getting at it and fixing it, and 
because also, even supposing it accomplished, evisceration and dismember- 
ment under the same difficulties would have been equally necessary. 

It was decided, therefore, to put the patient under chloroform, so as to 
suspend the action of the abdominal muscles, in order to endeavour to dis- 
place the tumour and turn the child : and failing that, to perform Caesarean 
section. This being done, the tumour was pushed out of the vagina with 
some difficulty, and delivery completed by version. The placenta being 
removed, and the uterus not contracting satisfactorily, the woman moreover 
being much exhausted, it was thought advisable to avoid any manipulation 
of tlie abdomen with a view to discover the nature of the remaining tumour. 
She never entirely rallied from the shock and exhaustion from the operation, 
and died within forty-eight hours. 

The autopsy was made four hours after death, Dr. Grreenhalgh, Dr. 
Kuman, Mr. Spencer Wells, Mr. Meates, Mr. Colbome, and Mr. R. L. 
CJooke being present. On opening the abdomen and reflecting the walls, 
the first thing revealed was the body of a full-grown female foetus contained 
in its proper membranes, which were unruptured, and distended with liquor 
amuii. The anterior or external surface of the chorion was perfectly smooth, 
and in immediate relation with the abdominal peritoneum. Beneath the 
tumour the uterus was seen, partially contracted and unruptured. There 
"was a large quantity of greenish-brown, grumous fluid in the peritoneal 
cavity. On opening the foetid membranes and removing the foetus, it was 
found that the placenta was «ituated in, and firmly attached to, a shallow 
capsule, formed of the expanded and enlarged fimbria of the right Fallopian 
tube, which on its convex or peritoneal aspect was firmly tied down by 
numerous and very tough bands of old adhesion. A stylet could be passed 
along the tube to its expanded extremity, when it became arrested by the 
placenta. 



Art. 187. — Slowness of the Pulse in the Puerjperal State, 

By M. Blot. 

{Oaz, Held, de M6d. et Chir., Juillet 31, 1863.) 

M. Blot gives the following summary of his observations on this 

subject in a memoir read before the Academy of Medicine in Paris : — 

1. In healthy parturient women there is generally observed a more 

or less marked retardation of the pulse. 2. The frequency of this 

phenomenon varies necessarily with the state of the health. In the 

physiological state the retardation of the pulse appears to bear a 

feneral relation to the uterine depletion ; its degree alone varies, 
t does not depend on the disposition, peculiar to some females, to 



280 MIDWI7EBY, ETC. 

bave ordinarily a slow pulse. In the cases which have come under 
M. Blot's observation, it has been ascertained, by subsequent 
examination, that in the non-puerperal state the pulse was 
of- the ordinary frequency. 3. The degree of retardation varies 
much. In three ot M. Blot's cases the pulse fell to 36 in the 
minute ; it most commonly varies from 44 to 60. Food has no 
manifest influence, as was proved in twenty-one casea observed at 
the H6iel Dieu. 4. Retardation of the pulse is more frequent in 
multiparsa than in primiparse; this, M. Blot thinks, may be ex- 
plained by the greater frequency of puerperal accidents in the latter. 
5. The duration of the retardation varies from some hours to ten or 
twelve days. It is generally most prolonged in eases where the 
amount of retardation is greatest, unless some diseased complication 
of the puerperal state supervene. 6. The progress of the retardation 
is almost always the same ; it ordinarily commences within the first 
twenty-four hours after delivery, increases, remains stationary for a 
time, and then gradually disappears. It often persists, even in a very 
marked degree, during the period which is described (often im- 
properly) as milk-fever. 7. The duration of labour does not appear 
to have any notable influence on its development or on its degree. 
On the other hand, the least pathological disturbance prevents its 
production or causes its disappearance. It occurs after abortion, and 
after spontaneous or artificial premature delivery, as well as after 
delivery at the full term. Uterine discharges, however copious, do 
not cause its disappearance j with haemorrhage the case is generally 
otherwise, but sometimes the retardation still persists after haemor- 
rhage that has not been too copious. 8. The retardation of the pulse 
is notably affected by the position of the patient. 9. Retardation of 
the pulse is a very favourable prognostic sign. It is only met with 
in women in good health. In hospital practice its frequent oc- 
currence indicates an excellent sanitary condition ; while its rarity 
should cause the physician to dread the approach of some of those 
morbid conditions which so often prevail in the epidemic form. 
10. The cause of the retardation of the pulse is not to be sought in a 
kind of nervous exhaustion. Researches with the sphygmograph, 
which M. Blot has made in conjunction with M.Marey, show plainly 
that it is connected with an increase of the arterial tension after 
delivery. 



Aet. 138. — A Case of Induction of PreTnature Labour hy 
Br. Barnes's Method. 

By Mr. F. M. Corner, Surgeon to the Poplar Hospital. 

{Lancet, June 31, 1863.) 

The following case illustrates in a very satisfactory manner the 

Sjrfection of the method of inducing premature labour introduced by 
r. Barnes, and it is an instance of a most useful application of the 
method in a case which could hardly have been reUeved so success- 
fully and so speedily by any other means : — 



MIDWIPEBT, ETC. 281 

Case. — My patient, aged about thirty, menstruated naturally at the end 
of July, when she considered she became pregnant of her third child. From 
this date to Sept. 10th she had a slight discharge of blood, lasting a day or 
so and disappearing for several days ; and then (Sept. 10th) a large quantity 
of aqueous discharge, with reduction of the size of the abdomen, but no 
change in the fulness of the breasts or other symptoms of pregnancy. On 
the 23rd of October a larger loss of blood took place, attended by shrinking 
of the mammsB, coldness in the abdomen and thighs, and a drain from the 
uterus of black thick fluid. Her general health underwent change, she 
feeling sickly, faint,^ and thoroughly "out of sorts.** 

I first saw her in the early part of Noyember, and found a tumour, shaped 
like the pregnant uterus, reaching to the umbilicus, soft and doughy to the 
touch, and giving the impression of nothing beyond fluid within. Internally 
the 06 was found patent, the sound being readily passed several inches. 
After watching her for several days, I determined on exploring the interior 
of the uterus, believing in the presence of a deceased fcetus. 

On the 8th of November, having opened the os somewhat by a sponge 
tent, I,. at a quarter past eight P.M., introduced Dr. Barnes's second-sized 
bag, and inflated it, to secure moderate pressure within the canal^ and left 
for an hour. It was then found that regular uterine pains had been estab- 
lished; and the os had dilated and seemed very dilatable. The largest-sized 
dilator was then passed, and at intervals of a few minutes was progressively 
filled, effecting, like the one first used, dilatation and uterine action. At 
eleven p.m. the os was sufficiently dilated to allow of a full examination, 
when I found a tough, membranous bag presertting, pressed down by eaclv 
pain. This failing to make much progress, I gave a dose of ergot and 
punctured, liquor amnii escaping, and almost directly following,, a foetus of, 
I should fancy, three months' gestation. The head was encircled by the os 
for some minutes, so that before expulsion I could not determine whether it 
was living or not ; it was not at all decomposed. I left at midnight, con- 
gratulating myself on the issue of the case. 

I may briefly mention what struck me particularly in the use of these 
instruments : the ease with which they were introduced within the os by 
the aid of a pair of long, straight, narrow-bladed forceps, commonly used, I 
believe, for cleansing or making applications to the uterus ; the absence of 
complaint on the part of the patient ; and their speedy action in dilating 
the parts and inducing natural expulsive pains. For the purpose intended 
by Dn Barnes I have no doubt they will prove everything he has stated. 
Certain, safe, and speedy, what more can be desired ? I never had any case 
the result of which pleased me more. Everything went on as one wished, 
neither more nor less. 



Art.. 139. — Tartrate of Antimony as an O^cytoxic. 

By Dr. Parker. 

{Edinburgh Medical Journal, January, 1863.) 

The following notes were communicated to the Obstetrical Society 
of Edinburgh. Dr. Parker says : — 

** Tartarized antimony has long been, as you are aware, in use in 
obstetric practice. Lecturers and authors have informed us, and 
still continue to do so, that the result of its administration is to 
advance the labour — 1st, By overcoming muscular rigidity ; 2nd, By 
causing a-£pee flow of mucus, and thu« lubricating the vaginal mucous 



282 HIBWIFEBY, STO. 

inembfane. While not eonfining its use to |>rimipar», they speak of 
it as more especially serviceable in this class of cases. 

** With this much theoretic knowledge oi its action, I, sixteen years 
since, commenced testing it practically, and it was not long berore I 
observed that, in addition to the actions previously attributed to it, 
a very important end was effected in a large majority ot cases by its 
administration. I refer to its influence on the uterine contractions ; 
in other words, to this agent as a powerful stimulant to the involun- 
tary muscular action of that organ. While relaxing the circular or 
sphincter fibres of the os uteri, I observed that it produced more 
powerful propulsive efforts, by stimulating the longitudinal and other 
muscular fibres concerned in effecting delivery. 

" As early as the years 1846 or 1847 I called the attention of some 
of my medical friends to the facts, and requested them to keep a 
record of caaes in which this auxiliary agent was prescribed. 

" It is unnecessary that I should occupy time by detailing minutely 
reports from my case- book. A brief summary of what I have 
observed in reference to this matter in a very large number of 
instances, and the deductions drawn therefrom, wiH suffice, and 
equally subserve the end I have in view. 

" Ist. Tartarized antimony relaxes both voluntary and involuntary 
muscular fibre concerned in resisting and retardmg labour^ in 
other words, it overcomes the rigidity of the os uteri and perineal 
muscles. 

"2nd. By increasing the vaginal mucous flow, and lubricating that 
surface, it essentially aids the progress of parturition. 

"3rd. It stimulates to increased contractile action the oblique, 
longitudinal and other muscular fibres concerned in expelling the 
child. It may be said that this increased contractile action is only 
apparent, and that the advance of the labour is due to the decreased 
rigidity and resistance of the os and more external parts, in conse- 
quence of the tartarized antimony having produced the results stated 
in the two preceding propositions. This objection is at once removed 
and proved to be incorrect by the results following its administration, 
in cases not primiparous, where there is * inertia uteri ' with the os 
fully dilated, the vagina patent, and the perineum not rigid. In just 
such labours I have been in the habit ot prescribing the tartarized 
antimony instead of ergot with the most marked results. 

"4th. Unlike ergot of rye, it does not produce continuous contrac- 
tions, but, in the majority of cases, enhances the power and force of 
the regular pains, and admits an interval of ease. 

" 5th. It continues to some extent to exert its contractile influence 
after the expulsion of the child, and hence reduces the risk of 
haemorrhage. Of course this result will be modified by the interval 
that has elapsed between the administration of the antimony and the 
delivery. 

" 6th. Unlike ergot, it does not interfere with the extraction of the 
placenta, by producing irregular uterine contractions. The superior 
and propelling portion of the organ, it is true, is generally more 
firmly contracted than natural after delivery ; but the sphincter (the 
os) is mobile and yielding, and but little difficulty (no morbid 



xniwmEBT, BTO. 283 

condition of the parts being present) is experienced in this particular ; 
abdominal pressure, and traction in the proper axis, will almost 
invariably effect the end without injury to tne cord. 

"7th. While perhaps more applicable to primipar», tartarized 
antimony may be administered with like results in subsequent 
labours, and that at any age or stage of labour, without risk of injury 
to the uterine texture. 

" 8th. Administered as I shall presently state, its emetic effects 
are not troublesome ; not more so when they do occur than from er^ot, 
when this latter, as it very frequently does, produces vomiting. This 
effect of the antimony, when present, will promptly yield to cold 
oatmeal, coffee, a mustard cataplasm over the stomach, or a dose or 
two of the trisnitrate of bismuth. 

" 9th. I have never known depression of the vital powers, or more 
than temporary inconvenience, to follow its use when administered 
in the mode hereinafter mentioned ; although I can readily conceive 
that there are cases in which it would not be inadmissible. In the 
selection of appropriate cases, and discriminating in this matter, 
medical men must have recourse to and be guided by their experience 
and general principles. 

"10th. Tartarized antimony, by facilitating and shortening the 
process of parturition, as above mentioned, without risk to the uterine 
apparatus or general system, will, we may confidently expect, by 
conserving the vital powers and reducing the nervous shock, show, 
on more extensive trial, favourable statistical results in the mortality 
attending obstetric practice. 

" The foregoing ooservations and conclusions have not been arrived 
at hurriedly, and they are not deductions drawn from a limited 
number of cases, or, as you are aware, from a limited field of obser- 
vation. While they will be found correct in a large majority of 
cases, I am free to admit that tartar emetic will not in all cases 
produce the same results. And, indeed, of what therapeutic agent 
can we write in other language P Once only (six or seven years 
since) I have met with a single recorded remark that would lead me 
to infer that the contractile influence to which I have referred has 
been noticed by others. I cannot now lay my hand on the periodical 
which contains it, but I recollect the writer states that, after inject- 
ing two grains (I think) of tartarized antimony into the rectum in a 
case of tedious labour, for the purpose of overcoming muscular 
rigidity, the pains very shortly became stronger and more effectual^ 
or words to that effect. 

" The rationale of its action is undoubtedly to be referred to the 
influence tartarized antimony exerts on the sympathetic system of 
nerves. The uterus, like the stomach and intestinal canal, is com- 
posed of involuntary or unstriated muscular fibre, and is, like the 
other abdominal organs, largely dependent for nervous supply on the 
sympathetic system. Now, we all know as the action of antimony 
on these hollow abdominal muscles or canals, that, when administered 
in sufficient quantity, forcible contractions of the circular and longi- 
tudinal fibres composing them, and relaxation of the sphincters, take 
place ; Just what I have remarked and recorded as occurring in the 



284 MIDWIPBBT, ETC. 

uterus. Similarity of texture and nervous supply would then 
analogically point to that which experience and observation have 
taught me is in reality the case in reference to the action of this agent 
in the uterus in the act of parturition. 

" Ergot of rye, while acting primarily and with more energy on 
uterine muscular fibre, exerts at the same time a secondary or inferior 
influence on the stomach, often producing, as I have before remarked, 
troublesome vomiting. 

" Now, the deduction one would naturally draw from the above 
observations is, that all, or most of what are termed " specifio 
emetics" would, through the agency of the sympathetic system, 
exert their contractile influence on the uterus, and vice versa, as just 
illustrated in the case of ergot — i. e., therapeutic agents which cause 
uterine contractions will have a similar action on the stomach and 
intestinal canal. I have not administered ipecacuanha with the same 
object in view, but have very little doubt that if tried it will be found 
to produce like results. Its taste and bulk would, however, other 
things being equal, give a preference to its more convenient ally, 
tartar emetic ; while, on the other hand, its depressing effects would 
not be so marked in cases where a continuance of the medicine 
should be considered advisable. In this connexion I may remark 
that it is suggestive, and at the same time corroborative of the views 
here stated, that nausea and actual vomiting, occurring naturally 
during labour, very generally advance, and often materidly shorten 
the process, by increasing tJie contractile power of the uterus. I 
administer the tartarized antimony as follows : — From one to two 
grains are dissolved in a wineglassful of water, and a dessert-spoonful 
given every ten or fifteen minutes ad nauseam ; and if the pains are 
not increased sufficiently, and there are no contra-indicating circum- 
stances present, it is continued beyond this point. The rectal mode, 
to which reference has been made, has its advantages, and, at the- 
same time, its inconveniences ; but there are cases in which it should 
have the preference. 

" It only remains for me, in conclusion, to ask the members of this- 
Society to give the subject their consideration, to note at the time 
the results attending its administration, and not to report their con- 
clusions until they have given the matter a fair and somewhatF 
extended triaL" 



Art. 140. — On Supporting the Perinaum, 

By Mr. John Russell, of Bawtry. 

{British Medical Journal, August 20, 1863.) 

In a letter upon this and other matters, Mr. Kussell sayfr : — " Judg- 
ing from my own attempts to retard the advancement of the headj 
I believe it to be impracticable (at any rate for any benefit). For 
supposing that by applying direct force to the prominent part of the 
child's head j^ou retard its progress, such pressure opposed by the 
vis a tergo must necessarily tend to shorten the long, and increase 
the short, diameter of the cranium, and thereby eause greater dis* 



HIDWIFEBT, ETC. 285 

tension of the perinaBtim. I never have myself had a ruptured 
perinseum in practice during the passage of the head in a natural 
presentation, although I have attended patients in whom ruptures had 
occurred in former labours. My plan has always been to carefully 
watch the advancement of the head, and as it passes ihe edge of the 
perinseum, to compress it with the point of the fingers (generally 
supported by the other hand), placed immediately anterior to the 
perineal margin, forcibly upward against the pubes ; carrying the 
fingers back as the head advances ; taking care not to entangle the 
perinseum between the fingers and head, and guarding especially 
against any injury by the finger-nails ; and relaxing the pressure 
during the intervals of relaxation of pains. By these means the 
elastic cranial bones will be found to yield under the fingers, reliev- 
ing the centre from all pressure, and leaving a space between it and 
the head ; and the secondary efifect is to transfer the strain to the 
sides, and on those points of the perineal edge where, in cases of 
threatened rupture, the bilateral section has been recommended. 

" We observe that where nature anticipates unusual distension of 
any ^art, she directs an additional quantity of blood to it ; and in no 
case is this fact more apparent than in the vulva, in anticipation of 
parturition. From this we may infer that blood is necessary for the 
distension of integument, <&c. And the effect of pressing against 
the child's head through the perinseum, as has been recommended , 
must be to express the blood, and thereby lessen the elasticity of the 
parts." 



Art. 141. — A New Mode of Froeeeding in Placenta Pravia. 

By Dr. W. H, Moore, of Buntingford, Herts. 
(Medical Times and Gazette, May 23, 1863.) 

In a short article on this subject Dr. Moore says : — " During the 
past ten years I have had in my practice six cases of placenta prsevia, 
and, although all the mothers are living, the results with respect to 
ihe children have been exceedingly unsatisfactory. My usual prac- 
tice has been to turn, but in my last case I adopted a difierent 
proceeding, an account of which I now give." 

Casb. — Mrs. K., aged 86, was taken m her fifth labour at 8 A.M., the 
first pains causing haemorrhage. On examination, the os was sufficiently 
dilated to permit of the presentation being accurately made out, and nothing 
could be felt but placenta. During the day pains kept off ; but towards 
5 P.H. they recommenced, were short and slight, and each one brought blood. 
About 6 P.M. the os being sufficiently dilated to allow of the introduction of 
the fingers, I carefully separated the placenta from around the sides and 
front of the os, leaving its attachment behind untouched. I then passed my 
fingers beyond the part I had detached, and found the head bearing down. 
Seizing a portion of the membranes covering it between my fore and middle 
fingers, I withdrew my hand, loosing ray hold of the membranes when they 
were in vagina, by which means I plugged the os with the detached portion 
of the placenta and the unruptured membranes. Haemorrhage ceased at 
once. After waiting fifteen minutes for pain, I gave a dose ergot with 



286 XXPWITBBT; KEOi 

brandy, and repeated it in half an hour, shortly after which good pains came 
on, and labour progressed and terminated in the natural manner, withoat 
further loss or danger, and the mother made a good recovery. 

The child, to all appearance a seven months* one, was still- bom, but re- 
vived under the Marshall Hall method of artificial respiration ; and although 
badly nourished and weak, has got on well, and is likely to live. 

From these facts I think I may reasonably conclude that had I delivered 
by turning, the child would have been irrecoverably still-bom. 

On examining the placenta, I found I had separated about one-third of it 
from its attachment to the uterus. 



Aet. 142. — On Broncho-Pneumonia in Lying-in Women, 

By Dr. Eobebt Barnes, Obstetrical Physician to the LondoB 

Hospital. 

(Trcmsactions of the Obstetrical Society of London, vol. iv., 1862.) 

In a communication on this subject Dr. Barnes writes : — " I have 
long been familiar with the fact that lylDg-in women are liable to a 
peculiar form of broncho-pneumonia, ft is generally considered 
that the pulmonary symptoms which arise during child-bed are the 
consequence of the violent straining attending the expulsive stage 
of labour, and of " taking cold ** during the exposure sometimes 
incident to that event. To me this explanation is far from sufficient. 
As in typhoid fever, so in puerperal fever, the lungs are apt to be 
involved. In either case the cause is similar. I may here observe 
that a marked characteristic of typhoid fever is extreme alkalinity 
of the blood. The urine I have frequently found highly ammouiacal 
on voiding. A similar condition commonly marks the blood in 
puerperal fever. On one occasion I observed that the bladder, being 
partially paralysed, and the urine consequently retained in the 
intervals of being drawn by the catheter three times a-day, the urine 
decomposed so rapidly in the bladder as to evolve large quantities of 
ammoniacal gas, which escaped in a stream with a gurgling sound 
when the catheter was introduced. These symptoms, with others 
which need not be enumerated, indicate a dyscrasia of the blood, 
which must produce certain irritating effects throughout the body. 
The diarrhoea of puerperal fever, and the diarrhoea which freouently 
appears in child-bed, apart from overt fever, is the simple enect of 
the irritation of the intestinal mucous membrane by the septic or 
other offending matter circulating with the blood. Peritonitis, 
cellulitis of the limbs, synovitis — all arise in the same way. 

"Accompanying this diarrhoea, or apart from it, we may have 
broncho-pneumonia. This, in like manner, is simply the effect of the 
irritation of the bronchial mucous membrane or parenchyma of the 
lungs by the same offending matter. In some of these cases the 
breath of the patient has possessed an odour distinctly resembling 
that of the lochial discharges. Broncho- pneumonia may, in short, 
be regarded as a symptom, or a part of puerperal fever. But in 
many cases the fever is masked, or so slight that it escapes obser- 
vation, and the attention is ffxed upon the pulmonary symptoms 
alone. 



HIDWIFXBT, ETC. 287 

"In these cases there is generally a considerable degree of prostration. 
The whole or the greater part of the mucous tract of the lungs is 
involved. The expectoration amounts to bronchorrhcea. Large and 
fine crepitation are heard in almost every part of the chest. The 
sputa are sometimes tinged with blood. Depletion is not borne. 
The most successful treatment consists in the administration of 
cinchona, senega, or serpentaria, in the form of decoction or infusion, 
with ammonia, and at a later stage with nitrohydrochloric acid, blisters 
to the chest, good nourishment, in the form of strong beef-tea, eggs 
and milk, and a moderate allowance of wine or brandy. 

" The form of broncho-pneumonia I have thus sketched is not to 
be confounded with that which is the result of capillary embolia of 
the pulmonary arteries, although there is this affinity between them, 
that both are set up by offending matter brought to the lung tissues 
by the circulating blood. 

" The importance of recognising this form of broncho-pneumonia 
will be admitted when its bearings upon childbed mortality are 
considered. In some statistical statements I have noticed that certain 
kinds of death are excluded, on the presumption that labour had 
nothing to do;with the fatal result. Bronchitis and pneumonia are thus 
treated, although to the informed critic the deaths from these causes 
may be as plainly traceable to the puerperal process as are the deaths 
from peritonitis. 

" It is by the complication of this form of pneumonic irritation 
that I account for the fatal acceleration of phthisis after labour." 



Art. 143. — A New MetJiod of Embryotomy and 
of Decapitation. 

Bj M. Pajot. 

(Archiv. Qen, de Mid,, Aoi^t, 1868.) 

M. Pajot describes a new method of embryotomy and of decapi- 
tation as follows :-— One branch of the forceps is used. The crotchet 
which terminates it (M. Pajot speaks, of course, of the French in- 
strument, of which the handle, made of iron, is so constructed) is 
perforated, and lets a fine cord, known by the common name of whip 
{/(met) pass through. At the summit of the loop formed and held in 
the canal of the crotchet is a ball of lead. This crotchet being intro- 
duced, the leaden ball tends to fall back towards the uterine neck, 
drawing the cord with it. A speculum introduced into the vagina 
to protect it, the surgeon draws upon the two ends of the cord by a 
sawing motion. Less than a mmute is enough to complete the 
section of the neck or trunk. In cases in which the child is bulky, 
where the scapulsB are caught by the cord, the operation may last 
five minutes. 



^88 HIDWIFBBY, ETC. 

Art. 144. — Dislocation of the 3nsiform Cartilage occurring 
during Pregnancy, 

By Dr. Kobebt Sim. 
(Edinhurgh Medical Jowrudf February, 1853.) 

Case. — ^The lady in whose case the eversion took place is rather under 
middle height, of a symmetrical form, and in the prime of life. 

About the end of the sixth month of her recent pregnancy, which was her 
fifth, she began to complain of great pain in the right side ; but, as Dr. 
Mackay observes, it would be difiBcult to ascribe this pain to the evention of 
the ensiform cartilage. There was pain at the place where it was turned 
over, but there was also great pain lower down, in the right hyp(>chondriac 
region,^ the cause of which I must leave to you to explain, as I know of no 
satisfactory reason given for the existence of these very violent pains, some- 
times so distressing, during the last months of pregnancy. 

The patient was delivered of twins in the mouth of October last, and my 
attention was drawn by her to a 'Mump'* under the right mamma, a few 
days after the confinement. I must tell you that this lady lives in constant 
dread of cancer of the breast, and that, when she drew my attention to the 
swelling, she evidently supposed it to be a scirrhous tumour. For two or 
three days I was afraid that her fears were too justly entertuined; but, after 
observing the tumour for a few days longer, I was gratified to find that it 
was gradually diminishing in its circumference, and that the bard central 
part was also changing its form and position. In short, I soon discovered 
that the hard central part of the swelling, which remained after the disap- 
pearance of the surrounding tumefaction, was simply the ensiform cartilage, 
which had been gradually everted, pressed upwards, and turned over to the 
right side by the encroachment of the gravid uterus. On the uterine pres- 
sure being removed, the cartilage gradually rose from its abnormal position. 
At first I could hardly insert my forefinger between it and the cartilages of 
the ribs on which it lay. After some time it was at right angles to the 
sternum, and thenceforth its progress to its own place was more rapid. At 
the end of the sixth week from parturition, the cartilage had resumed its 
proper position. 

There was nothing unusual in the labour. Its duration was only about 
three hours. The presentations were — first feet, next head. The liquor 
amnii was not unusually abundant, nor was there anything remarkable about 
the size of the placenta. The twins, together, weighed twelve and a half 
pounds avoirdupois. The former births were all single. 

The length of the sternum is seven inches, that of the ensiform cartilage 
rather more than two. The distance from the sternum to the pubis I have 
not ascertained, nor other abdominal measurements. 



Art. 145. — Case of Utero-Placental Adhesions which gave 

Rise to Severe Symptoms, 

By Dr. Delord. 

(Jowm. de Mid. et Chir. Prat.^ March, 1863 ; and Edinburgh 
Medical Journal, June, 1863.) 

Case. — In the month of May last, I was sent for by the wife of a notary, 
who was entering upon the ninth month of her first pregnancy. Although 
I could recognise no sign indicative of the commencement of labour, Mrs. A. 



HIDWIFEBT, BTC. 289, 

experienced dull constant pains in the loins and abdomen. Movement 
somewhat increased these pains, but not to such a degree as to render them 
insupportable. I prolonged my examination ; and ^pressure, carefully and 
methodically exerted over the whole surface of the uterus, having failed to 
discover any sensitive point, I concluded that the seat of the pain was 
situated more deeply. Pressed by my questions the patient stated, that in- 
dependent of the lumbar and abdominal pains, she experienced a peculiar 
dull pain, which was constant, and was located in the right portion of the 
fundus of the uterus. This avowal removed all the doubts I might have 
entertained, and I considered myself justified in diagnosing an inflammation 
. of the placenta, to combat which I prescribed repose, a light diet, and in* 
jections. Under the influence of this treatment Mrs. A. felt better, but she 
still experienced an unusual sensation, a sort of weight and dragging in the 
region of the uterus. The result proved that> in referring this sensation to 
the existence of utero-placental adhesions, I was not deceived. On the 18th 
of the following June, Mrs. A. was delivered at the full time of a healthy 
infant. Under any other circumstances I should have waited — according to 
the obstetrical rule I have laid down for myself — the natural expulsion of the 
placenta ; but as in this case I had serious grounds for apprehension, I 
applied slight firictions over the uterine region, hoping in this way to give 
rise to some effectual contractions, and so to hasten the delivery. At the 
end of half an hour of vain expectation, I administered a full dose of the 
decoction of ergot. The effect of this soon seemed to manifest itself; 
but at the same time the patient turned pale, and I discovered that in- 
ternal hsemoiThage had taken place. The cord, rendered friable by inflam- 
mation, gave way under the traction which I considered it right to employ 
without delay. I introduced my hand into the uterus, 6'om which a gush 
of blood took place ; fainting fits succeeded one another, and the pour mother 
seemed on the point of death. In this critical situation I compressed with 
my left hand the abdominal aorta ; then, by means of my right hand intro- 
duced deeply into the uterus, I separated all that part of the placenta which 
could be detached, pinching at the same time the inner surface of the uterus, 
with a view to provoking salutary contractions. This manceuvre was 
crovnied with success, and the patient was thus saved from the immediate 
danger of hesmorrhage. But if the condition of matters was now less alarm- 
ing, the fact of the retention of a considerable portion of the placenta could 
not but inspire me with inquietude. A consultation was held, and the 
unanimous opinion was, that the sole indication for the present consisted in 
sustaining the strength of the patient, and in extracting the remains of the 
placenta by every possible means. The next day the pulse became rapid, 
and the abdomen became somewhat painful over the uterine region. During 
the following days a sanious and fetid discharge took place from the genital 
organs. There were occasional rigors, extreme prostration, and other signs 
of purulent absorption. The treatment consisted in the administration of 
beef-tea, sulphate of quina, and cinchona wine, and in the employment of 
detersive and disinfectant injections. As to extracting the remains of the 
placenta, the idea required to be abandoned, as the patient peremptorily 
refused to allow any such attempt to be made. Nevertheless, after a few 
days, a portion of the placenta was expelled naturally, when, for a second 
time, alarming symptoms threatened to compromise the life of Mrs. A., 
which, however, yielded to the treatment previously employed. On the 
14th of June a second fragment of the placenta was expelled. From that 
time the amelioration was progressive and uninterrupted. Convalescence 
was established in the course of the fourth week, and on the 30th of August 
I could convince myself that the health of Mrs. A. was perfect. 

ZZXYIII. 19 



290 UIDWIFEBY, ETC, 

In this case, as in another which occurred to me in 1840, absorption of 
the placental substance retained in the uterus by adhesions consecutive to 
plastic inflammation of the placenta, took place without accident. The 
symptoms of putrid absorption observed in the present case depended ex* 
clusively on the presence of fragments detached from the mass of the 
placenta, as was proved by the circumstance that, after the expulsion of the 
fragments, all the dangerous symptoms disappeared. From these facts we 
may conclude that resorption of the placenta is only possible when it has 
been united to the surface of the uterus by means of an organized plastic 
growth, and when a common life has been established between the two 
organs by means of vessels of new formation. Under these circumstances, 
resorption may take place without any bad symptoms. If, on the contrary, 
the placenta has separated in a mass, it is only susceptible of diminution by 
means of putrid decomposition, and then it acts as a foreign body and as a 
source of infection, giving rise to accidents which are almost always mortal. 



