British and Foreign Medico-Chirurgical Review

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PRACTICAL MEDICINE AND SURGERY.

VOL. XLII.

JULY— OCTOBEE, 1868.

LONDON :
JOHN CHURCHILL AND SONS, NEW BURLINGTON STREET.

MDCCCLXVIII.

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PKINTKD B\
J. E. ADLABD, BABTU GLOME W CLOSE.

THE

BRITISH AND FOREIGN

MEDICO-CHIRURGICAL REVIEW.

JULY, 1868.

PABT EIRST.
^nalgtical antr Olritical i^ebietos.

Review I.

1. On the Use of the Sphygmograph in the Investigation of Dis-
ease. By Balthazar W. Foster, M.D., &c. London :
Churchill and Sons. 1866. Pp. 42.

2. On the Application of the Graphical Method to the Study of
Diseases of the Heart and Great Vessels. By Balthazar W.
Foster, M.D., &c. 'Medical Times and Gazette/ vol. ii,
1866; vol. i, 1867.

3. On the Application of Physical Methods to the Exploration
of the Movements of the Heart and Pulse in Disease. By T.
BuRDON Sanderson, M.D., and Francis E. Anstie, M.D.
' Lancet,' vol. ii, 1866, and vol. i, 1867.

4. Sphygmographic Observations on the Pulse of Typhus. By
Thomas Wrigley Grimshaw, A.B., M.B. *DubIi^ Quar-
terly Journal of Medical Science,' February, 1867.

5. Note on the Regulation of the Pressure on the Artery in the

Application of the Sphygmograph. By Balthazar W.
Foster, M.D. ' British and Foreign Medico-Chirurgical
Review,' July, 1867.

6. Lectures on the Prognosis and Treatment of Certain Acute

Diseases, with special reference to the indications afforded by
the graphic study of the Pulse, Delivered at the Royal
College of Physicians of Loudon. By Francis E. Anstie,
M.D., &c. ' Lancet,' vol. ii, 1867.

83— XLII. 1

2 Reviews. [July,

7. Handbook of the Sphygmograph : being a Guide to its Use in

Clinical Research. To ivhich is appended a Lecture delivered
at the Royal College of Physicians on the 29th March, 1867,
on the Mode and Duration of the Contraction of the Heart in
Health and Disease. By J. Burdon Sanderson, M.D., &c.
London : Hardwicke. 1867. Pp. 83.

8. On a Neiv Method of Increasing the Pressure on the Artery
in the Use of the Sphygmograph. By Balthazar W. Foster,
M.D., &c. ' The Journal of Anatomy and Physiology,^
November, 1867.

In glancing at the past history of medicine, the observer
cannot fail to be struck with the extremely slow advance made
during the earlier stages of its scientific growth. Science after
science, born later, has reached a comparative maturity more
quickly, and this, too, in spite of the fact that medicine has
ever had its special votaries. So slow has been the progress
that every now and then some impatient spirit asserts that
medicine can never attain a scientific form. A little careful
reflection leads to an explanation of this tardy evolution ;
for tbrough the whole range of human knowledge there runs
one invariable law of growth which determines the advance
from the more simple to the more complex. Hence we see
that those sciences which deal with the succession and relation
of the more simple phsenomena of nature, have been the first
to assume a scientific form ; for the method required to analyse
their less complicated problems has been more easily acquired.
The relatively high degree of perfection which astronomy has
attained, and the rapid growth of geology, notwithstanding the
late period at which its development began, seem almost dis-
couraging to the investigator of biological phenomena when
contrasted with the slow advance of his own study. A little
closer scrutiny, however, reminds us that the phaenomena with
which such sciences as astronomy and geology are occupied are
much less complicated with phenomena of a different kind
than those of biology.

Observation alone has sufiiced to penetrate into their more
simple secrets; hence such sciences have been well called
sciences of observation. On the contrary, when we come to
consider medicine in relation to the other sciences, we cannot
fail to mark the increased complexity of the questions with which
it has to deal, questions requiring for their solution not only a
knowledge of the laws which rule the phsenomena of healthy
life, but also those which regulate diseased action. Medicine
in its true sense is a triad of sciences, of which two parts —
physiology and pathology — are only partially developed, and the

1868.] Receni Works on ihe Sphygmoyrajih. 3

third — therapeutics— can only approach a scientific form, when
the two former are more matured. Yet the three component
parts exist together, each reacting upon the other, the more
complex often aiding the development of the more simple. But
in addition to the complexity of its pheenomena, a complexity
so great as to require all the other sciences to be impressed as
auxiliaries, we can find another explanation of slow progress in
the inefficiency of the method formerly applied. Medicine when
first cultivated could only be approached by the method of ob-
servation, which, while it achieved vast conquests in the region of
the simpler sciences, advanced but little the evolution of medicine.
Bernard has well shown that medicine could never arrive at any
high development as a science of observation, for such sciences
in their maturity lead simply to a knowledge of the invariable
laws which regulate the succession and relation of phaenomena,
but give no power of modifying this relation and succession at
will. Medicine entered on this stage of its growth long since,
and has given the physician a certain amount of prevision with
regard to disease, but little power of modifying its course. The
empiricists of old were ever struggling against this tendency of
medicine to become a mere science of observation, and in their
rude way were pointing out what a later age has taught us, that
only by employing experiment in addition to observation can
medicine attain its highest development. To the recognition
of the value of experiment in physiological research do we owe
the great discoveries of modern times, and in chemistry we see
the most brilliant results of the experimental method. Experi-
ment is, however, only an extension of observation, by means
of which the investigator repeatedly studies phsenomena under
known conditions,. in order that he may render his analysis of
their relation and succession more perfect. The observer studies
phsenomena which he cannot control in order to discover the
laws which they obey. The experimenter modifies at will the
conditions under which phaenomena exist, and thus gains a
deeper insight into their nature. In both cases it is of the
greatest importance to render more precise the investigator's
power of recognising the finer shades of resemblance and differ-
ence between phsenomena, for in proportion to this precision
will be the value of his results. Every means, then, which
renders our observation of phsenomena more exact gives an
impulse to science. So intimate is this relation between instru-
mental aid and progress, that the position of a science might
almost be inferred from the extent of its apparatus. How great
a part the telescope has played in the advance of astronomy,
how rapid has been the growth of our knowledge of the struc-
ture of the tissues since the invention of the microscope, must

4 Reviews. {j^^^y,

be familiarly known to every reader. More recently tlic inven-
tion of the spectroscope has given to chemistry a new vitality,
and directed the energy of observers into fresh channels. Indeed,
throughout the history of physics and chemistry the great land-
marks of progress correspond to the invention of new instrumental
contrivances to supplement the powers of the investigator.

Physiology bears witness also in almost every step of its
recent advance to the great utility of improved instrumental
aid. We may especially refer on this point to the recent work
of Marey, ' Du mouvement dans les fonctions de la vie/ which
tells us in every page how the accuracy of the experiments of
the physiologist has been increased by mechanical contrivances.
Medicine has not been ignorant of the benefits derived from
this striking feature of modern science, for its most brilliant
achievements have been made by the increased power of accu-
rate observation which the microscope has given to the patho-
logist, the stethoscope to the physician. The laryngoscope, the
endoscope, and the ophthalmoscope, have also added to our know-
ledge, and the last promises to quicken to a still greater degree
than it has hitherto done, our insight into the morbid conditions
of the deeper nervous structures. The thermometer has given
a precision to our estimate of the essential phsenomena of fever,
and thus increased the accuracy of our diagnosis and our cer-
tainty of prognosis. To enumerate all the mechanical means
which have advanced modern science would occupy too much of
our space ; we have already said enough to show how great has
been their influence for good in our own special branch of
study. Every fresh invention has given us, as it were, a new
sense wherewith to attack more successfully the great problems
which have hitherto defied our analysis.

The instrument which forms the subject of the present article
has in this way contributed largely to our knowledge of the phse-
nomena of the circulation. The finer features of arterial pulsa-
tion which escaped recognition by our mere sense of touch have
been elucidated by its aid. What appeared to our fingers as a
single or occasionally a double beat has been broken up into its
component parts, and these parts have been gradually recog-
nised in their true relation to other and antecedent phsenomena.
But, as we shall see^ this development of physiological know-
ledge has stimulated our observation of disease, and given
an accuracy to our power of distinguishing various forms of
pulse never before generally attained. Once or twice in a cen-
tury the tactus eruditus of a great master gave him a wonderful
power in discriminating the various peculiarities of pulse move-
ment, but the imperfection of the knowledge was shown by the
impossibility of communicating it. The sensation perceived

1868,] Recent fVorkfi on the Sphyrnnof/rctph. 5

was too vague to be conveyed to the mind of another, and thus
the exceptional knowledge was of little use to science. But
now the sphygmograph enables the student to refer his sensa-
tion of a pulse-beat to a visible representation of the pulse
movement, and thus promises to dispel that vagueness in the
description of the same pheenomena which is caused by the
varying delicacy of the sense of touch.

Students need no longer crowd round the bedside, anxious
but unable to perceive those finer features of the pulse to w^hicli
their teacher refers, for in future the tracing of the pulsation
will tell them, in unmistakeable language, the delicate shades of
movement which scarcely any finger can appreciate, and still
fewer physicians describe. That the invention of the sphygmo-
graph has already led to a much more exact knowledge of the
circulation, none will dispvite ; and, indeed, there can be little
doubt that it is also destined to render great services in the
hands of the physician. The few industrious investigators who
have applied it to purposes of clinical research in this country
have shown that it is capable of extended usefulness; and in the
following pages we propose to consider the results which their
publications placed at the head of this article contain. In so
doing we shall first present our readers with a brief exposition
of the recent advances of our knowledge of the healthy pulse
curve, and then, after alluding to the suggested modifications in
the form and application of the instrument, we shall proceed to
discuss its importance as an aid in the study of disease.

Marey, in his admirable work, ^Physiologic Medicale de la Cir-
culation du Sang,' did not notice some of the peculiarities of the
pulse curve, which have since been shown to be of high import-
ance, and consequently those who followed Marey's A'iews too
exclusively fell into the same error. Thus, in the earlier papers,
the pulse-curve recorded by the sphygmograph was described as
consisting of a line of ascension, a summit, and a line of descen-
sion, the last being broken normally by the occurrence of a
large undulation, which was called the dicrotism or second beat.
The forms of these several parts of the curve were stated to un-
dergo considerable modification in physiological conditions, and
still greater changes were referred to the existence of disease.
The line of descension, the most important part of the curve,
was soon noticed to vary very much in the number of its undula-
tions : and the occurrence of several of these, instead of the
single undulation or dicrotism, which obseiTers had been taught
to look for, suggested to some minds a doubt of the accuracy of
the record. The sphygmograph was accused of untruthfulness,
and the additional undulations were referred to acquired vibra-
tions of the writing lever, totally independent of the pulse move-

6 Revietvs. [Jwly>

ments. The defence of the sphygmograph was undertaken by
Wolff, who demonstrated that these undulations in the descend-
ing line of the curve were really normal features of the pulse
movement, and that under a more accurate mode of adjustment
the pulse could be always registered as distinctly tricrotous
instead of dicrotous, as Marey described it. The curve of the
normal radial pulse thus came to be recognised as possessing
features which the earlier observers had not figured. The de-
scending line of each pulsation was found to be marked by two
notches, each followed by an elevation. The first notch occur-
ring soon after the summit of the curve, was called by Wolff the
first incisure, and the elevation which follows, the first secondary
wave or undulation. The dicrotism of Marey was called the
great ascension, and the notch which precedes it and separates
it from the first secondary wave was designated the great in-
cisure. In the bottom of this great incisure another small
secondary wave, the second secondary wave, can be occasionally
seen. This more accurate recognition of the finer features of
each pulsation was first really arrived at by Wolff, and in this
country his results have been fully confirmed. In speaking of
the pulse-curve we shall, therefore, continue to use, for the most
part, terms similar to those applied to its difierent features by
Wolff, because such terms more conveniently adapt themselves
to the original language employed in Marey^s work. The next
important step was taken in reference to the significance of each
of these parts of the pulse trace. It was extremely interesting
to know that these various little movements occurred in the
radial pulse after each systole of the heart, but the value of the
knowledge would have been unimportant if no explanation of
the causation of these phenomena had been forthcoming. The
pulse-curve, as described by Marey, consisted roughly of two
elevations, the first of which was the greater, and corresponded
to the ventricular systole ; the second and smaller was termed
the dicrotism, or, by Wolf, the great secondary wave, and cor-
responded to the period of diastole. Whenever the break in
the line of descent of the curve which separated these two eleva-
tions could be distinguished the pulse-trace could be divided
into its systolic and diastolic portions. To refer the primary ele-
vation or ascending line of the pulse-curve to its cause seemed
easy ; it occurs immediately after the systole of the left ventricle,
and corresponds to that sensation perceived by the finger and
known as the pulse. Marey considered this part of the pulse-
curve to be due to the increase of tension in the arterial walls,
caused by the impletion of the artery produced by the passage
of a mass of blood driven onwards by each systole of the heart.
This view' was criticised by MM. Onimus and Viry, and after-

1868.] Recent Works on the Sphi/gmograph. 7

wards by Dr. Sanderson. These writers revived in part the
theory of Weber, which referred the pulse to a wave propagated
towards the periphery, and originating in the increased pressure
produced in the aorta, after each contraction of the heart. This
wave causes a gradual expansion of the artery, but we must bear
in mind Weber's expression, '^ Unda enim non est materia pro-
grediens, sed forma materiee progrediens." An experiment of
MM. Chauveau and Marey proves this wave to be independent of
the onward passage of the blood {vide ' Physiologic Medicale de
la Circulation du Sang,' pp. 199, 200). The following simple ex-
periment also supports the same view, and can be easily tested hy
any of our readers. The sphy gmograph having been applied to the
radial artery, or any other vessel to which it can be adjusted,
the artery is compressed below the point on which the tactile
spring of the instrument rests ; and although by this means the
onward flow of the blood is arrested, the pulse movements will
be still recorded by the writing lever. We may, therefore,
conclude that the systolic portion of the pulse-curve is not
directly caused by the onward flow of blood, but is produced by
a wave movement propagated along the arterial system. With
this wave movement there occur also vibrations in the blood-
column, of which we shall speak hereafter. The second eleva-
tion in the pulse-curve — the dicrotism or great ascension — has
given rise to much dispute concerning its mode of production.
Marey defined it as an oscillation in the blood-column in a direc-
tion alternately centripetal and centrifugal, originating in the
arteries of the periphery. Marey's critics, Onimus and Viry,
while supporting this view as to the direction of the dicrotic
wave, define it as a return wave, produced by the obstacles to
the passage of the blood through the capillaries. These obsta-
cles are of two kinds — " the spurs formed by the bifurcation of
the arterial trunks and the blood-globules contained in the
capillaries." The blood-globules entangled in the smallest
capillaries, form, these observers think, the chief obstacle to the
onward passage of the blood, and consequently the most in-
fluential factor in the production of the return wave or dicrotism.
This view has now been abandoned by many in favour of the
view originally propounded by Naumann, and recently ably ad-
vocated by Dr. Sanderson, which refers the phsenomenon to the
closure of the aortic valves, and which regards the dicrotic wave
as central in its origin and centrifugal in its direction. Dr.
Sanderson's investigation of the carotid-pulse-form strongly
supports the view that the notch preceding the dicrotism is due
to the reflux of blood which closes the aortic valves, and, con-
sequently, the succeeding elevation on the pulse-curve is referred
to the wave produced in the blood-column by the rebound of the

8 Reviews. [July,

blood in the aorta from the tensely closed valves. The notch
preceding the dicrotism, termed by AVolff the grosse incisur,
may be now more conveniently called the aortic notch^ as it is
synchronous with the reflux which closes the aortic valves. This
reflux begins after the contraction of the ventricle ceases.
In cases where the tension in the aorta is high the valves are
closed almost instantaneously, and the notch is not very distinct
in the radial pulse. On the other hand, when the aortic tension
is low, the valves close more slowly, the reflux towards the heart
lasts longer, and possibly a slight amount of regurgitation from
the aorta into the ventricle occurs ; the notch is consequently
very distinct in the radial pulse. The state of arterial tension
stands, therefore, in close relation Avith the occurrence of
dicrotism.