Art. 146. — Tubular Pregnancy followed by Recovery and 
Three Natural Labours, 

By Dr. Fabbri. 

{BuU, ddU Sc. Med. de Bologna ; and British Medical Journal, 
March 7, 1863. 

Case. — This case is that of a woman at Ravenna, who, after having had 
four ordinary labours, became pregnant for the fifth time. The movements 
of the foetus were felt earlier than usual ; the abdomen enlarged on the 
right side. At the ninth month, labour pains set in, and there was a sero- 
sanguinolent discharge from the uterus. These symptoms ceased in a few 
days ; but the usual discharge after delivery and the secretion of milk con- 
tinued several days longer. After this, severe symptoms set in, which con- 
fined the patient to bed, unable to move herself, for three months ; they 
were relieved by blood-letting, aperients and clysters, and the application 
of emollient poultices to the abdomen. In the course of two years, the 
tumour, being diminished somewhat in size, became stationary. After this, 
she recovered sufficiently to have three successful pregnancies and deliveries. 
She died at the age of 56, of an acute disease, leaving directions that her 
body should be examined. Dr. Fabbri found at the right side of the 
abdomen a tumour lying behind the intcHtines ; it was free from adhesions, 
but was attached to the uterus by the Fallopian tube and broad ligament. 
It was formed of a cyst containing a female foetus, apparently at the ninth 
month. 



Art. 147. — Case of Hxtra-uterine FcetatioHy the Foetus being 
in the Sac of a Hernia, 

By M. W. MiJLLER, of Hohenweihr. 

{Allgem. Wiener Med, Ztg.; and London Medical Review, May, 1863.) 

Case. — The woman was a strong person, aged 38, accustomed to very- 
hard physical labour, in consequence of which she had become affected with 
an inguinal hernia of the right side. Under these circumstances she ceased 
to menstruate, and began to experience all the signs of pregnancy, except 
that the belly did not enlarge. The hernial tumour, however, steadily 



MIDWIFEBT, ETC. 291 

iDcreased in size, and on M. MttUer's first visit to the patient he could de- 
tect by means of the stethoscope a sound exactly answering in character 
to a placental murmur. The diagnosis of a living extra-uterine foetus was 
confidently made, and, as the woman was at full term, an operation was 
proposed and assented to. An incision having been carefully made into the 
sac, the foetus was cautiously extracted, and found to be of full development 
and healthy. The cord was tied in the ordinary way, and divided. The 
superficial haemorrhage was easily arrested, the placenta removed, and a 
compress applied, when the patient was observed to become silent and pale ; 
and the signs of an internal haemorrhage developed themselves. In spite of 
remedies the woman sank one hour after the conclusion of the operation. 
Chloroform was used in the performance of the latter. Unfortunately no 
necroscopic inspection of the body could be obtained, as the friends had 
religious scruples on the subject. 



(b) concerning the diseases of women. 

Art. 148. — A Case in which a Large Calculus was expelled 
from the Bladder of a Female through the Urethra hy the 
Natural Efforts, 

Bj' Dr. Beatty. 

{Dublin Quarterly Journal of Medical Science^ May, 1863.) 

Case. — Eliza Simcock, aged 40, unmarried, by occupation a milliner, 
was always healthy until about a year ago, when she first complained of 
irritability of the bladder, and scalding in the passage of urine. At the 
end of a year she came up to Dublin from Waterford, where she resided ; 
and, before seeking medical advice, she was persuaded, by some of her 
friends with whom she was staying, to take a dose of turpentine, which 
greatly increased the scalding, and produced haemorrhage from the bladder. 
She was now seen by Mr. Haffield, who shortly afterwards asked me to take 
her into the City of Dublin Hospital. She was admitted on the 28th of 
September, 1861. 

She was at that time a most miserable object. She was attenuated to 
the last degree, her pulse fast and feeble, her sufferings constant. Night 
and day she had the bed-pan under her in the bed, an incessant incontinence 
of urine mixed with blood and pus, of a very abominable fetor, rendering it 
necessary ; and every drop that passed caused intense agony. The vulva 
was liighly inflamed, and pus flowed freely from the vagina. A quantity of 
sabulous matter, deposited from the urine, covered the orifice of the urethra 
and the labia, extending into the vagina. A warm hip-bath, and a draught 
with 30 drops of laudanum were ordered. These gave some slight relief, 
but no sleep. 

Sept. 29th. — Still suffering too much to permit of any exploration of the 
bladder. Camphor, hyoscyamus, and potash ordered ; and the hip-bath to 
be continued, with the anodyne at night. 

Oct. 5th. — Some alleviation of her suflFcrings having been obtained, I 
passed a catheter into the urethra, but not into the bladder, for it was ob- 
structed at the neck of the bladder by a solid body that occupied the canal. 
Being satisfied that there was a calculus in the bladder, 1 came the next 
day, Oct. 6th, determined to attempt its removal, when I found that, in the 
course of the night, after great pain and straining, and a dragging, tearing 
sensation in the urethra, she was suddenly relieved by something passing 

19—2 



2S92 mDWIFKBT, KTC 

»waj, foflowed by » large diacfamrge of urine, pm, and blood. Hie body 
which had been expelled was one and a half indi long, and one inch broad, 
and wdghed two dnu:hni& It was rather soft and pnltaceons <»i the 
snriace, and was laid aside for fhrther examination. 

The bladder was now well washed ont with warm water, injected through 
a gam- elastic catheter, and ten drops of dilate nitric acid in an oonce of 
water was ordered every six hoars. The warm bath and anodyne draught 
to be given at night. 

Oct. 7th. — The patient passed a tolerable night, and had the first sleep 
she had enjoyed for many weeks. The irritability of the bladder is madi 
diminished, but the incontinence of arine still remains. The bladder was 
again injected with half a pint of warm water, which was retained withont 
mach pain, and then withdirawn. The bath and anodyne at night. 

From this date she con tinned to improve steadily. The power of retainii^ 
the urine was gradually restored. The bladder was washed out every day, 
and the quantity of water thrown in was daily increased, and borne weU. 
She was finally discharged, without any incontinence of urine, on the 20th 
of October. 

On examining the calculus which had been expelled, it was found that the 
soft pultaceous matter that formed the outer coating was easily peeled ott, 
leaving a calculus of a very peculiar form. It looked like a common pebble, 
from whose surface stood out all round a vast number of stony processes, 
formiug an incrustation like stalactites. My first impression was that this 
was a foreign body that had been introduced into the bladder through the 
urethra, and had formed the nucleus around which these curiously-shaped 
deposits had been formed ; but it was not so. My friend. Dr. John Barker, 
kindly examined the specimen for me, and I give his analysis as he far- 
nished it to me . — " The body of the calculus is composed chiefly of oxalate 
of lime with some lithic acid. The stalactites on the calculus are neariy 
pure oxalate of lime. The envelope and crusts are formed of earthy phos- 
phates ; in the former is a quantity of animal matter." 



Art. 149. — On DysmenorrAosa and Sterility. 

By Dr. Gbeenhalqh, Physician- Accoucheur to St. Bartholomew's 

Hospital 
{Proceedings of the Obstetrical Society of London ; Lancet, July 11, 1863.) 

After taking a rapid glance at the importance, frequency, and close 
connexion of these affections, Dr. Greenhalgh directs attention to the 
treatment of mechanical dyemenorrhcea, which a large experience 
had convinced him is by far the most frequent form of this com- 
plaint. Having compared the relative merits of dilatation and division 
of the OS and cervix uteri in this affection, he expresses a decided 
preference in favour of the latter mode, for the safe performance of 
which operation he has invented an instrument which he proposes 
to call the " bilateral metrotome." He states that he has usea this 
instrument in upwards of thirty cases, without a single casualty, and 
in the ^reat majority with the best results. After giving a descrip- 
tion of this metrotome, together with a brief summary of the cases 
operated upon, and after enumerating the affections in which he 
has found the division of the os and cervix uteri most serviceable. 
Dr. GreeDlialgh points out the necessity of attending to the patho- 



MIDWIFBBT, ETC. 293 

lo^cal states of the uteras frequently induced by the persistence of 
dysmenorrhoea, and concludes by giving a short account of the plan 
and remedies which he has found most beneficial for the cure of 
these sereral conditions. 



Art, 150. — On Supra-pelvic Hamatocele, 

By M. GossELiK. 

(Gaz. det S&pitoMX, Avril 19, 1863 ; and Britith Medical Journal^ 
June 7, 1863.) 

In the accounts given of this affection, the blood is generally- 
described as being contained in the peritoneal cul-de-sac behind the 
uterus, and as forming a tumour capable of being felt tlirooigh the 
rectum and vagina, and sometimes by pressure in the hypogastric 
region. Some cases, however, which have come under M. Gosselin's 
observation, have led him to the conclusion that the effusion from 
the ovar^ may (from some as yet unknown cause) be arrested above 
the pelvis, and form a tumour capable of being detected by palpation 
in the hypogastric region alone, and not by the vagina or rectum. 
One patient under his care presented on two separate occasions, 
after symptoms resembling those of peritonitis, a tumour of the size 
of a fist in the left side of the abdomen^ it disappeared readily each 
time, without any discharge of pus by the alvine excretion, by the 
urine, or by the vagina. M. Gosselin proposes to term this variety 
** supra-pelvic hematocele." 

Art, 151. — Three Cases of Artificial Urethra, 

By Mr. I. Baker Brown, Senior Surgeon to the London 

Surgical Home, <fec. 

{British Medical Journal, Oct 10, 1863.) 

These cases are very interesting as proving that it is possible, in 
cases where the urethra has been injured and has lost the power of 
retaining urine, to give the patient an artificial urethra. In two of 
the cases Mr. Brown found matters much facilitated by the use of 
his colleague Mr. Harper's instrument for retaining the catheter. 

Case 1. — This case is mentioned in my work on '* Surgical Diseases of 
Women," under the head of Vesico- Vaginal Fistula, of which it is the thirty- 
seventh case, at page 170. She came under my oare in August, 1860, 
having a large vesico-vaginal iistula and an entirely obliterated urethra. In 
her case, I closed the fistula in the usual manner, and made an artificial 
urethra as much as possible in the track of the normal urethra. A catheter 
was then introduced, and kept in for a few days ; after which the urine was 
drawn off every four hours. 

The fistula healed nicely by the first operation ; and a month after she 
oould retain all her urine, and pass a little, but she had no power of com- 
pletely emptying the bladder, nor had she up to the time when last I heard 
from her, and she was obliged to pass the catheter two or three times a day. 
I have no doubt that if I had had the advantage of Mr. Harper*8 instrument^ 



294 UIDWTFEBY, STC. 

which I will presently describe, that I might have made a more serviceable 
urethra in this case. 

Case 2.— This is published in the Lancet of June 20th, 1863, p. 689. It 
was the worst case I have ever seen. There was su<^ cicatrization of the 
vagina, that it was only about an inch long ; there was a very large recto- 
vasrinal fistula, a vesico- vaginal fistula, and the urethra and neck of the 
bladder had entirely sloughed away. By various operations^ I healed the 
recto-vaginal fistula, and then operated on the fistula in the bladder, first 
puncturing the tissues under the arch of the pubos with a small trocar, 
rather to one side of the place where the urethra should be. 

It required great delicacy of operation, as there was so little tissue. T 
then closed the fistula, and introduced a metal catheter, which was retsused 
in position by the following instrument, which was invented by my col- 
league, Mr. Harper, and well made by Mr. Pratt^ of Oxford-street. This 
instrument is very simple in its construction. It consists of an abdominal 
belt, m£tde with hip and back lacings, and having in its front a piece of 
wood curved to fit the pubes, and well padded on the inner surface. The 
belt is retained steadily in its position by two thigh straps. Upon the piece 
of wood just over the pubic bones is attached an upright stem of silver plate, 
about an inch and a half high, and carrying at its upper end a ball and 
socket-joint ; the side of tl ^s joint is perforated, and is fitted with a screw, 
which regulates the pressure upon the ball of the joint, and fixes the 
horizontal arm in any required position. This arm is a piece of silver rod, 
about seven inches long, and having at its lower end a pair of broad pincer- 
points, which serve to grasp the catheter. The rod slides in another pair of 
pincers, closed by another screw, which may be termed the female part of 
the screw of which the rod is the male, and one end of which is fixed to the 
ball and socket joint. It will be seen that the action is as follows : — The 
belt is fixed around the abdomen, and the pincer end of the instrument lays 
hold of the catheter previously introduced into the bladder. It can be kept 
in any required position, and moved to any angle, and by means of the two 
screws can be fixed firmly, and the wood of the abdominal belt becomes, as 
it were, a part of the catheter. The catheter which is used with the 
instrument is a Kmall round one, and is open at both ends, so that it can be 
cleaned and kept open without the necessity of taking it out of the bladder. 
By means of this instrument, the catheter is kept steadily in the centre of 
the urethra, without any dragging whatever upon the walls. It is also 
introduced only just within the bladder, so that there is no fear of any irrita- 
tion of the internal walls. Moreover, the patient moves about in bed when- 
ever and wherever she pleases, without any fear of misplacing the catheter. 
It may be observed, that it is equally useful in certain cases where it is 
advisable to retain the catheter in the male urethra for any cause, and it pre- 
vents almost entirely the usual irritation which ensues. The action is 
exceedingly simple, and is much easier to observe than to describe*. 

After a few days, during which time the catheter was kept constantly in, 
the patient found that she could retain her water and pass it at pleasure ; 
and she had also perfect control over her motions ; and when I heard from 
her, a few days ago, she still continued perfectly well. This was a most satis- 
factory case, in which I succeeded beyond my hopes, but in which I should 
most likely have failed, but for Mr. Harper's instrument. 

Case 8. — The third case I will give mere in detail, from the notes o 
it kept in the case-book of the London Surgical Home by my son, Mr. 
Boyer Brown. 

E. G., aged 18, single, was admitted into the London Surgical Home oq 
November 5th, 1862. ^ 



UIDWI7BBT, ETC. 296 

History, — Six years ago, she had a large stone removed from her bladder 
per urethrSm; it weighed 2 J oz. 12 grains. During the extraction, the 
urethra was freely divided ; and it was afterwards stitched up with silk 
sutures. For two years after she never saved any urine, but lately has 
been able to retain a small quantity during the day. On examination, the 
urethra and neck of bladder were found to be quite destroyed ; and there 
was nothing to represent the meatus but a gaping orifice, which had not the 
least power of contraction. 

Dec. 14th. — Operation. — ^The patient being under the influence of chloro- 
form, and placed in the lithotomy position, I proceeded to pare the edges 
of the lower three-fourths of the orifice ; and I then brought Uie pared edges 
together by four silver sutures, which I twisted with my fingers in the 
same way as I do in vesico- vaginal fistula. A catheter was introduced; 
but for many hours there wits much troui)le, owing to very free haemorrhage, 
which clogged up the catheter, and prevented it acting. On the 22nd, the 
catheter was removed, and she was allowed to pass her own water; but she 
was not able to retain much. 

Dec. Slst. — I removed the sutures, and found the edges quite united. She 
was able to hold her urine for two hours at a time when up, but not when 
lying down. I was in hopes that the urethra would gradually gain strength, 
and that eventually she would be cured ; and I accordingly sent her home, 
but she returned in a few months, saying that she could not retain her urine 
as well as when she l^t the Home. She was, therefore, re-admitted on June 
25th, 1863. 

July 2nd. — 1 proceeded to operate, which I did in the following manner : 
She was, as before, in the lithotomy position, and under the influence of 
chloroform. I pared the edges of the entire urethra, and closed it with 
silver sutures ; but I first pierced with a thin-pointed knife under the pubes, 
a little on one side of the median line, until the knife entered the bladder. 
I then introduced a silver catheter, which was kept in position by Mr. 
Harper^s instrument, and the patient was put to bed. The catheter was 
kept in until the 10th, never being removed, except on two occasion to be 
cleaned. 

July 11th. — She passed her urine, which at first she held only a quarter 
of an hour, then half an hour ; and she gradually went on improving, until, 
July 28tb, she could hold it for four hours, and pass it at will. 

These cases are interesting, as showing that cases which we hitherto con- 
sidered incurable can be safely and effectively treated by using mechanical 
appliances after operation. At the same time, it is not probable that many 
cases like the last will occur in future, because stone in the female bladder 
will not hereafter be removed by dividing the urethra, but either by dilata- 
tion, crushing, or extraction through the vagina. 



Art. 152. — On the Use of Medicated Pessaries in the 
Treatment of Uterine Diseases, 

By Dr. Tanner. 

{^TraiMaetuyM of the Obstetrical Society of London for 1862.) 
The great value of a variety of local applications in the treatment 
of uterine disease seems to be insufl&oiently appreciated by the profes- 
sion at large. This is somewhat strange, considering the time which 
has elapsed since Dr. Simpson specially directed attention to their 
exceeding utility. Yet it is certain that a larj^e number of practi- 
tioners know d no agents which may be directly applied to the 



iSS6 . MIBWIFEBT. BIO. 

uterDs and Tagina save the yarious kinds of canatics and injections. 
The latter are certainly of great benefit in many cases ; but it must 
be allowed that, even when properly used, they are often of only 
temporary service, since they cannot be kept in contact with the 
diseased part for more than a few minutes. 

" The chief reason, I believe," says Dr. Tanner, |* for the non- 
employment of medicated pessaries has been the difficulty of so 
making them that they can be efficiently applied by the patient 
herself When formed of certain drugs mixed mto a mass with lard 
and wax, they are either so soft that the sufferer cannot introduce 
them into the vagina ; or, on the contrary, they are so hard that . 
they fail to dissolve, and are expelled in just the same condition as 
that in which they were introduced. Although I have now employed 
these agents very freely for some years, I have found very few 
druggists who would take the trouble so to make them that they 
were of any service. The difficulties just alluded to have, however, 
been overcome since Mr. White Cooper directed attention {Lancet^ 
28th June, 1862) to the utility of the butter obtained from the 
^rheobroma cacao nut, from which chocolate is made, as the basis for 
ophthalmic ointments. This material possesses many valuable 
qualities, the chief beiug these : — It has an agreeable smell, and does 
not soil the fingers when handled ; it does not become rancid ; while, 
more particularly, though very firm, it has the property of beoomii^ 
fluid at a low temperature. It is sometimes a little too stiff, but this 
fault is readily obviated by combining with it a Httle olive oil or 
glycerine. ' Pessaries made with cacao butter, though they have the 
consistence of wax while cold, are dissolved in the course of a few 
minutes when introduced into the vagina. 

** If ophthalmic surgeons are much indebted to Mr. White Cooper 
for directing attention to the' uses of this butter, obstetric physicians 
are under no less an obligation. For, although it had been used in 
America for making ointments for some time before this gentleman 
wrote of its merits, yet no physicians in this country were acquaint^ 
with its value, as far as I can learn from many inquiries. 

" There are few uterine diseases in which the use of medicated 
pessaries may not advantageously form a part of the treatment. But 
they are more especially valuable in acute and chronic inflammation 
of the cervix uteri ; in internal metritis, with exfoliation of the lining 
membrane of the uterus ; in slight prolapsus or procidentia ; in 
cancer ; in all varieties of ovaritis ; as well as in many affections of 
the female bladder. By means of them the diseased parts may be 
kept constantly bathed in such drugs as mercury, iodine, lead, zinc, 
belladonna, opium, conium, &c. They are not only most efficacious 
in relieving pain, but they also shield the diseased and irritable sur- 
face from contact with the vaginal walls. Owing to this latter 
Sroperty, they are of great utility in healing excoriations about the 
ibia uteri ; tliough, of course, part of the benefit derived from their 
use in these cases must be attributed to the absorption of the 
materials composing them. By their employment, moreover, the 
necessity for frequent examination of the morbid structures is greatly 
diminished. 



MIBWIFBBT, BTO, 29f 

" The following formulaB are given as examples of the way in which 
I generally prescribe these remedies. It is only necessary to 
premise that rather large doses of the drugs are necessary, mas- 
much as absorption through the walls of the vagina is slow and 
uncertain. 

" 1. Iodide of Lead and Belladonna Pessaries. — J^. Plumbi iodidt, 
3ij ; extracti belladonnse, 9j ; butyri cacao, 5^^ » ^^^^ olivse, 5]. 
Misoe. Divide into four pessaries, and order one to be introduced 
into the vagina every night or every other night. 

" 2. Mercurial Pessaries. — Jl. TTnguenti hydrargyri, 3iv — 5^ » 
butyri cacao, 5^^; oleiolivsB, 5j' Misce. Where there is tenderness 
of the cervix uteri, one scruple of extract of belladonna, or two 
scruples of extract of conium should be added to the mass. Divide 
into four pessaries. 

" 3. Lead and Opium Pessaries. — 9). Plumln acetatis, 3j ; extracti 
opii, gr. xij ; butyri cacao, Jiv ; olei olivse, ^ . Misce. Divide into 
four pessaries. Order one to be used every other night. 

" 4. Zi?ic and Belladonna Pessaries. — Jt. Zinci oxydi, 5j » ®^" 
tracti belladonnse, gr. xij — 3} ; butyri cacao, 5^^ » ®^®i oliv», 
5j. Misce. Divide into four pessaries. One to be used every 
night. 

"5. Iodide of Potassium and Conium Pessaries. — 1^. Potassii 
iodidi, Jj ; extracti conii, 9iv ; butyri cacao, Jiv ; glycerinii puri, 
5J. Misce. Divide into four pessaries, and direct one to be used 
every njglrt. p 

" 6. ^nnin and Catechu Pessaries.—]^. TanninsB, 9iT; pulveris 
catechu, 5j\; butyri cacao, Jiv; oleioKvsB, 5j. Misce. Divide into 
four pessaries, and order one to be used every other night. 

" Jul some diseases of the uterine cavity, attended with copious 
tnuco-purulent discharges or with hemorrhage, the greatest benefit 
may be obtained from the local use of astringents. Once or twice 
a-week a pessary made of tannin and the cacao^butter, about two and 
a half incnes long, and of the size of an ordinary stick of nitrate of 
silver, may be introduced up the canal of the uterus,*and left there.^ 
It soon dissolves, tind thus coats the whole seat of the discharge with 
the medicament, the coating remaining attached for ^any hours. 
Such a pessary, weighing about thirty-six grains, will usually contain 
from twelve to twenty grains of tannin. Of course, other sub- 
stances — as alum, sulphate of zinc, dried sulphate of iron, &c. — may 
he employed in the same manner, if their use be indicated. This plan 
of treatment has none of the objections which apply to throwing 
fluids into the cavity of the uterus, a proceeding that is certainly not 
^inattended with ^ianger. There is no necessity, moreover, for 
^dilating the cervix with sponge-tents prior to the mtroduction of the 

fessary ; inasmuch as, when sanguineous or purulent discharges 
ave long been present, the os and cervical canal will always be 
found sufficiently patulous to permit of the^introduction of these 
astringent rods." 



298 DISBASSS OF CHILDBEK. 

Art, 153,— J Pesaary Retained Thvrteen Tears. 
By Dr. Kidd.. 
{DvUin Medical PreaSf January 21, ISeS.) 
At a meeting of the Obstetrical Society of Dublin, held Ja^. 10, 
1862, Dr. Kidd exhibited a pessary which he had removed from the 
vagina of a woman on the previous- day. She stated that he had 
himself introduced it for her thirteen years previously, and that she 
allowed it to remain with the greatest comfort to herself until- within 
the last fortnight, when she began to experience a pain in the back, 
while some discharge took place from tne vagina; The string had 
broken soon after it was put in, so that she was not able to remove 
it. The pessary was composition — a mass of tow covered over with 
India-rubber. He effected its removal by introducing one of 
the blades of Dr. Churchill's forceps, which he got above the mass, 
extracting it with the greatest diflSculty i In another case he removed 
a pessary after a year, and on that occasion he had recourse to both 
blades of Dr. Churchill's forceps. The pessary was eoated over with 
an immense mass of calcareous matter. 



^) CONCEBNlNCh THB DISEASES OF CHILDBBK. 

Art. 154}^ — Operative Surgery, in Children^ 

^ By M. GUERSANT. 

{(Bidl. Qin. de I%er., March 15,.18QB-; and British MedicalJowmdl, 
May 16, 1863.). 

M. Guersant has published the conclusions at which he has 
arrived after an experience of twenty years as -surgeon to the 
Children's Hospital of Paris. He treats of the preparation of the 
patients; the performance of the operations; and the consecutive 
treatment. 

1. — I^reparation of Patients^ — Certain malformations, especially 
imperforation of natural openings, must be operated on ik birth 
without preparation. The treatment of others, which do not 
interfere with the performance of the vital functions and the child's 
growth, may be deferred to a later period; such as club foot, phimo- 
sis, webbed and supernumerary fingers, complicated hare-lip, cleft 
palate &c. In general, operations, even those which it is thought 
advisable to perform at an early date, are more likely to succeed if 
delayed a fortnight, three weeks, or a month, when there has been 
time for ascertaining whether the child thrives well, than if performed 
two or three days after birth. In the meantime, if there be danger 
of small' pox, the child may be vaccinated before being operated 
on. 

If the necessity for operation be not urgent, it is a principle of 
good surgery to choose for its performance, both in hospital and ia 
private practice, a period of the year, when the smallest amount of 
disease prevails, and especially when there is no epidemic. There 
will rarely be opportunity for operating in the spring, as has beea 



DI8BASE8 OT CHILDSBK. 299 

bitherto adyif>ed ; in general, the months of Jane, July, Angust, 
September, and even October, are to be preferred, as ordinarily 
presenting a more regular and less Tariable temperature than prevails 
at other seasons of the year. In these cases, the little patients 
should be vaccinated if this have not been already done; and even* 
those who are fifteen or sixteen years old should be re-vaccinated as 
a precautionary measure. If this be not done, children who are in 
a fair way of recovery after operation nwiy take smalKpox and die. 
M. Guersant performed disarticulation of the thigh, for osteosarcoma 
of the femur, on a child five years old : the wound was almost cic»> 
trised and recovery seemed certain, when the patient, who had not 
been vaccinated, was seized with small-pcx and died thirty days 
after the operation, 

It is of the greatest importance, before determining on an operation, 
that the surgeon should examine the patient with the most scrupu« 
lens attention, in order to ascertain that there is no internal disease 
or peeuliar condition which may endanger the success of the opera- 
tion and the life of the patient. Thus, it is extremely useful to 
know whether the child be liable to convulsions or of the h»moiw 
rha«;ic diathe^i^. M. Guersant has several times met with evidence of 
this diathesis in children. In one case of the kind he was obliged to 
defer excision of the tonsils in a little patient who had purpura 
hemorrhagica ; and it was not until a course of astringents and iroa 
had been persevered in for two months that he decided to operate ; 
and even then the excision was attended by akrming hemorrhage. 
He advises that children subject to hsemorrhage should be prepared 
for operation by the internal use of perchloride of iron for a week 
at least. In another case, a child from whom he excised the tonsils 
died of convulsions, to which it had been subject. 

Certain preparations, according; ta the operation to be performed, 
are often indispensable. Thus, before opening an imperfect anus, 
the bladder must be emptied ; before performing lithotomy, the 
rectum must be unloaded ; and, in all operations, digestion must 
have been completed, and the bowels as freely evacuated as possible. 

As to the morale there is not much to be done as regards infants. 
Some children, however, may be led to submit to operation by being 
made to understand, that if any pain is to be inflicted on them, it is 
for the purpose of curing them. Most, however, must be operated 
on by surprise. In all cases, it is indispensable to have efficient 
assistants. If it be proposed to use cliloroform, this should be 
sometimes attempted before the day of operation. 

Perf&rmcmce of Operations. — In'a tolerably large number of cases, 
anaesthesia may be dispensed with. In opening abscesses, sounding 
the bladder, examining the rectum, and removing small polypi from 
that region, M. Guersant generally operates without chloroform. In 
some operations, the use of this agent must be rejected, as in very 
nervous and impressionable individuals. In some such cases, local 
anaesthesia may be produced by the application of chloroform, or, 
still better, of ice, while in other instances, as in excision of the 
tonsils and in tracheotomy, no anaesthetic can be used. 

There are many circumstamses in. which the use of chloroform is 



SOO DI8BASES OF CHILDSEK. 

strongly indicated ; and after having employed it in the oases of 
6000 or 6000 children, M. Guersant sees no reason to re^et having 
done 80. He uses Charri^re's instrument; the ansesthetic may also 
be given on a sponge having a sufficiently large opening to allow the 
air to pass freely. He has never had to lament an accident from the 
use of chloroform. Very early age is not a contra-indication to its 
use ; he has given it to very young subjects ; among oth^:«, to two 
. diildren less than four months old, on whom he operated for strangu- 
lated hernia. He has often used chloroform to render children in- 
sensible during examination ; as when they refuse to open the eye- 
lids in diseases of the eyes, and in certain very painful cases of 
eoxalgia. He advocates especially the use of ehkHroform in opera- 
tions which give rise to much pain, and at the samo time demand 
precision in execution, such as lithotomy. 

The performance of an operation on a child demands the most 
perfect knowledge of anatomy on the part of the surgeon ; for^ the 
parts being of small extent, the incisions must be limited to the 
strictly necessary dimensions. As examples of the necessity of 
>attenaiug to this precept, he mentions tracheotomy and lithotomy in 
children two years of age ; and says that it is plam, although many 
ignore the fact, that operations are more difficult in children than in 
adults. In <;ertain cases, the precept which reeomnaends the surgeon 
to opiate slowly must be departed from'; for children endure pain 
for a less time than adults, ana losses of blood are generally more dan- 
:gerou6 in them. Thus, the tonsils must almost always be removed very 
rapidly. In some cases, tracheotomy must be perfwrmed quickly, in 
order to prevent the patient from dying under the surgeon's hands, 
especially if the veins have been opened and pour out much blood. 

Consecutive Treatment. — The first point to be attended to is the 
ligature or torsion of vessels ; and, when only a small number of 
vessels have required to be tied or twisted after an amputation of one 
of tiie large limbs or after extirpation of a tumour involving a gresit 
loss of substance, M. Guersant advises that the dressing should be 
delayed for half an hour or an hour after the operation. He says he 
has always followed this plan with advantage. This precept, which 
was given by Dupuytren, has the advantage of allowing time for the 
re-establishment of the circulation, and obviates the necessity of 
removing the dressings to arrest haemorrhage which has come on 
after the application. If it be necessary, after certain operations, to 
plug the wound with perchloride of iron, this should be well diluted 
with water, to avoid sloughing. 

M. Guersant, following the advice of Dupuytren and Lisfranc, 
almost always renews the dressings on the day after the operation. 
The removal of the charpie and lint, the bandages and sutures not 
being interfered with, prevents the danger of many accidents. 
Erysipelas is prevented, by the removal of charpie impregnated with 
blood and serosity ; pus, if it have formed, is allowed to escape from 
between the lips of the wound ; and, if the edges of the wound 
have been strangulated by the sutures being too numerous or drawn 
too tight, they can be removed or loosened. If there be erysipelas, 
M. Guersant has often seen benefit derived from the application of 



DISEASES OF CHILDBEN. 301 

collodion. This, with the internal use of tincture of aconite, some- 
times prevents purulent absorption— a very rare accident in children, 
but which occasionally occurs. 

If the wound become pale and grey, the application of charpie 
soaked in solution of chlorinated soda is very useful ; and the ap- 
plication of pure lemon -juice has, in M. Guersant's hands, given a 
nealthy aspect to an unhealthy looking wound. 

General treatment is often of still more importance than local 
treatment. Usually if there be no convulsions (an accident which 
rarely occurs even after the most severe operations), or if there be 
no special contra-indications, a nutritious aiet should be allowed from 
the day of operation. Whenever it is possible, infants should be put 
to the breast from the first day, rather than be fed from a botue j 
they should be allowed to suck as much as they desire, at intervals 
of two hours. For other children, the food should at first be liquid, 
and consist of milk and beef-tea ; after the first day, wine may be 
given. A return should be gradually made to the child's ordinary 
food, to which may sometimes be added chocolate, cofifee, quinine, and 
other tonics. This regimen is indispensable, unless consecutive in- 
ternal disease set in and demand on the part of the surgeon the 
amount of medical knowledge necessary for detecting and properly 
treating them — without which there is no success in surgery. We 
must, M. Guersant says, never forget that the operator must be a 
physician before operation, a surgeon during its performance, and 
again a physician to terminate and even to bring to a successful 
issue many surgical operations. 

Finally, all the means which have been here described may fail, if 
the hygiene of the patients be neglected. Thus, all things being 
otherwise equal, children who are operated on in the town, in the 
homes of parents in good circumstances, and who reside in well venti- 
lated and warmed rooms, according to the indications of the case, are 
in better conditions for recovery than those who are operated on in 
hospitals, where numerous patients are. collected in one room, of 
which the air is, in spite of all that can be done, more or less 
vitiated. 



Art. 155. — Practical Observations on the Treatment of 
Purulent Ophthalmia in Infants. 

By Mr. Wordsworth, Surgeon to the Royal London 
Ophthalmic Hospital, <fec. 

{British Medical Jcmmdl, May 2, 1863.) 

The treatment described is that almost always adopted at the 
Boyal London Ophthalmic Hospital, and usually, it appears, with the 
most satisfactory results. Mr. Wordsworth says : — 

'* Suppose, then, a case of the disease, in which it is confined to 
redness of the conjunctiva, especially of the lower lid, the mucous 
membrane being somewhat villous and prominent, and attended by 
some discharge of mucus or pus, and tears. This is the first stage. 



302 S1SBA8K8 OF CHILDBEK, 

How may sucli Tje best treated P I should be content to have the 
eyes bathed frequently with warm water, by means of a small piece 
of linen cloth, to wash away the discharge, and afterwards, with 
an astringent lotion, containing four grains of alum in an ounce of 
water, and then wiped dry, and a little spermaceti-ointment smeared 
on the edge^ of the lower lid, and the child put back to bed. A tea- 
spoonful of castor-oil may be given, if it have not already taken 
some aperient. If in a few days this does not terminate the treat- 
ment, 1 usually drop a solution of two grains of nitrate of silver in 
an ounce of distilled water on the conjunctiva twice a day. This 
rarely fails to produce a marked improvement in a few hours, espe- 
cially if the discharge have become thin ; the child opens its eyes 
and bears the light without inconvenience. 

" If the case have passed into the second stage — the lids being 
red, swollen, tense, and Mning; the conjunetiva of the globe 
swollen, and raised round the cornea ; the discharge profuse ; and 
the child hot, fretful, and restless — I apply a leech to each upper 
lid, and administer a ^rain of calomel at once. By means of 
the leech, the swelling is soon reduced, so that the cornea may be 
examined ; and, independently of the antiphlogistic effect of loss of 
blood which is thus gained, the application of remedies to the con- 
junctiva can be more easily effected. 

" Fomentation of the lid is continued for some time, to encourage 
bleeding, and soothe the inflamed structures. The child will usually 
be considerably reduced by the bleeding ; and, being also relieved of 
pain, soon falls asleep. If the calomd. do not soon open the bowels, 
a small dose of castor-oil may be given. The fomentation is re- 
newed at short intervals ; and, as soon as the case approaches the 
conditions of the first stage, the weak alum-lotion is substituted for 
the warm water ; and this again supplemented by the nitrate of 
silver drop, as this ceases to effect a cure. 

** I constantly find that the subjects of this affection are immature 
children of seven or eight months ; and that the mothers are feeble 
and delicate women, incapable of providing a full supply of good 
milk. Under these circumstances, I prescribe quinine and iron for 
the mother, and thus indirectly influence the child. 

** The late Mr. Tyrrell introduced the practice of dividing the 
chemotic swelling by a series of radiating incisions round the cornea 
— a practice that since his time has, I believe, fallen into disuse. It 
is long since I have known it employed ; but in his practice it seems 
to have been so satisfactory, that one could scarcely reconcile the 
disuse of it with one's duty, if a suitable case were presented. Yet 
I have no reason to think the practice of his successors at the 
hospital is less successful than that adopted by this excellent 
surgeon. 

" From considerable opportunities, I am persuaded that the plan 
above sketched is most satisfactory and efficient for the treatment of 
this important disease. I do not doubt that, if more generally em- 
ployed, it would conduce to diminiph materially, if not to entirely 
check, the sad and irremediable consequences of purulent oph- 
thalmia. It also has, to my mind, a great advantage over the cruel 



DI8SA8B8 OF CHILDBEK« 303 

and unnecessary practice of applying stimolants to the tender and 
acutely sensitive little patients; and assuredly, in the cause of 
humanity, we should endeavour to avoid the infliction of an unne- 
cessary pang, especially when we remember how acutely a sympa- 
thizing mother suffers in witnessing these painful cases ; and now 
heroic she must be, or neglect to apply the painful remedy that has 
been prescribed, when she sees the agony that its employment 
causes to her babe. Who can wonder, then, that such painful treat- 
ment is not fully carried into effect ; and that, conseq[uently, much 
risk is incurred by the attendants for the sake of saving the child's 
sufferings P Nor should we. forget that the mother's health mate- 
rially reacts on the child's ; and, consequently, how necessary it is 
that she should be spared these painful emotions." 



REPORTS 

Oir THB 

PROGRESS OF THE MEDICAL SCIENCES. 

Jv/at — Januaryy 1864. 



ZXXYIII. 20 



The intention of the following Keports is to pass in review the principal 
additions to each department of Medical Science which have been placed on 
record during the preceding six months. It is not contemplated that they 
should be confined exclusively to the notice of what is new; any fact or 
doctrine which may be considered practically useful will, although not strictly 
novel, be regarded as worthy of commemoration. It roust be obvious to all 
who are aware of the immense mass of information which is almost daily put 
forth by the medical press of this and other countries, that the notice of eveiy 
subject would be an impossibility. It therefore devolves upon the writers of 
each Report to select only such articles for retrospection as may possess 
superior recommendations, either of an intrinsic character, or in relation to 
the main end and aim of all medical knowledge — the alleviation of suffering 
and disease. 



I. 

REPORT ON PRACTICAL MEDICINE. 

A Practical Treatise on the Diseases and Infirmities of 
Advanced Life. 

By Daniel Maclachlan, M.D., F.RC.P., late Physician and 
Principal Medical Officer to Chelsea Hospital, &c. 

(8vo, London : Churchill aDd Sons. 1863. pp.719.) 

Thb diseases of declining and advanced life, as compared with the 
diseases of infancy, childhood, and maturity, have been compara- 
tively neglected ; and, therefore, a work like the one under notice is 
not out of season. Moreover, Dr. Maclachlan must be allowed to 
have special opportunities for discharging in a satisfactory manner 
the task which he has undertaken, for, as physician and senior 
medical officer to Chelsea Hospital for upwards of twenty years, he 
has always had under his eye at least 600 persons, fewof thera 
below 60 years of age, and most of them ranging from 60 to 90, 
or even upwards. Nor have these opportunities been neglected. 
At the same time, we are obliged to express a feeling of regret that 
Dr. Maclachlan has not used these opportunities so as to make his 
work savour more of the bed-side and less of the study. In this 
way, we think, he would have met with more favour in these days 
of high pressure, in which it is difficult to find time to deal with 
anything except the very barest essentials. 

Dr. Maclachlan, we are glad to find, is very far from believing 
that human life must come to an end at threescore years and ten. He 
agrees with Hufeland in thinking that almost all those kinds of 
deaths which take place before the 100th year are brought on arti- 
ficially — that is to say, by disease or accident: and, so thinking, 
he concludes that li& will be very much prolonged if we will only 
believe that it may be so prolonged and act accordingly. This is 
comforting doctrine, and yet not too comforting : for it is confirmed 
by the fact that the age of the Chelsea pensioners far exceeds the 
average age, although the majority of these men were the subject of 
grave infirmity and disease before admission. 

With respect to the diseases of the difi^erent periods of old age 
and their general characteristics. Dr. Maclachlan says :-^ 

** As maturity insensibly glides into decline, so the diseases of the 
first period of old age are very similar to those that more especially 

20—3 



308 EEPOET ON PEACTICAL MEDICINE. 

appertain to that stage of life and present analogous features. Dys- 
peptic, rheumatic and gouty affections ; renal diseases, including 
albuminuria and gravel, are then frequent. By-and-bye, the pre- 
dominance of the venous circulation, with the rigidity of the arteries, 
encourage congestion in the different organs and passive haemor- 
rhages. From these causes and others proceed hsematemesis, 
melaena, hsematuria, varices of the bladder and rectum— all common 
diseases of the declining and more advanced periods of life. Cere- 
bral and urinary maladies now also prevail, and are superadded to 
one or more of the disorders first mentioned. Sangumeous apo- 
plexy, softening and atrophy of the brain and spinal marrow, vrith 
their immediate result, paralysis, are among the most frequent 
diseases of the aged, and are remotely or directly connected with 
senile degeneration of the ar*«riea. 

" Gradually, diseases of an inflammatory kind participate in the 
decaying energy of the vital force, and evince this influence 
by a corresponding inactivity, by frequently presenting a sub- 
acute or even chronic character from the commencement ; by the 
proneness towards an asthenic type, and in more active attacks 
by the rapid disorganization of the structures implicated. The 
pain and redness accompanying inflammation are usually, but by 
no means invariably, less intense. Robust octogenarians some- 
times present examples of acute sthenic inflammation in its true 
pathological characters in a genuine form, with high constitutional 
disturbance. More generally, however, in the later epochs of life, 
an opposite tendency is observed ; the inflammation is of a conges- 
tive character, and the febrile re-action slightly manifested ; the 
redness in erysipelas, for example, is often of a dull-brown or 
livid hue ; the bullae of this disease contain a sanious liquid, and 
though dry externally, are pulpy or less tense than at other periods 
of life, while there is often little general re-action. Similar pheno- 
mena are frequently observed in herpes zoster — a not uncommon 
and sometimes severe affection in the aged, the vesicles containing 
a dark sanies, and the skin underneath becoming gangrenous. 
CEdenia is now a common accompaniment and sequela of all the 
phlegmasise. In the cellular tissue inflammation rapidly assumes a 
diffuse character. Gangrenous abscesses speedily form ; and when 
the inflammation in other cases is limited by the eflusion of lymph, 
fitill this disposition prevails. "What at another period would be a 
common boil now turns out a carbuncle, and too often places the life 
of the aged subject in great peril. Elsewhere, in the serous and 
mucous membranes, the same results are observed, occasioned by, 
and indicative of, the decaying vigour of the system. The inflam- 
mation, when acute, is very often of an asthenic kind, accompanied 
by low fever, a dark dry tongue, much prostration and stupor, 
or delirium, and speedily ends in destruction or injury of the mem- 
brane affected. Efiiision of lymph, Mhich in the instance of inflam- 
mation of the serous tissues, may be regarded as the natural process 
of cure, is often replaced by seious, sanious, or purulent matter ; and 
where the attempt at restoration seems to have been vigorously 
begun, Tt e find these inferior products in unusual quantities mixed 



EEPORT ON PEACTICi-L MEDICINE. 309 

with tbe more organized secretion. A few hours are often sufficient 
to fill the chest with purulent or more generally serous or sero- 
purulent fluid, in otherwise slight and obscure attacks of pleurisy ; 
oedema of the lungs frequently accompanies bronchitis, and the 
tendency towards serous discharge may be observed wherever the 
mucous membranes are inflamed by the infiltration of the sub- 
jacent cellular tissue. Resolution from inflammation of the serous 
or mucous membranes is usually slow and imperfect. Chronic bron- 
chitis and chronic inflammation of the whole or portions of the 
genito-urinary tract is one of the most common attendants on old 
age. 

** Thus diseases accumulate with the progress of years. The in- 
numerable maladies that openly or secretly besiege the frame leave 
sequelaB, are engrafted upon each other, and present themselves 
associated and complicated in such wise as to diversify the character 
of the symptoms and modify the prognosis and treatment. As life 
still further advances, and the silent degeneration of the tissues pro- 
ceeds, man becomes more and more obnoxious to a host of organic 
diseases, all tending towards the end. And it is in old people espe- 
cially that the anatomist encounters the most singular modifications 
of structure, and the pathologist the most perfect and varied 
specimens of disease, benign or malignant, in the brain, heart, lungs, 
and otl>er viscera. So common are structural lesions in the decline 
of life, that long-abiding so-called functional disturbance of an organ 
is very often dependent upon «ome associated anatomical change in 
one or more of its tissues." 

The account which Dr. Maclachlan gives of these several diseases 
is clear and exhaustive, and the v^ hole work, though long and too 
much in the conventional text-book style, is one which cannot fail to 
suppl^V a good deal of sound information where such information is 
certainly lacking. 



The Fifth Report of the Medical Officer of the Frivy Council, 

(Blue-Book. 1863.) 
Mk. Simon's Fifth Report of the proceedings of the Medical 
Department of the Privy Council in 1863, is of peculiar interest and 
importance. It is devoted to the following subjects : — 
i(l.) 'Vaccination. 

(2.) The Supply of Vaccine Lymph. 
(3^.) Industrial Diseases : 

(a) Occupations which have to do with Arsenical Green. 
\b) Occupations which have to do with Phosphorus. 
<4.) The Cotton Famine. 
(5.) Cattle Diseases in relation to the supply of Meat and Milk. 

I. Vaccination, 
The Privy Council inquiry into the state of public vaccination 
in England has now extended to half the kingdom. The conclusion 
to which this investigation leads, and which subsequent reports will 



310 EEPOBT ON PEACTICAL MEDICIKE. 

most probably rather strengthen than weaken, is this: that the 
intentions of the Legislature in respect to Taccination are but very 
imperfectly fulfilled, and that the public defences against small-pox 
are in great part insufficient and delusive. 

In the statutes 'which during the last twenty -three years have 
been enacted with a view to the extermination of small-pox in this 
country, the immediate intentions of the Legislature have been as 
follows :— 

1. That thoroughly good vaccination, provided at the public 
expense under proper and well-notified arrangements, should every- 
where and gratis be within reach of persons who may choose to aviul 
themselves of it. 

2. But of course subject to the above — that it should be obli- 
gatory on parents to have their children vaccinated, health permit- 
ting, within three calendar months from birth — not necessarily by 
the public vaccinator, but, if not by him, then by some other medical 
practitioner whom the parent may select (and then must himself 
pay) for the purpose. 

3. As machinery for enforcing this obligation — ^that the fulfilment 
or non-fulfilment of the obligation should be ascertainable by 
reference to local registries kept by the respective registrars of 
births and deaths— whom also the law requires to notify to parents 
the obligation which it has imposed on them; that penalties lor non- 
fulfilment of the obligation should be recoverable by summary pro- 
ceedings from parents who, after notice, are in default ; and that 
especidly boards of guardians in their respective unions and parishes 
should systematically cause such proceedings to be taken. 

With regard to the non-accomplishment of these intentions of the 
Legislature, — it is true that, owing to the utter and universal failnre 
of the intended register of vaccination, the failure of the other parts 
of the system cannot be quite accurately measured. But, again and 
again, the inspectors have come upon cases where, quite apart from 
the register, there was conclusive evidence of extreme local neglect 
of vaccination. Among the elementarjr schools which they visited, 
schools were numerous where the unvaccinated proportion of scholars 
was from 20 to 30 per cent, of the whole ; in more than a few cases 
it was from 30 to 4^) per cent. ; in some it was from 40 to 50 per 
cent. ; and in one case (that of Penn, in Buckinghamshire) was as 
high as 65^ per cent. So again among the young inmates of work- 
houses, though under the very eye of boards of guardians, the in- 
spectors found similar evidence that vaccination was not duly per- 
formed ; — for among 38 workhouses which Dr. Seaton inspected, 
there were 8 where the unvaccinated proportion of children ranged 
from 20 to 38 per cent. ; — and among 74 workhouses which Dr. 
Stevens inspected, there were 20 where the unvaccinated proportion 
of children was from 20 to 34 per cent. The less exact evidence 
furnished by the registers of vaccination justifies a conviction that 
in many cases the local neglect is greater, even very considerably 
greater, than those discreditable figures would suggest : — for there 
are whole unions where there is no reason to suppose that any im- 
portant number of vaccinations is performed by private practitioners 



SEPOST OK PBACTICAL MEDICINE. 311 

and where yet the number of vaccinations performed by the public 
Taccinators does not equal a third of the number of births, — unions, 
even, where the public vaccinators* vaccinations are as few as 19, 18, 
17, 12, and 7 per cent, in proportion to each hundred of births ; — 
and there are instances of districts remaining for long periods, even 
in one instance as long as three years, without a single public vacci- 
nation being performed. 

Evidently, then, the fundamental object of the Legislature — the 
object of ensuring that every infant (its health permitting) shall bo 
vaccinated within the first few months of life, is very imperfectly 
attained. And the machinery which the Legislature established for 
the purpose of enforcing the fulfilment of that object is evidently 
not operative for its purpose. In explanation of M'hich fact, there 
are three reasons to be stated : — 1 st. That boards of guardians, except 
when influenced either by panic of small-pox or by formal remon- 
strances on the subject, have very rarely done all that they might 
do, and in many cases have done nothing-, to set the machinery in 
motion. 2nd. That the machinery itself is so imperfect that, even 
when used with good will, it must be insusceptible of exact work- 
ing. And 3rd, that the compulsive provisions of the law (perhaps 
leniently intended by the Legislature to be ambiguous and feeble, 
rather than clear and stringent) have in different places been 
subject to different magisterial interpretations, and have in all 
places been found insufficient for thoroughly accomplishing their 
supposed object. 

It remains, however, to be observed, that imperfect stringency for 
compulsive purposes is not the only, nor in Mr. Simon's opinion the 
principal, defect of the present law. The condition which assuredly 
the Legislature intended to be a condition precedent to any enforce- 
ability of vaccination, — the condition " that thoroughly good vacci- 
nation provided at the public expense, under proper and well 
notified arrangements, should everywhere, and gratis, be within 
teach of persons who may choose to avail themselves of it," is 
hitherto very imperfectly realized. Both with regard to existing 
local arrangements for gratuitous vaccination, and with regard to the 
required notification of such arrangements, the public has at present 
ample reason to complain that the conditions are not fulfillect under 
which alone a system of compulsory vaccination can be tolerable. 
Partly through" the continuance of faults* to which Mr. Simon 
adverted in his Second Annual Keport, as faults which the Privy 
Council regulations of December 1859 were intended to correct, but 
atill more (as described in Mr. Simon 's last annual Eeport) through 
the general ill-devisedness and futility of those contracts which pre- 
tend to regtdate the duties of vaccinator^*, it results — not only that 
to a very great extent vaccination is given in a most impunctual and 
irregular way, often without proper local notification — but moreover, 
that thoroughly good gratuitous vaccination is by no means uniformly 

♦ The inferior quality and extreme subdivision of public vaccination, the 
latter rendering it often impoaaible to maintain proper local supplies of 
lymph. 



312 BEFOBT OK FBACTICAL HEDICIKE. 

given by those authorities whom the Legislature has made respon- 
sible for giving it. And under these circumstances it would mani- 
festly be unjust to punish, for non-compliance with the law, parents 
whose children are not vaccinated. 

Mr. Simon therefore has ha».l no alternative but to submit to the 
Privy Council for consideration, that the laws now in force for the 
purpose of extirpating small-pox are not likely to accomplish their 
object, and that the system established by law for the provision of 
puolic vaccination works in an unsatisfactory manner. 

II. Supply of Vaccine Lymph, 

The Privy Council, during 1862, took special means to satisfy 
themselves that the lymph which was being supplied under their 
auspices was lymph of undiminished efficiency. For this purpose, 
Mr. Eobert Ceely, of Aylesbury, was instructed to inspect all the 
sources whence lymph is contributed to the National Vaccine Esta- 
blishment. Mr. Ceely*s inspection did not lead him to recommend 
any change of the present sources of supply. On the contrary, in 
those stations which (as being most frequented) gave him the best 
opportunities of forming conclusions on the subject, he " met with 
abundant evidence of the perfectly satisfactory character of the 
lymph there in use." In reporting this judgment of Mr. Ceely 's,. 
Mr. Simon states that he cannot over-state the importance which 
he attaches to it. For to Mr. Ceely, more than to any man since 
Jenner, the medical profession of this country is indebted for its 
knowledge of the natural history of vaccination. And in Mr. Simon's 
opinion there is no living person on whose testimony the public could 
more entirely rely as to the quality of the lymph which the Privy 
Council are responsible for distributing. 

III. Industrial Diseases^ 

(a.) The inquiries instituted under the direction of the Privy Council 
into the occupations which have to do with arsenical green were 
conducted by Dr. Guy : — 

The industrial applications of the pigment are principally two :— 
first, in the colouring of various papers, either of the sorts used for 
ornamental wrapping and lining, or of the sorts used for hanging in 
rooms; secondly, in the colouring of artificial leaves, fruits, and 
fiowers. The pigment is also used, though less considerably, by 
chromo-lithographers and toy-makers. It is likewise used by house- 
painters. It is used as a colour for tarlatanes. And most oulpably» 
though only to a small extent, it is used by the makers of cake- 
ornaments and coloured con fectionery. So far as concerns the health 
of persons employed, only the first two occupations require particular 
notice : but, in them, there is very considerable suffering. 

Thus, for instance, in visiting one of the larger establishments 
where artificial leaves are made — an establishment employing about 
100 young women. Dr. Guy found that more or less sufi'ering was 
almost universal among the workpeople. The skin-affection, which 
hardly any of them escaped, and which sometimes would begin after 



BEPOET ON PBACTICAL MEDICINE, 313 

even so little as one day's working, occurred in different degrees ; 
sometimes as mere erythema, sometimes as an eruption of clustered 
papules, vesicles, or pustules, sometimes as more or less destruction 
of skin by process of ulceration or sloughing. The fingers, which, 
(often with accidental chaps and scratches on them) are the immediate 
agents in industry ; the face ; the neck, especially about the roots of 
the hair 4 the flexure of the arms; the axilla; the genitals; these 
were the parts where the skin-disease had most shown itself — parta, 
namely, to vshich the arsenical dust is most largely applied, and 
parts where it is likeliest to be retained, and parts where the cuticle is 
most thin and penetrable. The suffering from these skin-affections 
had been in many cases very considerable ; for instance, in several 
cases the mere pudendal affection had been such that the sufferers 
could not bear to sit down. But the skin-affection was only a 
minor part of the suffering. Of 25 of the sufferers whom Dr. Guy 
examine!, nearly all showed signs, often highly developed, of chronic 
arsenical poij^ouing; excessive thirst; nausea, and loss of appetite; 
sickness and vomiting, often with pain in the stomach ; palpitation 
and shortness of breath ; debility, fever, headaehe, drowsiness, 
dimness of sight, and tremblings, nervous twitchings or convulsions- 
" Of the wViole group of 25 fenjales," says Pr. Guy, '* four only did 
not complain of weakness ; and of the remaining 21, there were, 
again, only 4 who did not describe the weakness as extreme. 
Febrile symptoms were present in no less than 20 cases, in live of 
which they amounted to feverishness, while in the remainder ihey 
were described as fever. Headache, again, was an almost universal 
symptom. It was absent in two cases only, and was described as 
not severe in only three cases. Dimness of sight was complained of 
in two-thirds of the cases. In one the eyes were very sore, in an- 
other the sight was greatly impaired. Drowsiness was present as a 
marked symptom in every instance but one, and in two cases only 
was it spoken of as a trivial circumstance. Tremblings and con- 
vulsive twitchings were present in 7 cases out of the 25, and in 
one other instance well-marked convulsions were present.'* It is 
wonderful that, out of such a group as this, deaths are not constantly 
occurring in a way to demand the coroner's investigation. But 
whatever may be th explanation of the fact, only one such investiga- 
tion seems to have been nrnde. 

The restrictions under which this injurious, and perhaps not in- 
dispensable, brancli of industry ought alone to be carried on are, in 
Mr. Simon's opinion, as follows :— -First, as a cardinal rule (the en- 
forcement of which would make it an interest of each establishment 
to enforce various improvements in detail) the employment of any 
person while presenting even in the slightest degree any sign of 
general arsenical poisoning should be absolutely prohibited; secondly, 
by scrupulous cleanliness of the workplace and workers, by ventila- 
tion of the workplace, and, where necessary, by special apparatus, the 
best known means should be used"to prevent the diffusion of arsenical 
dust in the-common atmosphere of the workplace, and to reduce the 
worker's liability to receive the dust upon his hands. 

(b^) Br. Bnstowe conducted the Privy Council inquiry into the 



314 BEFOBT OK FBi.CTICi.L MEDICINE. 

occupations which have to do with phosphorus. The utilization of 
phosphorus in various popular contrivances for producing instan- 
taneous light has, for the iast 30 years, been a special industry. 
And with the growth of this industry a new disease has come into 
existence. About 18 years ago, observations began to be published 
to the effect that, of the workpeople who in the new industry were 
exposed to the vapours of phosphorus, some, but apparently not a 
large proportion, suffered, in consequence of the exposure, a peculiar 
disease of the jaw-bones. 

From the inquiry which has now been made under the directions 
of the Privy Council, into the circumstances of the phosphorus- 
industry in England, it appears (fis had been anticipated) that the 
jaw-disease is not of frequent occurrence. Dr. Bristowe, after visit- 
ing all the known match-making establishments in England--57 
establishments, employing about 2500 hands, has not been authen- 
tically informed of more than 59 cases (past or present) of jaw- 
disease. And though doubtless in some instances information has 
been withheld from him by manufacturers who feel that their 
experience has not been creditable to them — so that the total pro- 
duction of jaw-disease during the last 30 years has been greater, 
perhaps considerably greater, than these numbers express — yet very 
probably there v» ould be no under-statement of the truth in apply- 
ing these numbers to the present time, and in assuming that now 
(with the improved arrangements which a less favourable early 
experience has induced all respectable manufacturers to adopt) not 
more than two or three cases of the jaw-disease are annually produced 
in England. Almost certainly, however, these few cases occur under 
circumstances which the manufacturer ought not to let exist, and 
which — if dangerous occupations were subject to official superin- 
tendence — would of course be forbidden to continue. " For," as Dr. 
Bristowe observes, ** while it is the easiest thing in the world for a 
factory to be made a hot- bed of disease, it is little less easy, by 
adopting precautions of the simplest and most obvious description, 
to render the occurrence of jaw-disease therein a rare and quite 
exceptional occurrence.** 

Those precautions of the " simplest and most obvious descrip- 
tion," to which Dr. Bristowe refers as essential for the phosphorus- 
worker's safety, and respecting which he gives in his report all 
needful particulars, are, in principle, two : — first, that the organiza- 
tion of the establifshment should be such as not at any time to expose 
to phosphorus-fumes more workers than must necessarily be exposed 
to them, and such as to restrict necessary exposure within the 
narrowest possible limits of time and intensity ; secondly, that the 
establishment sliall have suitable ventilation — including, of course, 
special ventilating arrangements for those processes of the manu- 
facture which cause the greatest evolution of fumes. 

IV. The Cotton Famine, 
Three inquiries were instituted in the course of the past year, 
in connexion with the health aspects of the cotton famine, by 
the Privy CounciL One oi these inquiries had reference tO' 



BBFOBT OK FAACTICAL liEDIOIKB. 315 

the healtli of the distressed operatives and was conducted by Dr. 
Buchanan ; another referred to the health of the girls of the 
sewing schools at Preston, and was also conducted by Dr. Buchanan; 
and a third, relating to the nourishment of the distressed opera- 
tives, was conducted by Dr. Ed. Smith. An abstract of the 
results of the first of these inquiries was given in our last volume. 
The second inquiry arose from a report that the girls in the Preston 
sewiiig schools were suffering markedly in health, a report which 
Dr. Buchanan's investigation showed to be in a great measure 
erroneous. The third inquiry included the whole subject of dietaries 
for the poor. 

The Economies of Diet, — The questions which Dr. Ed. Smith was 
instructed to investigate were as follow : — (1.) What is the least 
cost per head per week for which food can be boui^jht in such 
quantity and in such quality as will avert starvation diseases from 
the unemployed population P (2.) What, with special reference to 
health, would be the most useful expenditure of a weekly minimum 
allowance granted exclusively for the purchase of food P (3.) What, 
with the same special reference, would be the most useful expendi- 
ture of small additional sums, say 25 and 50 per cent., or the 
minimum granted for the same exclusive purpose? Dr. Smith 
enters very minutely into the whole subject of dietaries for the 
poor, and his report is of great value on all that relates to the 
economics of diet. The following are his conclusions in reference 
to the first question submitted to him : — 
• 1. When food is purchased and cooked separately, the line between 
BufBciency and insiifiiciency in adults may be drawn at about 2«. per. 
head weekly. 

In the case of single persons living separately, it would incur 
a risk to limit the amount to 2s. weekly in all cases, and the mini- 
mum amount to be spent weekly in food should be 2*. Zd. for 
women, and 2is. Qd. for men. 

2. In the case of man and wife without children living with them, 
the minimum amount should be 4s. 9rf. weekly. 

3. The case of families must be considered chiefly in relation to 
the age of the members, for it is manifest that a child of six years of 
age requires less food than a youth of 16 years of age, and in this 
respect the present system of averages in the supply of relief accord- 
ing to, and diminishing per head with, the number of members in a 
family, is most defective. 

The minimum allowance to the husband and wife should be 4*. 6fl?. ; 
to each child over 12 years of age, 2«., and to all others 1*. 6c/. per 
week, except in the case of infants at the breast, when, if it be the 
only child, 1*. weekly should be allowed, but if there be other chil- 
dren no allowance will be necessary. 