The small secondary waves to which we referred above as
occurring in the descending line of the pulse-curve, now alone
remain to be explained. They appear in the systolic portion of
the curve, and we have therefore to look to conditions connected
with the cardiac systole for their origin. When the ventricle
contracts the first step is the tightening of the mitral valve, the
next the elevation of the curtains of the aortic valves. The
blood resting on the aortic surface of these valves is thus thrown
by their elevation into a series of vibrations which are propa-
gated rapidly towards the periphery, especially when the arterial
tension is low, for then the aortic valves can open suddenly.
These vibrations produce corresponding movements in the
arterial walls, which appear in the systolic portion of the pulse
curve. The true wave of the pulse occupies, it must be remem-
bered, the whole of the curve up to the aortic notch : the vibra-
tions modify the form of this part of the curve. Thus, the summit
of the pulsation, especially when sharp-pointed, is due to a vibra-
tory movement, and the wave which follows, that is to say, the
first secondary wave is due to the distension of the artery follow-
ing the hearths systole. In conditions of higher tension the first
secondary wave, or wave of distension, becomes rounder and
more distinct, giving to the pulse the quality of fulness. In
states of still higher tension the pointed summit wave or vibra-
tory wave, is blended in the summit of the curve with the
wave of distension, or pressure wave, as it is sometimes called.
In a pulse-curve then exhibiting all the features we have de-
scribed, the summit- wave may be considered as due to a sudden
vibration in the blood column, synchronous, or almost so with
the elevation of the aortic valves : the first secondary wave as due
to the wave of distension, or pressure wave, following the passage
of blood from the heart into the aorta. The second secondary
wave, which is not often seen, is most probably vibratory ; and

1868.] Becent Works on the Sphygmograph, 9

the great ascension or dicrotism represents the rebound of the
blood from the closed aortic valves. The first notch represents
the sudden collapse of the artery following the brusque elevation
caused by the vibration in the blood column, and the second or
aortic notch corresponds to the centripetal reflux which precedes
the closure of the aortic valves^ and marks the termination of
the ventriculai" systole.

We may now consider briefly the modifications in the mode
of application of the sphygmograph of Marey which have
enabled later observers to record pulse-curves so much more
perfect than those originally published. The form of instru-
ment has remained substantially the same^ but a nicer adjust-
ment has led to improved results. Wolff", with that patient
spirit of investigation which has made German observers so
great, discovered, early in his inquiries, that variations in the
pressure exerted on the artery pi'oduced considerable change
in the form of the pulse curve. The English observers appear
to have soon discovered this fact independently, and to have
endeavoured to remedy this possible source of error. In the
instrument of Marey there is a screw by which the tactile
portion of the spring can be made to descend and press upon
the artery, and the use of this screw seemed to offfer a solution
of the difficulty. The screw, as it was first made, however, was
of very little use, for although it permitted the increase of
pressure, it gave no information as to the amount of pressure
exerted, and consequently no two observations on the same
pulse could be accurately compared. In an instrument likely
to be used much in investigations as to the efl'ects of remedies
on the circulation, a greater defect can scarcely be imagined,
for all such inquiries must demand as a primary condition, a
power of comparing with precision the states of arterial tension
at different times. To remedy this defect Dr. Foster first pro-
posed that the screw should be made self-recording by the
addition of an index, which pointed out on a circle described
round the screw, the increase of pressure. By this simple
arrangement observations could be compared with some approach
to accuracy.

The great objection to this plan consisted, however, in the
fact that when the screw was used to exert any considerable
pressure on the artery, the tension of the spring was at the
same time so much increased that it ceased to follow with
the necessary delicacy the finer movements of the pulse.
The next plan proposed was that wiiile the screw we have
referred to should only be used occasionally, the pressure
should be applied directly over the artery by placing little
weights on the head of the screw which brings the writing lever

10 Reviews. [July,

in contact with the movements of the tactile spring. Additional
weight can no doubt be thus applied in the best possible posi-
tion with regard to the artery, but, in order to render either
plan complete, it is necessary that the equivalent of the pressure
exerted by the simple application to the wrist should be also
known. This might be easily done, in our opinion, by fixing to the
upper surface of the spring a very fine upright ivory scale, which
would indicate the distance between the upper surface of the spring
and the brass framework of the instrument. The shorter this dis-
tance the greater pressure the spring would necessarily exercise
on the blood-vessel, and thus the distance marked on the ivory
scale would always indicate the pressure. This simple plan
would have the great excellence of making the instrument itself
record in CA^ery application the actual weight exerted upon the
artery. In Dr. Sanderson's ' Handbook,' we find still another
method described by which satisfactory results seem to have
been obtained. The pressure screw is used to fix the tactile
spring permanently, and the pressure is ascertained by measur-
ing the distance between the spring and the under surface of
the lever, whenever the instrument is applied to the arm. To
diminish the pressure the framework of the sphygmograph is
raised by slipping beneath the carpal end little blocks of brass
and the withdrawal of similar blocks has the opposite effect. A
pressure of at least 100 grammes is recommended as the most
expedient to work with. "Would not the ivory index of which
we have spoken render this plan also more simple ? We hold
that the accurate adaptation of the pressure of the spring to the
various conditions of the pulse is of the highest importance.
Attention to this point has already led to a much more complete
knowledge of the pulse form, and no observations of the highest
value can be made in either physiological, pathological, or the-
rapeutical inquiry, without an accurate method of estimating
the pressure exerted upon the artery examined. We have dwelt
at length upon this part of our subject because notwithstanding
the good results obtained by the accurate adjustment of Wolff
and others, French authors appear inclined to underestimate its
importance. For instance in M. Souligoux's little work just
published, ' Du Diagnostic Medical et Chirurgical par les
moyens Physiques,' we find no reference to this point ; and the
pulse tracings contained in the interesting researches of Dr.
Moreno y Maiz on the physiological action of Coca, and those
figured in the chapter on " The Circulation in Cholera" of Prof.
P. Lorain's valuable treatise, are much diminished in value by
the want of any record of the pressure.

Another practical point of importance consists in the re-
duction to a minimum of the friction between the receiving

1868.] Recent Works on the Sphygmogra2)h, 11

plate and the point of the pen. Spurious tracings may be
manufactured if this be not carefully attended to, and when the
record is marked by ink on glazed paper such worthless tracings
are not unfrequently obtained. To obviate this difficulty the
pen at the end of the lever should be made of very flexible metal;
it can then be easily adjusted. Most observers in this country
have now wisely gone back to the old plan of using smoked
glass instead of paper and ink. The great advantages of this
plan are, that the pen seldom if ever fails to leave its record,
that the friction can be reduced more effectually than by the
other methods ; and lastly, that the traces when fixed, as they
can easily be by photographer's varnish, are much more conve-
nient for reproduction by photography.

We may now turn to the results yielded by the application
of the sphygmograpli to the study of disease; and here we
must confess, in limine, that Marey and his earlier followers
were too sanguine in their expectations. We nevertheless feel
confident that we have had at present but a very insignificant
portion of the fruits which the use of the instrument in clinical
research is destined to bear. Dr. Sanderson has said — •

" The sphygmograph is not to be regarded, like the laryngoscope
or the ophthalmoscope, as an aid in the discovery and discrimination
of organic diseases, for affections the most diverse communicate to
the pulse the same graphical characters. Its use is to enable the
physician to investigate the state of the circulation and circulatory
organs in diseases of which the general nature is already recognised,
with reference to (1) the mode and duration of the contraction of
the heart ; (2) the soundness of the arteries ; and (3) the relative
quantity of blood contained in the arteries and veins, or, in other
words, the balance of pressure between the venous and arterial
systems."

The reaction against the undue expectations raised by Marey
has led Dr. Sanderson a little too far in the opposite direction.
As the quotation itself shows, he has limited the uses of the
instrument somewhat too narrowly, but even his estimate of its
value is sufficient to teach us how indispensable it is to accurate
clinical work. The observations which have been published in
this country have been directed chiefly to the study of the
modifications of the pulse in aneurisms and valvular diseases of
the heart. Drs.Grimshaw and Anstie have also studied, with inte-
resting results, the changes of the pulse tracing in acute disease.
It is in the diagnosis of aneurysms, however, that the sphyg-
mograph has hitherto aflbrded the most valuable information: in
some cases leading to the correct diagnosis of the seat of the
disease, and in others to the discovery of the lesion before unsus-
pected. No investigation of a case in which there is the slightest

12 Revietvs. [July,

ground for suspecting the existence of an aneurysm, can now be
considered complete unless a careful sphygmographic observa-
tion has been made. Marey points out^ that the modifications in
the pulse produced by aneurysm are chiefly directed to a change
in force of the pulse, and a change in the intensity of the dicro-
tism. A still more valuable sign, often the only one in aortic
aneurysms, is also mentioned — the want of a parallelism between
the tracings of the radial arteries of opposite sides of the body.
Marey relates some ingenious experiments which induced him
to refer the modifications in force to the transforming effects of
the elastic walls of the sac ; but he also adds, that in many cases
the walls lose much of this elasticity, and consequently exert
much less influence. In the first-mentioned little book on our
list, a very interesting case of subclavian aneurysm is recorded,
in which the variations in the pulse tracings taken below the
aneurysm at difi'erent times were very remarkable. In one
observation the left radial tracing Avas reduced to a series of
curves almost semicircular in form, while in a subsequent
record which the pulse gave, the form was much more deve-
loped. Such a change can, we think, scarcely be accounted for
by the supposition of an alteration in the elasticity of the sac,
but would much more likely be due to the influence of the clots
Avithin the aneurism in impeding the force of the blood current.
We believe that in the great majority of cases the chief changes
in the pulse form are referable to the modifying influence of the
clots ; to produce anything like the great modifications of form
observed in the case we have referred to, and in another very
similar case published by Dr. Brondgeest, and quoted by Marey,
it would have required an enormous aneurysmal sac with most
elastic walls ; the history of neither case tells of such
conditions.

The number of complete cases of aneurysm recorded are as
yet too few to warrant any very decided conclusions ; all of
them, hoAvever, point to the correctness of Marey's views on the
mode in which the form of the pulse curve is influenced. In
the ' Lancet,' vol. i, 1866, will be found a very remarkable case,
in Avhich a correct diagnosis of the situation of an intra-
thoracic aneurysm Avas formed from the study of the pulse
tracings. In this case the question of operation depended on
the decision arrived at. The pulse traces pointed by their
slight want of parallelism to the aorta as the seat of the disease,
and consequently the idea of operative interference was aban-
doned. Tlie event proved the perfect accuracy of the testimony
of the sphygmograph. A brief account of an aneurysm of the
descending thoracic aorta will be found in the ' British Medical
* ' Physiologie Medicale de la Circulation du Sang,' chap, xxii, xxxiii.

1868.] Recent Works on the Sphygmograph. 13

Journal/ vol. i, 1867. The nature of the case had not beeu sus-
pected^ as the physical signs did not point to the existence of
aneurysm; the pulse tracings of the right and left radial arteries,
however, differed considerably in form ; the right pulse not only
gave a more ample tracing, but also exhibited an unusual
development of the dicrotism. These features led to the
diagnosis of aneurysm which the autopsy afterwards confirmed.
The situation of the aneurysm, we may remark, just below the
origin of the left subclavian was little calculated to influence
the force of the blood entering the innominate artery and the
vessels of the right arm, but on the contrary the mouth of the
sac attracted the current intended for the left subclavian, and
thus rendered the left pulse so much smaller than the right. A
somewhat similar explanation has been offered by Dr. Foster^ to
account for the relative smallness of the right pulse tracing in
cases of dilatation of the ascending portion of the aorta. In
such cases the dilatation towards the right side tends to impede
the current entering the innominate artery, while the vessels of
the left side receive an unchecked wave. We are greatly in
need of more sphygmographic observations in cases of aneu-
rysm, and we were much disappointed at not finding any
information on this subject in Dr. Sandersou^s ' Handbook.'
The few cases we have been able to refer to, indicate how much
important knowledge has to be gathered in this direction, and
we trust so rich a field will not long want a greater number of
skilled observers.

The pulse-curve, in cases of aortic regurgitation, as might be
expected, is very noteworthy, and we call attention to the tracing
in this form of valvular disease more particularly, because it
was formerly considered to possess specific characters, sufficient
of themselves to justify the diagnosis of the lesion. More
extended observation has proved this view to be incorrect,
although we are sorry to say it still holds a place in some recent
French publications. The pointed summit which the curve
usually presents, and the vertical line of ascension, were consi-
dered by Marey as the distinctive characters of this affection.
Functional disorder is now known to produce similar appear-
ances. When the heart contracts quickly and violently, as it
often does in ansemic patients, a pulse curve simulating that of
aortic regurgitation, in its vertical ascension line and pointed
summit, is often recorded. The valvular incompetency in
aortic disease, however, is not without its effect on the pulse
tracing ; when the regurgitation is at all copious, the descend-
ing line of the curve presents a marked peculiarity in its sudden

1 ' Med. Times and Gazette,' vol. ii, 1866.

14 Reviews. [July,

fall. The collapse of the artery is so complete during the
diastolic period, that the dicrotism is often almost suppressed.
No centrifugal wave rebounds from the closing aortic valves to
distend the blood-vessels, for these valves by their incompetency
allow the blood to flow back into the ventricle. The suppression
of the dicrotism and the form of the aortic notch vary of course in
proportion to the incompetency of the valves, and within certain
limits the amount of the disease may be inferred from the
extent to which these features of the curve are modified. The
vibratory phenomena of the pulse are highly developed in these
cases ; but the other feature, which the low arterial tension nor-
mally developes, the dicrotism, is lessened by the valvular lesion.
In this particular, and in the fact that the vertical line of ascent
in this disease is composed of the two elements of vibration
and distension, and consequently is not to be diminished by
increased pressure on the vessel, we have possibly the means
of distinguishing the pulse of aortic regurgitation from that
which occasionally simulates it.

The irregular pulse which often, but not invariably, accompanies
mitral regurgitant disease, gives a striking sphygmographic record,
but one not generally useful for diagnostic purposes. The com-
pressibility of the pulse, and the change of form produced by vary-
ing the pressure on the artery, however, often yield valuable
information of the amount of regurgitation. The irregularity
of the pulse in this condition appears to be intimately connected
with the rhythm of the respiratory act ; it obeys in many cases,
as we have long known, a certain law in its irregularity. Prof.
Marey and Dr. Sanderson have referred this to the effect of
inspiration, but we have not yet had the evidence laid before us
on which this view is based.

Some of the most interesting observations of Marey were
made in connection with the pulse-form of old age. The healthy
elasticity of the arteries being diminished by the senile change
in the arterial coats, its transforming effect on the blood-move-
ment was lessened, and the pulse approached more nearly in
its form to the aortic movement. Marey's tracings were, how-
ever, in many respects imperfect, and were generally taken in
conditions of too advanced arterial change to be of much use to
the physician. When an artery feels like a bony tube under
the finger, no sphygmograph is required to tell us of its senile
state. It is in the earlier and more obscure stages of arterial
degeneration that it is important for the physician to obtain in-
formation.

At present we have no sufficient evidence to show that
atheroma limited to the great vessels produces any material
alteration in the pulse-form. To solve this question we want a

1868.J Recent Works on the Sphygmograph. 15

series of carefully observed cases in ■which the state of the great
and smaller arteries has been carefully investigated. In certain
morbid conditions, however, in which the primary change occurs
in the capillaries, such as that recently noticed by Dr. George
Johnson, the pulse-trace gives a striking evidence of the diffi-
culty the blood meets in its onward passage. The systolic part
of the curve is prolonged in its duration, and the first secondary
wave is very marked, being relatively much greater than the di-
crotism, hence the fulness of the pulse which the finger perceives.
The summit of the curve resembles, in its rounded or flattened
form, that occurring in old age, but, in the latter case, the di-
crotism is much less developed. Morbid conditions of the
capillaries inducing undue tension of the arterial system, seem
likely to yield sphygmographic evidence of their occurrence
long before they can be recognised by other means.

The pulse-trace of undue impletion of the arterial system
leads us by an easy transition to the consideration of the pulse
peculiarities in the opposite conditions. In the former case
the high arterial tension showed itself by the striking develop-
ment of the first secondary wave; in the latter this wave
gradually disappears, and the dicrotism is developed in a corre-
sponding degree. A very simple experiment will enable any
observer to study the changes in the pulse-curve, between these
opposite conditions. A whiff or two of nitrite of amyl will
produce all the different phases in rapid succession. As soon
as the physiological action of the drug is felt, the pulse-curve
begins to lose its first and second secondary waves, which are
soon swallowed up in the aortic notch, while the dicrotism is
proportionally increased. Soon the aortic notch dips below
the level of the curve-basis, and the dicrotism becomes blended
more and more with the ascending line of the next pulsation,
on account of the rapidity of the heart's action. It l^is re-
markable that similar changes occur in acute febrile diseases,
and Wolff has given a very striking diagram which has been
borrowed by Anstie to illustrate these phases of the pulse-
change.

This diagram shows how the increase of the aortic notch iu
the pulse of acute febrile diseases corresponds with the height
of the fever. In the healthy pulse-curve the tricrotous form
exists, but the febrile pulse ever tends to become dicrotous and
may become monocrotous. These changes are chiefly effected
by the deepening of the aortic notch, and the classification of
febrile pulses depends on this feature. When the notch has not
sunk down to the level of the curve-basis, and has not quite
swallowed up the first secondary wave, but has annihilated the
second and slightly retarded the dicrotism^ the pulse is said to

16 Reviews. [July*

be hypo-dicrotous. With this form of pulse the temperature of
the body seldom exceeds 100° Fahr.