4. When food is prepared in large quantities and supplied at 
cost price, the allowance may be reduced, probably, to 2*. weekly 
for each person over 16 years of age, 1«. 6c?. for each over 10 
years of age, and I*. 3i. for each under 10 years of age, exclud- 
ing infants at the breast. It is also probable that the food thus 
supplied would be more nutritious in quality, better cooked, and 



31S B£FOBT ON FRA.CTICAL 1CEDII3INE. 

eaten hotter than would oc^ur under a system of separate cook- 
ing. 

in answering the second question, Dr. Smith subjects to exami- 
nation the economic and nutritive value of the foods chiefly in use 
among the operatives, and suggests certain dietaries for the unem- 
ployed operatives. Existing analyses of food, he holds, are insuffi- 
cient. We must take averages from fair samples, as of a whole 
beast, for example, in reference to meat. He refers to the earboa 
and nitrogen only for comparison with the excretions. He quotes 
also the free Iiydrogen, reckoning it as carbon. The adult individual 
requires 30" 100 grains of carbon and 1,400 grainsof nitrogen weekly. 
Meri require daily, on an averHge, 4*588 grains of carbon and 215 
grains oi nitrogen ; womeuj 3.758 grains of carbon and 155 grains of 
nitrogen. The daily excretion of carbon is from 7*85 oz. to 12*19 oz., 
of nitrogen, 200 grains. We quote the following summary of the 
different nutritive and economic value of foods : — 



Food. 


Coat. 


Carbon. 


Nitrogen. 


Remarks. 






1 
d. 


grains. 


grains. 




^Bread 


lb. 


n 


1968 


92 




Flour 


lb. 


If 


2656 


120 


MiiHiplj by I'^to find the quan- 
tity ot bread. 


Oatmeal 


lb. 


u 


2768 


140 




Peas 


lb. 


u 


2688 


262 


3 times cheaper than bread, in 

in nitrogen; but not equally 
assimilated. 


Eice ... ... 


lb. 


li 


2688 


70 


Cheaper thau' flour if Id. per lb. 
Must eat more. 


Sago 


lb. 




2552 


1-7 




Barley 


lb. 


2 


2656 


91 




Potatoes 


lb. 


1 


760 


24 


Requires 3\ times to be eqaal in 
carbon to flour ; 6 times to be 
equal in nitrog* n to flour; lOj 
times to be equal in nitrogen 
to peas. 


Turnips, swedes 


lb. 


i 


304 


15-3 


„ white 


Ih. 




175 


1-2 




Carrots 


lb. 


"i 


384 


14 




Succulent vegetables ... 




420 


14 




Sugar 


lb. 


ii 


.2768 




Much dearer than staroh, with 
equal nutritive values. 


Treacle 


lb. 


u 


2240 




Much cheaper than sugar. 


Butter, fresh ... 
„ salt ... 






4704 
4584 




j A very dear £at. 


Lard and dripping 






5320 






Bacon, green ... 




4" 


4265 


78 


The cheapest fat. 


„ ory 






4763 


96 




Meat, average for these 
dietaries 


]"• 


2660 


160 




Boi.es (lor liquv) 


lb. 


u 


783 


24 




JLiver 






1226 


210 




Herrings, dried... 


lb. 




1435 


840 


The che-.pest. animal food if it 
were more digestible. 


Blilk, ne«v 


pint 


ItoU 


' 646 


43 




„ skimmed... 


pint 


i^oi 


438 


43 


Is equal to new milk. when Cat>i8 
added. 


Butter-niUk ... 




\ 


420 


43 




Cheese 




6 


2667 


316 




Tea 


oz. 


3 




10 




Coffee 


oz. 


\ 




5 




Eggs, weight l|oz 


eaub 


•106 


16\ 





BEFOBT OK PEACTICAL MEDICINE. 317 

The estimated cost of the different dietaries suggested by Dr. 
Smith is founded on the lowest retail prices for private, and 
wholesale prices for public dietaries. He quotes the following 
retail prices : — 

Bread l^d. lb.,flour l^d. lb., oatmeal l^d. lb., rice l^d. lb., peas l^d, 
lb., potatoes 1*. 20 lbs., carrots and turnips ^d. lb., onions ^d. lb., 
beet 6c?. lb., bacon (American) 4o?. lb., liver 3^d. lb., cheese 6d. lb., 
skimmed milk ^d. pint, buttermilk ^d. pint, mutton fat 5o?. lb., 
mutton suet 6d. lb., sujrar 4id. lb., butter lOd. lb., treacle 2d. lb., tea 
3rf. oz., dripping 6d. lb. 

As a general principle Dr. Smith assumes that three meals per day 
will be taken, and as a model dietary premises the following : — 

Breakfast : milk, oatmeal, and bread, with bacon or herring, if 
possible. 

Dinner : meat or bacon, or herring with bread, and fresh vege- 
tables, cooked in various ways, and if possible cheese or pudding. 

Tea : tea or coffee, milk, oatmeal, and bread. 

Whenever tea or coffee is taken the cost will be greater, and con- 
sequently for the same cost the nutriment will be less ; and hence, if 
either must be taken, it should be reserved for the evening meal. 

Whenever it is practicable the skimmed milk and buttermilk to 
be used should be previously heated with one teaspoonful of flour 
and half an ounce of mutton fat per pint, and to the buttermilk 
should also be added a little allspice, ana thus render them in nutri- 
tive value nearly equal to new milk. 

As it is impossible to calculate the cost of each article in each 
meal correctly with reference to the value of our coins. Dr. Smith 
calculated the cost of each for eight meals, so as to enable him the 
better to divide the cost of the pound. 

The cost of the breakfast should be lid. to l^d. ; of the dinner 
l^d. to 2d. ; and of the tea Id. 

In tables which he appends as a Supplement to his E-eport he 
gives details for suitable dietaries at these and slightly different 
prices. 

As a general guide, it may be stated that in very low-priced 
dietaries bread must form almost the sole source of nutriment, since 
it is the only food which can furnish the required quantity of nutri- 
ment at the limited cost, with the daily constancy permitted by the 
appetite. The best addition of the same kind is oatmeal. " The 
cheapest kind of fat is that of bacon, and next, that of dripping. The 
cheapest source of nitrogen, in a food which may be eaten constantly, 
is buttermilk, and next, skimmed milk. The cheapest solid animal 
food is fish, as herring, but it cannot be eaten with advantage 
continually. The most economical sweet is treacle ; and as a con- 
tinuous supply of fresh vegetable, potato is the best. In the dietaries 
Dr. Smith usually allows 2d. weekly for fresh vegetables, and where 
the weekly cost of food exceeds 2*., this may be allowed. This will 
purchase 3i lbs. of potatoes weekly, or 2 lbs. of potatoes and 1 lb. of 
onions, or 2 lbs. of potatoes and 2 lbs. of carrots, any of which, 
probably, offer a sufficient supply of fresh vegetable juices. It is 
also to be desired that cabbage and turnip- tops in their season should 



318 REPORT OK PRACTICAL MEDICINE. 

form a part of the dietary, and the latter may often be obtained 
without cost. 

Dr. Smith gives much prominence to bread, oatmeal, milk, bacon, 
and fresh vegetables, whilst tea and coffee, sugar, and expensive fats, 
are used sparingly. 

" The aim in the selection of food," says Dr. Smith, " has been to 
provide three meals, each having the customary character. The 
breakfast will consist of bread and milk, rice milk and bread, milk 
porridge with bread, oatmeal brose with milk or treacle, or coffee 
with milk, sugar or treacle, and some kind of fat and bread. Butter- 
milk will sometimes wholly or partially supplant milk. The dinner 
will consist of meat, bacon, liver or herring, with vegetables and 
bread. Sometimes pudding made of oatmeal, rice, or flour, will be 
added to or supplant the animal food, and occasionally buttermilk is 
provided as a beverage. 

" The evening metu will usually consist of oatmeal and milk por- 
ridge with bread, or oatmeal brose with treacle or dripping, or coffee 
or tea, with sugar, milk, and bread, to which butter, dripping, or 
treacle is added. 

" Hence bread will be eaten with milk porridge or meat, or with 
the addition of treacle, butter, or dripping ; flour will be used in 
makint; porridge or pudding ; oatmeal in making porridge or brose, 
and eaten with milk or buttermilk ; rice in rice milk or pudding, or 
eaten dry with treacle, dripping, or meat ; peas with bacon or liver ; 
coffee with boiled milk and sugar or treacle ; and suet with rice or 
flour." 

Dr. Smith does not enter at length into the third question submitted 
to him. ** It may suffice to state," he says, ** that additional dietaries 
would be especially applicable to persons of large stature, to the 
sick, and to the aged. The former would demand a larger amount 
of bread and meat, while the sick and aged would need a larger pro- 
portion of the luxuries or comforts of foods. To the latter, therewre, 
a larger addition of tea, coffee, butter, and perhaps meat might be 
allowed, and the articles should be of better flavour and quality — as, 
for example, new milk and fresh butter." 

V. Diseases of Live Stock in their Relation to the Public Supplies 
of Meat and Milk. 

Allegations have, during the last few years, been abundantly 
made, and have with the progress of time become more and 
more definite, that the flesh of animals slaughtered while in a 
state of disease, and likewise the milk of diseased animals, are 
extensively sold for human consumption in the United Kingdom. 
The substance of these allegations was submitted to the Lords of the 
Council by Mr. Simon. In 1862 their Lordships ordered an inquiry 
to be made in this matter, and under their directions Mr. Simon 
requested Mr. John Gamgee, Principal and Professor in the Edin- 
burgh New Veterinary College, to report on it. 

Mr. Gamgee's evidence is, in substance, as follows : — That disease 
prevails very extensively in the United Kingdom among horned 
cattle, sheep, and swine ; that the diseased state of an animal not 
only does not commonly lead the owner to withhold it from being 



BBPOET ON PEACTICAL MEDICINE. 319 

glauglitered for consumption as human food, but on the contrary, in 
large classes of cases (especially where the disease is of an acute 
kind), leads him to take immediate measures with a view to this 
application of the diseased animal ; and that consequently a yery 
large proportion (Mr. Gamgee believes as much as a fifth part) of the 
common meat of the country — beef, veal, mutton, lamb, and pork — 
comes from animals which are considerably diseased. 

The diseases which figure behind the scenes of our dead meat 
market are of course various. For the purposes of Mr. Simon's 
report it was necessary, however, to refer to three forms only — viz., 
first, contagious fevers ; secondly, the so-called anthracic and 
anthracoid diseases ; thirdly, parasitic diseases. 

Of the contagious fevers of stock, two are now widely prevalent in 
the United Kingdom — namely, the pleura-pneumonia or lung fetter, 
which is peculiar to horned cattle, and the aphthous fever ^ or foot- 
and-mouth disease, which affects indifferently and in common horned 
cattle, sheep, and swine. A third disease of the same class— the 
small-pox of sheep, perhaps of all murrains the most dreaded in this 
country, is not known to be now prevailing among our flocks ; but, a 
few months ago, an outbreak of it in Wiltshire excited the greatest 
alarm ; and it is a disease which may at any moment be spreading 
here. A fourth most important contagious fever of stock — the very 
fatal typhoid fever or steppe murrain of Kussian horned cattle, has 
happily been kept away from us for more than a century, partly by 
the exertions which are made in Kussia to limit the disease to those 
provinces where it is endemic, partly by the strict precautions which 
are taken at the eastern frontiers of Prussia and Austria to prevent 
. contagious importations; and while this system continues in operation 
the steppe-murrain is of little practical interest to us. 

Of the so-called anthracic and anthracoid diseases of stock— 
distases which German pathologists have generalized under the 
name of milzbrand — many prevail to a great extent in the United 
Kingdom, though for the most part as endemic diseases, localized in 
particular sections of the country. It is said to be an essential 
character of these diseases, that the blood of the diseased animal 
imdergoes peculiar — in some respects putrefactive — changes; but 
commonly the disease involves an occurrence of local infiltrations 
and effusions of putrescent blood-ingredients or blood ; and in many 
cases there also occur, either primarily or secondarily, gangrenous 
changes (erysipelatous or carbuncular) in some superticial solid 
texture of the body. Diseases of this class are further characterized 
by the fact that, during their course, the diseased body develops in 
itself a specific morbid poison which, by inoculation, can be made to 
spread the disease to other animals, including man. The diseases 
which Professor Gamgee counts under the present head are as 
follows: — the splenic apoplexy of horned cattle and sheep, the 
braxy of sheep, the black quarter of homed cattle and sheep, the 
glossanthrax or tangue-carbuncle of (almost exclusively) horned 
cattle, the forms of anthrax which affect the mouth, pharynx, and 
neck in swine, the apoplexy of swine, ana theirso-called blue-sickness or 
hog-cholera, the parturition fever of cows, the corresponding heaving- 
^ains of ewes^ the navel-ill of lambs^ and the red-water of sheep. 



320 EEPOIIT ON PBACTTCAL MEDICINE. 

Thirdly, there are the parasitic diseases of stock — diseases whicli 
consist in the colonization of the living animal's body by lower 
animal forms, larval or mature, subsisting; at its expense. Such are 
the following diseases ; the so-called *' measles,** of the pig, in which 
disease the cystieercus cellulosa (larva of the solium tapeworm) is 
found more or less abundantly diffused through the muscular system, 
and perhaps in other parts, of the animal ; the analogous disease of 
horned cattle, due to the larva of the t. medio- canellata ; the various, 
chiefly visceral, diseases of stock which depend on larvae of the iania 
marginaia and U eckinoeoccus ; the brain disease ** gid ** or " sturdy," 
which is due to a larva, mostly of the t. ccenurus; the rot of sheep, 
due to swarms of adult and oviparous flukeworms (distoma) in the 
liver ; the lung disease, which, especially in calves and lambs, is pro- 
duc ed by different species of strongylus ; the easily overlooked, but 
highly important disease of swine, which consists in an infection of 
their muscular system by the minute forms of the trichina, 

" It is for obvious reasons impossible,*' Mr. Simon writes, ** in 
the present state of knowledge, to state in detail what income of 
morbid product flows from each of the above-mentioned sources 
into the markets \^ hich supply us with food. But from Mr. Gam- 
gee*s report, together with such other information as he has given 
me, I gather that, so far as he can learn, the truth is about as 
follows : — That horned cattle affected with pleuro-pneumonia are, 
much often er than not, slaughtered on account of the disease, and 
when slaughtered, are commonly (except their lungs) eaten ; and 
this even though the lung-disease have made such progress as 
notably to taint the carcase ; that animals affected with foot and 
mouth disease are not often slaughtered on account of it, but, if , 
slaughtered, are uniformly eaten j that animals affected with 
anthracic and anthracoid diseases, especially swine and homefl 
cattle thus affected, are (except their gangrenous parts) very ef- 
tensively eaten ; that the presence of parasites in the flesh of an 
animal never influences the owner against selling it for food ; that 
carcases, too obviously ill-conditioned for exposure in the butcher's 
shop, are abundantly sent to the sausage-makers, or sometimes 
pickled and dried ; that specially diseased organs will often, perhaps 
commonly, be thrown aside ; but that some sausage-makers will utilize 
even the most diseased organs which can be furnished them ; that the 
principal alternative, on a large scale, to the above-described human 
consumption of diseased carcases is, that in connexion with some 
slaughtering establishments, swine (destined themselves presently to 
become human food) are habitually fed on the offal and scaverage of the 
shambles, and devour, often raw, and with other abominable filth, 
such diseased organs as are below the sausage-makers' standard of 
usefulness. , 

" This, in general terms, is Mr. Gamgee's report on the subject. 
Disgusting as are the reflections which it suggests, there is not in it, 
I think, anything intrinsically improbable, hot obviously wherever 
there is dangerous disease among stock, the owner's commercial 
instinct will be to make whatever salvage he can, and while he 
must well know that selling dead stock for meat pays better than 



BEPOIIT ON FBACTICAL HEDICIKI. 321 

selling it for manure, the public has no sufficient safeguard against 
his yielding unreservedly to that motive. And if, while the stock is 
suffering with even the most loathsome of diseases, he thinks fit 
to have each animal as it sickens, or even as it gets moribund, 
slaughtered and dressed for the market, assuredly there will often 
not be any efiTectual obstacle to his carrying that wish into 
effect. 

" One doubt, however, may well be raised on the subject. A first 
popular impression would be, that, if things are as described, pesti- 
lences must be bearing witness to the fact. Is it possible — it may be 
asked — that cattle, having all the foulness of fever in their blood, or 
having local sores and infiltrations that yield one of the deadliest of 
inoculable morbid poisons, or having their flesh thronged with 
larval parasites — is it possible that such cattle can be converted into 
human food, and yet not only the immediate scandal of a general 
poisoning be escaped, but even something not unlike general im- 
punity be the result P Though the affirmative answer to this ques- 
tion may at first sight seem strange, nevertheless it is, with some 
qualifications, the true one. And doubtless the impunity, such as it 
is — but it perhaps is far less general than it appears — results from 
the operation of well-known chemical and physiological laws. Our 
animal food before we take it has for the most part been exposed to 
so high a temperature that any parasites which had their home in it 
are killed, and that whatever albuminous morbid contagium it con- 
tained has been coagulated and made inert. Probably, too, against 
small quantities of animal poison — and against such as communicate 
small-pox and glanders, just as against the venom of the cobra and 
rattlesnake — the stomach has resources of its own; for any such 
organic product entering the stomach is at once (as regards that 
mobile chemical constitution on which its efficiency depends) exposed 
to the strong disinfectant chemistry of digestion, and thus, within 
narrow limits of quantity, is likely to be rendered inert before it can 
soak into living texture. Both these influences may count for some- 
thing, and the first-mentioned of them for almost everything, in 
explaining the fact (so far as it is a fact) that many sorts of diseased 
meat are eaten with impunity. On the other hand it must be re- 
membered, that, in this theoretical explanation, the two protective 
influences do not cover the whole field of danger : for, in the first 
place, not all meat that is eaten is exposed throughout (nor in every 
instance even at all exposed) to a temperature sufficient to kill para- 
sites and coagulate albumen ; in the second place, even complete 
coagulation of albumen maj^, for aught which we know to the con- 
trary, leave some morbid poisons in operation ; in the third place, 
it may very well be that, even where cooking can divest a meat of 
someoriginal specific infectiveness, the meat may still not be susceptible 
of quite the same digestional changes as healthy meat, when eaten, 
undergoes. And thus the theoretical apprehension would be that, 
with our alleged large consumption of variously- diseased meat, the 
impunity of consumers, thougn it were the rule, might be subject to 
considerable exceptions. Accurate empirical knowledge in this, 
matter is hitherto only beginning to be gathered, and wUl not yet 

XXXYIII. 21 



322 BEPOBT OK FBACTICAL MEDICINE. 

warrant any general dogmatic statements as to the effects of diseased 
meat on human consumers. 

With regard to that minor branch of the inquiry which relates to 
the MILK of diseased animals, Mr. Simon states : — "It appears that, 
in this country, the most important question is as to the wholesome- 
ness of milk from animals with aphtha. Mr. Gamgee points out that 
on some occasions when aphtha has been prevailing among the cattle 
of a country, the human population in the same places has suffered 
from the same or from some similar disorder. And experiment 
seems to have established as certain, that at least under some cir- 
cumstances, the human affection may be caused by the^consumption 
of milk drawn from a diseased animal. It may be that the frequency 
of such communications of the disease, as compared with the number 
of persons who (more or less) are consumers of milk, is not great. 
But the danger is one of which the public ought to be aware. 
Further inquiry is wanted to ascertain whether the allegation, which 
has been made and contradicted, be true or untrue — that the milk 
of aphthous cows, if used for food (especially by young children, who 
are likely to be the largest consumers of it,) is apt to produce diatur- 
bance of the stomach and bowels." 



Army Medical Department : Statistical, Sanitary , and 
Medical Reports for the Year 1861. 

{Blue-BooJc. 1863.) 

The first section of this important Blue-book includes the Statistics 
of Health and Diseases in the Army prepared under the superin- 
tendence of Deputy Inspector-General Dr. Balfour, F.E.S., head of 
the Statistical Branch. This formidable mass of figures, dressed 
into all the various shapes which statisticians love, is for civilians 
rather hard of digestion ; but it naturally claims the first attention, 
since these figures are the crucial tests of the work done, and serve 
to prove success, denounce failure, and declare want. The ratio of 
deaths per 1000 of mean strength in the home troops in 1861 was 
9*24, being a slight improvement on that of the previous year (9*95), 
and a most important one iudeed on that which had prevailed prior 
to the adoption of the measures recommended by the Sanitary 
Commission of 1858, when the ratio of mortality was estimated at 
17'5. Analysis of the admissions and deaths shows the reduction to 
have been chiefly in theclassesof miasmatic and venereal diseases; but, 
as the reporter sets forth, the leading facts of the great prevalence of 
venereal and high raortalitv by tubercular diseases remain unchanged. 
More than one-third of all the admissions were due to venereal, and 
about one-third of all the deaths to tubercular disease. Let us for a 
while fix our attention on these prominent features. 

The admissions into hospital in the home army of 91,000 men, for 
venereal diseases, during the year, amounted to about 32,000 ; 
upwards of 2200 have been constantly in hospital, and the average 
duration of the cases has been 2419 days. The inefficiency caused 



BEPOBT OK FBACTICAL MEDICINE. 323 

by it has been equal to the loss of the services of every soldier 
at home for 8*56 days, or the loss of the services of a body of 10(X) 
men for two years. 

Turning now to tubercular disease, we find it causing 283 deaths 
out of a total of 822 from all causes, and swelling the per-ceutage of 
the invaliding lists to a proportionate extent. Dr. Balfour, the 
author of the Statistical Eeturn, confines himself to marshalling the 
facts and figures, drawing only arithmetical deductions from them ; 
and the tables are varied so skilfully and accurately as to enable any 
one at all accustomed to figures to draw out any series of facts into 
a given order, although nearly every form of important deduction U 
abready there satisfactorily made. Dr. Balfour certainly foresaw that 
pathologists and physicians, in reviewing these statistical labours, 
must ask themselves whether these two leading facts are not some- 
thing more than merely isolated circumstances demanding indepen- 
dent consideration, for the researches of our modern pathology tend 
more and more to determine the signs by which the effects of 
syphilis may be recognised in the causation of structural disease of 
internal organs. 

The question which these figures sugsjest is the solution of the 
doubt whether the large amount of pulmonary disease in the army is 
not the direct effect of the great extent of syphilitic infection. This 
question is one of vast importance in civil as well as in military life. 
The labours of Virchow in Germany, and of Dr. Wilks in this 
country, together with those of many other able workers, have espe- 
cially served to advance our knowledge of this subject. But it is 
in the army that the greatest facilities exist for the solution of this 
important medical question ; for there the patients, instead of form- 
ing part of an ever-shifting population, remain for years under the 
observation of the same medical officer, who watches the first begin- 
nings of syphilis, observes the ravages of subsequent pulmonary 
disease, and is by the post-mortem examination able to ascertain the 
precise structural conditions after death. In our hospitals, the 
division of practice into ** pure surgery,** which takes to itself the 
venereal disease, and ** pure medicine," which absorbs pulmonary 
disease, opposes this continuous observation, even where the changing 
habits of a civil population do not render it impossible. Turning to 
the report of Deputy Inspector-General Dr. Mapleton, head of the 
Medical Branch, we find with satisfaction that this important topic 
is about seriously to engage the attention of the Department. Dr. 
Aitken, the Professor of Pathology in the Army Medical School, 
Netley, contributes an admirable paper on Pulmonary Lesions 
associated with Syphilis. Although buried in a report of which the 
circulation has hitherto been by no means commensurate with its 
value, tins paper is certainly destined to influence considerably the 
advance of our pathology in respect to constitutional syphilis, for 
army surgeons will find m it all necessary indications for pursuing 
this subject, and foreshado wings of the promise which such labours 
hold out. Dr. Aitken observes : — 

** Foremost amongst the evils engendered by syphilis is the deteri- 
oration of the constitution. A condition of ill-health or cachexia is 

21—2 



324 BBFOST OK PBACTICAL HEDIOIKB. 

undoubtedly established ; and the development of lesions essentiallj 
specific are brought about in many of the internal organs. There is 
perhaps no morbid poison — the paludal or malarious poison not 
excepted — which has so extensive a range of influence as the 
syphilitic poison. Hardly any organ is exempt from its destructive 
ravages ; for its virus seems to exert its power chiefly on the con- 
nective tissue, and that tissue takes a part in the structure of every 
organ of the body. 

" The medical periodicals for several years past, as well as several 
monographs on the subject, and the records of the Pathological 
Society of London, have been mainly instrumental in demonstrating 
the very remote eflects which syphilis exercises upon the organs and 
the coDstitution of man. Great advances have thus been made in 
the pathology of syphilis — advances which are due to clinical, 
experimental, and post-mortem observatious. It has now been 
clearly shown that many doubtful cases of ill-health are in reality due 
to the influence of the specific poison of syphilis, the morbid effects 
of which mav not be fully developed till many months, and even 
years, after the primary infection." 

He points out that the more remote effects of syphilis, as to 
which lurther definite information is to be desired, are, (1) the specific 
condition of constitutional ill-health associated with (2) the definite 
structural injuries, and especially those new growths of connective 
tissue known as nodes, or gummatous tumours. Surgeons have 
long been cognizant of such gummatous growths or nodes of the 
periosteal investment of the bones, especially of the shin, skull, and 
clavicle, as amongst the commonest features of secondary syphilis ; 
it is now known that they are developed in the lung, liver, brain, 
heart, voluntary muscles, testicles, and in the eyes. Dr. Aitken 
discusses with practised skill the tests by which such growths are 
recognised ; and while noting that the post-mortem examinations 
at the invaliding hospital of the army are extremely rich in syphilitic 
lesions, notes also that, " whatever explanation may be given of the 
fact, it is undoubted that a very large proportion of the cases 
dissected acknowledge in the history of their illness or ill-health that 
syphilis was the starting point." Dr. David Milroy, assistant- 
surgeon 30th Kegiment, gives also an important paper on pul- 
monary diseases and their relation to syphilis ; and they both furnish 
notes of cases which clinically support the views expressed. Emi- 
nent civilians, such as Graves, Stokes, Walshe, and Virohow, 
amongst physicians, and Eicord and Acton amongst venereal prac- 
titioners, have urgently directed attention to this subject : neverthe- 
less, it has not yet attracted that attention which it deserves ; and 
in the recent able medical report from the physicians of the Con- 
sumption Hospital, on the last ten years of their experience, we do 
not find any reference to the subject. No doubt tneir experience 
will be found proportionately less ample, when they turn thejr atten- 
tion to this point, than that of army medical officers, who in a 
limited number of autopsies, after death from pulmonary disease, 
find a large proportion of cases presenting syphilitic lesion of the 
lung. But, on the other hand, these lesions are not of themselves 



BSPOBT ON FSAOTICAL HBDICIKB. 325 

easily to be recoenised, unless the mind of the observer be on tbe 
alert. We do not remember to have seen anywhere a more dear 
and rational account than that which Dr. Aitken gives in his paper ; 
and believing that such description will possess great interest for all 
our readers, we think it right to quote his account of the character 
of syphilitic alteration of the internal tissues : — 

"The lesions just noticed eventually assume a great variety of 
anatomical forms ; but in the first instance they are to be recognised 
in the typical form of nodes, or aummatoits nodules. The minute 
structure of these gummatous noaules has been closely examined by 
many observers. This gummatous nodule consists of a growth of 
elements which leads to the development of an elastic tumour com- 
posed of well-defined tissue, and the elements of which are extremely 
minute. The tumour takes origin from the connective tissue or the 
analogues of such ; and hence the universality of the site of syphi- 
litic lesions. When they are sufficiently large to attract attention— 
as in the form of a node on the shin-bone, or on some part of the 
true skin — they are small, solid, pale knots, like a hard kernel, about 
the size of a pea. They are generally first seen on some part of the 
true skin or subcutaneous or submucous tissue; and when the 
tissue in which they happen to grow is sufficiently lax, they grow to 
a considerable size, and convey to the touch a sensation as if they 
were filled with gum. Kepeated examinations of this growth show 
that in its gelatinous or soft state it arises from a prolification of 
nuclei amongst the elements of the connective tissue, not unlike the 
formation of granulations in a wound. The component cell elements 
appear as round, oval, or oat-shaped particles imbedded in a matrix 
of fine connective tissue of a granular character, and tending to 
fibrillation. The cell elements are a little larger than blood-globules, 
and are distinctly granular in their interior when mature. In the 
growing part of the node, and immediately in its vicinity where 
growth is abnormally active, the minute cell elements are seen to be 
developed in groups within the elongated and enlarged corpuscles 
of the connective tissue. In form, therefore, the node or gumma- 
tous nodule resembles a tubercle, and, bv fatty degeneration or 
tuberculization, may not be capable eventually of being distinguished 
from tubercular deposit. How, then, are we to recognise the specific 
nature of such gummatous nodules P There is nothing in them so 
specifically and anatomically distinct that, apart from their history, 
they can be recognised^ The history of the syphilitic case during 
life is the great guide. The nodes on the shin-bone or clavicles 
have long been recognised as the product of syphilis. It may almost 
be said that they have been seen to grow under the eyes of the patient 
and the observer ; and their anatomical characters are found to be 
such as compose the gummatous nodules just described. In a case 
of inveterate syphilis, therefore, whose history is fully known, in 
whom the node on the shin is characteristic and has been seen to 
grow, and in whom also we find similar nodules in the lungs or in 
the liver and in the testicles — symmetrically growing in these latter 
organs — and consisting of minute cell elements exactly the same as 
the node on the shin, it is impossible to overlook the fact, or not be 



326 BEPOBT OK PSACTICAL MEDICINB. 

impressed witli the belief, that all these lesions acknowledge one and 
the same cause of development — namely, the syphilitic poison — of 
■which they are the expression. The progress of the node is also 
characteristic and suggestive. Growths of a similar form which 
result from idiopathic inflammation generally proceed to the forma- 
tion of an abscess or to the hypertrophy of fibrous tissue. Abscesses 
are recognised by their pus ; fibrous tumours or hypertrophies by 
the fibre elements which compose them. 

** Growths of a form similar to the node which result from cancer 
are in general to be recognised by the juice expressed from them. 
In the gummatous nodule we have no juice ; and the cell elements 
seen in cancer are generally so diversified in their form and mode of 
growth as not to be easily mistaken. The gummatous nodule is 
uniform as to the size and form of its cell elements, and forms 
growths less highly supplied with bloodvessels than cancers. Can- 
cers also tend to infiltrate and involve neighbouring textures ; the 
gummatous nodule remains isolated and distinct. 

'* By way of elimination, therefore, and by duly observing the 
history of the case, we are generally able to recognise the nature 
of such growths, and to assign to them their proper place in patho- 
logy." 



Report of the Royal Commission on the Sanitary State of 

the Indian Army. 

(Blue- Book, 1863.) 

In 1859, a Eoyal Commission was appointed to inquire into the 
sanitary state of the Indian Army. This Commission, a natural 
sequence of the great Commission of 1857 on the health of the 
British Army at home and in the colonies, and, like the latter Com- 
mission, chiefly brought about by the energy of the late Lord 
Herbert of Lea, terminated its investigations, in May of the present 
year. The results of these investigations are commensurate in 
importance with the imusual and prolonged labour which the Com- 
mission devoted to its weighty task. 

The data from which a correct notion has to be derived of the 
sanitary condition of the European soldier in India are, in several 
important respects, defective. One of the first and most weighty 
consequences of the present inquiry must be the accurate registra- 
tion, on a systematic plan for all the three presidencies, of the facts 
most intimately connected with the health-status of the soldier. 
This want has been in part anticipated by the extension of the scheme 
of vital statistics adopted by the Army Medical Department to 
Indian stations. Meanwhile, the data which have been reduced and 
subjected to discussion by the Commission disclose an almost in- 
credible waste of life. During the present century the annual rate 
of mortality amongst the East India Company's European troops 
amounted to no less than 69 per 1000. In the healthy parts of' 
England and Wales, 8 out of every 1000 men of the soldier's ajje 
die annually ; in the unhealthiest parts of England, and among the 



BBPOBT ON PBACTICAL HBDTCINB. 327 

unhealthiest trades, the mortality is at the rate of 12 in 1000. Thus, 
taking the English standard, besides deaths from natural causes, 60 
head per 1000 of our troops perish in India annually. At twenty 
years of age the mean after-lifetime is diminished, as compared with 
England, nearly 22 years. 

But a remarkable difference is observed in the rate of mortality 
among different classes of the European population of India. The 
annual death-rate among officers in India has been hitherto 38 per 
1000 — ^little more than half that of the non-commissioned officers and 
men. Again, among the civil service the death-rate does not range 
higher than 20 per 1000 — a rate which approximates to the highest 
average mortality occurring among the native troops. An equally 
great difference it is to be presumed, if the data admitted of a just 
comparison, would be observed between the constant-sickness rates of 
the various services, European and native. In Bengal the average 
constant-sickness rate among the European troops is 84 per 1000. 
" With this amount of sickness, an army of 70,000 British in India 
has, so to speak, a vast hospital of 5880 beds constantly full of sick, 
and loses yearly by death 4830 men, or nearly five regiments." 

Officers, civil servants, and native troops are a like exposed to the 
same climatic and local conditions as the European rank and file : 
whence, then, arises the vast disproportion between the waste of 
life among the different services and classes of the European popu- 
lation ? The diseases most inimical to life are the same m each case 
— to wit, fevers, dysenteries, diseases of the liver, and epidemic 
cholera. Three-fourths of the mortality among European troops 
serving in the presidency of Bombay between 1830 and 1846 was, 
according to Sir Kanald Martin, due to these endemic diseases. The 
most influential and pertsistently active cause of disease is also the 
same in each service and class of population. Writing of British 
troops, the great authority just referred to says that, ** taking any 
one cause, he would say that the union of heat, moisture, and malaria 
constitutes the most powerful one in destroying the integrity 
of the European soldier's health, and conducing to his fall by 
disease." 

To learn the sources of the extraordinary proclivity of the Euro- 
pean soldier to disease in India, and its fatal effects upon him, it is 
requisite to trace his history from the time of leaving these shores. 
Too commonly he is sent away unformed ; and, until very recently, 
on his way out, he was apt to acquire — thanks to a liberal spirit- 
ration — a taste for ardent spirits, or, if the taste had been already 
acquired, to have it fostered. If there be one evil habit among 
soldiers in India having a pre-eminence of mischievousness, it is 
dram- drinking. Military and medical officers alike condemn the 
practice. The Commission give a prominence to the questions arising 
out of it commensurate with their importance. " The great disease 

with officers and men," said Sir Charles Napier, " is drink 

Why, their ration is two drams a day, and eight of these drams make 
a quart bottle ! So the sober soldier swallows one-fourth of a bottle 
of raw spirits every day !" To tempt the soldier from the canteen, 
efforts have been largely made by commanding-officers to provide 



azb BBPOBT Oir PRACTICAL HBDICIITB. 

athletic and other means of amusement. But the establishment of 
these means, as well as of other benefits, is dependent upon a tax 
levied upon the spirits sold to the soldier ! " There is, as it were," 
says the Commission, " a tacit encouragement for the soldier to drink 
that which is admitted to be injurious to health, in order that he 
may be benefited in other ways which may be conducive to health." 
On landing in India, the soldier, if unformed, is subjected to a course 
of drill most trying to the phy&ical powers and detrimental to 
health under the intense heat j if formed, he has before him^ a life 
of weary and over-fed idleness. " He rises at gun-fire ; attends his 

Earade or drill, over soon after sunrise. He then returns to his 
arrack, and during the hot season he is not allowed to leave it till 
late in the afternoon. At one o'clock he consumes a large amount 
of both animal food and vegetables, porter (perhapa a quart)* and 
spirits. He has few or no means of occupying himself rationally. 
He lies on his bed and perhaps sleeps most Of tne day. He has his 
evening parade or drill r and his turn of guard duty once every Qve, 
seven, or ten days. Even at home this kind of regimen would be 
far from conducive to health. In India, both physically and morally, 
it helps to destroy it in men in the prime of life, with abundance of 
nervous power to dispose of.'* For the rest, he is constantlv exposed 
to miasmatic and malarious influences of a character suck as very 
nearly to exhaust the descriptive powers of the Commission. Every 
native town, every bazaar contiguous to a cantonment, and every 
encampment of native troops, is a veritable Malebolge, 

'^Holding sharp converse with the sight and smell.** 

Nay, still following I>ante, we might go further, and describe tke 
natives as 

"A crowd immersed in ordure, thaiappeared 
Drafi*of the human body.*' 

There is not a station which does not sufier more or less- from con- 
tiguity with native habitations, and which itself does not suffer from a 
bad site or grave sanitary defects, or both, and more particularly from 
an imperfect and probably polluted water supply. But European 
troops are less exposed to the evils arising from these sources than 
the native troops, and they are affected by them to a great degree 
in common with their own officers and the civil service. Again, the 
much lower degree of mortality among the officers and civil servants 
shows that climate has little of itself to do with the exaggerated 
mortality among the soldiers. The source of this is to be further 
sought m some circumstances peculiar to the soldier^s life. There 
is but one class of the native community which is placed under con- 
ditions of aggregation and comparative inaction at all approaching 
those in which the soldier is found — namely, the prisoners in jails. 
J^Tow, the mortality among the Indian prisoners approximates to that 
observed among British soldiers. It is in the very conditions of 
aafgregation and inaction, moreover, that the British soldier 
differs most widely from his officer, the members of the civil service, 
and the native troops. It would almost seem as if the barracks of 
our Indian Army were contrived as condensers of the malarious and 



IISPOBT OK PRACTICAL MEDICIKB. 6W 

xniasmatic influences to which the troops were exposed. In short* 
the enormoas sickness and mortality of the European forces in India 
may be traced to certain well-understood causes. 

The recommendations of the Commission include (1) the dimi- 
nution of the number of stations in the plains, and the removal of as 
large a proportion of troops to the hills and table lands as would be 
consisteni with the security 06 the country ; (2) the organization of 
an efficient sanitary service ; and (3) suggestions for the removal of 
theparticular hygienic evils disclosed by the inquiry. 

The results of flie Commission's inquiry into the important subject 
of hill-stations are stated as follows : — 

1; " To reduce to a minimum the strategic points on the alluvial 
plains, and to hold in force as few unhealthy stations as possible. 

2. " To locate a third part of the force required to hold these points 
on the nearest convenient hill-station or elevated plain, including in 
this third, by preference, men whose constitutions are becoming 
enfeebled, and recruits on their first arrival ; and to give the other 
two-thirds their turn. 

H: "^ever to trust to simple elevation as a means of protecting 
health; but while occupying the best available elevated stations, to 
place these (for they want it just as much as the stations in the 
plains) in the very best sanitary condition.** 

The diminution of the number of stations in the plains and 
establishment of one-third or more of the forces in the hills, although 
the reoommendatiou best fitted to effect the most thorough and 
permanent amelioration of the sanitary condition of the Indian 
Army, is that probably which will be least readily carried into 
operation. Involving a radical change in the distribution of the 
European troops in Hindostan, it may be anticipated that the 
necessity for so important a step will not be immediately perceived 
by the military authorities, and that time will be required in order 
that they may familiarize themselves with, and for tiie growth of a 
just estimate of, the conception. 

The organization of a special sanitary service, the second of the 
two principal recommendations of the Commission, must follow as a 
necessary consequence of the inquiry, if this is to give rise to any 
pennanent practical results. To the absence of such a service may 
DC traced the whole of those great evils which have been laid bare by 
the investigation. It might have seemed a self-evident truth that 
the measures requisite for the preservation of the health and vigour 
of the soldier demanded as scrupulous and systematic organization 
as those necessary for his care when sick, or for his training in arms ; 
but this- truth has never been learnt by governments or military 
authorities, unless as the result of bitter or even disastrous 
experience. 

"There are, no doubt, considerable difficulties,'* says the Com- 
mission, *' in the way of organizing an efficient sanitary service for 
India, and in adapting it to the various exigencies of the country ; 
but there are, nevertheless, certain leading principles which should 
be kept in view in any administrative arrangements to be introduced 
for the purpose. It is, for example, of great^ importance that the 



330 EEPOET ON PEACTICAL MEDICINE. 

procedure should be as far as possible uniform in eaeh presidency ; 
and this could be best secured by appointing^ commissions of health, 
one at each seat of government, representing the various elements — 
civil, military, engineering, sanitary, and medical, on the co-operation 
of which depends the solution of many health questions. We are 
of opinion that such commissions are necessary also to give apractical 
direction to sanitary improvements and works. Their lunctions 
would be chiefly consultative and advising on all questions relating 
to the selection and laying out of stations, proper construction of 
barracks, hospitals, and other buildings, drainage, water supply, 
cleansing, and general sanitary supervision in stations, cities, and 
towns, and on the prevention of epidemic diseases. To fulfil the 
other object of taking advantage of home experience, it would be 
necessary to afford these commissions every needful information on 
the most approved and economical methods of laying out sanitary 
works, and in those healthy principles of construction and improve- 
ment of barracks. and hospitals which have been successfully carried 
out in England, but which have still to be introduced into India, 
and adapted to the circumstances of the country. The sanitary 
improvements which have been recently introduced at home military 
stations, and which are about to be carried into effect at certain 
foreign stations by the War OflBce, as well as the improved principles 
of construction in barracks and hospitals now in use, were adopted 
on the advice of a commission specially appointed by the War OflSce 
to inquire into the subject. The questions which arise out of the 
evidence from the Indian stations are of the same nature as those 
which have come under the examination of, and have been dealt 
with by, the War Office Commission; and it would be highly 
advisable to make their experience available for India by adding to 
the existing Commission an engineer and a medical officer conversant 
with Indian sanitary questions, or to form a similar commission in 
England for this object. Such a commission, if considered prefer- 
able, should include members specially conversant with recent 
improvement, military and civil, an engineer of Indian experience 
who has given attention to sanitary works, and a medical member 
acquainted with the sanitary question as it presents itself in India. 
The function of such a commission could, of course, be consulted 
only. It would simply be the medium of advising and informing 
the Indian Government and the presidency commissions on the latest 
improvements, and on the best principles of sanitary construction. 
For this purpose it might give its advice on the healthiness or 
otherwise of plans, and as to the sanitary details of buildings to be 
occupied by troops ; on the best and most economical methods of 
water supply and drainage : it might collect and publish useful 
information and instructive matter regarding improvements, and it 
might possibly be able to give a more practical direction to the 
education of cadets of engineers destined for service in India, to 
enable them to devise works and improvements on healthy prin- 
ciples. It would in no way interfere with perfect freedom of action. 
It would place at the disposal of the Indian Government and 
presidency commissions the latest experience, classify and generalize 



BEPOBT ON PBACTICAL MEDICINE. 331 

the results of their several pablications in a sammary form, and 
thus enable all to arrive at a more satisfactory decision as regards 
measures to be carried out for protecting the health of troops thaa 
would otherwise be possible," 



1. A New Method of Treating Disease ly Controlling the 
Circulation of the Blood in Different Farts of the Body. 

By John Chapman, M.D., M.R.C.P. 

{Medical Times and Gazette, July 10, 1863.) 

2. An Experimental Inquiry into the Effect of the Application 
of Ice to the Back of the Neck on the Retinal Circulation. 

By Dr. J. Hughlings Jackson, M.D., M.K.C.P., Assistant- 
Physician to the National Hospital for the Paralysed and 
Epileptic. 

(Medical Times wnd Gazette, July 28, 1863.) 

By means of cold and heat applied to different parts of the back. 
Dr. Chapman holds that the supply of blood to any part of the 
body may be diminished or increasea at pleasure, ana that in this 
way we are put in possession of a new curative system which will give 
us the mastery in a lai'ge number of diseases. He believes that this 
controlling power over the circulation is exercised through the 
instrumentality of the vaso-motor system of nerves, the supply of 
blood being diminished when increased action in these nerves pro- 
duces a state of contraction in the vessels, the supply of blood being 
increased when paralysis of these nerves allows the vessels to become 
relaxed. The idea (which may have been suggested by Dr. Brown- 
S^quard's practice of applying cold and heat as a mode of treatment 
in various affections of the nervous system) is, in its author's opinion, 
in strict accordance with the discoveries respecting the vaso-motor 
functions of the symjathetic nerve which have made the names of 
Professor Claude Bernard and Dr. Brown-S6quard famous among 
physiologists. 

** In order to lessen the excito-motor power of the spinal cord 
only," writes Dr. Chapman, " I apply ic€f in an india-rubber bag 
about two inches wide along that part of the spinal column contain- 
ing the part of the cord on which I wish to act. On the same 
principle, the vitality of the spinal cord my be increased by applying 
not water and ice alternately, each in an india-rubber bag, if very 
energetic action be required ; if less vigorous action be necessary, I 
apply ice, or iced water only, using it several times a day, for a 
short time on each occasion, with a long interval between each 
application. 

" If it be desirable to increase the circulation in any given part of 
the* body, this I have found myself able to effect by exerting a 
soothing, sedative, depressing, or paralysing influence (according to 
the amount of power required) over those ganglia of the sympa- 



332 BBPOBT ON PBACTICAL HEDICINB. 

thetic which send vaeo-motor nerves to the part intended to be acted 
on. This influence may be exerted by applying ice to the central 
part of the back, over a width of from four to four and a half inches, 
and e](tending longitudinally over the partieular segments of the 
sympathetic and of the spinal cord on which it is desired to 
act. 

" For example, intending to direct a filler and more equable flow 
of blood to the brain, I apply ice to the back of the neck and between 
the scapulse ; increased circulation in and warmth of the upper 
extremities are induced in the same way ; the thoracic and abdominal 
viscera can be influenced in like manner by applications to the dorsal 
and lumbar regions ; while the legs and the coldest feet ever felt 
can have their circulation so increased that they become thoroughly 
warm by an ice-bag applied to the lower part of the back. 

" The bags I use are of different lengths : of the width already 
named for adults, and of lesser widths, of course, fo» children, i 
have had them made both of india-rubber and of linen with a surface 
of india-rubber upon it : the former are the best. The width of the 
bags is equal throughout, except at the opening, which is narrowed 
to facilitate tying, and elastic to admit easily the lumps of ice. 
When the bag is full, I divide it, if a long one, mto three segments : 
this can be done by constricting it forcibly with string;. the ice 
of the upper part is thus prevented from descending, as the melting 
goes on, into the lower part of the bag. I am preparing a bag on a 
new principle, which will be a great improvement on those I now 
use ; but as it is not yet complete, T abstain from describing it here. 
I sustain the bag in the position intended by means of ribbon or 
tape passed through loops at the back of it, then over the shouldersy 
and round the body." 

Dr. Chapman is very sanguine. 

" Theoretically,** he writes, " I feel aswired that by the methods 1 
have desc^ribed physicians will be able to control the great ujajority 
of diHeases ; experimentally, I have already received numerous and 
wonderful proofs that this assurance is well founded. By thus 
acting, by means of cold or heat, or both alternately or combined, 
on the spinal cord and ganglia of the sympathetio, I have succeeded 
in completely arresting the fits of many epileptics, and in curing the 
following maladies : — Paralysis; long-continued and extreme head- 
aches; prolonged giddiness ; extreme somnolence ; a feeling of want 
of firmness in standing and of security in walking ; habitual halluci- 
nations ; loss of memory ; weakness and dimness of sight : ocular 
spectra ;. inequality of the pupils ; lateral anaesthesia ; incontroUable 
spasmodic opening and shutting of the mouth ; cramps of the limbs 
(m two cases of the hands, incapacitating the patients to continue 
their work) ; numbness of the fingers, incapacitating the patient to 
pick up small objects, or to use a needle ; paralysis of the bladder : 
mcapacity to retain the urine more than a few minutes (two cases 
recovered to a surprising extent); profuse and too-irequent men- 
struation ; scanty and irregular nienstruation ; extreme menstrual 
pains ; profuse leucorrhoea, with long-continued bearing down of the 
womb, and extreme pain of the back ; habitual constipation ;. 



BBPOBT OV PRACTICAL MEDICINE. 333 

habitual diarrhoea; general coldness of the surface of the body 
which has continued for many years ; habitually and hitherto 
irremediably cold feet." 

Judging from what we have seen of the results of this mode of 
treatment, our opinion would be oxpressed in very different words to 
those of its author. Whether further evidence will lead us to alter 
this opiftion remains to be seen. We shall certainly remain open to 
conviction; and in the meantime all we will do is to quote the 
following clever and important remarks by Dr. Hughlings Jack- 
8oni and leave them to speak for themselves, without further 
comment : — 

** At the Hospital for the Epileptic and Paralysed I tried the 
following experiments in order to see if I could influence the eye — 
the size of the pupil, the calibre of the retinal arteries, and coloration 
of the optic disc — by applying cold to the back of the neck. Ic 
occurred to me to do so on reading Dr. Chapman's paper on * A New 
Method of Treating Disease by Controlling the Circulation of the 
Blood in Different Parts of the Body.' I'he patient on whom I 
tried it was a girl of fair general health, but who was subject to 
sudden startings of the whole body, for which she had been admitted. 
When ice was applied to the back of the neck and upper part of the 
dorsal spine, I could detect no alteration whatever in the size of the 
pupil. I confined my attention to one. It varied readily in light 
and shade. (I tried this experiment on another little girl several 
times with the same result.) I then examined the fundus with the 
ophthalmoscope, noting carefully the size of all the vessels, and the 
degree of coloration of the optic disc. The nurse then applied the 
ice to the back at the lower cervical and upper dorsal regions, but 
there was no change whatever ; the vessels remained of the same 
size and the disc of the same colour. I next examined when the ice 
was applied to the back of the head, and then to the side of the 
neck, and I tried the same experiments on a second patient ; in both 
with the same results. 

** Now, the pupil not being artificially dilated, it was of course not 
Tery easy to estimate the size of the vessels and the coloration of the 
disc, let I had it well and steadily under view when the ice was 
applied, and when it was taken away. I, however, dilated one pupil 
with atropine, and then saw the disc as plainly almost as the child's 
face. Had it, to use such expressions, blushed or paled, it would 
have been readily detected. I looked both before, during, and after 
the application of the ice. The large vessels did not alter in the 
least, nor did a small artery, like a hair, that I watched with great 
care, and, what is of more importance, I did nut detect the least 
change in the colour of the optic disc. The ice was applied to the 
tack of the neck for exactly nineteen minutes. I was very careful 
to keep the disc steadily under view the moment the ice was sud- 
denly applied and when it was suddenly taken off, and indeed I kept 
the disc under a steady gaze nearly the whole of the nineteen 
minutes. Finding no difference on taking away the ice afier this long 
application, it was re-applied almost directly, and then, the disc 
being under view, the nurse took the ice away, and immediately 



334 BEPORT ON PEACTICAL MEDICIBTB. 

substituted a flannel wrung out of very hot water. I could find no 
change. 

*' I used the ordinary ophthalmoscope in the above examinations. 

** Next morniner I examined the retina again, and this time by the 
direct method. The disc seemed of course of large size, and I had no 
difficulty in keeping it under view at the moment of suddenly 
'making contact' and of suddenly * breaking contact.' I found no 
change in the size of the arteries or veins, nor in the coloration of 
the disc. 

** So far, then, I could see no change in the circulation, no change of 
colour in tlie disc; but I freely admit that very likely with the 
greatest care I nHtjht be unable to detect some little alteration 
of colour. Nor would any one I suppose who adopts Dr. Chapman's 
views believe that the changes would be very marked, so as to be 
easily appreciated by the eye. Still these observations may be of 
some value, if confirmed, in settling that point by experiment — ^viz., 
that there is no perceptible alteration. 

" I tried then to get information from patients in the Hospital who 
were using the ice for purposes of treatment as to any alteration 
in the function of the eyes. [The ice is applied for half an liour, and 
then hot flannels for half an hour, the patient sitting in a chair so 
that there could be no defect from position.] One little girl com- 
plained that several times a day her sight was * queer,' but tiiis is a 
common complaint in epileptics, and this patient's sight did not fail 
when the ice was applied. Two other patients were not intelligent 
enough to give me any answers at all. In a fourth the answers were 
unsatisfactory. I asked the patient what she felt, and she described 
the local sensation, and spoke of a pain over the right eye, and, 
in reply to several questions, said there was no other feeling. 
But, on asking the leading question, * Is there anything wrong 
with your sight when the ice is applied P' she said there was a little 
dimness. 

" Of course the next thing was to apply the ice to myself, and see 
if it affected my own sight, but I have not had time, and this has 
been the case with a medical friend who kindly offered to submit 
himself to the experiment. I have, however, been informed by the 
Matron of the Hospital, who, at my request, tried the experiment on 
herself, that it produced for a time dimness of vision, which was 
followed by greater clearness. I shall proceed to make further 
experiments on intelligent patients, in order to get a wider basis of 
evidence than can be supplied by one case. 

" My object in making these experiments was not so much for the 
sake of learning the effect of this treatment on the circulation in the 
eye, as to be able to form some idea of its effect on the cerebriU 
cu'culation. Dr. Chapman, in the communication referred to, writes 
(page 60) : * For exam i)le, intending to direct a fuller and more eouable 
flow of blood to the brain, I apply ice to the back of the nect and 
between the scapulae.' If the circulation in the brain were affected 
by the application of ice to the back of the neck, it is, I think, 
probable that the branches of the arterise centralis retinae would be 
affected too." 



BEPOBT ON PRACTICAL MEDICINE. 335 

Practical Hints on the Treatment of Nervous Pain and 
Neuralgia. 

By C. B. Radclipfe, M.D., Physician to the Westminster 
Hospital, and to the National Hospital for the Paralysed 
and Epileptic. 

{British Medical Jmimal, Nov. 7, 1863.) 

In a paper read at the last annual meeting of the British Medical 
Association, at Bristol, Dr. Badcliffe said : — 

" In the remarks I have to make, I do not propose to suggest a 

f articular plan as applicable to the treatment of all kinds of pain, 
propose merely to speak of the kinds of pain which are known as 
nervous pain and neuralgia, and which are sufficiently well known to 
need no formal definition; and upon this small part of a wide sub- 
ject I do not propose to do more than read the rough notes of three 
or four cases, with a few paragraphs of preliminary observations. 
And in doing this, I feel no little hesitation, Mr. President, in speak- 
ing before you upon a subject which you yourself have elucidated, 
in one of its most important bearings, in so satisfactory a manner. 

" The outline of the plan of treatment which I have to propose is 
this : — to take care that the diet does not contain too much lean 
meat and too little fatty and oily matter ; to look upon the properly 
regulated use of alcoholic drinks as essential to success in treatment ; 
to avoid tea altogether ; to be very chary in the use of sugar ; to 
give some preparations of phosphorus, with or without cod-liver oil, 
as nutrients for a starved nerve-tissue ; to avoid the habitual em- 
ployment of aperients ; and, as a rule, to eschew the use of sedatives 
in sedative doses. This plan is, indeed, that which I have carried 
out for four or five years in many cases in which the primary indi- 
cation of treatment was to remedy an asthenic condition of the 
nervous system — various convulsive maladies, many forms of para- 
lysis, and so on. 

*' In the few minutes at my disposal, it is impossible for me to do 
more than hint in the most cursory manner at the reasons which 
have dictated this plan. 

" I have used fatty and oily articles of food, and cod-liver oil, on 
the supposition that these substances might be essential to the proper 
nutrition of nerve-tissue ; for this tissue, in the main, is built up of 
fatty and oily matter. 

** I have used some preparations of phosphorus, with a view to 
promote the nutrition and functional activity of nerve-tissue ; for 
phosphorus, like fat, is an important ingredient in this tissue. I 
nave given the phosphorus for the same reason as that which 
would induce me to give iron in cases where I wanted to favour 
the nutrition of the red corpuscles of the blood. For the last 
seven or eight months I have used the hypophosphites as a means 
of giving phosphorus; and the results at which I have arrived 
would seem to show that these salts are quite as effectual as, and 
much more convenient than, the phosphorated oil of the Prussian 
Pharmacopma, or the ethereal tincture of the French Codex — pre- 



336 SEPOST ON PBACTICAL HEDICINB. 

parationfl which I have been usm^ on a somewhat extensive scale for 
the three or four years previously. I find, indeed, that the hy- 
pophosphites are almost as effectual remedies in the treatment of 
nervous pain and neuralgia, and of various other asthenic conditions 
of the nervous system, as Dr. J. F. Churchill of Paris would have us 
believe them to be in the treatment of phthisis; and I think that 
the science of healing is indebted in no small deffree to Dr. Churchill 
for having brought these salts into the service of medicine. 

" I do not take upon myself to explain why an excess of lean meat 
should do harm in the cases under consideration. I do not profess 
to know. It may be, in some cases, that it favours a gouty condi- 
tion of the system — a condition which is at the foundation of many 
kinds of pain ; but, whatever be the explanation, I have no doubt 
that excess of lean meat does do harm in many cases of nervous pain 
and neuralgia ; and that the common notion, not always confined to 
non-medical circles, that lean meat is the one nutrient substance, is 
a mischievous fallacy. In the lectures which I had the honour of 
delivering before the College of Physicians a few months ago, and 
which have recently been occupying a place in the pages of the 
Lancet, one great point was to show that pain was the sign of 
depressed, and not of exalted vitality ; and that alcoholic drinks, 
properly administered, were the natural anodynes. And to these 
lectures I must refer for my reasons for arriving at these conclusions. 
Indeed, here I will only say, that experience has taught me to look 
upon the properly -regulated use of alcoholic drinks as essential to 
the successful treatment of nervous pain and neuralgia. 

" Why tea should be unsuitable as a common beverage, in the 
cases under consideration, may also be a difficult and complicated 
problem. I am, however, disposed to think that tea must be hurtful 
if alcoholic drinks are required, except it be to correct the results of 
excess in the use of such drinks. Tea — cold tea, for the action of 
hot water must be separated, if we would know the true action of 
tea — would seem to be not remotely analogous in its action to 
digitalis, and therefore only tolerable when there is an active con- 
dition of the circulation to subdue — a condition which is not oflen 
met with in cases of nervous pain and neuralgia. But, be the reason 
what it may, I am perfectly satisfied that it is a matter of vital im- 
portance to eschew tea as an habitual beverage, if we would fight 
successfully against nervous pain and neuralgia. 

** As to sugar, I am disposed to think that this substance does 
harm in cases where a rheumatic habit is at the bottom of the 
trouble; and that it may do harm by favouring the formation of 
that substance which, upon very good grounds, is believed to have 
much to do with the production of rheumatic fever — viz., lactic 
acid. At any rate, I have now seen several cases in which a 
patient, who had taken a good deal of sugar, was much more free 
from pain upon taking this substance in moderation. 

" Aperients will scarcely ever be wanted, if a sufficient amount 
of fatty and oily matter be introduced into the diet ; and this, I 
take it, is a very great advantage ; for, in my opinion, there is no 
one practice which so much tends to keep up a habit of nervous 



XBPOBT OK PSACTICAL HEDICINB. 337 

pain and neuralgia as that of ofling aperients and purgatives habitu- 
ally. 

•'With respect to the use or sedatives in sedative doses for the 
relief of pain, I will only say tliis, that this practice seems to be 
cutting the Gordian knot, instead of untying it — a plain confession, 
in fact, that treatment has failed. 

" It is, however, more than time that I bring these prefatory hints 
to a close, and proceed to the cases of which I have spoken. I read 
the notes taken at the time ; and I leave unread many similar 
notes, at least tenfold in number." 

Case 1. — Jan. 8th, 1863. Mrs. W., aged 36, the widow of a clergyman, 
complained of distressing headache, low spirits, and sleeplessness, saying 
that she had suffered in this manner almost incessantly for the last five 
years. Trouble connected with the death of her husband was the primary 
cause — ^not privation, for her circumstances were tolerably easy. 

lliere was nothing remarkable in her appearance, except that she was 
very thin. Pulse 86 ; the hands and feet were habitually cold ; there was 
complete want of appetite ; the bowels were exceedingly constipated. For 
the last two years she had lived almost entirely upon the lean of mutton- 
chops and strong-beef tea. Butter and fat had been avoided, from a fear 
that they would cause biliousness ; and tea had been taken at least twice a 
day, because it was liked. Alcoholic drinks had been not entirely abstained 
from ; but a wineglassful of very weak brandy and water would be the 
maximum quantity allowed during the course of the day. All light and 
noise had been intolerable for some months past ; and her time hud been 
spent chiefly in a darkened room upon a sofa. 

She had had no treatment during the last two years, except occasional 
doses of quinine and eight grains of compound rhubarb pills every other 
night. She had previously tried arsenic, quinine, valerian, and "every- 
thmg," without any permanent benefit. Change to the seaside had been 
the only thing that had done any good. 

She was recommended to use weak coffee for breakfast, instead of tea, 
with an egg or a little fat bacon ; a little milk and cream and brandy at 
11 A.M. ; a light early dinner, with a glass of sherry; a little coffee and 
bread and butter at 5 p.m. ; and an hour before bedtime, a good supper, 
something like the dinner, with a full glass of Bass's aie or Guinness's 
stout, in place of sherry. She was also recommended to take as large 
an amount of oily and fatty matter as she could, and to diminish the 
amount of lean meat. She was ordered to take ten grains of hypophosphite 
of 'soda and a drachm of tincture of hops three times a day. 

January 16th. — She was better; had more animation and freshness in the 
countenance. She slept four hours continuously last night. There was 
leas excitability. The medicine was continued. 

Jan. 30th. — There was a great change for the better : she said that she 
had scarcely had a headache for the last week. Yesterday she had a walk 
of two miles without bringing on headache — a most unwonted thing with 
her. The bowels had acted every day for a week without aperients. The 
medicine was continued. 

March Ist. — She looked ten years younger than when I saw her last ; 
slept well ; and ate well. The bowels acted without aperients. There had 
been do headache to speak of since the last visit. 

June 2nd. — She brought her daughter to see me. She herself continues 
quite weU. 

Case 2.— Feb. 6th, 1863. Mr. J. W., aged 52, occupied in the Custom 
xxxYiii. 22 



338 fiBPOBT ON PRACTICAL MEDICINE. 

House, very thin and spare, walked with great difficulty by the aid of 
a stick, and complained of constant sciatica in both legs. He had lum- 
bago three years ago ; and this pain, after troubling him for some weeks, 
shifted first into one leg and then into the other, and from that time to 
this had been progressively getting worse. He had rheumatic fever when 25 
years of age. 