When the notch sinks to the level of the curve basis, the first
secondary wave having almost disappeared, and the dicrotism
being still more retarded, the pulse is called dicrotous or per-
fectly dicrotous. In this condition the temperature is about
103° F., and the pulse-rate about 100 per minute. When the
aortic notch sinks below the level of the curve-basis, and the
dicrotism appears partly blended with the line of ascent of the
next pulsation, the pulse is called hyper-dicrotous, and the
temperature usually ranges above 104° F. The value of these
researches of Wolff can scarcely be overestimated, and the
lectures delivered by Dr. Anstie at the College of Physicians,
were of interest as confirming and popularising such important
information. Other signs occur in acute febrile diseases besides
the modifications of which we have spoken, and afibrd useful
indications on points of vital interest. On account of the low
state of arterial tension in these maladies, the heart while
acting well, gives a lofty and vertical line of ascent, terminating
in a sharp apex. On the other hand a short and non-vertical
ascension-line with a square or blunt summit indicates weak
and failing heart-action. The occurrence of irregularity in the
pulse-curve at the height of the pyrexia is another grave sign.
In its mildest form the irregularity betrays itself in a want of
exact similarity in the successive pulsations, which affects the
systolic portion more particularly and tells of a varying vigour of
ventricular systole. When, however, there is an undulatory
irregularity of the general line of the pulse-trace, we have a sign
of still graver import which informs us that the power of the
ventricle is momentarily changing. This form of irregularity
has no relation to the respiratory movements, and must not be
confounded with that undulation of the general line of the
tracing which is produced by the varying tension of the arterial
system caused by respiration. In the latter case the undulations
form a series of equal curves occurring at regular intervals,
characteristics not to be recognised in the former.

When the hyper-dicrotous pulse changes at an advanced stage
of the fever into the monocrotous or imperfectly monocrotous
form, both Wolff and Anstie concur in regarding it as an almost
certain indication of death.

Such are the chief points on which the sphygmograph informs
us in acute disease. Dr. Anstie has certainly not overestimated
its value in the following words which form part of the conclusion
to his first lecture : —

" Let me conclude this lecture by again enforcing the general
estimate of the prognostic value of the sphygmograph in acute

1868.] Satnt-Lager on Goitre and Cretinism. 17

disease, wWch I expressed at the commencement. Used in conjunc-
tion with the strictest and most diligent observance of other means
of clinical research, I believe that the instrument affords us an
additional test of the progress of acute disease, and the patient's
chances of safety, which is of very high value,"

The action of alcohol occupied Dr. Anstie's second lecture,
and some of the observations on its influence on the pulse
deserve much attention. Alcohol seems to modify the pulse-
form in accordance with its action as a stimulant or narcotic.
When given in the typhoid stages of acute diseases its effect is
to diminish the dicrotism, and to slow the pulse^ in other words
to increase the arterial tension. On the contrary when alcohol
acts as a narcotic it quickens the pulse and increases the
dicrotism. These observations of Dr. Anstie's, which we can
ourselves confirm, are very important, and point out what a
ready guide the sphygmograph may become in the treatment
of acute diseases. Hitherto we have been sadly in want of
some rule to help us in the administration of stimulants, and
some means of ascertaining their effects when administered. The
sphygmograph seems to promise this aid, and if it were proved
useless in the investigation of all those other problems concerning
Avhich it has already told us much, and has given us good reason
to expect still more, this one result of its use is surely sufficient to
earn for it our gratitude, and to induce all who seek to advance
medicine to apply it to the study of disease at the bedside.

Keview II.

Etudes sur les Causes du Cretinism et du Goitre endemique.
Par le Dr. J. Saint-Lager. Paris, Bailliere. 1867.

On the Causes of Cretinism and Endemic Goitre. By Dr. J.
Saint- Lager. Paris, Bailliere. 1867.

It is remarkable enough that the old saying, " obsta prin-
cipiis, sero medicina paratur," is more generally accepted now,
in spite of the marvellous and continued progress in the art of
healing, than at any previous time in the history of medicine.
Its truth is most strikingly illustrated by the case of acute spe-
cific diseases ; for, Avhile our increased knowledge of them has
led us to adopt heartily the principles of treatment laid down
by the English Hippocrates, we can no longer endorse his say-
ing, that God is the author of acute diseases, and we ourselves
of chronic ones; we are convinced that the former are the

83— XLii. 2

18 Reviews. ['^^^y>

well-merited and natural results of a general abuse and neglect
of the gifts of Providence ; and that, although care would pre-
vent the formation of animal poisons, we are powerless to do
much more than watch their effects upon individuals.

Again, a more careful study of the phenomena of local
diseases has shown us, that we very frequently cannot hope to
effect a substantial cure, and that our efforts should be directed
to averting those anatomical changes which, when once made,
we cannot alter.

For the purposes of preventive medicine, a thorough know-
ledge of the causes of disease is necessary, and hence the im-
portance now attached to the study of setiology even where no
immediately practical result is to be anticipated.

The work before us would commend itself to us by its sub-
ject, if it treated only of morbid causes, which from their nature
and complexity, were beyond human control ; but goitre and
cretinism are so very probably dependent on the quality of
Avater drunk in the districts where they prevail, that the dis-
covery of their origin would be a certain prelude to their sup-
pression. It is difficult to overestimate what humanity would
gain by such a result ; but, to give some idea of the extent of
the evil, we may mention that in France alone, at least 450,000
persons suffer from goitre, and about 30,000 from cretinism.
In our own country, though we are comparatively free from
this latter scourge, bronchocele is common in some of our most
favoured and otherwise healthy counties ; and both are endemic
in many parts of our Indian and American possessions.

We believe, therefore, that our readers will be interested in
learning the conclusions to which Dr. Saint-Lager has been led
by a very careful study of this important question. They are
novel, and it will be seen that, without somewhat extensive
observation and experiment, we should not be in a position to
do more than present an analysis of the book ; but we are bound
to say at once that its author is evidently a man of great indus-
try and care, whose statements, so far as we have verified them,
are accurate, and whose conclusions appear to be warranted by
the premises.

He begins by some general remarks, such as that goitre is
much more common in women than men,i Avhile, on the other
hand, there are more male than female cretins.

Some modern writers have supposed that these are two

^ The excess among women is very much greafcei' here than in France ;
evidently because the French statistics are compiled with a view to exemption
from military service, so that men would register more carefully than women ;
while in our dispensaries and hospitals, women present themselves more readily
thau men.

1868. 1 Saint-Lager on Goitre and Cretinism. 19

essentially different diseases, but our author points out that
exact observation will show that some amount of bronchocele
almost invariably accompanies cretinism (when it has been
overlooked, the tumour has developed laterally and pos-
teriorly, and is to be detected rather from its interfering with
respiration than from its external projection), and that, on the
other hand, many who have goitre are, if not cretins, at any
rate, weak-minded and eccentric. Cretinism would appear ^to
be the ultimate result of a poison which, in a less degree pro-
duces goitre ; thus, in the Alps and Pyrenees, on entering the
regions where these diseases abound, goitre is first met with,
and cretins are only found in any number near the centre of
the district.

Dental caries, albinism, stammering, and deafness, are un-
usually common in those suffering from goitre or cretinism,
and in the countries where these are endemic ; where the pro-
portion of deaf and dumb people is also greater than elsewhere.
These disorders seem, therefore, to be symptoms of what our
author calls the "cretinous diathesis,^' modified by circum-
stances of which we at present know nothing. The conditions,
whatever they may be, which produce goitre in man, affect the
lower animals in the same manner. Thus, dogs, cats, pigs,
sheep, horses, mules, oxen, have all been observed to have bron-
chocele ; the wool or hair at the same time becoming rough,
the voice hoarse, the hearing obtuse : the animal falls at last
into a state of torpor, and dogs have even been noticed in a
state of true cretinism.

Many authors (among others Mead, White, S. Cooper, in
England, and Bazin, in France) have supposed that goitre is
only an extreme form of scrofula. But the weight of authority
is against this opinion, Avhich is disproved by the diflerent
geographical distribution of the two diseases, bronchocele being
on the whole common, where scrofula is rare, and vice versa,
and by the different pathological characters of the two affec-
tions ; thus, goitre is by far most common between the ages of
twenty and thirty, is rare before puberty, is not hereditary,
has no connection with disease of bones, or of other glands, the
mind is dull or imbecile, instead of being precocious, and the
tumour does not suppurate, — in all of which points it differs
from scrofula.

Cretinism, again, has been looked upon by some Italian phy-
sicians as a result of pellagra; but nothing (according to the
Lombard commission and other authorities) can be more un-
founded, since there is even a sort of antagonism between the
two diseases, at any rate as to the places of their occurrence.

The cretinous diathesis attacks alike each of the chief races

20 Reviews. [July*

of mankind; it is not inherited, since healthy parents, who have
previously borne healthy children, on going to live where cre-
tinism is endemic, have often had other offspring who were
cretins. Nor has intermarriage any apparent influence ; for, in
Italy especially, the inhabitants of affected districts are in the
habit of marrying among their more fortunate neighbours;
while in many other villages not a single cretin is to be seen,
though all are connected by ties of marriage.

So much for the indirect evidence that goitre is an endemic
disease, due to local conditions. As direct evidence, we have
the testimony of Pliny, Vitruvius, and Juvenal, that it existed
in the Alps and in Lombardy in their day. In mediaeval times
the references to it become more numerous and precise, so as
to leave no doubt that it has always prevailed in many of the
places on the continent of Europe, where it is now observed.

What are the local conditions producing the cretinous
diathesis ?

De Saussure, Demrae, and GUggenbuhl believed it to be
unknown at a greater height than 1200 metres (nearly 4000
feet) above the sea-level. The fact is true as far as regards the
Swiss Valais; but that the connection is merely accidental is
proved by its existence at very much greater altitudes in the
Himalayas and Andes, and by its prevalence on one bank of
several rivers (as the Isere and the Aral), while the inhabitants
of the other bank enjoy perfect immunity.

The popular idea that mountainous gorges are the favorite
habitat of this disease is equally unfounded; witness the
plains of the St. Laurence, Danube, Ganges, and Po, and the
flat country of Piedmont, Alsace, the Palatinate, and Ceylon.
When it does occur in valleys, it is not confined to those which
take any particular direction, or which are open to any particular
wind.

Nor can climate and electric conditions have any effect on the
development of a diathesis which is observed alike in the oases
of the Sahara, in Ceylon, Java, and Brazil ; in the perpetual
spring of the " tierras templadas" of Mexico ; in the variable
temperature of the Himalayan valleys, and in Europe ; and in
the wintry climes of Canada, Finland, and Siberia.

A favorite opinion at the present day, and one supported by
the authority of Vingtrinier, Morel, Virchow, and Koeberle,
ascribes the production of cretinism and goitre to some aerial
miasm, either ordinary paludal malaria or some independent
poison. Now, on the whole, malarial fevers are most common
in low, marshy countries, and the cretinous diathesis in hilly
ones ; but they may coexist, so that there is evidently neither
connection nor antagonism between them. And if an aerial

1868.] Saint-Lager on Goitre and Cretimsm. 21

" cretinising^' miasm of any kind existed the disease could be
acquired by a few hours' sojourn in an affected district, and
ozone would be deficient, which is not the case.

The vapour of sulphurous acid has been said by some authors
to be a cause of goitre ; and it is true that the disease is observed
near the "solfataras" of Naples, Tivoli, Java, Sumatra, and
Mexico. We shall see the probable explanation of this fact
by and by ; at present it is enough to remark that we have no
account of goitre being ever caused by exposure to the fumes of
sulphurous acid when used in the arts ; it occurs, too, in many
places where the acid is not found.

Stagnation of air and absence of direct sunlight have been
set down as causes of cretinism by eminent authorities ; but it
is not found in many of the worst ventilated Swiss valleys, and
is common, on the other hand, in some of the healthiest
positions.

It is unnecessary to fatigue the reader with more than a
passing mention of the theories which have ascribed goitre to
drunkenness, or to the use of various kinds of food. The
Sardinian commission had more plausible reasons for sup-
posing poverty, and a generally defective hygiene, to be the
true cause, for it is certain that the proportion of those suffer-
ing from cretinism or goitre is much greater in the lower than
in the middle or upper classes, but the absence of the diseases
in the midst of the deep distress of our large towns, and their
frequent occurrence in persons of even the highest rank in
countries where it is endemic, prove that unfavorable hygienic
circumstances may indeed be set down as predisposing to the
cretinous diathesis in the same sense as they predispose to the
tuberculous or syphilitic, but that they are by no means the
proximate causes.

Putting, therefore, all these assigned causes apart, there is
abundant evidence to show that the real source of mischief is
some peculiarity in the water consumed. Many instances are
cited by our author, in which either individuals or whole vil-
lages or towns having obtained a fresh water supply, became
free from goitre and cretinism, which had previously affected
them : many families are mentioned who have preserved them-
selves in places where these diseases were decidedly endemic, by
drinking rain water, or water that had been boiled or filtered ;
nay, it seems to be matter of notoriety that there are in Savoy
springs, which will infallibly give goitre to all those -who drink
of them, and which are for this reason frequented by young men
who wish to escape the conscription. The few cases in which
goitre has been acquired, although only rain or filtered water
has been used, are probably to be explained by the presence of

23 Reviews. [July,

the common water of the district in bread and other articles of
food.

So much may be safely assumed as certain ; but the greatest
difficulty is to determine which of all the numerous substances
present in water is the one to blame.

There are many cases on record (McLelland gives, we believe,
one very remarkable one) where goitre and cretinism are com-
mon near the source of a stream, and rare a short distance be-
low. This has led some persons to doubt the influence of water
in causing these diseases ; but it is evident that a stream in its
course deposits sediment, and that the result is a sort of natural
filtering. At Saillon in the Valais, the villagers have uninten-
tionally performed an experimentum crucis ; for, on their taking
their water supply some hundred yards higher up the stream
than usual, goitre, previously unknown among them, made its
appearance.

The epidemics of goitre, which have occurred from time to
time, have almost always affected regiments which have been
freshly sent to garrison towns where goitre is endemic, and
therefore are readily accounted for on the assumption that the
water is at fault.

Coxe and Deluc, towards the end of the last century, first
suggested that carbonate of lime was the noxious ingredient in
water ; . and, more recently, M. Grange has supposed the salts
of magnesia to be in fault. Both of these opinions have acquired
a certain popularity, and it is true that the waters of many
goitrous districts do contain a large proportion of calcareous
and magnesian salts ; but the case of the city of Paris, where
the water is extremely hard, and contains sulphate of magnesia
enough to purge most new comers, but where goitre is almost
unknown, is alone sufficient to make us reject them.

McLelland, whose excellent work was fully noticed in the
number of this Review for January, 1861, is often said to have
maintained that the cretinous diathesis is due to the use of
water containing calcareous salts ; but this is not the case. He
confines himself to showing that it is much more frequent upon
limestone than upon any other soil, and supposes " some subtle
combination, derived perhaps from those strata of the rock
called by miners copper-slate, so distinguished from the quantity
of metals it contains," is the noxious principle.

Prevost of Geneva, after Coindet had discovered the curative
action of iodine in goitre, suggested that the disease might be
perhaps owing to the absence of that element from the water
used. This hypothesis received some confirmation from Inglis's
remark, that goitre did not occur in the town of Harrogate,
where the waters contain iodine, although endemic in the sur-

1868.] Saint-Lager on GoUre and Cretinism. 23

rounding country : it has, however, been shown that iodine
may be either present or absent in places where goitre prevails ;
— nay, that some of the Alpine springs most notorious for their
goitre-producing powers contain a very large proportion of
iodine.

The ancient opinion ascribing goitre to the use of snow or
ice- water is decidedly negatived by the absence of the disease in
Lapland, Greenland, and other arctic regions, where ice-water
is used all the winter ; and its occurrence in tropical climates,
such as Brazil, Java, and Sumatra. We are compelled to con-
clude from these instances that the epidemic of goitre which
occurred in Captain Cook^s voyage, in 1772, among the men
who had drunk water from the melted fragments of an iceberg
was due to some other cause. The ice "was melted in large iron
cauldrons : this will possibly supply an explanation, according
to the theory we shall presently develope.

Van Helmont and Cardan were the first propounders of an
opinion, which has since been held by such men as Lugol and
Koeberle, that the presence of some organic substance in the
water is the cause of the cretinous diathesis. The ordinary
products of decomposing animal and vegetable matter may be
at once set aside, as, on the whole, goitre is more common on
the banks of fresh mountain streams than of polluted rivers.
M. Saint Lager informs us also that in many analyses of waters
known to produce goitre, he has found the organic matter of
every kind to vary from the merest trace to a very large pro-
portion.

We may be assisted in coming to a conclusion as to the
nature of the offending substance, if we remember that filtering
the water used, or even allowing it to stand for some time
before using it, deprives it almost entirely of its noxious
qualities. This proves that the poison is evidently some solid
substance, either already existing in the water, or precipitated
on exposure to the air, which enables us to put out of the ques-
tion the soluble salts of lime and magnesia, and makes us look
upon a study of the geological character of the soils on which
goitre prevails as the only key to the mystery.

Dr. St. Lager proceeds, therefore, to a very careful examina-
tion of the geology of France, Switzerland, and Lombardy,
noting especially the places where goitre and cretinism occur.
His account of the rest of Europe, and of the other countries
■where these diseases are known to exist, is necessarily less minute,
but, as far as we have been able to test it by the case of Eng-
land, apparently correct, both in its geological and statistical
data. Of course we are unable to follow closely these tables,
which fill nearly 200 pages of the work, but we may state briefly

24 Reviews. [July>

the conclusion he arrives at, viz., that where goitre and cretinism
are endemic, the soil will always be found to contain iron
pyrites ; copper pyrites, galena, and baryta are also frequently
found.

To give a few examples : — In the miocene strata these diseases
are endemic on the molasse (containing pyrites and lignite) of
Switzerland, Baden, &c. ; they are unknown on the " nagelflue,^^
which is in Switzerland in some places superposed on the
molasse. They are endemic, in our own country in Surrey,
Sussex, Hants, Bucks, and Norfolk, on chalk containing silex
and pyrites, and on the greensand and gault, in which pyrites also
occur. The coal-measures of Durham, York, and Northumber-
land, do not contain pyrites, and the diseases do not prevail
there ; but they are endemic over the coal, containing pyrites, of
Derbyshire, Nottingham, Belgium, and Pennsylvania. The old
red sandstone in England does not coincide with the presence
of goitre ; but in Scotland, where the two are found together,
it is traversed by veins of serpentine, iron, and copper. Cre-
tinism and goitre occur only upon granite, gneiss, and por-
phyry, when those strata contain metallic veins ; and on vol-
canic soil they are only observed near the solfataras where
sulphurous vapours are in contact with ferruginous clays, as
in the Terra di Lavoro, in Java, Sumatra, and the Azores.
When they occur on alluvium, the soil has been brought down
from strata containing pyrites, as in the valleys of the Ehine
and the Po.

Many apparent exceptions to this rule of coincidence of the
cretinous diathesis with iron pyrites will be found ; they are due,
according to our author, either to the presence of a thick super-
ficial layer of alluvium containing pyrites, or to the water-
supply being derived from some distant source.

M. St. Lager has, of course, foreseen the objection that will,
no doubt, have occurred ere this to our readers, that preparations
of iron are constantly administered medicinally, without even
producing these diseases. He replies that medicines vary
according to all the elements of which they are composed (as
for example, the chloride of sodium and the sulphate of soda) ,
and that the bi-sulphide of iron is never employed in medicine.
We would hint, in addition, that it is, perhaps, conceivable that
in some of the cases of Graves's disease, the goitre may have
been produced by the excessive use of iron for long standing
anaemia ; at any rate Trousseau has taught us that iron, appa-
rently so plainly indicated, is injurious in this remarkable
malady.

The epidemic of goitre which occurred during Captain Cook^s
voyage in 1772, presents diificulties, whatever hypothesis we

1868.] Saint-Lager on Goitre and Cretinism. 25

may adopt : it is, however, probable tbat the water having been
heated in foul iron cauldrons, held in suspension a certain
amount of sulphide of iron.

M. St. Lager has performed some experiments on the lower
animals with the object of testing his theory. He has found
that mice acquire goitre very readily j out of a dozen of these
animals, whom he kept for three months, three only had en-
largement of the thyroid gland at the end of the time j these
three had had sulphide and sulphate of iron mixed with their
food, while the rest had had various other mineral substances
administered to them. He also experimented on two dogs, but
both of these came to an untimely end by devouring the
"appats^' which the French police employ to destroy stray
dogs; one, however, who had been taking small doses of the
sulphide of iron daily for four months, had a decided, though
slight hypertrophy of the thyroid gland.

He suggests that, in case any one should desire to repeat
these experiments, either dogs or pigs should be selected; as
the herbivora acquire goitre less frequently where it is endemic.
As we have already said, we are not in a position to offer any
serious critical remarks on a theory which has been so elaborately
constructed; we will merely mention in support of it — valeat
quantum — that in two parts of England where we have special
personal knowledge of goitre, viz., Sussex and Dorset, the
springs are in many places decidedly chalybeate. We would
also suggest that iodine may possibly cure goitre in the same
way as it relieves lead-poisoning, — by favouring the excretion
of the offending substance.

We have been most favorably impressed by the very unusual
amount of research exhibited by M. St. Lager. The only omis-
sion of matter bearing on his subject which we have noticed, is
that of ChevreuVs account of the mode in which the ^'eaux
sulfureuses accidentelles " are produced.^ Being evidently a
novice in the great art of book-making, our author has intro-
duced a number of learned digressions, which, in the hands of a
skilful manipulator, might be turned into as many separate
works ; an antiquary might read with profit his account of
" touching ^^ for goitre, an ethnologist learn much from his
history of the " cagots " of Western France ; and a geologist
derive much information as to the Alpine coal-measures.

Should his theory, however, be confirmed by further observa-
tion and experiment, he may fairly claim a much higher praise
than for mere learning; he will be reckoned among the greatest
benefactors of humanity.

^ By the decomposition of alkaline or earthy sulphates in their passage through
soil containing organic matter. (See Wurtz, ' Chimie Medicale/ i, p. 119.)

36 Reviews, [July,

Review III.

1. Etudes siir la Tuberculose. Par J. A. Villemin.
Observations on Tuberculosis. By J. A. Villemin. Paris.

18G8. Pp. 640.

2. Die Krankhaften GeschivUlste. Von Rudolph Vine how.
Einundzwanzigste Vorlesuxig. Band. II. Iltilfte II.

On Tumours. By Rudolph Vmciiow. Twenty-first Lecture.
Vol. II. Part II. Berlin. 1864. Pp. 555—749.

3. The Nature and Affinities of Tubercle ; being the Gulstonian
Lectures for the Year 1867. By Reginald Southey, M.D.
London, 1867. Pp. 118.

4. Sulla Struttura dei Tubercoli prodotti per Inoculazione. Nota

del Dottor Giidio Bizzozero.
Remarks on the Structure of Tubercle produced by Inoculation.
By Dr. Julius Bizzozero. Milan. 1867. Pp. 10.

5. Beitrdge zur Experimental-Pathologic. VonDr. Lebert und
Dr. Oscar Wyss.

Contributions to Experimental Pathology. By Dr. Lebert and
Dr. Oscar Wyss. Vircli., Archiv., 1867. Pp. 142— 170;
and 532—580.

6. Lecture o?i the Artificial Production of Tubercle, at the Royal

College of Physicians, By Wilson Fox, M.D.

The history of tuberculosis has been so recently and so fully
related in the pages of this Journal, that a renewal of the
subject might, for the present, well seem to be unnecessary and
superfluous : but the original observations by Virchow on the
anatomy of tubercle, and the close affinity that it has to other
kindred diseases ; above all, the remarkable views concerning its
causes and nature lately put forth by Villemin, and endorsed by
other trustworthy observers, furnish abundant and most impor-
tant material for another review.

That which will chiefly force itself upon the attention of any
one who will refer to the list of books here introduced to notice,
is the fact that the very groundwork of our pathology is rapidly
undergoing a complete transformation. It requires no pro-
phetic spirit to predict the extinction of those humoralistic doc-
trines of plastic exudation and crasis with which we were as
students imbued, so completely are they becoming supplanted
by the teachings of the new cell-pathology. We see a patholo-
gist of Lebert^s fame enunciating cellular doctrines as a matter
of course. Southey, an ardent admirer of Virchow, puts forth in
an agreeable English dress for English readers the teachings of the

1868.] Recent Works on Tubercle, 27

great Berlin master. Bizzozero's writing breathes of them from
the first to the last page of his pamphlet. But, most remark-
able of all, a Frenchman, Villemin, — and the French have been
notoriously the last and the least inclined to accept Prussian
authority — not only builds up the first part of his excellent
book on the strictest precepts of cellular pathology, but shows
by his writing that he has been led by a contemplation of
this new pathology to the discovery that he has made.

We purpose first to give a short account of tubercle, its birth,
life, and death ; secondly, to inquire into the marks of relation-
ship that it bears to other kindred diseases, as scrofula, glanders,
syphilis, typhoid fever, cancer ; thirdly, to discuss the influence
of supposed causes in its production ; fourthly, to make mention
of the lower animals in which it is naturally met with ; fifthly,
to enumerate the experiments that have been made to show its
capability of communication from man to the lower animals,
and from one animal to another, by means of inoculation ;
sixthly, to examine the arguments that have been drawn from
these experiments, and from other facts, in favour of its commu-
nical ility by contagion from man to man, and to endeavour to
show how far we are justified, in the present state of our know-
ledge, in accepting any such conclusions on this most en-
grossing subject, all-important as it is for the welfare of
mankind.

It may, perhaps, be well, before proceeding with our subject,
to say a few words against the tendency, which has long and
much prevailed, to regard diseases as strange entities, or to
confound disease itself — a complication of effects produced by
certain causes in the tissues of the body — with the causes of
disease. Thus fallaciously guided, the student of biology,
instead of being led step by step up a gradual ascent from the
study of physiological to that of pathological processes, is made
to spring over a wide gulf into a new and strange land. The
truth is, that we pass by a scarcely perceptible transition from
the phenomena of healthy nutrition to hypertrophy, inflam-
mation, tubercle, tumours, fevers, and other forms of perverted
nutrition or disease. A hypertrophy may be an excess of
healthy nutrition, or it may be what -we call disease; this
distinction being not one whit founded on intrinsic differences,
but being an arbitrary distinction of our own according to the
usefulness or harmfulness, as observed by us, of the changes
which take place. We see a blacksmith^s arm enlarge as he
works at his forge, and we see a thyroid or a cervical gland
enlarge from some cause which we cannot so clearly appreciate.
We examine the condition of the tissues in both, and we find in
both alike what we call hypertrophy or hyperplasia. The ele-

28 Reviews. [«^uly,

mental increase in both is identical, but we call the one "healthy-
action/' because we see why it occurs and what a useful purpose
it subserves ; while we denominate the other " disease/^ because
we cannot see its purpose in the economy, and therefore regard
it as hurtful. From hypertrophies to tumours is but another
mere step or shade of gradation. Between certain tumours, in
their early stage, and products of inflammation, no distinction
can be made : and we shall hereafter see how identical in their
structure are tubercles with products of inflammation on the
one hand and certain tumours on the other. Hence, from the
merest hypertrophy up to the most aberrant form of tumour,
disease is nothing more than an unusual activity or perversion
of the very changes which are ceaselessly going on in the nutri-
tion of the body, and which constitute what we understand by
the life of the individual.

Perhaps nowhere is the birth of tubercle better studied than
in the pia mater of a person who has died of acute tubercular
meningitis. A piece of this membrane, spread out and examined
under a moderately high power of the microscope, is found to be
the seat of an extraordinary cellular increase. The cells and
nuclei which mark this increase or proliferation are seen part
scattered profusely and at random through the membrane,
giving it the well-known milky appearance that it offers to the
naked eye, part clustered into little whitish or grayish knots or
particles — the individual tubercles. A close scrutiny of these
latter will show that they are especially abundant along the
smaller branches of the cerebral arteries, and seem here to take
their origin in the cells of the connective tissue which composes
the adventitia or outer coat of these blood-vessels. So markedly
is this the case that, although the tubercle cells must be allowed
to arise from the connective-tissue-cells of the membrane gene-
rally, yet the adventitia appears to be certainly the part most
actively concerned in their development. The tubercle-cells
generally are rather smaller than a white blood-cell, have faintly
granular contents, and are very brittle, so as very readily to
rupture and set free their shining nucleus. Towards the border
of the tubercle are seen cells larger than the above, often con-
taining many nuclei, and manifestly representing connective-
tissue-cells in a state of active hyperplasia or tubercular
development. In and among the cluster of cells which compose
the tubercle is a faint stroma, the original connective tissue,
together with, occasionally, blood-vessels, not newly formed, for
tubercle is non- vascular, but belonging to the tissue in which
the tubercle arises. Very much the same appearance is ob-
tained from fine sections of liver or kidney, and from serous
membranes affected with tubercle, the connective tissue in all

1868.] Recent Works on Tubercle. 29

cases serving as the matrix for development. In the lungs,
wherever connective tissue is to be found there may tubercles be
present : but whether tubercle may also be developed out of
the epithelium lining the alveoli and grow inside the air-cells,
is a point on which we find our authors at issue. Virchow denies
that the little deposits found inside the air-passages and air-
cells are tubercles. For him these are mere products of inflam-
mation or catarrh which choke up the small bronchi and, on
section, so closely resemble tubercle proper that they may be
called " spurious tubercle. '■' He professes himself able to
distinguish between these spurious tubercles and the true
tubercles of the connective tissue, a distinction which, if it
be real, mast require unusual skill and assurance to make.
Villemin, on the contrary, maintains that there are positive
intravesicular tubercles, which are no more the products of
catarrh than the extravesicular. Careful microscopical ob-
servation enables him to assert, that the fine wall which parti-
tions ofi" the air-sacs from one another is not a homogeneous
membrane, but encloses in its substance a cellular element pecu-
liar to itself. Under a high magnifying power a beautiful
network of capillaries is seen covering this wall, between the
meshes of which network he can detect a cellular element occu-
pying nearly the whole of each open space. There is, he asserts,
no epithelial lining to the alveoli, but the tubercles are formed
out of the above cells, and grow into the cavities of the air-sacs,
filling them up. Lebert, again, believes that pulmonary tuber-
cles or granules, as he calls them, take origin indiflPerently in
the cells of the connective tissue or in the epithelium of the
alveoli, being both intra- and extra- alveolar. If, he says, you
call the little particles outside the alveoli tubercles, you must
call those that are within likewise tubercles. They are all a
part of the same disease, a result of the self-same irritant.
Bizzozero likewise holds that the little intra- alveolar masses
which accompany tubercle are really tubercles and spring out of
the epithelium that lines the alveoli. In the case of the
lymphatic and ductless glands, Virchow, though he alludes on
more than one occasion to the closeness of the link which binds
the connective tissue with the lymphatic system, yet insists that
it is in the connective-tissue-framework of these glands, not in
the gland-cells, that the tubercles originate. But Villemin,
looking at the connective tissue and lymphatics as parts of one
great system, which he designates the '' lymphatico-connective
system,^' believes that tubercle may originate both in the cells and
in the connective tissue of the lymphatic and ductless glands.
Hence, in tubercular disease of these organs, the microscope
cannot of itself distinguish tubercle from simple hyperplasia.

30 Reviews. [July^

inasmuch as elements identical with those already existing in
health are simply reproduced in excess. It is, consequently, a
matter of extreme difficulty, nay, in some cases impossible, to
say -whether a given change in one of these glands is simple
hyperplasia or tubercle. This question, then, must remain for
the present an open one. That tubercle originates mainly in
the connective tissue is the expressed opinion of all these
modern authors. That it may also find a nidus of deve-
lopment in epithelium and gland-cells is probable, but not yet
clearly determined.

Tubercle has the shortest life of any pathological product ; it
is born but to die. Hence its power of growth is exceedingly
limited, and its hurtfulness, when solitary, but small. Herein,
however, consists its deadliness — that it is the expression of a
general disease ; that the same cause which produces it is cir-
culating through the body, and may produce thousands similar
to it wherever connective tissue is present ; and that it has, as
Virchow was the first to point out, manifestly malignant pro-
perties, spreading to the tissues in its neighbourhood and
infecting distant organs by dissemination of its germs or juices.
Thus, though there is a marked limit to the size of the indivi-
dual tubercle, there is no limit to the size of the masses that
are formed by agglomeration of tubercles, or to the number of
tubercles which may be scattered through the body. Do we
not see in these properties something that reminds us of the
outbreak of an eruptive fever, and something, too, that recalls
the behaviour of cancer ?

An early tendency to die is, then, the most characteristic and
distinguishing mark of tubercle. Fatty degeneration, beginning
first at the centre of the knot, gradually spreads to the circum-
ference, and gives it the well-known yellow colour from whence
the name of ''yellow tubercle ^^ is derived; till, little by little,
the whole particle softens and breaks doAvn into a " cheesy "
granular debris. We have, therefore, but to picture to ourselves
a large cluster of tubercles passing through this change in the
midst of some organ, as the lung or the kidney, in order to
understand what wholesale devastation may be thus wrought,
and how a cavity or " vomica " may be formed, in wliich are
contained the remains of the softened tubercles, and of the
broken-down tissue involved by the tubercles in destruction.
On the other hand, if the part diseased be a free surface (as a
mucous membrane), the disintegration and softening of the
tubercular mass will give rise to the formation of an idcer which
differs from the ordinary process of ulceration by the fact that
the base and sides of the ulcer are walled in by the remaining
tubercular matter.