His pulse was 70, and very weak ; the appetite very bad. For a long 
time, almost all his life, he had lived upon a very dry diet, disliking fat in any 
form, and taking very little butter. He had been a teetotaler for fifteen 
years. Three years ago he took hydrochlorate of ammonia for several 
months, with some benefit. Since this time he had been under homoeo- 
pathic treatment, without any benefit. Part of the latter treatment was a 
permission to take fifteen dropd of Battley's sedative solution every night 
on going to bed. 

I put him on the same plan of treatment as that described in the first 
case, with half an ounce of cod-liver oil twice a day in addition. The 
sedative at night was discontinued, and some stout ordered to be taken in 
its place. 

Feb. 16. — ^There was no change for the better ; but, on examination, it 
appeared that he had yet to beyin the treatment recommended at the first 
visit. He would have it that the fat and oily matters would make him 
bilious. The treatment was ordered (o be continued. 

March 2nd. — He was better. For the last week he had slept better 
than he had done from the commencement of his illness. He found that 
the oily and fatty matters did not disagree with him, and that his bowels for 
the last week had acted without medicine. The pain was somewhat relieved, 
but not so much as could be wished. He told me that he was in the habit, 
and had been for years, of taking three or four times a day, with his meals, 
or between his meals, cafi noiVf without milk, but with as much sugar as 
the coffee would dissolve ; and, therefore, I recommended him to leave off 
sugar as much as possible, and to diminish the amount of coffee. The treat- 
ment was continued. 

April 16th. — He walked into the room without any apparent stiffness, and 
without bis stick. He had lost the pain in the legs altogether for the last 
fortnight, and had gained ten pounds in weight during the last month. He 
was hungry now, and slept very fairly at night. He had never required 
any aperient medicine since the adoption of this plan of treatment. 

Case 3. — Mrs. T., aged 38, the wife of an artist, was admitted under my 
care into the Westminster Hospital for tic douloureux in the right side of the 
face. She was tall and flabby in build, without family, and, as it appeared, 
had been the subject of much privation and misery for the last four years, 
during which time she had scarcely been free from the tic. At present, 
the pain, which was alriost incessant, was brought on by any attempt to 
masticate or swallov; ; and she appeared to have very little relief, except 
when she was stupified by opium. She confessed to having taken half a 
teaspoonful of laudanum every night at bedtime for two years, and a ** little 
extra" now and then in the course of the day. Bread and tea appeared 
to have been the principal articles in her dietary. 

She was recommended to have a chop, two eggs, and a pint and a half of 
fltout, the greater part of the pint to be taken at bedtime ; also coffee, in 
place of tea ; and, for medicine, cod- liver oil in three-drachm doses, and 
iiypophosphite of soda in seven-grain doses three times a day. 

March 7th. — She slept lour hours in the night continuously. 

March 8th. — She had a good night, upon the whole ; and took her break- 
fa»t with some appetite. The pain was more tolerable. 



BSPOBT OK PBACTICAL HEDICIKB. 339 

March 10th. — Yesterday she found herself able to eat and swallow without 
bringmg on the pain. She asked foi; more food. 

March 20th. — She had been progressively improving since the last report. 
There was no tic yesterday. The bowels now acted regularly without medi- 
cine. She had a long walk yesterday, without bringing on pain. 

March 30th. — She was now suffering from severe pain in the face, which 
was referred to a wetting in the rain yesterday. A hot bath was ordered, 
and the medicine continued. 

April 3rd. — She was well again. The treatment was continued. 

April 15th. — She was discharged cured. She had no pain on eating or 
«wallowing ; no pain at any time for the last fortnight, or, at any rate, 
no pain to speak of. She looked stronger and fresher;. and was so in 
fact. 

May 6th. — I saw this patient accidentally in the ward. She considered 
herself well, but had been taking oil and hypophosphite almost regularly ever 
since her discharge from the hospital. 

Case 4. — March 16th, 1863. M. Adolphe B , aged 40, a musician, 

was suffering from severe tic in the right cheek, and had the muscles of this 
side of the face drawn and contracted to a considerable degree. With few 
intervals, he had suffered from the pain for three and a half years. The 
face became contracted on the painful side two years ago. Before the pain 
began, he had been treated for three months with iodide of potassium for 
constitutional syphilis. He smoked excessively, and allowed that he had 
for many years been very intemperate in sexual matters. His dinner con- 
sisted chiefly of a beef-steak and a pint of stout, taken at a chop-house. He 
drank tea in large quantity, taking it cold with his tobacco. He never 
drank any spirits. He had had nearly all bis teeth drawn, in the hope that 
the pain in the cheek might be referred to the irritation from some diseased 
tooth. 

He was recommended to smoke less, and to try a mild tobacco when he 
did smoke ; to take coffee in place of tea ; to eat oily and fatty matters, and 
less lean meat; and to take three drachms of cod-liver oil and ten grains of 
hypophosphite of soda three times a day. 

March 23rd. — For the last three days he had been almost altogether free 
from pain ; and last night he slept for several hours continuously (he had 
been recommended to take a glass of stout shortly before going to bed). 
This — i.e., sleeping satisfactorily — for several years had been unknown to 
him. 

March 30th. — He had had no pain whatever since last visit, and con- 
sidered himself quite well. 

May 19th. — Except an occasional pang, for which he said there had been 
generally good reason, the tic might be said to be altogether at an end. He 
had lost altogether the anxious nervous look which he had when I first saw 
him ; and the contracted facial muscles had almost altogether recovered their 
natural condition. 

Case 5. — M. W , aged 28, a lady's maid, suffered from almost con- 
stant nervous headaches. She had never been quite free from these pains 
for two years, but lately they had been much worse — so much worse, that 
she was now compelled to leave a good situation. A great moral shock, 
arising from the discovery of a fellow-servant dead by her side on waking 
one morning was referred to as the cause of the pain. 

She had had a great deal of medicine ; but did not know what kind of 
medicines were given, except that they were generally intended to act on 
the bowels, and to promote menstruation, which was always very scanty and 
painful, and which was once, six or seven years ago, often accompanied with 

22—2 



340 BSPOBT ON PBACTICAL MEDICIXB. 

a great deal of hysterical agitation. She was ordered to take cod- liver oil 
and hypophosphite of soda, with middle diet and porter. 

April 4th. — The oil made her siok. She was ordered to take the hypo- 
phosphite by itself. 

April 6th. — She slept much better, and woke this morning without head- 
ache — Si thing she had not done for two years. She was ordered to resume 
the oil. 

April 8th. — She was evidently gaining ground. She had a bad headache 
now, brought on, it appears, by a violent altercation with another patient in 
the same ward. The medicine was continued. 

April 15th. — She had been improving progressively since the last report. 
There had been no headache for the last three days. The treatment wag 
continued. 

May 2nd. — ^There had been no headache at all since the last report. The 
bowels now acted regularly without medicine. She was much improved in 
general health. 



Eemarks on the Hamostatic Treatment of Cholera, 
Hcemorrhagey Exhaustion, Sfc, 

By Dr. Thomas A. Wise. 

(DMin Quarterly Journal of Medical Science^ August, 1863.) 

These remarks appear to ns to be in the highest degree important, 
and we shall lose no time in putting them to a practical test m many 
cases, for the " &c." in the title obviously includes a very wide fiela. 
We can indeed see in them a fair prospect of good for manj 
disorders of the nervous system. What we have wanted in these 
disorders is a remedy which for a time will produce the very 
opposite effects to those of venesection, and here we conceive ^ e 
find what we wanted. And what we have wanted here we have 
wanted also in a countless host of other diseases, for the teaching 
of modern pathology is, that the object to be gained is very generally 
the opposite of that which was aimed at when venesection was in 
vogue. At present we have no difficulty in recalling at least a 
dozen cases of epilepsy in which the fits could be averted, almost at 
will, by tightening a tourniquet around an arm or leg. This plan 
was adopted with a view to arrest an aura ; it may have done good 
by shutting-in or shutting-off a given amount of blood. 

With these few remarks we leave Dr. Wi«e to tell his own story 
in his own words : — 

" When the Spanish pilot smiled on the late Dr. Kelly, shivering 
tinder the influence of a cold fit of ague, and pointed out how easily 
it might be removed by the application of a garter to stop the blood 
of one or two of his limbs, he suggested a plan of treatment which 
has long appeared to me worthy of more attention than it has 
received. When in India I had, on one occasion, a regiment pros- 
trated with fever unexpectedly placed under my charge; and, as 
I had but a small supply of quinine, and could not obtain more, I 
employed tourniquets to intercept the blood in the extremities, and 



SBPOBT OK PRACTICAL MEDICIKB. 341 

vith a degree of success that induced me to publish the result in 
McClelland* 8 Journal of Natural History , Calcutta, I have not 
the journal by me; but the result was so favourable that I fre- 
quently employed it in the cure of intermittent fevers ; and I after- 
wards extended the application of this powerful remedy to other 
diseases, and propose again to bring the subject under the notice of 
the profession. 

. ** The great discovery of Harvey determined the principle that 
we had, by means of the tourniquet, the complete command of the 
arterial circulation of a limb, and could, by means of a tight ban- 
dage, retard the return of a considerable quantity of blood from the 
extremity. Modem physiologists inform us that the quantity of 
blood in the whole body is about 28 lbs. ; and that in ordinary health 
there is about two pounds weight in each of the four extremities. 
The numbers will, perhaps, be allowed to be nearly correct, although 
the absolute quantity will vary in different individuals, and in dif- 
ferent parts and conditions of the body. For instance, a person 
during active exercise will have the distribution of the blood all 
over the body considerably different from an individual in repose ; 
and this difference will often be still greater in disease. The attack 
of an intermittent disease is accompanied with a congestion of blood 
in certain organs ; and, as we have the complete control of at least 
a pound of blood in each limb — ^may we not act on this with great 
advantage in the cure of disease P 

" The circulation may be controlled in two ways — 1st, by retard- 
ing the blood in veins, and, 2nd, by stopping the circulation in 
arteries. 

" The retarded blood in the veins of a limb as a therapeutical 
agent, — In patients with the premonitory symptoms of apoplexy, in 
aevere cases of dyspncea, in some organic diseases, and even in inflam- 
mation of particular organs, the temporary withdrawal of a certain 
quantity of blood from the general system, and its retention in the 
extremities may sometimes be used with great advantage. It is 
easily accomplished, by the application of a field tourniquet upon 
one or more extremities. 

" Stopping the arterial circulation in a limb. — It must not be 
supposed that a clamp or horse-shoe tourniquet, when compressing 
the chief artery of a limb, acts merely on the part, by stopping the 
circulation — it powerfully affects the whole system. If applied to 
the femoral artery, probably a pound, of the two pounds of blood 
intended for the limo, is prevented passing into it, and makes its 
way back to the heart, causing a more rapid and forcible circulation 
over the diminished circle. 

" Secondly. — As many diseases are local, and are connected more 
or less with morbid congestions of blood, which generally produce 
the pain and the derangement of the functions of the affected 
organs, by so closing a portion of the circle you thus enlarge the 
volume of blood, and increase the force of the heart, which has a 
moat powerful influence in removing local congestions in the internal 
organs. 

''It is not, however, in every case that the treatment can be 



342 BEPOBT ON FBACTICAL MEDICINE* 

employed with the same good effect. It is in the large class of 
functional diseases that the partial stoppage of the circulation is of 
so much permanent use ; and even in some organic diseases it may 
be employed with advantage by withdrawing so much blood from 
the circulating system of the part. By thus placing a ligature so 
as to press upon the chief artery of one or two extremities, the 
general mass of blood circulates through a smaller circle, and in 
some diseases produces a powerful tonic or stimulating effect upon 
the general system. 

" In those sudden and appalling cases of uterine haemorrhage the 
effect is very marked ; and the fatal result is often arrested by this 
prompt and energetic interference. In such cases the patient is 
often left in a collapsed pulseless state, without the quantity of blood 
necessary for carrying on the vital functions, for which the strongest 
stimulants are used in vain ; and in a large proportion of these cases, 
after a faint return of animation, the patient sinks into a state of 
collapse, and dies from exhaustion, without any further loss of 
blood. In such a case, the simple means of contracting the extent 
of the circulation, by closing one or more of the arterial trunks, will 
be of great advantage : Mr. Wardrop states that the effort of raising 
a patient, in such a case, and accidentally closing the humeral 
arteries, was found sufficient for nature to rally. This will be more 
effectually done by raising the limb, pressing the venous blood on- 
wards, and applying a clamp- tourniquet to the humeral and femoral 
arteries, by which upwards of a pound of blood, sent to each limb, 
is stopped, and finds its way back to the heart. This diminished 
vascular circle, and increase of blood, stimulates the heart's action, 
and the greater volume of blood has a powerful influence in strength- 
ening the weakened system. 

" In the collapsed stage of cholera, when, in many cases, the 
physician first sees his patient, the system is so much prostrated 
that the most powerful medifjines have no effect, the application of 
the tourniquet affords the only chance of cure. This most powerful 
remedy immediately removes the painful cramps, and produces the 
same equalizing effect as blood-letting, without the debility caused 
by this evacuation. It likewise increases the volume of blood, 
which stimulates the heart to increased action, removes morbid con- 
gestions, and, changing the morbid distribution of blood from the 
secreting surface of the alimentary canal, sets up a new and salutary 
action in their place. It thus affords the most ready and most 
powerful means of rousing the system. By this means the purging 
and vomiting are stopped, the pulse becomes stronger, the heat and 
strength of the system are quickly restored, and time is allowed for 
medicines to act. ' 

*• The tourniquet may be applied to two or to the four extremities, 
according to the effect intended to be produced. When the indi- 
vidual is weak, and the state of collapse great, more care is required 
in emptying, by friction, the blood in the veins of the extremity to 
be bandaged ; and the effect will be more marked if the tourniquet 
be applied to four extremities. It maybe kept on for hours, or. 
even for a day or two. In one case I kept the tourniquets applied 



EBPOBT ON PRACTICAL MBDICINE. 343 

for three days — as the exhaustion was very great — with the best 
effects ; on]y relaxing one or more, as it appeared necessary. When 
reaction has taken place, by relaxing cautiously one or more of the 
tourniquets, so as to allow the blood to flow to the extremities, it 
afforded a ready means of reb'ef. In a pretty extensive experience 
I have not seen any bad effects produced by the application of tour- 
niquets. The effect, however, varies according to the stage and 
severity of the disease. When the patient is stronger, or when re- 
action has taken place, the pressure of the tourniquets is complained 
of— and much care is required to prevent the patient loosening 
them. If it be done too abruptly, the blood spreads over the ex- 
tremities, and the patient rapidly sinks." 

Br. Wise relates two cases in illustration of the danger of leaving 
off the tourniquets, or slackening them too soon. In cases such as 
these, he advises that the tourniquets should be kept on until reac- 
tion begins, when one extremity is to be set free at a time, and 
again tightened, if there be any sign of relapse. 

Case. — A young lady joined her parents in India ; and, on a damp even- 
ing, walked along the moist bank of the river, which had been covered with 
water during the rains. She wore a light dress, and thin shoes, which she 
did not change at dinner, and went early to bed. During the night symp- 
toms of oholera appeared, and I was sent for. The frequent and peculiar 
discharges, the state of the pulse, and the cramps, proved the severity of 
the attack. I immediately acted in the usual energetic manner, but without 
much effect ; and in the morning I requested the assistance of an old and 
able physician. On learning the history, and the result of the treatment 
that had been employed, and as she appeared sinking, he considered there 
was no hope. I proposed the application of tourniquets, which he warmly 
recommended. They were applied to an arm and a thigh ; and the result 
was soon most marked and gratifying. The cramps ceased, the cold and 
clammy skin became warm, the puloe resumed its action, and the pale 
sunken face became animated with a flush. I then slowly relaxed one of 
the tourniquets ; and, having other urgent calls, I left the patient under the 
charge of my friend, with strict injunctions not to touch the tourniquets 
until my return, and pointed out the danger of such a proceeding. He 
understood, . and carefully observed, my instructions; but, as the young 
lady dozed, he left the room, and did not return for some time, when he 
found all the unfavourable symptoms returned ; and then it was he learned 
the young lady herself had persuaded her sister to unscrew the tourniquets ; 
the- blood that waa animating the body flowed again to the extremities — the 
hbart, weakened by the loss, ceased to act with the same energy — and al 
the fatal symptoms returned, and she died that night. 

Dr. Wise also gives half a dozen cases in which tourniquets were 
used, and in which, in all probability^ medicines would have been 
used in vain. This is one : — 

Case. — Shakh Hoosen, admitted into hospital, under the care of Dr. 
Eastall, with the usual symptoms of cholera. The pulse was imperceptible 
at the wrist — body covered with edd perspiration — no secretion of urine — 
and the evacuations from the bowels were passed involuntarily. Four 
grains of calomel, and four of quinine, with a grain of opium, were given, 
and washed down with brandy and spiced warm water. As the unfavour- 
able symptoms continued, four tourniquets were applied to the four arterial 



344 BEPOBT ON PEACTICAL MEDICINE. 

trunks of the extrpmities, and at the same time a draught of the drogue 
amere, laudanum, and peppennint water was administered. In the evening 
he was found without pain, the action of the heart stronger, and the body 
warmer. He complained of the tourniquets, and loosened them himself 
during the night. In the morning they were again tightened. All the bad 
symptoms had disappeared, he was warm, his voice was stronger, and he 
felt better. The improvement continued during the day, and two of the 
tourniquets were removed at night He continued to improve, and he soon 
left hospital quite well. 

The final conclusions at which Dr. Wise arrives are these, and 
with them we take leave of the subject for the present : — 

" Ist. By its obstructing the circulation it immediately stops the 
distressing cramps of the extremities in cholera. 

"2nd. By increasing the quantity of the circulating fluid in the 
trunk, and thereby stimulating the heart's action, it removes morbid 
congestions, stops the secretions from the bowels, increases the 
animal heat, and powerfully tends to restore health. 

" 3rd. By improving the vigour of the s;ystem, medicines act more 
powerfully, and in a more salutary manner in removing morbid 
actions. 

" 4th. When the reaction has taken place by loosening the tourni- 
quets with care, the determination of blood to the internal parts is 
diminished by its diffusion over the extremities, upon which the 
tourniquet had been placed. They are immediately to be re-tightened 
when there is any coldness or weakness experienced or any ten- 
dency to relapse. This must be most carefully watched for and 
prevented. 

5th. By increasing the volume of blood in the contracted circola- 
tion, the force of tiie heart is increased, local congestions are 
removed, and the whole system is strengthened. 



On the Diagnostic Value of an Accentuated Cardiac Second 

Sound, 

By Dr. J. Warburton Begbie, Physician to the Royal 

Intirriiary, Edinburgh. 

{Edinburgh Medical Journal, June, 1863.) 

As the result of careful observation and continued attention. Dr. 
Begbie has found that, after excluding the accentuated pulmonary 
second sound, and the intensified aortic second sound in some cases 
of hypertrophy and dilatation of the left ventricle, the accentuated 
second sound in the aorta is an indication of aortic aneurism or of 
dilatation of the aorta associated with atheromatous degeneration. 

An accentuated pulmonary second sound is no uncommon pheno- 
mena ; and its value in relation to the condition of mitral valve con- 
striction is well known to all careful auscultators. Of this sound, it 
is scarcely necessary to say, Dr. Begbie is not speaking. 

A case of aneurism of the aorta, pointing externally and bursting 
through the lung into the left pleura, is used by Dr. Begbie in 
illustration of ^ hat he has to say. 



BBFOBT ON FBACTICAL MEDICINB. 345 

Casb. — S. M., set. 36, under my care in the Infirmary, Ward V., during 
August and Septeiuber, 1862. Between the second and third left ribs, 
near their cartilages, a pulsating tumour was detected on the patient's 
admission. On auscultation, a soft bruit was audible over the tumour ; and 
at the base of heart, as well as over the upper bone of sternum, a very loud 
ringing second sound. The latter phenomenon never varied during the 
patient's six weeks' residence in hospital. He died suddenly, after expecto- 
rating a little blood. On examination of the body after death, serous fluid 
and coagulated blood, to the amount of more than half a gallon, were 
found in the cavity of the left pleura ; the heart was pushed downwards and 
backwards ; it weighed fourteen ounces. The valves were perfectly healthy. 
Ab aneurism was found commencing abruptly an inch and a half above the 
semilunar valves — the whole vessel suddenly dilating to a point immediately 
beyond the origin of the left carotid, where the dilatation as suddenly ceased. 
The pouch so formed was six inches in length ; it passed behind and was 
applied to the back of the manubrium sterni, and made its appearance 
externally between the second and third left ribs. The left extremity of the 
sac was intimately united to the left lung, the edge of which had become 
thinned by pressure, and the pleura having then given way, allowed the 
escape of the aneurismal contents into the pleural sac. 

In the foregoing case the peculiarity of the second sound was of com- 
paratively little value in leading to the recognition of the aneurism, other 
and still more distinctive signs, especially the visible pulsating tumour, of 
that condition being in existence ; but the accentuated sound led to the 
diagnosis of the competency of the semilunar valves, which post'-mortein 
examination confirmed. In the following case the accentuated second 
sound was the earliest noted reliable sign of aortic aneurism. 

W. M'A., aet. 35, a hawker, was first seen by me in March, 1862, com- 
plaining of slight chest symptoms, particularly cough and expectoration of a 
little phlegm. Had not been a sober man. 

Condition on first examination. — Has a slight bronchitic .aflfection. 
Heart's second sound markedly accentuated over the aortic valves. No 
other auscultatory phenomenon connected with heart or gi*eat vessels. 

I had frequent opportunities of seeing and examining this man up to 
November 6th, when he entered the Infirmary, becoming a patient in Ward 
IV. During this time his general health had failed considerably; he had 
become thinner, feebler, less able for his occupation, though still moving 
about and doing something as a traveller. 

On 6th November the following notes of his condition were made. Has 
been suffering from dyspncea, which has seized him on a few occasions 
suddenly, and without any previous effort or exertion having been made. 
Cough is somewhat clanging in character. Has some pain and peculiar 
sense of weight in region of sternum. Over the left portion of manubrium 
there is visible pulsation — the latter readily distinguished on pulsation. 
Left radial pulse is feebler than right. Murmur of soft blowing character 
accompanies first sound over the seat of pulsation, and is heard less distinctly 
over the base of heart. The second sound at base is of a loud booming 
character. Kespiratory sounds in upper part of left lung, feeble. Pos- 
teriorly there is a little bronchial stridor. 

This man, so far as I know, survives : he left the Infirmary about eight 
weeks since. With such signs as those detailed, the existence of aneurism 
becomes unquestionable, they have become gradually developed in succes- 
sion to the accentuated second sound, the earliest noticed of all. 

After relating this case Dr. Begbie proceeds to say : — 

" Of this kind I might furuiflh other examples, several are kaowa 



346 BBPOBT OV PS;lCTIOAL MBDIGIKE. 

to me^ and the opportunity has occurred for directing the attention 
of students to these, in the ordinary course of clinical instruction. 

** I have further to remark, that a similar condition of the second 
cardiac sound may be caused by dilatation of the aorta, associated 
with more or less of atheromatous degeneration. To distinguish 
between the two — in other words, to know when the accentuated 
second sound is due to aneurism and when to dilatation of the 
aorta, is not always easy. Keliance is chiefly to be placed on the 
associated physical signs in the former case, more particularly 
prominence, pulsation, extended percussion dulness, and the signs of 
internal pressure. If atheromatous dilatation exist, and that is the 
special condition, independent of aneurism, which gives rise to the 
accentuated second sound, there will probably be more or less 
pulsation in jugular fossa, atheromatous eonuitio^a of superficial 
pulses (radials, temporal arteries, &c.) noticeable, and probably the 
arcus senilis. 

**The following points appear to me to be of importance in 
endeavouring to explain the mechanism of an accentuated second 
sound, under the circumstances now considered : — 

" 1. The condition of the vessel, both in cases of aneurism and of 
dilatation with atheromatous degeneration, being such as greatly to 
diminish, if not to destroy, the support given to the eircidation by 
the artery, there results an increased recoil of blood on the closing 
or closed valves. 

" 2. It is possible that a morbid condition of the valvular apparatus 
itself heightens or intensifies the sound. The valves are not incom- 
petent, but in such cases they are sometimes found thickened, and 
even presenting a hjard surface at parts. 

" 3. Something may, I conceive, be due to the increased calibre 
of the vessel, in connexion with the altered condition of its internal 
tunic, in causing the peculiarity of sound. 

" But in whatever way the phenomenon is to be correctly explained, 
there can be no doubt of its existence being entitled to very con- 
siderable value as a clinical fact. I have noticed that the accentuated 
second sound is most readily appreciable over the aortic valves in 
both conditions. In the cases or dilatation of t-he aorta it has, how- 
ever, been more decided in character over the manubrium sterni 
than in aneurismal cases. I may add, that in the majority of xBases 
observed by myself, in which the accentuated second sound has 
existed under the circumstances now detailed, the expression, booming 
second sound, or second sound with rtX^'t//^ boom, has best described 
the acoustic character of the sound itself. I have known the boom- 
ing sound continue for many weeks, and in one remarkable case of 
aneurism lately observed (Walker, in Ward V„ and afterwards in 
Ward IV.), for months, and thereafter become at first obscured, 
and ultimately entirely replaced by a loud diastolic murmur, telling 
plainly that the semi-lunar valves had become insuilicient owing to 
the extension of the disease towards the heart." 



BXPOBT OS PSACnCAL XXDICHTX. 347 

Oh Australasian Climates and their Inflnenct in tie Fnren^ 
tion and Arrest of Pulmonarif Consumption. 

By S. DouGAK Bird, M.D., L.RC.P. Land,, Physician to the 
B^ievolent Asylain, Melboarne. 

(L<Hidon : Longman, Green and Co., Paternoster-row.) 

Himself a poitrinaire, the writer has personal as well as pro- 
fessional experience of the effects of antipodal climates on consurap* 
tion. More than three months ago, two of the hest stethoscopists 
in London pronounced his lungs tuberculous, and to this opinion aaily 
hemoptysis, rapid loss of flesh, shortness of breath and known 
hereditary predisposition gave but too sure confirmation. A six 
months' rest from business, occupied in amusing trarel, with careful 
treatment in the meantime, failed to do more than check the more 
urgent symptoms ; and, therefore, a total change by a Toyage to 
Australia was recommended, and at once undertaken. £n lees than 
three months from his landing in this colony the patient gained 
sixteen pounds in weight, lost all his symptoms, and remains at the 
present time in excellent heidth. Impelled by an easily conceivable 
gratitude towards the climate which has wrought these great results, 
and by a conviction that others, in " the old country," who are 
suffering as he once suffered, m^ by a change to the antipodes 
benefit as he has benefitted. Dr. Bird has penned this work. It is 
a work of very unusual interest. It makes known to the English 
reader for the first time in a trustworthy form, a scries of clinmtes 
unrivalled in their general salubrity, and peculiarly calculated to 
promote the recovery of oases which have hitherto been the despair 
of physicians in England ; it makes known refuges to the phthistoal, 
such as would be sought for in vain in Europe or Africa, and where 
the invalid, although separated thousands of miles from his birth- 
place is still at **home" — at home in language, in thoughts, in 
feelings, in manaers, in habits with those about him — an advantage 
of no ordinary character. *' For to live," as Dr. Bird says, ** and 
(if it must be) to die amongst one's own people is no small consola- 
tion to an invalid." 

Dr. Bird after a preliminary chapter on the nature of tubercu- 
lous and scrofnlous disease, and the principles which should 
guide its treatment by change of climate, contrasts the vital atatistics 
of the northern and southern hemispiieres, points out the method of 
utilizing the peculiarities of antipodal climates for the prevention or 
arrest of the>early stages of consumption contracted in Kuropo, and, 
finally, terminates the work with a brief sketch of colonial life and 
Australian scenery. 

" It needs but a glance at the globe to show that tlio southern 
hemisphere must present remarkable and distinctive dillorcnces of 
climate from the northern. In the southern horni>»phere water 
greatly preponderates over land, and the land is so far removed from 
the influence of the antarctic regions that ercesalve oliiuutes such as 
exist in the nocthem heia^isphere have no place. 



348 BEPOBT ON PEACTICAL MEDICINE. 

" The geographical position and geological conformation of the 
enormous sweep of coast east and west of the great Australian 
island, from Cape Leeman to Bass's Straits," says Dr. Bird, ** give 
it characteristics of climate absolutely distinctive, as no other part 
of the world is placed under the same conditions ; and it offers, a 
special contrast to those parts of the northern hemisphere which are 
exposed to the influences of the Gulf-stream. The prevailing winds 
during a great part of the year, are from the west and south, or 
south- east ; from the two former quarters they sometimes blow con- 
tinuously for weeks together, and having traversed such a vast 
expanse of unbroken ocean, unaffected by any terraneous influences, 
Ihey have a purely marine and highly ozoniferous character, such as are 
only met with in the trade winds far from land. From the general 
absence of high mountain ranges on the continent, and the general 
tendency the ranges of the coast bear to the north-east and south- 
west, the whole of the settled districts within a few degrees of the 
3cean enjoy more or less of the tempering, equalizing and ozoniferous 
'ifluences of these west and south winds, without suffering the 
•orresponding amount of damp and doud which they bear with 
hem in Europe. For an ocean wind, so far from being of necessity 
accompanied by rain and cloud — as we are accustomed to see it in 
the North Atlantic, from the reasons I have mentioned — brings with 
it bright sunny weather, as a rule. It hardly ever rains in the trade 
winds, far from land ; it is only when some lofty island forms a 
nucleus-point of attraction for the result of co-operation that these 
are condensed into vapour or rain. 

** The climate of the colony of Victoria may be taken as a medium 
tvpe of the climate of Australasia. It is cooler than South Australia, 
New South Wales, or Queensland; warmer and drier than Tasmania, 
or New Zealand's southern districts. 

" . . . . The mean yearly temperature of Melbourne is about the 
same as that of Montpellier, Marseilles, Nice, Genoa, Pau, or 
Florence, which are on or near the corresponding isothermal in the 
northern hemisphere ; but that of Melbourne has gi;^atly the advan- 
age of these in the fact that the mean range of the sea8ons\& far less : 
that is to say, it has a warmer average temperature in winter, and a 
cooler one in summer. In this respect it is on a par with Lisbon, 
which is considered the model climate of Europe as regards tempera- 
ture, having a winter average equal to, or higher than, that of 
Naples, Valencia, or Barcelona, whose yearly and summer averages 
are considerably higher. 

". . . . Looking at the question of temperature from existing data 
of yearly and seasonal means, the great superiority of the Victorian 
climate to those of Southern Europe is seen at a glance ; but siick 
figures do not give a suflBciently close view of the medical aspects of 
the question. Although the average summer heat is moderate in the 
neighbourhood of Melbourne, being only 4° higher than that of 
London, occasional extremes of heat occur under the influence of the 
* hot wind,* when the thermometer rises even so high as 100°, 105°, or 
111° in the shade. Such a temperature occurs usually in December 
or January, but is very exceptional, and. lasts but a few boors at a 



BEPOET ON PRACTICAL MEDICINE. 349 

time. The lowest temperature ever experienced is 32^, and this is 
yery rare. 