ISGS."! Recent Works on Tubercle, 31

Foremost among the diseases which, either anatomically or
clinically, bear decided marks of relationship to tubercle, stands
scrofula. The word '' scrofula " seems to have been originally
employed to designate a chronic swelling of the cervical lymphatic
glands, in consequence of which the neck loses its contours and
comes to bear some resemblance to the neck of a ^"^scrofa^^ or pig.
It was then noticed that certain eruptions of the skin or affections
of the mucous membrane were accompanied by this same glan-
dular enlargement, and it was agreed to include them too under
the title of scrofula. After a while, it followed that every glan-
dular enlargement, no matter where situated, must be a mani-
festation of scrofula. Certain internal glands, as the bronchial
or mesenteric, Avere now observed to be often in a state of
hypertrophy and cheesy degeneration, Avhile, at the same time,
tubercles were present in the lungs or bowels. What more
natural than to look at the ganglionic lesion and the tubercular
products as the common effects of the same cause, scrofula ?
The thing seemed clear enough, especially when the French
school detected the same " specific cells " in the cheesy scrofula
of the glands as had been found in the cheesy tubercle of the
lungs and intestines. Thus the terms scrofulous and tubercular
came to be synonymous, and a scrofulo-tubercular diathesis was
a convenient refuge for the destitute in all doubtful cases.
Gradually, however, facts in contradiction of this view began to
accumulate, and to be noted down by independent observers.
Foremost among those who combated the identity of the two
diseases was our own Jenner, whose masterly exposition of the
subject, ('Med. Times and Gaz.,' March, 1860), is well known
to all. Virchow at the same time completed Jenner^s clinical
picture by upsetting the doctrine of specific tubercle-elements,
and showing that the cheesy metamorphosis is peculiar neither
to scrofula nor yet to tubercle, but is met with as a termination
of simple inflammation, of syphilitic tumours, of farcy-buds, and
sometimes of cancer. Both Virchow and Villemin look on
scrofula and tubercle as distinct things. In the opinion of both
pathologists, scrofula signifies a weak, '' impressionable," or
'Vulnerable" state of the body, in consequence of which, irri-
tants act upon the tissues with unusual severity and jjersistence.
From this point of view, a simple glandular swelling following
an ordinary irritant is not scrofulous ; but when a superficial
irritation of the skin or mucous membrane persists, and is fol-
lowed by swelling of the adjacent glands which likewise persists
even after the primary irritation has been removed, we have a
scrofulous person before us. Three great groups of glands may
thus be affected with a scrofulous or chronic change, — the cer-
vical, the bronchial, and the mesenteric. Villemin is of opinion

33 Reviews. [July,

that no anatomical distinction can be made between the scro-
fulous and tubercular gland ; that in both there is simple
hyperplasia with a retrograde tendency. He thinks that it is
in the exciting cause that the true distinction is to be sought ;
scrofula being a mere tendency to chronic glandular enlarge-
ment in consequence of slight external and local causes or
irritants, in a child whose lymphatic system is unusually im-
pressionable ; tubercle being, on the contrary, due to a specific
cause or virus which provokes a more general outbreak. That
which holds good for the glands holds good equally for the
bones, in which scrofulous disease is a mere chronic and very per-
sistent inflammation, while tubercular disease is a specific lesion.
Scrofula is, further, a disease almost peculiar to childhood; it is,
therefore, intimately connected with the development of the
body, and manifests its presence at a time when the lym-
phatico-connective system is in the zenith of its functional
activity. Tubercle, on the contrary, prevails between twenty
and thirty, at an age when scrofula has ceased to disturb the
body. Scrofula is not hereditary as a disease ; but the exag-
gerated lymphatic vulnerability which favours its attack is
strongly hereditary. Virchow goes still further, and finds a
positive anatomical difference between the scrofulous and tuber-
cular lesion in the diseased gland as well as in the lung. In the
gland, scrofula is for him a simple chronic hypertrophy of the
glandular tissue generally, with a tendency to '' nekrobiosis" or
degeneration ; tubercle is a true neoplasm forming in the con-
nective tissue only of the gland and not involving, save by
extension, the proper glandular structure. In the lung, tubercle
is in the connective tissue alone ; scrofula, or " scrofulous pneu-
monia," is a chronic inflammation of the bronchi and air-cells,
which become stuffed up with their accumulated contents in a
state of cheesy degeneration, and form cheesy deposits of larger
or smaller size according to the extent of the inflammation.
No one who has had much to do with children's diseases can
hesitate to accept the accuracy of this distinction. These cheesy
patches in the lungs, accompanied by cheesy degeneration of the
bronchial glands, without a trace of anything like a tubercle in
any part of the body, are, from time to time, met with. We
cannot avoid, therefore, accepting a scrofulous pneumonia in
youth as distinct from tubercular disease.^ At the same time

1 A very striking example of this scrofulous pneumonia has lately occurred to
the writer in the case of a boy, aged 12, who, after having been some months
under observation, died and disclosed the following appearances. The right lung
was converted, from apex to base, into a solid compact yellow substance, which, in
all the lower part, cut firm like new cheese, but towards the apex was softer and
more putty-like, breaking down readily under the finger. All round the root of
the lung, the large blood-vessels, and the trachea, were masses of enlarged glands.

1868, J Recent Works on Tubercle. 33

we agree with Villemin that Virchow and his followers ride their
liobby a little too hard in the case of the cheesy infiltrations
which accompany real tubercular disease in adults. These, the
Germans assert, are not softened tubercular masses, but are
mere patches of chronic inflammation that accompany the tuber-
cles, and have passed through the same cheesy metamorphosis
that tubercle itself undergoes. It is in vain that you put before
them their own assertion that degenerate products of inflamma-
tion and degenerate tubercle are exactly similar in appearance,
and that these patches are, therefore, at least as likely to be
tubercles as inflammatory products, or that you point to the
tubercles grouping themselves around these patches, as if ready
to form fresh ones. You are told that what you see are not
tubercles, but sections of small bronchi filled with catarrhal
accumulations. Lebert simplifies this matter most agreeably
by assuming that there is no such thing at all as tubercle, but
that all these deposits, intra- and extra- alveolar, miliary and
diff\ise, grey and cheesy, are nothing but inflammatory products.
We shall return to this difficulty under the head of inoculation.
It is thus seen that tubercle and scrofula, though they have,
anatomically considered, certain marked affinities with one
another, are yet essentially distinct diseases.

It is in glanders that Villemin thinks he has found the closest
marks of analogy with tubercle, not only in its anatomy, but
also in its symptoms and causation. He seems to have been
conducted from the study of glanders direct to the inoculation of
tubercle. The characteristic lesion of glanders is a small tubercle
which is strewn either in the mucous membrane of the nasal
passages, or in the lungs, or, more rarely, in the liver and spleen.
At first a greyish-white firm granulation, composed of cells and
nuclei apparently dcA^loped by hyperplasia of connective tissue,
it soon tends to soften centrally and form ulcers on the mucous
membrane, cavities in the lungs. Like miliaiy tubercle, it occurs
isolated or in clusters. Together Avith this little granulation,
streaks and bands of fibrous tissue, as well as patches of cheesy
infiltration, are not infrequently met with in the lungs of glan-
dered horses. It is interesting, too, that the same doubts have
been raised concerning the real nature of these '^ infiltrations "

yellow in cJolour, some of them firm like the firmer parts of the lung, others soft
like rotten cheese. In the left lung were several patches of the size of a hazel
nut, exactly similar in appearance to the firmer part of the right lung; but the
rest of the lung was healthy, without a trace of tubercle. The mesenteric
glands were in the same state as the bronchial and cervical. The ileum contained
a considerable number of ragged ulcers, one of which had perforated and been
the immediate cause of death. Neither in the neighbourhood of the ulcers nor
in the peritoneum was there a single tubercle. Here was a genuine instance of
uncomplicated scrofula, and it seems impossible to deny the existence of scrofula
as distinct from tubercle when one encounters such cases as this.

83— XLii. 3

81 Reviews. I July,

ill glanders as in tubercle. They are regarded by Villemin as
one form of glanders, just as in man they are one form of
tubercle. As to which is the part primarily affected in glanders —
the nasal membrane or the lungs, there is some difference of
opinion j Virchow maintaining that the deposits in the lungs
are always secondary and by metastasis from the nasal mem-
brane ; Phillippe and Bouley being convinced by repeated post-
mortem examinations that the primary lesions are always in the
viscera, more particularly the lungs, and that the formations in
the nasal membrane are invariably secondary. If, say they, a
horse has the "jetage'" (discharge from the nose), he is already
thoroughly glandered. It really matters very little which part
of the body is first affected. In either case the analogy with a
tubercular outbreak remains as strong as can be. The intes-
tinal ulceration of tuberculosis — in which we see the counterpart
of the nasal ulceration in glanders — is more often secondary to
the pulmonary disease, but occasionally shows itself before any
evidence of mischief can be detected in the lungs. Again, glan-
dular enlargement of a severe and persistent kind, constitutes
an important part of glanders as it does of tubercle. The mode
of invasion is likewise identical in the two diseases ; now acute,
foudroyant, destroying life in a few days as by an overwhelming
blood-poison, now chronic so as to last for years. Further, in
the chronic form, the same recurrence of acute attacks com-
plicating and adding to the chronic mischief is observed in
glanders as in tuberculosis. To read a description of chronic
glanders is, mutatis mutandis, to read an account of chronic
phthisis. It is, therefore, not surprising that Dupuy goes so
far as to say that glanders is a tubercular disease in the horse.
In speaking of the supposed causes of tubercle, we propose
presently to follow out still further this remarkable thread of
resemblance; but for the present it will suffice to say that
glanders is transmissible by inoculation, and contagious from
horse to horse, and that it is also unmistakeably communicable
from horse to man. Can we hesitate to believe, says Villemin,
that the parallel between tubercle and glanders must here find
its completion ? To conclude, glanders and tubercle are so
closely akin that they must be looked upon as nearly related
species of the same genus.

Syphilitic formations have in certain organs, more particularly
the brain, so close a resemblance to tubercle that the one may
well be mistaken for the other. AVe see in both, the same little
cells and nuclei forming apparently by proliferation of the connec-
tive tissue and heaped together in an inter-cellular substance ; in
both, too, a tendency to fatty degeneration, though less prominent
in the syphilitic gummy tumour than in the tubercular deposit.

1868.]

Recent Works on Tubercle, 86

Syphilis must therefore take its place with glanders and tubercle
as one of a family.

Who is there that has watched a case of acute tuberculosis
from its outset^ but must have been impressed with the remark-
able similarity that it bears to the eruptive fevers^ and, more
especially, hjpho'id fever . It is, indeed, doubtful whether in the
first few days of the attack it be possible to make a diagnosis in
such a case. It is only as the disease makes progress that
special symptoms declare themselves, which enable a careful
physician to recognise the presence of this most deadly of
diseases. The question as to how far tubercle and typhoid
fever are antagonistic is disputed. Villemin is strongly in favour
of such an antagonism. He maintains that those who speak of
fever as a frequent precursor of tubercle have been led into error
by the great likeness of acute tuberculosis in its early stage to
typhoid fever. What they have witnessed has been tuberculosis
throughout, and not fever followed by tuberculosis. Murchison's
authority is as strongly against any such antagonism. He
says : — " Whether it be true or not that persons labouring
under phthisis are rarely attacked Avith pythogenic fever, an
attack of pythogenic fever is often followed by tubercular deposit
in the lungs.'^ But this is certain, that the post-mortem
appearances in the liver, spleen, kidneys, and intestines of
persons who have died of acute tuberculosis have sometimes a
most striking resemblance to the appearances in the same organs
after death from fever.^

From cancer in its early stages tubercle in its early stages is
structurally indistinguishable. Both take origin from the con-
nective-tissue-cells, and tubercle has been already shown to have
malignant properties which assimilate it to cancer. There are,
likewise, cases of acute general cancerous eruption which have
some points of resemblance to acute tuberculosis. Cancer, how-

1 The writei" of this review examined, a few weeks ago, the body of a young
woman, aged 23, who died of tubercular meningitis, after an illness of three
weeks. In the pia mater were the usual appearances met with in this disease,
but the condition of the spleen, liver, and kidneys was quite noteworthy. The
spleen was swollen, soft, and rotten, breaking down under the finger exactly like
the spleen of typhus. The liver was large and swollen as in cases of blood
poisoning. The kidneys were very large, congested, and swollen ; the capsule
stripping off more readily than natural ; the tubules stuffed with cells. In none
of these organs was there any tubercle present. An interesting feature in the
disease was this, that, at the end of the second week of the disease, the urine
having been from the commencement daily examined and no albumen having been
hitherto detected, albumen began to appear in considerable quantity, and was
detected daily in increasing quantity till the end of the third week, when death
ensued. The time of the first occurrence and the amount of the albuminuria, as
also the post-mortem appearance of the kidneys, were just what might have been
looked for in scarlatina. It seems hard to deny that acute tuberculosis, like acute
glanders, finds its natural place in classification among the zymotic diseases.

36 Reviews. [July,

ever, lias an innate vigour and power of growtli which sufficiently
characterise it as contrasted with the sorry degraded tubercle
and its kindred.

In criticising the influence of supposed causes in the jjroduction
of tubercle, Villemin, convinced as he is of the specific contagious
character of tubercle, uses all his energies to upset the current
doctrines. He first endeavours to show that tubercular disease
is not hereditary as a disease, but only as an '' aptitude for dis-
ease." A child born of parents, both of whom have died of
tubercular disease, inherits a very strong tendency to be affected
by the tubercular virus, whenever he is brought in contact with
it. On the other hand, there are people who will never catch
tubercle, just as there are people who will never catch smallpox
even when exposed to'the action of a concentrated poison. Now
this seems to strike at the foundation of the whole system of
modern life assurance, which is mainly based upon the acknow-
ledged hereditary transmission of the so-called tubercular dia-
thesis. But not so in reality ; for, this aptitude for contagion
being strongly inherited, and man being a gregarious animal,
and tubercle literally infesting mankind wherever they congre-
gate, so his may be considered the best ^Hife^' whose power of
withstanding tubercular disease is greatest. There is, therefore,
no such thing as a " phthisical temperament" in the ordinary
acceptation of the term, and there is no such thing as a con-
formation of thorax which predisposes to tubercle; the only-
peculiarities of thoracic conformation connected in any way
with tubercle are those which follow as the effects of tubercular
disease. Villemin certainly seems here to have overshot his
mark, and to be trying to prove too much. For, supposing
tubercle to be a zymotic or contagious disease, and supposing it
to be thus capable of influencing the offspring through the
parents, it seems reasonable to believe that the influence thus
propagated would rather tend to prevent the child from catching
the same disease during its lifetime than to produce any apti-
tude for taking the disease. It is difficult to see why he has
gone out of his way to argue in favour of any such extraordinary
and improbable hypothesis. He need only have looked to
syphilis to find a parallel disease which is contagious, but is,
nevertheless, communicable as a disease to the offspring. The
inherited tubercular type, as sketched by Jenner, is as surely
seen and recognised as is the inherited syphilitic type portrayed
by Hutchinson. It would be just as ridiculous to say that a
child can inherit from its parents an aptitude to catch
syphilis, because they have both had the disease, as to
affim that an aptitude to catch tubercle can be inherited
by the offspring of tubercular parents. Much more pro-

18o8.J Recent Works on Tubercle. 37

bable and convincing are some of the following remarks.
And firsts as regards the influence of trades and professions
on tubercle, tliere is not, he thinks, any satisfactory proof
to show that it is in the exercise of his trade, or in the
substances which he handles that the artisan finds the cause
of his phthisis. Cold is equally powerless to excite tubercle.
The soldier, exposed to all the inclemencies of a campaign,
sees phthisis disappear from the ranks, while in the com-
fort and warmth of garrison life he finds his comrades deci-
mated by it. Both Villemin and W. Budd, {' Lancet,' 1867,
p. 452), have hit upon precisely the same arguments in
dealing with the topography and geographical distribution of
tubercle. Tubercle, like the zymotic diseases, loves low-lying
places, and is not met with at certain altitudes : rare at the
poles, it increases in intensity towards the tropics, where
it becomes exceedingly '' malignant.''^ It finds its habitat in
crowded places, and is intense in direct proportion to the con-
centration of the population. This is singularly exemplified in
the case of prisons, barracks, manufactories, and convents.
Baly, in his observations on the prevalence of phthisis in Mill-
bank, draws a comparison between the mortality there noticed
and that in London generally, and shows that phthisis is three
times more prevalent in the prison than in the metropolis, the
large majority of the prisoners having contracted the disease
after their admission. Pietra Santa arrives at the same con-
clusions in the prisons of France and Algeria. Still more
striking is the evidence afforded by barracks. Here we have
picked men coming from the country, well cared for, well clad,
well fed, in time of peace certainly not over- worked. But yet
the mortality among soldiers is decidedly greater than among
the rest of the population. On the other hand phthisis spares
those who live a nomad life, and visits with less severity soldiers
on the march. The very slight mortality from phthisis among
the French soldiers in the Crimean War is commented on by
Tholozan. Interesting it is too that, as with phthisis in the
trooper, so with glanders in the horse, barrack life is alike un-
favorable to both. The barrack is to the soldier in the produc-
tion of phthisis what the stable is to his horse in the production
of glanders. Lastly, the fact that tubercle was unknown in
certain parts of the world, as the South-Sea Islands and Ame-
rica (Rush), before the contactof the aborigines with Europeans,
and that, as Budd points out, tubercle is common along the
African sea-board, wherever there has been contact with whites,
while it is unknown in the interior where the white man has
not penetrated, is a strong argument in favour of the contagious
nature of tubercle and its propagation by some virus or germ.

38 Reviews. [July,

Tubercle is only met with in a limited number of zoological
species, and in this respect has a decided claim to be regarded
as a specific disease. ThuSj glanders is a disease peculiar to
solipeds and man. Cholera^ measles^ and scarlatina are the
appanage of mankind. Were tubercle, as some assert, a mere
form of inflammation in which the products are characterised
by a tendency to degeneration, it is difficult to say why it
should be thus restricted to certain species, and why all animals
alike should not be subject to its evil influences. The greatest
care is necessary in distinguishing genuine from spurious
tubercular disease in the lower animals. Thus, in certain
animals, as the sheep, it is not uncommon to meet with a dis-
ease termed ^'verminous phthisis,^' in which symptoms very
like those of tubercular disease — cough, dyspnoea, wasting — are
present, and in which the post-mortem appearances very closely
resemble those in real phthisis. Masses, having the closest pos-
sible similitude to tubercle, and, like tubercle, subject to cheesy
or calcareous degeneitvtion, are found scattered through the
various organs of the body, more particularly the lungs and
the liver. A careful microscopical examination will, however,
in all cases, reveal the presence of a parasite occupying the
centre of the mass, and is therefore indispensable in all exami-
nations of animals that are supposed to be tubercular. Innu-
merable mistakes have been made in consequence of this
omission, and many an animal has been condemned as tubercu-
lar which was really infested with parasites. Real tubercular
disease is met with in the apes, in cows, in rabbits, and a few
other of the rodents.

Pathologists had forgotten or neglected the experiments of
Erdt,who, thirty years ago, strewed the lungs of horses with tuber-
cular nodules by inoculating them with a so-called scrofulous
matter from men, when Villemin, in 1865, astonished the world by
the publication of his ewperiments showing the inoculability of
tubercle from man to the lower animals and from one animal to
another. His experiments consisted in the introduction of por-
tions of gray or miliary and agglomerated tubercle, and of that
which is called the cheesy infiltration, but which, in his opinion,
is as strictly tubercular as the rest, beneath the skin of rabbits
and guinea-pigs, by means of which he obtained, with scarcely
a single failure, the following results : — For two or three days
after the operation nothing appeared ; but, at the expiration of
that time, the part operated on became red ; and on the fifth or
sixth day a little nodule was felt under the skin, recalling the pri-
mary induration of syphilis. This nodule slowly increased in
size, and at last, softening centrally, discharged through a hole
in the skin a cheesy substance. In some of the experiments,

1868.] Recent Works on Tubercle. 39

tliosc^ namely, where the inoculation -was from man to rabbit,
the animal did not suffer much in health, but kept its flesh and
was at last killed ; but in others, those more particularly where
the inoculation was from cow to rabbit or from rabbit to rabbit,
the animal began, somewhere between the tenth and fifteenth
day, to suffer in health, refusing food and slowly wasting till it
died, generally before the completion of the third month. There
was now found at the seat of inoculation a sore, sometimes
covered with a crust, and having a hard base, in, and for some
little distance around, which, were distributed numibers of small,
miliary, yellowish granulations, single or agminated, in a
thickened, sometimes lardaceous connective tissue. The adja-
cent lymphatic glands were generally swollen and filled with
scattered nodules and granulations, sometimes undergoing the
regular cheesy transformation, and often connected with the
centre of inoculation by hard and knotted cords of lymphatics,
whose walls were infiltrated with tubercles, and which recalled the
lymphatic cords of glanders. The lungs and other viscera were
strcAvn with tubercles for the most part miliary, but often agglome-
rated, and occasionally cheesy. He next inoculated a rabbit with
tubercular matter from a cow, and produced a still more rapid
and general tuberculosis. Again, he inoculated from rabbit to
rabbit,^taking the matter from the one animal before its heart had
ceased to beat, and obtained now a more intense and widespread
disease than in any previous experiment. Very interesting
also is his statement that the cheesy matter which forms at the
seat of inoculation is itself virulent, and produces tuberculosis
when inoculated. In like manner, the sputa of phthisical patients
and the blood of tubercular rabbits produced, without fail, tu-
berculosis in rabbits. He draws special attention to the fact
that the cheesy pneumonia which accompanies tubercle is just
as inoculable as the gray miliary tubercle, perhaps more so, and
points to this as strong evidence in favour of all these substances
being alike tubercular in their nature. On the other hand, he
failed altogether in the inoculation of cancer, of ordinary hepa-
tised lung in pneumonia, and of pus in its difierent forms.
Least satisfactory of all were his experiments with genuine scro-
fulous matter — i.e., cheesy substance taken from cervical glands
in cases where there was some chronic eruption of the skin of
the head or face. There is but one trustworthy experiment of
this kind recorded, in which the inoculation proved fruit-
less. These startling results, which we have thought right
to detail somewhat at length, were then tested by Simon
in this country, who {' Lancet,' 1867, p. 367), corroborated
Yillemin's discovery in all respects, remarking that both the
yellow and the gray tubercle are inoculable from man to

40 Revleus. [J"ly^

tlie rabbit, and from rabbit to rabbit, with more intense and
general results in tbe latter than the former case. The results
of his experiments Avere even more conclusive than Yillemin's,
in that he inoculated the smallest possible quantity of tubercular
matter, '' not more than is employed in vaccination/' He con-
cluded that, '^ whether called tubercle or not, the action must be
allowed to be specific." A commission of inquiry appointed by
the Pathological Society to report on Simon's specimens,
'' thought the tuberculous nature of the specimens was beyond
reasonable doubt." In like manner, a French commission
(^ Lancet,' 1867, p. 135) gave Villemin credit for revealing " a
fact of the highest interest, the transmission of phthisis by the
inoculation of tuberculous matter." Bizzozero's evidence has
likewise confirmed Villemin's discovery. After alluding to the
little metastic abscesses produced in the lungs of animals by the
subcutaneous injection of decomposing fluids, and pointing to the
difference which exists between them and tubercles in the eyes
of an experienced pathologist, he states that he set himself care-
fully to ascertain by experiment and microscopical observation —
1, whether the neoplasms produced in the lungs by inoculation
of tubercular matter are themselves really tubercular ; 2, how,
supposing them to be tubercular, they originate. 1. He, as well
as Biffi of Milan and Mantegazza of Pavia have satisfied them-
selves that the deposits in the viscera of rabbits inoculated with
human tubercle are really tubercles. 2. He next watched the
tubercles in different stages of their formation, and after very
numerous investigations, concludes positively that the tubercles
in inoculated rabbits are formed by proliferation both of the
connective tissue and epithelial elements. The abundant nuclei,
partly free, partly surrounded with a scanty protoplasma (the
tubercle cells), may be seen in process of development in four
different parts of the lung — the subpleural and interstitial con-
nective tissue, the adventitia of the blood-vessels, the peribron-
chial tissue, and the walls of the alveoli. In addition to this, in
a lung where tubercle is rapidly developing, the epithelial cells
of the alveoli may be also seen in a state of active hyperplastic
cliange; but, after a time, the elements become so crowded and
compressed at the centre, that it is no longer possible to mark
the limit which separates the small cells of proliferating connec-
tive tissue from the larger cells of proliferating epithelium : the
two seem to coalesce. Next, Herard (' Arch. Gen. de Med.'
July, 1867), seeking to verify Villemin's experiments, took
seven rabbits and inoculated five only of the seven. Three of
these five were inoculated with tubercular granulations, either
gray and semitransparent or yellowish, taken from the pleura
and peritoneum of a phthisical patient. The two others were

1868.] lieccrd Works on Tubercle. 41

inoculated with clieesy matter from what is called catarrhal
pneumonia as contradistinguished from tubercle. At the end ot
two months, all the seven rabbits were killed. The two which
had not been inoculated were in every respect healthy ; the two
which had been inoculated with cheesy substance were likewise
healthy; two of the three which had been inoculated with
tubercle were manifestly tubercular. Herard concludes, first,
that tubei'cle is inoculable from man to the rabbit ; secondly,
that the cheesy inflammatory products .are not inoculable, and
therefore not tubercular ; thirdly, that the miliary tubercle is
alone inoculable and is the specific lesion of tuberculosis.

Thus far, the evidence of all these observers pointed but to
one conclusion — that the disease which we call tubercle in man
is directly communicable by inoculation to the lower animals :
but the experiments of Lebert and Wyss, performed last year
at Breslau, and, more recently, the very interesting facts com-
municated to the Pathological Society by Sanderson, as
also the convincing testimony of Wilson Fox, have thrown
a new light on the whole matter. The contributions of
Lebert and Wyss are chiefly interesting from the wider range
their experiments have taken. For they have employed not
only tubercle, and the cheesy products of inflammation in the
lungs and lymphatic glands, but also melanoma, cancer, can-
croid and sarcoma, and they have compared the results of these
inoculations with the efi'ects produced by the injection of
simple mechanical irritants, as charcoal and mercury, into the
veins of animals. In the first seven of their experiments,
rabbits and guinea-pigs were inoculated with various kinds of
tubercle, gray or miliary, and yellow or cheesy. In five of
these seven, tubercle was unmistakeably communicated. In
the sixth, the lymphatic glands in the shoulder were found
swollen and filled with yellow matter, but there were no tuber-
cles in the viscera. In the seventh, the rabbit died in a month
with an enormous superficial abscess, but with no marks of
tubercle. Four inoculations were then made with what are
described as cheesy products of inflammation, or patches of
degenerate lung-tissue following simple chronic inflammation.
In not one of these was tubercular disease produced : in one only
was there found clieesy infiltration of some of the lymphatic
glands. Pus from an ordinary abscess was injected into the
veins of two dogs. In one of these dogs the usual small circum-
scribed abscesses were found in the lungs, and what are described
as small tubercles in the liver. In the other dog, numerous
gray half-translucent granulations were found both in the lungs
and the liver. Next followed nine inoculations with the
secretions from bronchi and voraicse, muco-purulent and gan-

^ Reviews. [July*

grenous sputa. In all of these^ save one, death occurred so
rapidly (witliiii four or five days), that no results were obtained.
The case of a dog is afterwards instanced, in which, some time
after a fistulous opening had been made for another purpose,
death followed, and there were found, beneatli the pleurae and
scattered through the lungs, numerous granulations identical
with tubercular granulations. Lebert attributes the formation
of the tubercles in this case to the mere traumatic effects of
the fistulous opening, and regards the case as a striking argu-
ment in favour of his views, to be presently cited, concerning
the real nature of tubercle. In one only of three rabbits,
inoculated with melanotic cancer from the horse, Avere small
nodules found scattered beneath the skin in the proximity of
the wound : in the other two, no results were obtained. One
of two rabbits, inoculated with sarcomatous tumour from the
tibia of a man, was found, after death, to have diflFused through-
out the parenchyma and beneath the pleura of its lungs, small
" infiltrated spots of tissue,^' soft in consistence and composed
of large, round, well-formed cells, with large round nuclei.
The other was unaffected. A dog, into whose jugular vein the
juice from a human cancer, diluted with water, was injected,
died in fourteen days, and disclosed well-marked cancerous
nodules dispersed through its heart and liver. On the other
hand, three rabbits, inoculated with cancerous matter from
the liver of a woman, gave a negative result. A fourth rabbit,
inoculated with the juice from an epithelial cancer of the
oesophagus, died at the expiration of a month, and disclosed
some small granulations in the lungs, together with a number
of superficial abscesses. Lastly, finely divided charcoal and
mercury were injected into the veins of animals, in order to
compare the effects of mechanical obstruction or embolism of
the small pulmonary branches with the so-called tubercles. It
was found, according to the statements of these two pathologists,
that such an artificial capillary embolism gives rise, by propa -
gated irritation, to changes very nearly akin to those observed
in induced tubercular disease. Thus, there were noticed
hyperplastic changes in the cells lining the alveoli, in the inter-
stitial connective tissue, and in the adventitia of the smaller
pulmonary branches, as well as lobular, and even lobar, conso-
lidation when the obstruction was more considerable, the changes
in all these cases being seen to originate in the immediate
neighbourhood of the occluded vessel.

Lebert is evidently inclined to think that the general laws of
inflammation are dominant in the production of all these morbid
appearances after inoculation, rather than that any specific
property resides in the inoculated matter. We see, he says,

1868.] Recent Works on Tubercle. 43

that the same cells (connective tissue) are stimulated into
excessive development by the most diverse kinds of irritants,
and that like irritants throw into a state of hyperplastic increase
different kinds of cells (connective tissue and epithelium) . If
he is asked the question, — " Have you obtained real tubercle by
inoculation/^ he answers, — '^What is real tubercle?" His
endeavour throughout is to show that there is no real difference
between tubercle as a supposed neoplasm and the products of
inflammation, and that the granulation of the so-called tubercle
is nothing more than a secondary, often metastatic, product of
some primary inflammation. " An undeniable primary inflam-
mation which can show all grades of transition from a small
punctate granulation up to an extensive infiltration, and which
finds its habitat in the connective tissue as well as in the
epithelium, produces ordinarily as a secondary effect, by trans-
port or dissemination, the small granules termed genuine
tubercle." Such is his view of the would-be tubercular ino-
culation. He thus combats the dualistic doctrine, which would
separate tubercles proper (miliary granulations) from cheesy
products of inflammation (cheesy pneumonia), and thinks that
they are both to be regarded, not as parts or stages of a specific
affection called tuberculosis, but as eff'ects of inflammation ;
the pneumonia, or cheesy depot, being the primary, and the
tubercular eruption the secondary or metastatic, disease.. The
authority of Dr. Sanderson's name has lately added fresh
weight to these views of Leberf s.^ He, like Lebert, has found
that not only will inoculation of tuoerculous matter in the
rodents be followed, in the large majority of cases, by a diffusion
of miliary granulations throughout the various internal organs
of the body, but that the self-same results may be also obtained
in these animals by any severe and prolonged subcutaneous
irritation. The instance of Lebert's dog^ with the fistulous
opening, which, at first sight, seemed so improbable as to be
almost incredible, is fully confirmed by Sanderson's experi-
ments of inserting setons in rabbits and producing morbid
changes in their internal organs not to be distinguished from
those which we have seen to follow after inoculation of tubercle.
Sanderson's minute description of the way in which these
miliary granulations are developed, bears valuable testimony to
the correctness of the account that has been given of the birth
of tubercle — an account condensed from VirchoVs writings

1 Dr. A. Clarke deserves the credit of having, even prior to Lebert's publication,
stated that he had, by employing other non-tuberculous pathological products,
succeeded in producing the same results as could be obtained by the inoculation
of tubercle.

' That which Lebert here observed in the dog, Barwell had observed in rabbits
whose bones had been injured.

44 Revieivs. [Jiily?

on the subject. We find in them^ therefore, additional and
weighty evidence in favour of the cellular pathology. Lebert,
Sanderson^ and Fox, working independently and without any
knowledge of each other's conclusions, have thus overthrown
Villemin's doctrine of specific tubercle-inoculation. They have
shown unmistakeably that the inoculation of human tubercle in
certain of the lower animals produces in them a condition undis-
tinguishable from general tuberculosis in man, not, however, by
virtue of any specific properties present in the tubercular matter
inoculated, but by the mere irritating effects of the inoculation.
When, on the one hand, we find Fox rendering guinea-pigs
tubercular, not merely by introducing minute atoms of ordinary
putrid muscle, bone, and kidney beneath their skin, but also by
vaccination and inoculation of pus ; or, on the other hand, we
hear of Sanderson and Fox causing tuberculosis in these rodents
by setons and cotton threads ; we must be convinced that it is
not tubercle which is communicated, but a series of inflam-
matory changes of a low kind, which may be set up in these
susceptible animals by almost any irritant. At the same time,
we cannot, with Lebert, argue from these appearances as to the
real nature of tubercle in man : nor can we look at every out-
break of miliary tubercle as a mere metastasis of inflammation:
for then we must, in every case of tuberculosis, presuppose the
existence of some inflammatory depot or centre, from whence
such a metastasis of germs can arise. But, as Southey very
justly observes —

" In acute tuberculosis, without any local abscess, or any such
source of primary infection, we find new growths of apparently the
same age and date springing up in various and distant parts : be
it granted that this is very rare, still the one single instance would
be enough to prove that tubercle was not then produced by the
re-absorption of retrograde tissue products into the blood."

We would add that the one single instance would also be
enough to prove that tubercle was not then produced by dis-
semination from a primary focus. This difficulty, however,
must remain unsolved, as long as these experiments are per-
formed on the lower animals. The time may, perhaps, be not
far distant when our confreres on the other side of the channel,
who, in their devotion to science, have not shrunk from syphilis-
inoculation in man, will put an end to all doubts by practising
tubercle-inoculation either on themselves or on each other.
We know that the introduction of setons in men will not cause
them to become tuberculous, but we do not yet know whether
tubercle is communicable by inoculation from man to man.
Let us now shortly examine the arguments deduced from these

1368.]