Of the hot wind, the " b6te noire " of new arrivals in the colony , 
Dr. Bird states that, although the temperature at times rises during: 
its prevalence higher than in the sirocco of Sicily and Malta, and 
even exceeds Indian heat, this wind " never interferes with business, 
and hardly with pleasure," while, " to a new comer, the little incon- 
renience he experiences from these high temperatures is marvellous, 
though the cool southerly sea-breeze is delightful to every one." 

** To summarize the main characteristics of the Victorian climate, 
it is a temperate, warm climate, whose average summer heat is but 
two or three degrees above that of London ; while in winter it is 
warmer than Nice or Naples, and as warm as Valencia or Barcelona, 
and actual cold is never felt at or near the sea-level. The air is 
generally dry, always stimulating and ozoniferous, but so tempered 
by the prevalence of ocean winds, that it is prevented from becoming 
irritating, like that of Nice or Provence. With this is a very large 
proportion of sunny weather during the whole year." 

The mortuary statistics of Victoria amply testify to the great 
healthiness of the climate, and the little liability of the colonists, as 
compared with home populations, to tuberculous disease and affections 
of the respiratory organs. 

Good examples of all the varieties of climate, air, and soil required 
for the treatment of the local phases of pulmonary consumption, 
whether in winter or summer, are, according to Dr. Bird, found in 
the Australasian colonies. Launoeston, in Tasmania, (twenty-four 
hours by steamer from Melbourne), " fulfils every condition which 
we could require for the cases to which Pau is beneficial." The winter 
climate of Launceston is compared by Count Strezelecki to that of 
Lisbon, while in summer it is not warmer than Cheltenham. " There 
are other parts of the northern coast of the island whose winter 
climate is identical with that of Algiers, or Sicily, considerably 
warmer, and less damp and relaxing than Pau, without the dry and 
stimulating air of the mainland." Hobart Town and the neighbour- 
hood is to DC regarded rather as a summer than winter residence for 
invalids, although it would take high rank as the latter in Europe, its 
coldest month having a mean of 45'82' Fah. The whole of Tasmania 
is highly salubrious. ** Auckland, in the northern island of New 
Zealand, is another good example of a moist, warm, and rather 
relaxing climate, suitable to the irritable, dry, bronchial compli- 
cations of consumption ; but it has the disadvantage of being windy 
and boisterous." " But the winter climate par excellence of these 
colonies (continues Dr. Bird) is that of More ton Bay, and its neigh- 
bourhood, in Queensland, not far from the southern limit of the 
tropics. Here the average winter temperature on the coast is 62° 
or 63° — warmer even than Madeira— an air soft and soothing, with- 
out being relaxing, and sunny, brilliant weather. This of all climates 
that I ever heard of is the one most likely to prolong the life of an 
advanced case of consumption in an irritable constitution, whose 
bronchial membrane resents any fall in the temperature. And here, 
too, the invalid may gradually adopt a more stimulating air as he 



350 BEFOBT ON FBACTICAL MEDICINE. 

finds Ids local irritation quieted down. Inland, a few miles from the 
coast, the land rises, and the climate, equally suuny and enjoyable, 
is more dry and tonic in its character. A considerable number of 
instances are familiar to the inhabitants of the more southern 
colonies of persons apparently in a hopeless stage of disease recover- 
ing sufficiently in Queensland to follow ordinary avocations." 

The temperature of South Australia may be compared with 
Malta or even Tunis, but its general salubrity far excels the latter 
places. Many of the northern districts of Victoria have dry, warm, 
and tonic climates, but less stimulating than those of South 
Australia. Sydney possesses a favourable winter and spring climate 
for an invalid. In summer its heat is frequently oppressive. 

" Taking it all in all," Pr. Bird writes, " there is perhaps no 
climate in the world so generally suitable to consumptive cases at all 
seasons of the year as Melbourne and its neighbourhood. With the 
winter temperature of Rome or Barcelona, the southern littoral of 
Victoria is not hotter in summer than Paris ; less moist and 
boisterous than New Zealand it equally falls short of the excessive 
dryness of South Australia, and the close damp heat occasionally 
experienced at Sydney. Although as winter or summer climates we 
may find the other colonies more suitable to individual cases of 
advanced consumption, none of them are so suitable all the year 
round to early cases arriving from Europe." 

We heartily commend Dr. Bird's work to our readers. It is 
charmingly written, is singularly interesting, and forms a most 
valuable addition to medical climatology. 



351 



II. 
REPORT ON MIDWIFERY. 

The Diagnosis and Treatment of Diseases of Women, including 
the Diagnosis of Pregnancy, Founded on a Course of 
Lectures Delivered at SL Marfs Hospital Medical 
School. 

By Gkaily Hewitt, M.D. Lond., M.R.C.P., Physician to the 
British Lying-in Hospital ; Lecturer on Midwifery and 
Diseases of Women and Children at St. Mary's Hospital 
Medical School ; Honorary Secretary to the Obstetrical 
Society of London. 

(8vo. London : Longman, Green and Co. pp. 628.) 

This work by Dr. Graily Hewitt, who is well known as one of the 
most painstakmg of modem physicians, deserves a more extended 
notice than the limited space at our disposal permits. As the author 
explains in his preface, the primarv omect of the work is to afford 
increased facilities for diagnosis, feoubtless, a correct diagnosis is 
all-important, for, as Dr. Hewitt remarks, " without diagnosis, no 
advance can be made but on the imperfect basis of surmise and con- 
jecture ;" in other words, to use a homely and well-known proverb— 
" the knowledge of the disease is half the cure." In forming this 
correct diagnosis. Dr. Hewitt takes as his ground- work the value of 
symptoms or signs of disease ; for the experienced practitioner, who 
wishes to establish a conclusion on any particular case, will, un- 
consciously or otherwise, necessarily pass in review all the morbid 
conditions or diseases with which he knows the sign in question to be 
associated, carefully bearing in mind the many cases exceptional to 
general rules which may have been noticed by himself or recorded by 
others. The plan is, in short, a thoroughly exhaustive one ; all the 
possible causes of certain symptoms beins set forth, and all the dif- 
ferences abstracted, to use the phraseology of the logicians, it is 
hardly possible that important disorders should escape attention. In 
order tnat the reader may duly appreciate, and profit by, the manner 
in which the author has carried out this plan, ne must refer to the 
work itself, which will be found to be exhaustive in more senses 
than one, as it includes the consideration of the whole range of the 
important class of diseases comprised in the expression, Diseases of 



352 EEPOET ON MIDWIFEET. 

Women. Out of so many topics it is diflScult to select illustrative 
passages. In any topic it would be easy to find much that is at 
once interesting and important, and more especially, perhaps, in the 
remarks on inflammation of the uterus, on the cause of pain in 
dysmenorrhcea, and on treatment generally. The chapter on 
diseases of the ovary, for example, contains a very able resumS of 
the natural history of ovarian tumours and dropsy, and much 
valuable information bearing on the comparative advantages of 
ovariotomy, tapping, the system of doing nothing, &c., &c., and the 
contents of this chapter shall furnish a sample of the contents of 
the companion chapters. 

Regarding the natural history of ovarian dropsy, " the interest 
felt," says the author, " attaches for the most part to the prognosis 
of cases of ovarian dropsy or tumour in which the tumour is as large 
or larger than the head of a child, because these are the cases concern- 
ing which our advice and opinion are most frequently requested." 

" What, then, is the natural termination of these cases if left to 
themselves?" 

From an analysis of the cases recorded by Mr. Safford Lee, by 
Dr. Robert Lee, and others, it is endeavoured to procure an answer 
to the above question. 

Respecting Dr. Robert Lee*s cases it appears that, '* on the most 
favourable interpretation of individual cases, 84 per cent, of those 
cases died, and so far as the majority of these are concerned, the 
death occurred within two years. On the other hand, in 16 per 
cent, of the cases an opposite result ensued, or at all events there is 
no proof that such an opposite result might not have ensued. It is 
natural to conclude, however, from an examination of the above list, 
that 16 is a very high figure, and that had all these ^ cases been 
allowed to pursue their natural course, the actual per centage of 
favourable results would have been nearer 10 than 16. The general 
conclusion deducible from Dr. Lee's cases is, that taking the case of 
a woman, the subject of * progressive * ovarian tumour or dropsy to 
the extent contemplated in the above-mentioned category of cases, 
the chances are as ten to one that the case will end fatally in less 
than two years, the disease being left to itself or palliative measures 
only, such as tapping, being employed." (p. 584.) 

from an examination of Mr. Safibrd Lee's cases it appears that, 
in 76 per cent. (94 out of 123) the duration of the disease ** was under 
five years. But it is necessary to analyse more fully the data in 
question in order to compare them properly with those afforded in Dr. 
Lee's cases. It is more satisfactory, as before remarked, to have 
the whole experience of one individual. 

" In Mr. Safford Lee's table we find 20 cases of Dr. Kilgour's — of 
these 20 cases, 17 died in three years and under — viz., 85 per cent., a 
figure very closely approximating to that obtained from Dr. Lee's 
cases. 

" In 12 cases reported by Dr. Ashwell, 9— t.e., 75 per cent., died 
in the same period — three years and under. In 10 cases reported by 
Mr. Saflbrd Lee himself, 9 — i.e., 90 per cent., died within tbree years. 
The experience of one reporter. Dr. Macfarlane, nias more favour- 



BBFOBT ON MIDWIFEBT. 353 

able, for, of the 14 cases reported by him, the duration was four 
years or under in 4 cases, and of the other ten 4 survived twelve 
years, and 4 as long as sixteen years. Dr. Macfarlane*s ex- 
perience would seem to have included a larger number than usual 
of exceptional cases. 

. " As a gui le to actual results which may be expected in practice, 
the cases of Dr. Eobert Lee and the particular cases just referred to 
as contained in Mr. Safibrd Lee's tables, are worth more than those 
collected from various sources, for reasons already stated. Such 
eases as those in which it is recorded, that the disease lasted 20, 30, 
or even 60 years, do undoubtedly occur : much mischief has 
resulted, however, from looking on such cases as typical ones, while 
the large majority of the cases, the end of which is naturally death 
in a much shorter time, have been considered as the exceptional 
ones. 

" Taking everything into consideration, we shall not be probably 
far wrong in drawing from Dr. Lee's and from Mr. Safford Lee's 
cases, the conclusion that the probable duration of a case of ovarian 
disease of progressive character is, in 85 to 90 per cent, of the 
cases, two, or at the most, three years ; of the * apparently ' stationary 
or chronic cases, the prognosis is more favourable ; but in such cases 
the disease is liable at any moment to start into fresh activity. 

" The foregoing observations give some idea — an idea which can- 
not be very wide of the truth — as to the nature of the evil we 
have before us, when a patient presents herself with ovarian dropsy. 
The first question we naturally put to ourselves with a case of this 
kind to decide upon, is, does this case belong to the fortunate series, 
the 10 or 15 in the 100, or is she one of the 90 who must die in the 
course of two or three years if unrelieved? It must be confessed 
that at present we have, as a rule, no means of enabling us to decide 
— at an early period of the growth of the tumour, and when the 
tumour does not exceed six or seven inches in diameter — what the 
future of the case will be. In some few cases tbe cancerous nature 
of the tumour is obvious at an early period ; in some few cases also, 
the great unevenness and irregularity of the surface point to the 
presence of several cysts, a circumstance indicative for the most part 
of rapid growth — and these cases lay open their future before us 
more quickly ; but in the large bulk of cases it is not so. We 
generally have to wait until the tumour has grown to a larger size 
before we are able to say much as to the prognosis ; and it is the 
rapidity of growth, taken together with the nature of the growth 
itself, which then guides us to an opinion. 

** So long as a tumour, which is smooth externally, and apparently 
composed of a single cyst, continues tolerably q^aiescent, increasing 
but slowly, and without evidence of formation ol fresh cysts (for the 
determination of which examinations must be made from time to 
time), so long our prognosis will be tolerably favourable, and we may 
expect that the case will prove to be one of the fortunate 10 per 
cent, series. Kapid increase, new formation of cysts, addition of 
solid matter to the tumour, addition of ascites, increased pressure 
signs in the pelvis, rapid refilling after tapping — all these are signs 

xxxYiii. 23 



S54, BEFOBT ON MIDWIFBBT. 

of bad augnry, and should indaoe us to place the patient in the un- 
favourable series, and to act accordingly." 

The results of the operation of ovariotomy, as practised in this 
country of late years, are brought up to the present time, and the 
author gives the following as the results of the operations per- 
formed by operators up to September, 1863. 



Name of Operator. 


Total Number 
of Completed 
Operations. 


Cores. 


Deaths. 


Mr. Baker Brown . . . 

Dr. Clay 

Mr. Jonathan Hutchinson 

Mr. Lane 

Dr. Tyler Smith . . . . 
Mr. Spencer Wells . . . 


58 
107 
7 
11 
19 
74 


82 

73 

4 

8 
15 
49 


26 

34 

3 

3 

4 

25 



" The average percentage of cures will be found to be 65 ; the 
highest and lowest percentage being 55 and 78 respectively. This 
is very satisfactory. If the results of recent operations only — that is 
to say, of operations practised within the last four years, had been 
given, it would be seen that a cure was effected by those who have 
operated most largely. Mr. Baker Brown, Dr. Clay, Dr. Tyler 
Smith, and Mr. Spencer Wells, in considerably over 60 per cent, of 
the cases." (p. 589.) 

" On the whole," says Dr. Graily Hewitt, " the present aspect of 
the operation warrants us in taking 65 as the percentage of cures 
which may be expected when the operation is undertaken by ex- 
perienced operators ; and, substituting this figure for 53, which 
expresses the results of Dr. Clay's statistics, the case stands thus : 
In a case of ovarian cystic disease, the chances of recovery after 
ovariotomy are as 65 to 35, taking one case with another." 

Lastly, Dr. Graily Hewitt considers dispassionately the arguments 
which have been/brought forward against the opei^ation of ovari- 
otomy : — "It i^ urged that women may live a long time with 
palliative treatment. The value of this argument is tested by 
reference to the natural history of ovarian disease. The argument 
only holds good in respect of cases where the disease is evidently not 
of a progressive character, and such cases would not be considered 
cases for ovariotomy. Although in individual instances life is pro- 
longed even under apparently unfavourable circumstances, yet, 
what we have to consider first is the fate of the bulk of the cases 
which present themselves for treatment (see the analysis of Dr. 
Lee's cases at p. 583) , and how that fate is to be averted. 

" It is urged also that the diagnosis is difficult, and that it is at 
times impossible to say whether a tumour be ovarian or uterine. 
This is only an argument for increased attention to the subject of 
diagnosis. Serious mistakes need occur but very rarely. 

" In the next place, it is urged that ovariotomy is reaUy a more 



EBPOBT ON MIDWIFEBT. 355 

dangferons operation than the published statistics prove. This 
statement is met by the statistics of several well-known and well 
credited operators, showing that the operation is really a very 
snccessful one in good hands. To what extent it is a successful 
operation as now practised has been already shown (see p. 588). 
Further, there is every reason for believing that the mortality will 
yearly become less, and that dernier ressort operations will become 
fewer and fewer in number. 

" The most important arguments used against the operation are 
those of Dr. West, in his very impartial and elaborate analysis of 
the subject. These must now be considered. 

" To Dr. West's first argument, that the rate of mortality from 
ovariotomy is not decreasing (the date of this statement is 1858), it 
is sufficient to reply that late experience does not sustain it, and that, 
on the contrary, the mortality is decreasing. In proof of this, Mr. 
Baker Brown's experience is very instructive. The percentage of 
success obtained by the operator was formerly 31 ; the percentage 
of success in later operations has been 65. The next argument of 
Dr. West is, that the operation is most successful when the disease 
is advancing tardily, or where it has become stationary. Of late it 
has been shown that recovery has frequently followed in the very 
worst cases ; and on the other hand, death occasionally results 
when everything seems to promise a successful result. There is no 
proof that a fatal result is necessarily connected with any particular 
condition of the patient whatsoever. 

" Further, Dr. West urges that, in the cases apparently most 
favourable for operation, it is a venture, and that we cannot give 
in any case a sure prognosis. This is undoubtedly true; the opera- 
tion is a venture, but a venture less considerable than it was, and one 
which it can be demonstrated by figures, it is to the advantage of 
the patient to run, under certain circumstances. 

" There is another objection mentioned by Dr. West, viz., the un- 
certainty which exists as to the possibility of performing the opera- 
tion. * There is no other operation,* says Dr. West, * concerning 
which the chances are nearly one in three that some unforeseen 
difficulty will prevent its completion.* The proportion 'one in 
three * of failures to complete the operation, is, judjijing from Dr. 
Clay's statistics, too high, i. e. excludmg cases in which the diagnosis 
was wrong, and in which the operation was for this reason not com- 
pleted ; and reasons have been already given (see p. 590), for con- 
cluding that the percentage of failures to complete the operation 
may now be taken at about 10. And lastly, since the date of these 
remarks by Dr. West (1858), it cannot for a moment be denied that 
much has been done to remove the operation of ovariotomy from its 
place by the side of those exceptional proceedings, the expediency 
of which must be determined by each one for himself after a careful 
consideration of the peculiarities of the case, and the idiosyncrasies 
of the patient. 

" Finally, the argument used by Mr. Erichsen, at the late meeting 
of the Boyal Medical and Chirurgical Society, at which Mr. Wells's 
paper on ovariotomy was discussed, may be adduced on this impor- 

23—2 



856 EEPOBT ON MIDWIFEET. 

tant question. ' It is old and trodden ground,' says Mr. Ericlisen, 

• to compare ovariotomy with the result of the operations for hernia, 
ligature of arteries, &c.; and in these cases also the comparison is 
scarcely fair, as these are operations of necessity, whilst ovariotomy 
is an operation of expediency, and not of immediate and imperative 
necessity. But compare it with * amputations of expediency * of 
the lower extremity. He would take for this purpose the statistics 
of a most able paper published two years ago in the * Transactions * 
of the Society, giving the results of amputations performed in one 
of the largest hospitals in London — Guy's. In that paper Mr. 
Bryant stated that the mortality after amputation of the lower ex- 
tremity for tumours was 36 ner cent., and the mortality after 

* amputations of expediency * or the leg was 68 per cent. Compare 
this result of amputations performed under the most favourable 
circumstances, by men of the greatest skill and judgment, with 
those of ovariotomy, and the advantageous position of the latter 
operation is at once seen. With the aid of the facts and conclusions 
first stated, we may next consider the indications for ovariotomy. 
The average opinion among those in favour of this operation, may be 
stated as being to the effect that when the ovarian tumour is grow- 
ing fast, and when by reason of this, or in some other manner, life is 
threatened at no distant period, the operation is to be recommended. 
But it is necessary to be more explicit. 

"If our examination convinces us that the tumour is of cystic 
nature, that it is growing fast, that it is made up of three or more 
cysts, and the general health is threatened, this seems a case for 
ovariotomy. Equally so if the tumour be partly cyatic, partly solid, 
this solid matter not being cancerous. The alveolar tumour of the 
ovary falls under the same category, and also cases of dermoid or 
fat cysts * progressive ' in nature. But if the ovarian tumour be 
simply fibrous, this is scarcely a case for ovariotomy. An operation 
may possibly be justifiable in such a case, but scarcely on the ground 
that life is threatened by the presence of the tumour in question. 

*' Upon the next class of cases it is more difficult to pronounce an 
opinion. They are cases in which there is only one cyst in the 
ovary, or possibly two, and the disease is not strictly a progressive 
one ; or, at all events, this quality of it has not yet declared itself. 
It is quite clear that in very many such cases ovariotomy is not 
called for, but there are cases in which good reasons might be given 
for preferring to recommend ovariotomy — viz., where there is a 
rapia formation of fluid requiring frequent tapping, and threatening 
life in this manner. A tendency of this kind is hardly less destruc* 
tive to the patient than the tendency to rapid formation of other 
cysts. The arguments for ovariotomy in cases where the * badness' 
of the case falls short of that just spoken of, are, that the earlier the 
operation is performed the safer it is, and the less risk also that the 
operation will be interfered with by the presence of adhesions. The 
difficulty experienced in deciding as to what is the best thing to be 
done in individual cases is one which cannot be got over by any 
amount of generalization on the subject ; and, in a doubtful case, 
small things turn the balance. 



BBPOBT ON MIDWirBET. S5T 

" Another class of cases in which ovariotomy might be performed 
are those in which, although the case is not a * favourable * one for 
operation, the disease is so far advanced that the patient must 
otherwise certainly die soon, and where the operation might possibly 
save life. 

" It will be observed that the indications for ovariotomy chiefly 
resolve themselves into two— viz., the necessarily progressive nature 
of the disease pathologically considered, and the presence of such 
marked failing of the general health as to show that from radical 
measures only good can be expected. There is a special class of 
cases, as pointed out by Dr. Tyler Smith, in which patients insist 
on the performance of the operation, the idea of a possible operation 
looming in the distance being, to them, more intolerable than the 
present risk." (pp. 591—4.) 

The contra-indications are next considered in detail. The author 
concludes with the remark — ** The decision for or against ovariotomy 
should be left to the patient or her friends; it is for them to take 
the responsibility. It is our duty, firstly, to make a diagnosis as 
accurately as possible, taking the whole circumstances, past and 
present, into consideration; secondly, to make^ to the best of our 
ability, a prognosis of the case, and to lay before the patient and her 
friends the results arrived at ; and, if possible to state the chances 
for or against her numerically, it is better to do so. 

" For reasons which have been already suflSciently alluded to, it 
is occasionally most difficult to put our prognosis into a numerical 
shape, but until we can do so, a decision for or against ovariotomy 
cannot be come to satisfactorily ; and the patient must be informed 
what are the probabilities of her life being saved by the different 
methods of treatment, ovariotomy, tapping, &c., respectively." (p. 697.) 

The other methods of treatment applicable in cases of ovarian 
dropsy or tumour, receive their due amount of attention ; and, as will 
have been gathered from the foregoing extracts, the author has taken 
considerable pains to show how we may draw from the condition of 
the patient, indications as to the course of practice which ought to be 
pursued. 

In conclusion, we would heartily commend Dr. Hewitt's work as 
a sound guide, not only in diagnosis, but also in treatment — a double 
commendation, which we oould not apply to all text-books on the 
subject. 

On Ovariotomy in Gr^at Britain, 

By Mr. T, Spencer Wells, Surgeon to the Samaritan Free 

Hospital, &c. 
;(Tranmction8 of the Royal Medico-Chirurgical Society, voL xlvi. 1863.) 

This is a paper of more than ordinary value and importance. It 
contains (what was much wanted) a clear and concise history of thfe 
operation, and it gives the results of Mr. Wells's very large expe- 
rience in it ; and in doing this, it does all that is needful to remove 



358 BEFOST ON MIDWIFEBY. 

the doubts which exist in many quarters as to the propriety of an 
operation which in reality is not less justifiable than any other 
capital operation. 

Mr. Wells has performed ovariotomy in 50 cases, with 33 reco* 
veries and 17 deaths : he has commenced the operation, but not 
completed it in 3 case?, without any damage to the patient : and he 
has made an exploratory incision in aid of diagnosis fn 3 cases, 
with a fatal result in one of them. This experience and these results 
entitle Mr. Wells to speak on this subject with peculiar authority. 
In particular they remove one objection which, more than any 
other perhaps, has been oftenest urged against ovariotomy, viz., the 
diflBculty of diagnosis. Upon this point, however, and upon any 
other, it is best that Mr. Wells should b^ left to speak for himself. 

" If it were possible that a skilful surgeon could open the abdomen 
with the intention of removing an ovarian tumour — or in the belief 
that an ovarian tumour was present, after careful examination of a 
patient — and yet in one in ten, or one in fifteen cases, no such 
tumour existed, I should at once confess that this was a very strong 
argument against admitting the principle of the operation. But as 
no such mistake was made in any one of the cases now before the 
Society, nor in any one of the numerous cases in which I have 
simply tapped, or nave injected iodine, it must be considered as 
* sufficiently proved that the alleged difficulty of diagnosis is greatly 
exaggerated. 

" Another error, which, if uncorrected, would retard the progress 
of the operation, is a belief that it is one of so very grave a nature, 
and so uncertain in its results, that no surgeon can do more than 
make a rough guess at the probable issue in any given case. Because 
a very favourable case has sometimes terminated unfavourably, while 
a very desperate one has occasionally succeeded, it has not only been 
argued that the rules which guide us in estimating the risk of other 
serious operations do not apply in the case of ovariotomy ; but it 
has been gravely maintained that this operation stands alone, and 
that the more the general health of the patient has been broken 
down by the disease, the more the peritoneum has been changed 
from its normal state by distension and adhesions, the greater is the 
probability of success. This pernicious error, which has led to 
manv promising cases being deferred until too late, or until what 
would have been a very simple operation has become a very com^ 
plicated and difficult one, I am most anxious to correct. On looking 
over the above table, I am reminded of some very hopeless cases of 
large tumours, with firm adhesions, which I removed successfully 
from women who were very much broken down by the disease ; apd . 
I see one case which was in every respect most favourable, but in 
which death occurred from tetanus. I see another which was fatal, 
but which, in all probability, would have been successful, had I 
known at the time of the operation all that I have since learned 
and endeavoured to teach, as to the mode of securing the pedicle, 
of closing the wound, and of restricting the use of opium. But 
classing cases of this kind among those exceptional occurrences 
which every surgeon who has much experience of capital opera- 



REPOBT ON MIDWIFEET. 369 

lions occasionally meets with, and accepts as lessons to be cautious 
in prognosis, when so many unforeseen circumstances may arise 
to disturb the most careful calculations, I can state most distinctly 
that ovariotomy does not differ from other serious operations with 
regard to the rule that the better the general health of the patient, 
and the smaller the injury that is done in the removal of any 
diseased part, the greater is the probability of success. 

" Then as to the condition in which a patient is placed before and 
after operation, it is to be observed that when I began to perform 
ovariotomy it was held that a patient should undergo a long course 
of preparatory treatment, and that during and after the operation 
she should be kept in a close room filled with hot vapour. A 
state of copious perspiration was encouraged, and opium was given 
in such large and frequent doses, that some patients who died were 
not killed by ovariotomy, but were poisoned by opium. In my 
earlier cases, I followed the traditional routine ; but I soon found 
that in some cases no opium* need be given, and that when it was 
wanted to relieve pain, very moderate doses, repeated according to 
the continuance or recurrence of pain, were quite suflScient. Brandy, 
wine, and strong beef-tea were also given from the first by some 
operators, while one kept his patients on the most meagre diet. I 
avoided both extremes, finding that in n;iost cases little or no 
stimulus was needed during the first two or three days, and that the 
patients did much better on barley-water, gruel, or arrowroot, the 
quantity being regulated entirely by the appetite ; animal food not 
being given imtil the fourth or fifth day, and stimulants being 
administered or not in accordance with the state of the pulse and 
the general condition of the patient. I also found that the sickness 
and faintness which were supposed to be the proofs that large quan- 
tities of stimulants are required, depended in a great measure on 
the practice of keeping the patients in an atmosphere artificially 
heated and moistened, and that when the room was kept warm by a 
large open fire, and fresh air was admitted freely by an open window 
— the patients being protected from currents of cold air by a screen 
and a full supply of bed-clothes— the condition after the operation 
differed from the healthy state much less than under the former 
plan of treatment. I have known patients declare that the night 
flfter the operation was the best they had had for weeks, and some 
have recovered without taking a single dose of any sort of medicine. 
It may be seen that of my last fifteen cases, fourteen have recovered 
or are convalescent. I attribute this increasing success to the fact 
that in all these cases, even in winter, a window has been kept open 
night and day (except when the patient was uncovered for dressing), 
while the room has been warmed by an open fire kept constantly 
burning. 

" I have trespassed so long upon the attention of the Society that 
I cannot at present enter upon the consideration of the mode of 
performing the operation, the instruments found most useftd, or the 
best mode of meeting the various difficulties which may embarrass 
the surgeon in complicated cases. And these are all matters of 
detail, well deserving of careful study, it is true, but still of far 



360 BBFOBT OK MIDWIFEB-r. 

inferior importance to the question whether the principle of the 
operation is to be acknowledged by this Society. I shall, therefore, 
conclude by referring? to the condition of the patients who have 
recovered as a proof that when they escape the immediate dangers 
of the operation, their health becomes remarkably good. 

" It may be seen by reference to the table that one patient who 
recovered died ten months afterwards of cancer of the peritoneum, 
and one two years afterwards of hemiplegia ; but all the others 
have maintained a condition of vigorous health. Last May, M. 
!N61aton saw several patients upon whom I had operated in 1 859, 
1860, and 1861. He examined them very carefully, and was very 
deeply impressed by the perfect health they enjoyed. Menstruation 
has returned in manv oases with perfect regularity, and one patient 
bore a healthy child afterwards. As many of these women, now 
young and healthy, who are fulfilling their various duties in domes- 
tic service, or in the home life of single ladies, or as wives and 
mothers, and who are likely to continue to do so for many years, 
would in all probability have died a miserable death, months or 
years ago, had not their lives been saved by ovariotomy — it is for 
the Fellows of this Society to determine whether an operation which . 
has led to such results is still to be stigmatised as unjustifiable — 
whether they who perform it are necessarily open to the reproach 
that they do so rather for their own selfish purposes than for the 
good of their patients — whether they who, in the face of evidence, 
sufficient to convince any unprejudiced mind, continue to withhold* 
from their patients a tried and approved means of curing a disease 
otherwise incurable and certainly fatal, are not open to a still more 
serious reproach — whether it does ^ot become us {as men of science 
who practise our art, not for our own advantage only, but with the ear- 
nest desire to do the very best that can be done for those who are 
confided to our care, or who trust in our knowledge, our skill, and our 
honour) no longer to oppose or condemn this operation, but rather 
to study its past history — to regard it with pride, as an off*8pring of 
British genius, cultivated by British industry — and to aid its future 
progress by perfecting our means of diagnosis ; by ascertaining the 
conditions wnich should in any case encourage us to recommend 
the operation, or should deter us from doing so ; and by investi- 
gating the avoidable or removable causes of excessive mortality, 
reduce it to that comparatively low proportion to which I feel con- 
fident it may be and will be reduced, and thus render ovariotomy in 
each coming vear more honourable to British Surgery, and more 
useful to Mankind." 



BEPORT ON MIDWIFBBY. 361 

A Ca^e of Di/uble Ovariotomy ^in which tlie Patient was saved 
by Daily Injeetioris into the Peritoneal Cavity for Eigh t 
Weeks. 

By Dr. E. R. Peaslee, Professor of Aitatomy, &c. 
(American Qticirterly JotirTicU -of Medical Science, April, 1863.) 

This is an important tjase on two accounts. It is important for its 
rarity, for instances of double ovariotomy with a successful result 
are quite exceptional : it is still more important as showing what may 
be expected from the use of large injections into the peritoneal cavity. 

This is the second case of successful double ovariotomy which has 
occurred in Dr. Peaslee's practice. The first happened -twelve 
years ago. The patient was 24 years of age, and unmarried. About 
a year after the operation she married, and ever since that time she 
has had uniform good health, not oven suffering from headaches, 
and capable, Dr. Peaslee says, " of fulfilling all the functions 
attributable to her sex," with *he necessary exception of menstrua- 
tion and conception. Dr. Peaslee also states expressly, that no 
change has taken place in her external physical conformation 
or mental characteristics ; and that now, at 36 years of age, she is a 
splendidly developed woman. 