Recent Works on Tubercle. -15

experiments, and other facts, in favour of the transmissibility of
tubercle by contagion from man to man. " Phthisicorum cadavera
fugi adolescens, fugio etiam senex/^ wrote Morgagni in the
eighteenth century : and now again, after the notion of the con-
tagion of phthisis has been so long scouted from us as absurd, we,
in this advanced nineteenth century, are coming round again to
the doctrines of the old pathologist. Laennec, J. Frank, Sir James
Clark, and Perroud, have all upheld the belief that the inhalations
from a phthisical person certainly predispose those who are long
submitted to their action to become phthisical : while Andral
('Auscult. Mediate,' t, ii, p. 179) has gone so far as to assert
that it is possible for such tubercular emanations to act
as a positive source of contagion. Watson's views on this
matter, as coming from a true physician, have a peculiar interest.
He says, in answer to the question, " is phthisis contagious ?''
"No, I verily believe it is not." But a few lines farther on we
read, " Nevertheless, if consulted on the subject, I should, for
obvious reasons, dissuade the occupation of the same bed, or
even of the same sleeping apartment, by two persons, one of
whom was known to labour under pulmonary consumption.'^ He
had here probably in his mind some cases of apparent contagion
that he had seen. There has been, doubtless, a latent suspicion in
the mind of many a physician that a tubercular husband may
infect his wife, or vice versa; and that not through the medium of
the foetus, concerning the possibility of which there can be little
doubt,^ but by direct contagion ; for there are few practitioners
who do not occasionally come into contact with such cases.

If, now, passing over as not trustworthy the facts of inoculation,
we consider the very close resemblance which tubercle has to
glanders, not only in its anatomy, for this is of small account, but
in its symptomatology and in the laws which it seems to obey; if,
secondly, we compare typhoid fever with acute tuberculosis ; if,
thirdly, we put tubercle side by side with other zymotic and
contagious diseases in its habitat, its geographical range, and its
presence in only a limited number of zoological species; if,
lastly, we look at the fact, which Virchow, who is no conta-
gionist, was the first to point out, that tubercle will sometimes,
more especially in the summer months, occur as an epidemic in
its acute and miliary form, it must be conceded that not with-
out reason are men inclined now-a-days to revive the teachings
of old Morgagni, and to believe that tubercle will yet somehow
or other prove to be really contagious. The strongest argu-
ment as yet adduced against any such belief is that which Cot-
ton has employed. He quotes ('Lancet,' 1867, p. 550) statistics
from the Brompton Hospital to show that among resident
1 See this Review, April, 1807, p. 327.

46 Reviews. fJuly,

medical officers, chaplain,, raatron, secretaries, and nurses work-
ing in the institution, no evidence whatever of contagion from
phthisis is to be found. So that in the place which ought, if
phthisis be contagious, to be a very pest-house, contagion is a
thing unknown. But what of typhoid fever ? Here is a disease
which, in most of the metropolitan, and in all the large conti-
nental hospitals, is mixed up indiscriminately in the medical
wards with every other kind of disease. During a few years'
residence in London, Paris, or Vienna, some hundreds of cases
of typhoid fever may be seen scattered hap-hazard among other
medical cases ; and yet such a thing as contagion from typhoid
fever is so rare that many of the best authorities disbelieve
altogether in its possibility. Our greatest authority on fever,
Murchison, states (p. 428) that, during fourteen and a half
years, while 3,506 cases of typhoid fever were admitted into the
Fever Hospital, eight cases only were reported to have origi-
nated there. On the other hand, one case of typhoid fever shall
come to a village where the houses, wells, and cesspools lie close
huddled together, and in a few weeks the disease shall have
spread from house to house in a way that rivals the contagion of
typhus.^

As with typhoid fever, so with cholera, contagion in the wards
of a hospital is by no means a marked phenomenon •/ and yet
one case of cholera under the circumstances above mentioned,
may spread the disease far and wide in a community which has
been exempt up to the time of the new arrival. Now it is only

^ In the summer of the past year two boys came home from a school in which
typhoid fever was prevalent, the one to an isolated farm-house in which there
had been no previous history of fever ; the other to a large village situated
several miles from the farm house. Both boys were attacked with typhoid fever
directly after their arrival. . He in the farm-house died. His father, mother, two
sisters, three labourers, and a farm boy, who worked in the house, all sickened
with typhoid fever one after another, and two out of the eight died. He in the
adjacent village recovered, but his nurse caught the disease and took it home to
her cottage, where she communicated it to her own child and to a labourer and his
child in the adjoining cottage. Two children, who lived at some little distance
from these cottages, but who were in the habit of going backwards and forwards to
inquire after the sick people, and who, as ^vas ascertained on inquiry, occasionally
had a drink of water in the house where fever was present, next sickened with
fever, and from them the fever, cases of which have been till recently (March,
1868) under observation, spread around the neighbourhood. The water in the
nurse's cottage, which supplied also the adjacent cottage, came from a well which
was only a few yards from, and on a lower level than, the privy, and was found
on examination to be so impure as actually to stink.

" Persons labouring under pythogenic fever," says Murchison, " sometimes
transport it into localities where it was before unknown, but where it then
spreads as from a centre."

2 "Cholera," says Goodeve (Reynold's 'Syst. of Med.,' vol. i, p. 142)^" seldom
spreads from bed to bed in a ward; on the contrary, when people are attacked in
hospitals, they lie generally in distant corners or in another ward. Cholera does
not spread from the sick to the whole by any rapidly acting emanation."

1868.]

Recent Works on Tubercle. 47

quite recently, and thanks more particularly to the investigations
of Snow, Budd, and Acland, that we have learnt to understand
how it is that typhoid fever and cholera may thus be propagated
— namely, by contamination of the water-supply : and that
which twenty years ago would have been treated as an absurdity
is now not only discussed as a matter of course in the medical
journals, but has become public property ; so that every house-
wife buys her filter and talks learnedly of disinfection. Again,
there can be no doubt that glanders — cousin-germanto tubercle
— is strictly contagious ; and yet how subtle and mysterious are
the ways of its contagion. Leblanc enclosed the head of a
healthy horse in the same sack with that of a glandered horse,
and thus forced the healthy animal to inspire, directly and un-
diluted, the exhalations of the diseased one for a period of seven
or eight hours. In eight horses thus experimented on, not one
single instance of contagion occurred, and yet it is certain that
glanders is inoculable from horse to horse, and from horse to
man, and that it is, in some mysterious Avay, contagious. We
are, therefore, hardly warranted in denying that tubercle is con-
tagious, because we do not see the disease communicated from
oae to another in hospitals, or in refusing to accept the pos-
sibility of its successful inoculation in man because we cannot
produce any instances of students who have cut their fingers at
post-mortem examinations of tubercular subjects, and have be-
come tubercular. Is it, we ask, too much to hope that we shall
ere long get a nearer insight into the real cause of this pest of man-
kind ? that what has happened for typhoid fever may yet happen in
the case of tubercle ? and that we shall be able to prevent, or at
least to hold in check, the ravages of the one as we shall certainly
restrain the spread of the other ? We think that such an ex-
pectation is by no means Utopian.^ " By the destruction of the

' Since the above was sent to the press, the writer's attention has been called
to the highly interesting facts communicated by Dr. Buchanan, in the ' Ninth
Report of the Medical Officer of the Privy Council.' It is there clearly shown
(p. 17 and 48) that, while typhoid fever and cholera have been to a considerable
extent diminished by the able sanitary administration of our authorities, the
mortality from phthisis has been in like manner decidedly reduced. It has been
found, to quote Mr. Simon's words, " that the drying of the soil, which has in
most cases accompanied the laying of main sewers in the improved towns, has led
to the dhTiiuution, more or less considerable, of phthisis." No less interesting is
the fact announced that " diseases of the lungs, other than consumption, have
undergone no regular reduction in their amount;" and " that neither directly nor
inversely did the class of lung disease fluctuate according to the fluctuations of
phthisis." These facts, though they prove nothing as to either the communica-
bility or non-communicability of phthisis by contagion, do at any rate show
that phthisis, in common with typhoid fever and cholera, can be directly influ-
enced by sanitary improvements ; and that the very improvements, which limit
the spread of phthisis, have no effect on the ordinary inflammatory affections of
the lungs.

48 Reviews. [Ju^S

specific morbid matter of tubercle," says Biidd^ '' as it issues
from the body, by means of proper chemicals, and by good
sanitary conditions, there is reason to hope that we may even-
tually, and at no very distant time, rid ourselves entirely of this
fatal scourge/^

Review IV.

Si. George's Hospital Reports. Edited bv John W. Ogle,
M.D.,&c., and T. Holmes, Rll.C.S. VoLIT, 1867. London.
Pp. 486.

The publication of hospital reports on the plan of this and
the preceding volume, as edited by Dr. J. Ogle and Mr. Holmes,
needs no disquisition to prove its utility and value as a means
of recording and preserving the results of experience, particu-
larly to those engaged in actual practice; moreover, such
volumes serve also as, what may be termed, excellent centres of
attraction to old students of the hospital identified with their
production, not only by affording them an admirable medium
for placing on record the results of observation, but also by
inciting them, from an abiding feeling of interest and esteem
for their alma mater, to become contributors.

Without further preface, we may observe that this second
volume contains twenty-two communications on medical and
surgical topics, illustrated, Avhere requisite, by wood engravings.
They are of an eminently practical character; some of them are
brief clinical records with remarks, whilst a few partake rather
of the nature of essays on special subjects. Mr. Prescott
Hewett, in continuation of the series of " Contributions to the
Surgery of the Head,''^ commenced in the previous volume,
leads the way with a very complete notice of exostoses of the
skull, describing therein the varieties, connections, consequences,
origin and treatment of those morbid outgrowths. Among
other remarkable forms mentioned is that found in some of the
lower animals, and especially the ox tribe, to which from the
form it often assumes, and a misconception of its true nature,
the name of petrified brain was given. In short, the supposed
petrified brain was nothing more than an ivory exostosis of the
frontal sinus, which, following a course inward, breaks down
the wall of the frontal sinus and projects into the brain-case.

Internal exostoses may give rise to epilepsy and to various
cerebral symptoms, of which instances are cited. But the
extreme density of exostoses is something remarkable, and
many examples are cited in which saws and chisels have failed

1868.] ' SL George'^ Hospital Reports. 49

to make any decided impression upon them; so much so that
attempts at their removal by such mechanical means have had
to be given up in despair. Mr. Hewitt, indeed, recommends
them not to be meddled with at all unless for some very cogent
reason. If their removal be decided upon, sawing them off on
a level with the skull, when feasible, is perhaps the best way of
proceeding, but mostly the use of caustics is required, and is
also of much easier application.

Clinical Cases of Insanity is the subject of a short paper by
Dr. Blandford. Three cases of chronic insanity are described
in which recovery took place after illness of seven, six, and five
years^ duration, and following these are notes of five instances of
mania transitoria or acute delirium, in the production of which
epilepsy was considered to be not concerned. The practical
question put is — How are such transitory cases to be diagnosed ?
To this question Dr. Blandford attempts a reply, stating his
impression to be that, in such transient cases, the invasion is
very sudden, and a definite and sufficient mental cause dis-
coverable.

This paper should be read in conjunction with that by
Dr. Handfield Jones, On Delirium, found in this same volume
(p. 123), under the title of Reports of Cases of Nervous Disease.
Eight cases are detailed, differing widely among themselves in
character and causation. Each case is followed by a com-
mentary, and the paper concludes with some speculations on
the cerebral nature of delirium. The point on Avhich Dr. H.
Jones wishes to lay stress is —

" that though we have no exact knowledge as to what is the peculiar
state of the cerebral tissue which conditionates delirium and con-
vulsions, we are assured that it is, at least in most cases, a \evy
similar if not an identical one. The essential features of delirium
are undue excitability and mobility. The very same may be said of
convulsions generally ; and we may conclude that the difference in
the phenomena depends much more on the locality affected and on
the special endowments of the tissue than on any alteration in the
pathological process itself."

Dr. H. Jones proceeds to enlarge upon this hypothesis of the
nature of delirium, and viewing it as a type of irritation
affecting a certain tissue and locality, justly observes that
clinical experience proves to us that irritation

" is not a constant condition, even where its principal phenomena
are apparently identical. Thus, taking a very simple and typical
instance of irritation, the so-called strumou3 oplithalmia, where the
liyperresthesia (photophobia) is most intense, we find that the same
b3— xLii. 4

50 Reviews* [July,

remedies are by no means always appropriate. Quinine, iron, and
cod oil, are successful in many instances, but in others small doses
of tartar emetic are of mucb more avail, as stated by Mr. Chessliire.
This is very much what we find to occur in disorders of the hemi-
spheres and other nervous centres, and while it proves, I think, the
varying quality of morbid states of nervous tissue, it also shows the
general similarity of the derangements which occur both in the
peripheral and central organs."

Dr. John Charles Hall^ of Sheffield, commences, as would
appear, a series of papers on the Diseases of Artisans. The
Sheffield file-cutters' disease is the subject of the present com-
munication. The mode in which the workpeople, chiefly file-
cutters, carry on their trade, and the way in which they become
exposed to lead by contact and by inhalation of dust, are
described ; and this description is followed by the record of a
few cases of lead-poisoning, exhibited by wrist-drop and other
paralytic symptoms and by colic. Dr. Hall is not an advocate
for iodide of potassium in such cases, but prefers sulphuric acid
with sulphate of magnesia. He appends some useful rules to be
observed by the operatives to prevent the " file-cutters' disease."

The next essay, on Certain Epileptic Phenomena, by Dr.
Edward Fox, is of considerable length, but will repay perusal.
Of late years epilepsy has been so largely written about that
little remains to be said of the disease, considered from a symp-
tomatic point of view, although ample scope for speculation
exists when the intrinsic cause of the malady is made the topic.
Dr. E. Fox attacks the subject from both sides, first reviewing the
phenomena of epilepsy, and then speculating on their causation.
In his apprehension the blood is the true seat of lesion j arterial
spasm is the proximate cause of most of the epileptic phe-
nomena, and the pathological appearances met Avith in the brain
of epileptics are the effects of the attacks. As bearing upon
the opinions last quoted, we would call Dr. Fox's attention to
Mr. Hewitt's memoranda on internal exostosis of the skull as a
cause of epilepsy. Blood lesion is undoubtedly but one of many
causes.

Mr. G. F. Hodgson narrates an interesting case of Encephalo'id
Disease of a Retained Testicle. A woodcut is given in illus-
tration, and serves well to display the immense size which the
morbid growth acquired before death carried off its victim.
Mr. Hodgson enters into the question of operating, and in
determining it. examines the records of similar cases. The
conclusion is, that an attempt at removal is undesirable where
the tumour has attained a considerable size, and especially if
the peritoneum have to be opened. Yet if he saw such a case

1868.] St. Georgeh Hospital Reports. 51

early he would operate, believing, as he does, the doctrines of
cancer as laid down by Mr. Moore, Dr. Hughes Bennett, and
others. Moreover, he appears to approve of the removal of the
testicle Avhen arrested in the groin, quoting in favour of the
practice the fact that such testicles are useless, without ability to
secrete true spermatic fluid, and that, besides this, they are more
prone to cancer than the normal organ, and also will give rise
to more suffering when attacked by inflammation of any sort.

Dr. Reginald E. Thompson describes the results of Thermo-
metrical Observations in Typhoid Fever, carried out by himself,
and which proved in general confirmatory of those made and
recorded by Wunderlich. Dr. Thompson found that the ther-
mometer afforded no reliable criterion for diagnosis between
typhoid fever and certain other diseases, though it sufficed to
distinguish it from acute granular kidney, meningitis, and peri-
tonitis, as likewise to appreciate intestinal lesions before they
were recognised by the ordinary symptoms. Moreover, the
thermograph of typhoid supplies an additional distinction
between this fever and typhus. A table of observations in a case
of typhoid fever is appended.

Aphasia and Agraphia constitute the subject of one of the
longest essays in the volume. It is a contribution by Dr.
William Ogle, presenting a summary of the present state
of knowledge of those maladies, accompanied by critical re-
marks and brief records of cases that have occurred in St.
George's Hospital. Dr. Ogle upholds the hypothesis of MM.
Dax and Broca, as to the localisation of the faculty of ar-
ticulate speech in the inferior or third frontal convolution of
the left hemisphere, and attempts to overturn the arguments
against it advanced by Trousseau and others. To meet the
objection that in a double organ so symmetrical as the brain it
is hard to conceive a difference of function between its two
sides, he makes the most of the absence of exact symmetry in
the arrangement of the convolutions; but being dissatisfied,
apparently, with the cogency of the argument so derivable, he
resorts to the remarkable suggestion of Dr. Moxon, that we
may, and, if Broca be right, universally do, educate the left
hemisphere as the organ of language in a much higher degree,
or well nigh to the exclusion of the right half of the cerebrum.
And in support of this notion he appeals to anatomy, which, as
he conceives, shows that the left hemisphere receives by the left
carotid a more direct, and therefore freer supply of blood than
does the right, by reason of the mode of origin of that carotid
from the aortic arch. He farther urges that the left hemisphere

52 "Reviews. [July^

is more fully developed at an earlier period of existence than the
right. We must^, however, confess that these anatomical arguments
do not at all satisfy our mind, even were they valid, which we doubt ;
and we are likewise unwilling to believe the right hemispherical
frontal convolutions to be in vain and of no purpose in the
cerebral economy, an inference Dr. Moxon's hypothesis would
involve. If they remain normally so uneducated or so unused,
how is it they acquire and retain equal dimensions with those
on the left side ? We have, however, no space at present to
take up with this discussion. In further notice of this essay,
we may state that Dr. W. Ogle follows Trousseau in recog-
nising two forms of Aphasia, termed respectively. Amnemonic
and Atactic; the former implying that condition in which
appropriate words fail the patient, owing to a defect of memory,
the latter failure in the power of co-ordination of the muscles
necessary to articulation. The two disordered conditions are
frequently associated together.