Dr. Peaslee employed large injections into the peritoneal cavity 
about seven years ago, in a case of ovariotomy, ana with very satis- 
factory results. In that case he used them for only seven days : ia 
the present case, he used them for ffty^in^ days in succession, 
often three times in the course of the twenty-four hours. 

Case.— Aug. SQth,* 1862, Mrs. E. L. S , of Port- Mills, Vermont, setat. 

35, a highly-educated lady, of delicate constitution, married eleven years, 
but never pregnant. A year after marriage she had inflammation of the 
kft ovary. The history of the progress of the case, and of the operation, is 
given by Dr. Peaslee, but is of no special interest : moreover, everything 
went on in a satisfactory manner until the nineteenth day. On this day a 
change took place in the symptoms, and the injections were resorted to; and 
now it becomes necessary to state details : — 

** 19th day. — Was called to see her at 1 A.M., because 'she seemed stupid, 
and it was difficult to arouse her.' Quinise gr. ss., brandy 5ij. Altliough 
the bowels had been freely moved by hydrarg. cum cret& and rheum, and 
injections yesterday, the dizziness and headache increased. The tongue was 
red, and becoming more and -more dry. Feeling sure that these symptoms 
were due to the presence of decomposing fluid in the peritoneal cavity, I 
decided to wash out that cavity. Accordingly, at 10 p.m., T passed an elastic 
bougie (No. 5) 'into it by the side of the five ligatures ; applied to the tubea 
syringe, and injected a quart of the artificial* serum before described, at a 
temperature of 9S** (Fahren.), and then changing the position of the 
patient, and depressmg the outer end of the bougie so as to bring it to a 
lower level than the other extremity in the peritoneal cavity — thus rendering 
the tube a syphon — about three pints of very fetid fluid were discharged in 
the course of an hour. 

"As it was found necessary to repeat this operation from one to three 
times daily for the next fifty- eight days, and, as this was the important and 
peculiar feature 6f the case, I will give the results in as brief a form as 
possible, omitting the minor details of the patient's progress. 



362 



BEPOET ON MIDWIFEBT. 



" 20th day. — Injected two quarts of the solution, and it ran out turbid 
and fetid, but not quite as much so as yesterday. Pulse 106; tongue 
better; appetite good. Liqr. sodse chlorinatse gtt. v, qu&que sext& hor^ 
sumendae. 8 P.M. — Injected Oij of the solution, and left it to run out through 
the syphon. 

** 21st day. — Syphon has discharged during the night Oiij of thick, 
creamy- looking, very fetid fluid. She feels better. Pulse 100 ; less thirst 
than for several days ; appetite good. 7 P.M. — Oij injected, and left to run out. 

*'22nd day, 10 a.m. — Slept well last night. Uas been passing limpid 
urine freely every few hours. Bowels moved once naturally.. Washed out 
the peritoneal cavity four times — injecting Oj each time — and drawing it out 
with the syringe. The fluid ran out quite clear the last time. 7 p.m. — Ojss 
of the solution injected at once and left to flow out. It had very little odour, 
but the operation was repeated in the evening. 

"23rd day, 10 A.M. — Pulse 110, and good. Two semi-fluid evacuations 
from the bowels since last report. Tinct. opii camph. 3j- Appetite good. 
While introducing the tube a fetid gas escaped through it. Injected as 
usual, but the fluid that came away was not very fetid. Pulse, after 
injection, 104. 8 p.m. — Before injecting, applied the syringe to the tube, 
and drew off" Oj of somewhat fetid fluid ; then injected Ojss, and left to flow 
out through the syphon. Pulse, before injecting, 110 ; afterwards, 104. 
Best day yet. 

" (The bowels were moved naturally once a day after this date.) 

"24th day, 10 A.M. — Drew off Oss of thick, creamy- looking fluid, by 
suction wiUi the syringe. Then injected as before. 8 P.M. — Drew off ^W, 
very nearly, of thick fluid — not fetid, but quite oftensive. Then injected as 
before. 

" 25th day, A.M.— The fluid drawn off by the syphon last night was quite 
transparent. Injected Ojss, and, on raising her up in bed, a somewhat 
thicker fluid came away. Tinct. opii camph. Sj* 8 PJtf. — She was fatigued 
by the prolonged operation of the morning, but is better now. Fluid comes 
away clearer after the injection. 

" 26th day, a.m. — Pulse 100, good; tongue ditto. Syphon fluid clearer 
during the night. 5iij drawn by suction — offensive, but thinner. No gas 
escapes around the tube. One ligature, the highest on the pedicle of the 
left side, removed. 

"27th day. — About ^W of the thick fluid by suction ; but 5>j of the solu- 
tion was injected and left in last night. Hitherto the tube had been removed 
each time after being used, but as the opening through the abdominal wall 
was getting smaller, and as the introduction of the tube was beginning to 
cause considerable pain, it was now allowed to remain in, and was seldom 
aiterward removed during the entire period of her convalescence. Being 
satisfied also that the albumen in the solution underwent decomposition on 
commixture with the fetid fluid in the peritoneal cavity, I henceforth used 
the following solution: — R. Liqr. sodaB chlorinatae f3j, sodii chloridi 3j, aquae 
Oj. M. — instead of the one before mentioned; and I had reason to be per- 
fectly satisfied with the change. 

"28th day.— Fluid drawn out clearer and odourless. Says she has 
noticed, during the last two or three days, an escape of air from the vagina 
in puffs, and also a whitish discharge, about one drachm, three times a day, 
for about one week. I feared the fetid accumulation in the abdomen bad 
caused ulceration through the vaginal wall, but, on examination, found this 
was not the fact. 

" 29th day, a.m. — Passed a good night, 5ij of odourless but thick fluid, 
by suction,, p.m. — gj by suction. Injected fluid ran off.clear. 



EKPOET ON MIDWIFEET. 363 

" 30th day. — Pulse about the same, 104. The tube causes some irritation, 
aud about 3j of healthy pus has been discharged around it. 5"j of the 
creamy fluid by suction, but there is no offensive odour. Other ligatures not 
loose yet. 

** At this time I returned to New York, leaving Mrs. S. under the care of 
Prof. Albert Smith, of the N. H. Medical Institution, and to him and to the 
husband of the patient I am indebted for the remainder of this report. I 
advised them to continue the injections daily, once or twice accijrding to the 
character and the quantity of the fluid removed, and as long as it continued 
to be fetid. This was done ; the patient always feeling an immediate benefit 
from each washing out, and relapsing into a languid state if the operation 
was omitted or too long deferred. 

" Sept. 30, A.M. — Pulse 100 ; 5ij of the peculiar fluid by suction, and in 
the evening a like amount. Sat up in bed to eat, for the first time. 

" Oct. 6. — The amount of fluid in the abdomen has been slowly decreas- 
ing ; only 5J8S has accumulated in twenty -four hours. 

*^ 16tb. — The abdominal walls have contracted to such an extent that only 
5ij of the dilute solution of chlorinated soda can be conveniently injected 
and retained. Since the 6th inst. the experiment has been tried of drawing 
out all the matter and omitting the injection ; but the fetor increased to 
such an extent that the solution of soda was resorted to again. Sat up 
to-day in a chair half an hour. Pulse 100. Appetite good. Bowels con- 
stipated for several days ; moved by enema. PU. rbei comp. iij produced no 
effect. 

'^ 27th. Sits up an hour or two at a time, and walks across the room once 
or twice. Only 3j of thick fluid removed by suction. Pulse 98. 

"28th. 59th day.— She was placed on a mattress in a covered carriage 
to-day, and earned to her home, twelve miles distant. The journey caused 
some fatigue, but otherwise no inconvenience. 

"Nov. 6th. — Remaining four ligatures were removed. Mr. Smith remarks 
in a letter : ' 1 think they are held by the knot on the inner side of the 
abdomen, as pulling has caused no pain for a week past.' 

" From this time onward she gained gradually in strength, her convales- 
cence being interrupted only by a severe attack of constipation and colic, 
which caused no little apprehension, but she was very skilfully treated by 
Dr. Worcester (before mentioned), and finally relieved. Less and less matter 
was drawn from the peritoneal cavity until Nov, 14th, when none whatever 
could be obtained. 

" On the 16th of November, seventy- eight days after the operation, her 
husband writes : * With the consent of Dr. Worcester, I have tliis morning 
removed the tube and closed up the opening.' The injections had thus been 
used for fifty-nine days in succession, or from the nineteenth to the seventy- 
eighth day after the operation. 

"Jan. 1st, 1863. — Mrs. S. wrote me to present the compliments of the sea- 
son, and said she had as few aches and pains as the majority of people 
have; and up to the 13th of Mar^h. I hear of her continuing in good 
health." 



INDEX TO VOL. XXXVIII. 



Advanced life, a practical treatise on the diseases and ixifirmities of . 307 
Albuminuria, on the pathological relations between . puerperal mania 

and . 92 

Amaurosis, more especially that form of it supposed to be. induced by 

tobacco, clinical data respecting 201 

Aneurism of the walls of the left ventricle, on circumscribed . .140 
Annandale, case in which a breast-pin was swallowed by. a child, and 

passed by stool 20 hours after 244 

Apoplexy, on the influence of hypertrophy of the heart and disease of 

the cerebral arteries in the production of . . . . . fi7 
Army medical department, statistical sanitary and medical reports for 

1861 822 

Abokbum, on the effect of petroleum or "rock oil*' in a case of 

beriberi 1Q7 

Arsenical green, on the Occupations which have to do with . .. 312 

Arsenicated mineral waters, on the^medicinal use of . . . . 9 

Artificial xirethra, three oases of . . .... . • 293 

Australian climates in the prevention and arrest of phthisis, on the 

infl.uencevof . . • 347 

Babn£6, on broncho- pneumonia in lying-iB women . . . . 288 
Beany, on a new method of treating inflammation of the testicle . 259 
Beattt, case in which a large calculus was expelled from the bladder 

of a female through the urethra by naturaJi efforts . . .291 

Begbis, on Graves* disease . 137 

Begbie, on the diagnostic value of accentuated -second sound of the heaH 844 
Bennett, on .tuberculosis . . . . . . . .49 

,, on the unfavourable influence of sudden change of climate . 1 

Beriberi, petroleum or " rock oil " in a case of 107 

Bethune, on double vision with each and both eyes .... 207 
Bevan, a specimen of the odontoid process of the axis, with perfect 
anchylosis of its apex with the occipital bone, and partial luxation 

forwards of the atlas . ^ 227 

BiBD, on Australian climates and their influence in the prevention 

and arrest of phthisis . . 847 

Bitot, on undescribed lesion of the conjunctiva, associated with night- 
blindness 211 

,, OH a lesion of the conjunctiva coinciding with hemeralopia . . 204 
Bladder, case of encephaloid disease of the ..... 180 

Blot, on slowness of the pulse in the puerperal state . . . 279 

B0UCHUT,x)n chronic congestion of the lungs .126 

„ on the efficacy of artificial and mineral tar in the treatment 
of diphtheria, ulcers, and cutaneous affections . . . .194 

BouLET, on rabies 98 

Bowman, on a cheap spirometer .131 

Bbichetrau, on the inefficiency and dangers of cauterization in the 

treatment of croup 121 

Bbinton, on the use of bromine, in hospital erysipelas . . .186 
Bbistowe, on the occupations which have to do with phosphorus . 313 
Bbodekick, on a valuable diagnostic sign of the existence of acquired 

syphilitic taint .^ • • .• «6S 



INDEX. 865 

PAGH 

Bronchitis, on capillary . ^ 112 

„ on pseudo-gangrenous , ^ ^ , , , . 119 

Broncho-pneumonia in Ijing-in women, on , . . . , 286 
Bbougkam, on nursing upon the same principle as that of the French 

aoeurs de ckavitS . . , , ..••-,- 7 

Brown, a fatal case of varicella 40 

,, three cases of artificial urethra 293 

,, on ephemeral mania . . . . . . • .81 

Bruit de moulin, on ........ . 137 

BuDD, on the influence of a long course of nitric acid in reducing the 
enlargement of the liver and spleen that sometimes results- from' 

the syphilitic cachexy . . . . . . , . 152 

BuRLEr, on spiritualism as a cause of insanity 84 

Butcher, on a case of elephantiasis arabum of. the lower extremity 

successfully treated by tying the femoi-al artery ^ . . 268 

„ on excision of the knee-joint . . • . . . 271 

Calculus expelled from the bladder of a female, through the urethra^ by 

natural efforts , 291 

Caries and sinus, on- the efficacy of Villate*s lotion for the cure of .194 

Carter, on iridectomy in destructive ulceration of the cornea ^ . 193 

Catalepsy, on .....■«.. ^ .. 96 

Cbely, on the supply of vaccine lymph .,..,. 312 
Chambbrs, on the treatment of rheumatic fever . . • .31 

„ on the therapeutics of continued fever .... 20 
Chafmait, a new method of. treating disease by contr^ling the circula- 
tion of the blood in different parts of the body . . . .331 
Chevance, case of pneumatocele of the skull, following fracture of the 

petrous bone, in which the patient recovered .... 225 

Cholera, on the disinfecting treatment of 25 

„ exhaustion, haemorrhage, &c., on the hsemostatic treatment of 340 

Chelestenne, on the physiological and pathological import of . . 158 

Chopart's operation, on « 274 

Chorea to rheumatism, valvular disease of the heart, and pregnancy, 

on the rdation of ......... 67 

Circulation of the blood in different parts of the body, a new metbod 

of treating disease by controlling the 331 

Circulation, an experimental inquiry into the effect of the application 

of ice to the back of the neck on the retinal .... 331 

Climate, on the unfavourable influence of sudden change of . . 1 
Clouston, on the connexion between tuberculosis and insanity . .53 
Cooke, spontaneous uterine and extrauterine gestation proceeding to 

the full term 278 

Cornea, on iridectomy in destructive ulceration of the . . .198 
Corner, on a case of induction of premature labour by Dr. Barnes's 

method 280 

Cotton famine, the • 314 

Croup, on the inefficiency and dangers of cauterization in the treat- 
ment of , . 121 

Curling, observations on sterility in man ..... 265 
Cutaneous affections, on the efficacy of artificial and mineral tar in the 

treatment of 194 

Dat, Curious reunion of an amputated toe . . . • .276 
Delord, case of utero-placental adhesions which give rise to severe 

symptoms 288 



366 INDEX. 

PAOV 

Delpech, on measly pork , . . • . * . .17 

Dementia paralytica, on bloody sweating from the head in . . 88 
Demeuret, certain consequences of the bite of a viper reappearing 

periodically for 89 years 195 

Diabetes, a question as to the pathological distinctions in cases of . 170 

,, on the oerebro-spinal lesions consequent upon . . , 106 
,f treated by the use of the Turkish bath . . . .175 

,, mellitus, effects of diet and drugs in the treatment of . 177 
,, f, on the excretion of sugar and urea under the use 

of benzoic acid in cases of . « 179 

Dickenson, case of inguinal hernia treated successfully by Professor 

Cbisholm's method 256 

DiDAT, on the precautions calculated to prevent the transmission of 

syphilis by vaccination ...*.... 55 

Diet« economics of . 315 

Digitalis in the treatment of insanity, on the use of . • . .86 
Diphtheria, on the use of sulphites in .46 

,, on the efficacy of artificial and mineral tar in the treatment 

of 194 

Diseases of live stock in their relation to the public supply of meat 

and milk 318 

Dislocation of the ensiform cartilage occurring during pregnancy . 288 

DoLBEAU, a symptom of fracture of the base of the skull . . 226 
Don KIN, on the pathological relations between puerperal mania and 

albuminuria ...**..... 92 

Double vision with each and both eyes 207 

Dubois-Reymond, on hemicrania or migrain 73 

Dysentery, on the use of ipecacuanha in the treatment of tropical . 148 

Dysmenorrhea and sterility 292 

Edmunds, on a case of malignant pustule . . . . . 47 

Eggs, puddings without 13 

Elephantiasis arabura of the lower extremity successfully treated by 

tying the femoral artery, case of 268 

Embolus of the pulmonary artery, case of 142 

Embryotomy and decapitation, on a new method of . . , .287 

Empis, on pseudo-gangrenous bronchitis 119 

Epidemic from eating the flesh of a diseased cow . . . .16 

Epiglottis, on the the normal position of the 233 

Erysipelas, on the use of bromine in hospital . . . . .186 
Estbad£re on the employment of shampooing in certain affections 

of the muscular system, especially in lumbago . ... 74 
Eulenburo, on the influence of hypertrophy of the heart and disease 

of the cerebral arteries in the production of apoplexy . . 67 
EwART, on the use of ipecacuanha in the treatment of tropical dy- 
sentery , 148 

Extra-uterine foetation, the foetus being in the sac of a hernia, case of 290 

Fabbri, case of tubular pregnancy followed by recovery and three 

natural labours 290 

Favre's galvanic probe . . » 196 

Fairer, case of traumatic tetanus in which the nerve was divided 

with seemingly satisfactory results 197 

„ on the means of controlling hsemorrhage in the removal of 

scrotal tumours . . 263 



IKDSX, 867 

PAGB 

Fever, contribution to the therapeutics of continued ... 20 
,, on tlie treatment of malarious, by the subcutaneous injection 

of quinine 41 

Fevers of the south-east coast of Africa on the .... 42 

Fibula, luxation of the head of the 273 

Fischer, on the inefficiency and danger of cauterization in treatment 

of croup , . 121 

Flkury, on the danger of temporizing too much with encysted 

tumours 191 

Flint, on the management of pulmonary tuberculosis with special 

reference to the employment of alcoholic stimulants . . .124 

„ on the physiological and pathological import of cholesterine . 158 

Fracture of the base of the skull, a symptom of . . . . 226 

Fuller, on rheumatic gout 57 

Gamgee, on diseases of live stock in their relation to the public sup- 
plies of meat and milk 818 

Gaems, on an easy method of reducing a dislocated humerus . . 268 
GiBB, on the normal position of the epiglottis as determined by the 

laryngoscope 233 

GiMSON, case of prolonged and profound sleep occurring at intervals 

during twenty yeare ... ...... 108 

GiRALDES, on the performance of tracheotomy in children . . 238 
GooLDEN, on a case of diabetes treated by the use of the Turkish 

bath 175 

GoBBELiN, on supra-pelvic hsematocele 293 

Gout, on rheumatic 57 

Graves' disease, on ........ 137, 13$ 

Greenhaloh, on dysmenorrhoea and sterility 292 

Griepenkarl, on the treatment of whooping-cough by ergot of rye . 13X 

GuERBANT, on Operative surgery in children 298 

Gullet, on a simple mode of removing foreign bodies from the . . 234. 
Gunshot and penetrating wounds of chest and abdomen by her- 
metically sealing, treatment of 242 

Gur, on th6 occupations which have to do with arsenical green . 312 

Hsematocele, on supra-pelvic 293 

Hsematuria, case of encephaloid disease of the bladder with remarks 

on the semiotic value and treatment of 180 

Haemorrhage from the rectum, on . 258 

Hallucinations, on muscular 103 

Hancock, on Chopart's operation 274 

Harlut, on cases of whooping-cough, treated with bromide of am- 
monium 129 

Hart, on smoking as a cause of optic atrophy, &c 203 

Heart and disease of the cerebral arteries in the production of 

apoplexy, on the influence of hypertrophy of the ... 67 

„ on the relation of chorea to valvular disease of the ... 67 

„ on the diagnostic value of an accentuated second sound of . 344 

Heart-sounds, on the double pulse and double 145 

Hemeralopia, on a lesion of the conjunctiva coinciding with . . 204 

Hemicrania or migrain, on 73 

Hewitt, on diseases of women 251 

Hip-joint disease in children 27^ 



368 INDEX. 

PAOl 

Hoarseness and loss of voice by the direct application of galvanism 

to the vocal cords, on the treatment of 235 

HoDCFKiN, on nightmare . . .75 

Howard, on the treatment of gunEdiot-wounds by hermetically 

sealing 242 

HoTLAND, case of reeovery after transfixing of the thorax by an iron 

bar 241 

Humerus,, on an easy means of reducing a dislocated . . . 208 

HuSEMANN, on an epidemic from eating the flesh of a diseased cow . 16 
HuTOHiNSON, on amaurosis, more especially that form of it supposed 

to be induced by tobacco . . . . . . .201 

„ on tertiary syphilis without history of any primary or 

secondary stages 68 

Hydrophobia, on the incubation of • • 107 

India, how people may live and not die in • ... 4 

Indian army, report of the Royal Commission on the samtary state of 

the 326 

Inguinal hernia treated successfully by Professor Chisholm's method . 256 
Insane, on hsematoma of the external ear in the . , . .91 
Insanity, on the connexion between tuberculosis and ... 53 

„ on spiritualism as a cause of 84 

,, on the URe of digitalis in the treatment of , . . .86 
Inzani, on the importance of tapping joints distended with fluid • 193 
Iodine a^ a deodorizer and disinfectant 8 

Jackson, an experimental inquiry into the effect of the application 

of ice to the back of the neck on the retinal circulation . . 331 

Jackson, on the use of Uie ophthalmoscope in affections of the nervous 

system ........... 110 

Jenneb, on impediments to successful vaccination .... 39 

Johns, on the treatment of incontinence of urine . • . . 249 
Joints distended with fluid, on the importance of tapping , , .193 
Jones, on a case of throat dyssBsthesia, with clinical remarks . .145 
Jones, on catalepsy 96 

KiDD, a pessary retained thirteen years 298 

KiRKES, on pericarditis consequent upon pywmia . . . .13 
, , on the relation of chorea to rheumatism, valvular disease of 

the heart, and pregnancy 367 

Knee-joint, on excision of the ....... 271 

KussMAUL, on tubercular disease of the urinary organs . . . 251 

Lacteals, on dilatation of the . . . . . . . .143 

IjAWSON, on the treatment of strabismus at the Eoyal Ophthalmic 

Hospital, Moorfields 205 

Latcock, on Graves* disease .138 

Lesion of the conjunctiva associated with night* blindness, on un- 

described 211 

Lesion of the conjunctiva coinciding with hemeralopia, on a . .204 
Liver resulting from syphilitic cachexy, on the influence of a long 

courae of nitric acid in reducing enlargement of the . . . 152 
Lumbago, on the employment of shampooing in certain affections of 

the muscular system especially in 74 

Lungs, on chronic disease of the 126 

Ltell, on the use of sulphites in diphthena • . . • « 46 



INDEX. 369 

PAOS 

Maoeat, on the disinfecting treatment of cholera • • • . 25 
Mackenzie, on the treatment of hoarseness and loss of voice by the 

direct application of galvanism to the vocal cords . . . 235 
Maolaohlan, a practical treatise on the diseases and infirmities of 

advanced life 307 

Maisonnehve, on a new application of elastic bandu in strangulated 

hernia 254 

Mania, on ephemeral 81 

Maktell, case of abscess of the spleen discharged into the left long 168 

Mabchal, on the cerebro-spiual lesions consequent upon diabetes • 106 

Mabson, on sairacenia purpurea or pitcher-plant in small-pox . . 33 

Measles and scarlet-fever — are they distinct diseases ? ... 36 

Measly pork, on 17 

Mellob, on the fevers of the south-east coast of Africa * . .42 

Migrain, on hemicrania or • 73 

Milk, poisoning by 15 

MOOBX, on a new mode of proceeding in placenta prsBvia . . 285 
„ on the treatment of malarious fever by the subcutaneous injec- 
tion of quinine 41 

,, on Graves' disease 138 

MoBEL-LEYALLii on " le bruit de moulin ^ 137 

Mouth, on syphilitic disease of the 219 

MtJLLBR, case of extra-uterine foetation, the foetus being in the sac of 

a hernia . . . . .290 

Myelitis, in which recovery was materially assisted by cod-liver oil . 77 

Nelaton'b porcelain probe 196 

Nervous pain and neuralgia, practical hints on the treatment of . 335 
Nervous system, on the use of the ophthalmoscope in affections of 

the 110 

Neuralgia, practical hints on the treatment of 335 

New methods of discovering tlie presence of a ball or other metallic 

body in a wound 196 

NiOHTiNOALE, how people may live and not die in India ... 4 

Nightmare, on 75 

Noble, on the pathological distinctions in cases of diabetes . . 170 
NoTTA, on the efficacy of Villate's lotion for the cure of caries and 

sinus 194 

Nursing, on the same principle as that of the French Soeurs de 

Charit6 7 

Ocular tunic and its relations and bearings in ophthalmic practice, on 212 

Ogle, on the treatment of taenia, especially by the use of oil of male-fern 1 62 
Operative surgery in children . . . , . . . .298 
Ophthalmia in infants, practical observations on the treatment of 

purulent 301 

Ophthalmoscope in affections of the nervous system, on the use of the 110 

Optic atrophy, on smoking as a cause of 203 

Osteomyelitis, on 190 

Otitis and deafness induced by the immoderate use of tobacco and 

fermented liquids, on a peculiar form of 217 

Ovariotomy in Great Britain, on 357 

„ in which the patient was saved by daily injections into 

the peritoneal cavity for eight weeks, a case of double . . 361 

Paokabd, a simplified apparatus for the radical cure of varicocele . 262 
xxxviu. 24 



37(y INDEX. 

PAGS 

Pa JOT, on a new method of embryotomy and decapitation . . 286 
Pancreas, two cases of cancerous disease of the . . . .164 

Parkbb on tartrate of antimony as an oxytoxic .... 281 
Peaslee, a case of double ovariotomy, in which injections into the 

peritoneal cavity were successfully used 361 

Pericarditis consequent upon pyaemia 133 

Perinseum, on supporting the 294 

Periostitis, on .......... 170 

Pessary retained thirteen years, a 298 

Phosphorus, the occupations that have to do with .... 813 
Phthisis, on the influence of Austi-alasian climates in the prevention and 

arrest of .... - 347 

Placenta praevia, a new mode of proceeding in "... 285 

Pneumatocele of the skull following fracture of the petrous bone • 225 

Potter, opei-ation for compression of the spinal cord .... 239 
Pregnancy, on the relation of chorea to rheumatism, valvular disease 

of the heart, and 67 

Premature labour by Dr. Barnes's method, induction of . . . 280 

Price, on the treatment of early stages of hip-joint disease in children 275 

Privy Couucil, the fifth report of the medical officer of the . . 309 
Puerperal mania and albuminuria, on the pathological relations 

between 92 

Pulse in the puerperal state, slowness of the . . . . . 279 

Pustule, on a case of malignant 47 

Pyaemia, on . 184 

QuAiN, on pyaemia . 184 

Kabies, on 98 

Radcliffe, case of acute myelitis in which recovery was materially 

assisted by cod-liver oil 77 

,, practical hints on the treatment of nervous pain and 

neuralgia 835 

Ranking, case of enceplialoid disease of the bladder, with remarks on 

the semiotic value and treatment of haematuria . . . .180 

Renault, on the incubation of hydrophobia ..... 107 

Report of the medical officer of the Privy Council, the fifth . . 309 
„ of the Royal Commission on the sanitary state of the Indian 

army . 326 

,, statistical, sanitary, and medical, of army medical department . 322 

Reynolds, case of incipient wasting palsy cured .... 79 
Rheumatic fever, statistics of the treatment of . . ^ . .31 
Rheumatism, valvular disease of the heart, and pregnancy, on the 

relation of chorea to .67 

Richardson, on iodine as a deodorizer and disinfectant ... 8 
,, on tobacco in its relation to the health of individuals and 

communities 11 

„ luxation of the head of the fibula 273 

Robinson, on the medicinal use of arsenicated mineral waters . . 9 
Robertson, on the use of digitalis in the treatment of . . .86 
RosER, on periostitis and osteomyelitis . . . ., . ,190 

Russell, on supporting the perinaeum 284 

Salter, on capillary bronchitis 112 

Scarlet fever and measles, are they distinct diseases ? . . . .36 
Scrotal tumours, on the means of controlling haemorrhage in the 

removal of 268 



INDEX. 871 

Semebii, on muscular hallucinatious 108 

Sebvaeb, on bloody sweating from the head in dementia paralytica . 88 
Shampooing in certain affections of the muscular system, especially in 

lumbago, on the employment of 74 

Stomund, on syphilitic disease of the mouth 219 

Siguatera, or fish- poison disease^ on 18 

Sim, on dislocation of the ensiform cartilasre occurring during pregnancy 288 

Simon, the fifth report of the medical officer of the Privy Council . 809 

Skoda, on the double-pulse and double heart-sound. . . . 145 
Sleep, occurring at intervals during twenty years, ease of prolonged 

and profound 108 

Small-pox, trial of sarracenia purpurea, or pitcher-plant, in . .88 
Smart, on the efiGects of diet and xlrugs in the treatment of diabetes 

mellitus 177 

Smith, on economics of diet ........ 815 

Solomon, on the diagnosis and treatment of syphilitic tubercle of the- 

eyelid . . . .208 

Spina bifida was successfully removed by operation, case in which tlie sac 

ofa 248 

Spinal cord,, operation for compression of the 289 

Spirometer, a cheap ......... 181 

Spleen discharged into the left lung, case of abscess of the . .168 

Spleen resulting from the syphilitic cachexy, on the infiuence of a long 

course of nitric acid in reducing the enlargement of the ■ . .158 

Sterility in man, on • . . 265 

Stewabt, dilatation of the lacteals 148 

Stiff, on haematoma of the external ear in the insane ... 91 
Stockvis, on the excretion of sugar and urea under the use of benzoic 

acid in two cases of diabetes mellitus • . . . . 179 

Strabismus, on the treatment of 205 

Strangulated hernia, new application of elastic bands in . . . 254 
Stricture of the urethra by gradual distension at a single sitting, on 

the successful treatment of 247 

Sutherland, fatal obstruction of the bowels from the presence of a 

hydatid tumour springing from the -mesentery . . . .170 

Stme, on hsemorrhage froiii the rectum 268 

Syphilis by vaccination, on the precautions calculated to prevent the 

transmission of ......... 55 

Syphilitic tubercle of the eyelid, on the diagnosis and treatment of . 208 

„ taint, on a valuable diagnostic sign of an acquired . . 65 
Syphilis, without history of any- primary or secondary stages, on ter- 
tiary 68 

Taenia by the use of oil of male fern, treatment of . . .162 

Tartrate of antimony as an oxytoxic 281 

Testicle, on a new method of treating inflafnmation of the . . . 259 
Teeyan, on tumours in voluntary muscles, with an analysis of 62 cases, 

and remarks on treatment 191 

Tetanus in which the nerve was divided with seemingly satisfactory 

results, case of traumatic 197 

Thompson, on thd successful treatment of severe stricture of the urethra 

by gradual distension, at a single sitting 247 

Thorax by an iron bar, case of recovery after transfixion of the , .241 
Throat dyssesthesia, with elinical remarks, case of . . . .145 

Tobacco, in its relations to the health of individuals and communities 11 

Toe curious re-union of an amputated » . .. .. ... 276