Agraphia is the term invented to designate inability to
express ideas in written language, and this faulty condition is
distinguished as of two kinds, just as in the case of aphasia,
viz. the amnemonic and the atactic. In the former the patient
misuses words, or writes a confused series of letters, having
apparently no connection with the words intended; in the
latter, the power of writing even separate letters is lost, and
only meaningless strokes made with the pen.

Loose cartilages in the knee-joint, especially such as result
from accident, are briefly considered by Mr. Brodhurst, who
draws the conclusion that, as a rule, they are detached portions
of semilunar cartilage, set free within the cavity of the joint.
A case is related where the loose cartilage was removed as early
as six weeks after the accident producing it.

Mr. Edgcombe Venning opens the question of diagnosis
between infecting and non-infecting chancres^ and, after a brief
discussion, illustrated by cases, expresses his belief that the
infecting form is always attended with the amygdaloid enlarge-
ment of the glands of the groin, an opinion not many will
endorse.

The limits allotted to this review constitute a bar to even the
shortest adequate analysis of the contents and conclusions of
many of the valuable contributions collected in this volume of
reports. We must consequently pass over some of the re-
maining papers, very unwillingly indeed, with little more notice
than that of their titles.

The serious and rare form of morbid growths known as nasO'

1868.] ;S^/. George's Hospital Reports. 53

pharyngeal polypi are well described, and tlieir treatment care-
fully discussed by Mr, Thomas P. Pick. These tumours do not_,
as generally supposed, invariably grow from the base of the
skull, for M. Kobert describes one that appeared to be connected
with the fibrous tissue in front of the cervical vertebrae. They
increase rapidly, and individuals afflicted with them live but
comparatively a brief period. To diagnose their nature and
attachments is not generally so easy as might be imagined.
Various plans of treatment have been suggested and adopted :
these Mr. Pick has carefully noted, citing published cases, and
in summing up his inquiries remarks :

" That the methods by the palate and by the ligature are inadmis-
sible on account of the fact that the root of the disease cannot be
reached. Of the method by the galvanic current we do not possess
sufficient experience to speak with any degree of certainty. There
remains, then, only the methods by the nose, and by the removal of
the superior maxilla. The former of these methods is applicable to
and is to be preferred in polypi of small size ; whilst the latter must
be employed in cases where the tumour is large, and especially where
it has prolonged itself in the manner mentioned above."

The liability of such tumours to return after their excision is
as yet a problem not satisfactorily solved.

Croup and Diphtheria, and their treatment, is the subject of
a communication by Mr. J. W. Haward. This writer advocates
tracheotomy early in diphtheria, to avoid the exhausting effects
of the dyspncea, otherwise urgent, and he ''goes so far as to
think that no child should be allowed to die of suffocation,
however bad and hopeless the case ; for we have at present no
means of judging how far the exudation has extended, and I do
not think the existence of bronchitis should exclude the ope-
ration.^^ He adds the caution, that the operation should not
be hastily performed. The differential diagnosis is well
examined.

The Significationof Skin Affections inthe Classification of Disease
is a philosophic disquisition of much merit, by Dr. C. Allbutt,
which must be read through to be appreciated. Mr. Nourse
narrates more or less briefly some seventeen " Cases of fever'' of
various sorts, with the view of elucidating their origin. A much
larger series of cases, however, is needed to give weight to the
conclusions he would draw. At the same time it may be
remarked, Mr. Nourse's inferences agree in the main with those
generally received by the profession.

On the Forms of Pneumonia. This is a contribution of con-

64 Revieivs. [July,

siderable lengthy -wlierein the author. Dr. Sturges, examines
critically the various morbid conditions comprehended under
the general appellation pneumonia. In carrying out this exa-
mination Dr. Sturges avails himself of the cases placed on
record at St. George's Hospital during the last twenty years,
excluding such as were connected with tuberculosis, or with
secondary deposit. The cases collected, and which are also most
carefully tabulated, exhibited, for the most part, that stage
which has been called red hepatisation ; and whether they be
held to prove the author's deductions or not, they constitute in
themselves a monument of his industry, and a repertory of
observations valuable to all future inquirers into the pathology
of pneumonia.

In the course of the labour of tabulating the cases, Dr. Sturges
observes that he

" Soon found that all the fatal instances of so-called pneumonia
occurring in a series of years fell naturally, in view of their clinical
histories, into four classes. The ^first and largest class would com-
prise patients who died of tedious and exhausting diseases of wliat-

ever kind, such as the constant drain of an abscess or generally

where lingering was unusually prolonged, and emaciation extreme.
Lung consolidation, indeed, is a familiar apj)earance in connection
with this form of decay A second class would consist of the sub-
jects of a specific fever, or of some definite afiection of a secreting
organ, and conspicuously of ursemic poisoning and the poison of

typhus In a third class hepatisation would seem due almost

entirely to mechanical causes, and quite independent of any inflam-
matory affection whatever Fourthly, hepatisation occurs, there is

reason to suppose, as the result of idiopathic inflammation of the
lung. It is then invariably connected with pleurisy, and often with
pericarditis. It runs a rapid and tolerably uniform Course, and would
seem to be but rarely fatal."

Having thus indicated four varieties of morbid action, the
author proceeds to examine each in turn from a pathological
stand-point j and he points it out as a curious circumstance,
that wherever recent pericarditis is associated with marked
pneumonia, it is always the ric/ht lung which suffers either
mainly or solely.

The general conclusion is, that the term pneumonia, if
retained, can apply only to a certain combination of physical
signs, which, in themselves, are diagnostic of no one disease or
morbid entity. This being so, the " laudable attempt" made of
late years by Dr. Hughes Bennett to test the comparative
efficacy of various modes of treatment in certain definitive
diseases by means of statistics must be, so far at least as concerns

1868.1 St. George*s Hospital Reports, 55

the selection of pneumonia for that purpose, both iuconclusive
and abortive. For

" Simple pueumoula Is rarely a fatal disease under any mode of
treatment ; and as a secondary disease the associations of pneumonia
are so many and various, that it seems almost hopeless to attempt a
classification sufficiently precise to bring cases into fair comparison.
In a word, If the term pneumonia be used to express all the cases of
consolidation which I have been noticing, or the majority of them, no
disease can so little be treated in this way or that because of its
name. If, on the other hand, the word Is to be restricted to pure
uncomplicated cases of Inflammation of the lungs, it is clear that our
knowledge at present does not enable us always during life to discri-
minate such cases. The argument of treatment derivable from tables
must concern Itself with simpler diseases than this."

Dr. John W. Ogle, one of the editors of the volume, recounts
a case of death from hemorrhage into the pericardium, as a
result of rupture of one of three true and circumscribed aneu-
rysms of the coronary artery of the heart, and follows with
observations on aneurysm or aneurysmal dilatation as a result of
embolism or thrombosis. A woodcut shows the position of the
aneurysms and of the rupture. The writer carefully examines
the relation discoverable between the lesions found after death
and the symptoms presented by the patient during life. Cases
of aneurysm of the cardiac coronary are very rare, and Dr. Ogle
has done good service in culling examples from all available
records in illustration of the history and pathology of the
lesion, and also in reviewing them in connection with the
instance that fell under his own observation. The same writer
has likewise contributed a most instructive and copious collec-
tion of " Instances of some of the rarer varieties of morbid
fjroivths, swellkigs, ^c, co7inected ivith the organs contained
within the abdominal cavity/' and purposes, in a future number,
to add to this present collection. He informs the reader that
he has gathered the instances now published from the hospital
records, and from practice among the out- and in-patients, as
illustrating difficult points of diagnosis, or as presenting features
of interest as regards morbid anatomy determined by post-
mortem research. The cases related, their features during life,
and the appearances noted after death, maybe divided into three
groups : — " 1. Affections of the peritoneum, stomach, intestines,
liver, pancreas, and lymphatic glands. 2. Affections of the
uterus and urinary bladder. 3. Affections of the bones, arte-
ries, &c."

This catalogue of cases offers, we think, a valuable supplement
to Dr. Bright's excellent clinical essay on abdominal tumours.

56 Reviews. [July,

The same storcliouse of facts — the case-books of St. George's
Hospital — furnishes the other editor, Mr. T. Holmes, with the
material for the " Statistics of Strangulated Hernia," as adduced
to elucidate some facts relative to this lesion and its surgical
treatment. This paper will recommend itself to our surgical
readers, especially to those who desire to ascertain the results
of cases at St. George^s Hospital with the view of comparing
therewith their own experience.

A case of convulsions, occurring after delivery, is narrated by
Dr. A. D. Mackay, who in the accompanying remarks ex-
presses his opinion to be that the puerperal convulsions occur-
ring in women whose urine is albuminous depend on an impure
state of the blood, or excrementitious matter in it ; and it also
appears to be his belief that albuminuria is, as a rule, associated
with convulsions, though these do not necessarily follow on its
existence.

The volume concludes with reports on the medical and on
the surgical cases admitted into St. George's Hospital during
the year 1866-67. The medical report is from Dr. Reginald
E. Thompson, and the surgical from Mr. Edmund C. Ring, the
surgical registrar. Each report is accompanied by copious
tables. The first table of medical cases exhibits the nature of
the disease, the total number admitted, the total number of
deaths, the percentage of deaths, the circumstance of complica-
cations with other diseases, and the deaths among complicated
cases. To these particulars are added brief observations. A
second table sets forth the cases v/here lardaceous or araylo'id
degeneration was discovered after death, and shows the age of
the patients, the disease for which they were especially treated,
and its duration and symptoms. Subjoined is a notice of the
organs found degenerated. A third table is occupied with
various annotations on some of the cases of pneumonia admitted
during the year. These cases were thirty-one in number. The
tables of surgical cases and of operations performed are even
more extensive. The first set refer to compound fractures, and
indicate their cause — the limb injured, the state of fracture, and
the treatment and results. A few brief remarks are appended
in a final column. The cases of pyaemia are likewise tabulated
in such a way as to convey a clear conception of their history.
Last of all comes a tabular statement of operations performed
during 1866, divided into classes according as the operations
were on the head, neck, or face, ou the upper extremity, on the
thorax, on the abdomen, on the genito-urinary organs, or on the
lower extremity. The surgical report concludes with a tabular
outline of the surgical cases admitted during the year 186fi.

1868.] Recent Works on Physiolof/y, 6fc. 57

The medical and surgieal registrars of the hospital deserve
great credit and encouragement for the immense pains taken
by them in framing these tables, and in collecting the large
amount of information conveyed in their several columns.
Indeed, to these reports of the cases admitted into the St.
George's during the year in strict language belong the title of
reports of St. George^s Hospital. It is these that especially de-
monstrate the amount of work done — of good effected by the
hospital. Many of the other contributions in the volume are
founded upon observations made in the course of private prac-
tice by former students, and, consequently, in strict parlance,
constitute no portion of the St. George's Hospital Reports.

Morever, both Dr. Thompson and Mr. Hing supply notes on
very many cases and groups of cases, conveying memoranda of
peculiar symptoms, of remarkable pathological conditions, and
of particulars of treatment; so that, indeed, the student is
supplied with a very excellent sketch of the year's practice,
both medical and surgical, at the hospital, whilst every medical
man is furnished, both by notes and tables, with particulars and
summaries of great value in instituting investigations relative
to almost every disease of temperate climates.

We trust that the plan of publishing such volumes of hospital
reports may prove no temporary fashion, but will assume a per-
manent character; a consummation to be attained, however,
only by an encouraging list of subscribers.

Review V.

1. The Physiology of Man, designed to represent the existing
state of Physiological Science, as applied to the functions of
the Human Body. By Austin Flint, Jun., M.D., Pro-
fessor of Physiology and Microscopy in the Bellevue Hos-
pital Medical College, New York, &c. &c. Vols. I and II.
New York. 1866 and 1867. Pp. 502 and 556.

2. A Treatise on Human Physiology, designed for the use of

Students and Practitioners of Medicine. By John C.
Dalton, M.D., Professor of Physiology and Microscopic
Anatomy in the College of Physicians and Surgeons, New
York, &C.&C. Philadelphia. 1867. Fourth edition. Pp.695.

3. Outlines of Physiology, Human and Comparative. By John
Marshall, F.R.S., Professor of Surgery in University
College, London ; Surgeon to the University College Hos-
pital. Illustrated by numerous woodcuts ; in two volumes.
1867. Pp. 607 and 699.

58 Reviews. [July,

4. Handbook of Physiology. By William Senhouse Kirkes,

M.D. Sixth edition. Edited by W. Morrant Baker,
F.R.C.S., &c. London. 1867. Pp. 802.

5. Lehrbuch der Physiologie fur Akademische Vorlesungen und
zum Selbst-Studium. Otto Funke. 1863-6. Band i and ii.

A Treatise on Physiology for Academic Lectures and for Self
Instruction. By Dr. Otto Funke, Professor of Physiology
in the University of Freiburg. Fourth thoroughly revised
edition; in two volumes. Pp. 1014 and 1182.

G. Lessons in Elementary Physiology. By Thomas H. Huxley,
LL.D., F.R.S. London. 1866. Pp.319.

7. Quain's Anatomy. Seventh edition. Edited by Dr. Sharpey,
Dr. Thomson, and Dr. Cleland. 1864-67.

8. On the Elimination of Nitrogen during Rest and Exercise on
a Regulated Diet of Nitrogen and on a Diet without Nitrogen.
By E. A. Parkes, M.D., F.R.S. Proceedings of the
Royal Society, Nos. 89 and 94. 1867.

9. Lehrbuch der Physiologischen Chemie. Von Dr. W. Kuhne,

Leipsic. Pp. 605. 1868.
Treatise on Physiological Chemistry. By Dr. W. Kuhne.

10. Archives de Physiologie iiormale et Pathologique, publiees
par MM. Brown-Sequard, Charcot et Vulpian. Paris.
1868. Parts I and II.

Archives of Normal and Pathological Physiology. Edited by
MM. Brown-Sequard, Charcot, and Vulpian,

11. The Journal of Anatomy and Physiology. Conducted by G.
M.Humphry,M.D., F.R.S,, and W. Turner, M.B., F.R.S.E.
Second series. Nos. 1 and 2, with nine plates. Pp. 452.
Macmillan and Co. 1868.

12. Essais de Physiologie Philosophique. Par M. J. P.
Durand (de Gros). Paris. 1866.

Essays on Philosophical Physiology. By M. J. P. Durand.

With slight modification the old Hanstown motto of

"Nurembergs hand
Geht durcli alles land

may be applied to physiology. With each succeeding year
its hand reaches into more and more distant provinces of
science, and its connection with other branches of knowledge
becomes more extensive and close. Occupied of old as its
etymology implies, with the interpretation of nature in all her
varied aspects, its scope subsequently became limited to the
consideration of the general phenomena exhibited in the life of
animals and vegetables — embracing, therefore, the science of
biology as now constituted. Still more recently its aim and

1868.] Recent Works on Physiology, ^c. 59

object has been held to be restricted to the investigation of the
laws of life, and to the description of the functions of the
several organs in opposition to their general and minute ana-
tomy. Within the last few years_, however, in spite of these
limitations, physiology has again begun to extend her relations,
and is now most intimately connected with chemistry, botany,
and physics. That its progress sliould be slow is by no means
surprising when it is remembered that it is engaged with the
examination of incomparably the most complex phenomena of
nature, but the very complexity and variability of these phe-
nomena possess a powerful charm for the highest class of minds,
and we may refer to the researches of a host of observers on
the electrical properties of nerve and muscle, as well as to the
recent investigation of Stokes on Cruorine ; of Haughton and
Frankland on Muscular Force ; and of Helmholtz on the Eye
and Ear, as evidence of the interest it excites in those whose
studies for the most part lie in a different direction, as well as of
the light which may be thrown upon its several departments by
those who are pursuing widely different lines of inquiry. The
direct connection that exists between physiology and pathology,
and the evident and immediate bearing that all questions of
physiology have on medicine and surgery, is constantly becoming
more clearly recognised, and we trust that in a few years the
impropriety, to use no harsher term, of permitting a student to
enter on the practice of his profession without a sound know-
ledge of what must always be considered as one of its most
important bases will no longer exist.

The two works at the head of our list by Dr. Austin Flint
and Dr. Dalton are highly creditable to our American brethren.
Both constitute excellent text-books of physiology, well arranged,
perspicuously written, and enriched by original observations.
The treatise of Dr. Flint is as yet incomplete, the two first
volumes only having been published ; but if the remaining
portions are compiled — for every physiological work embracing
the whole subject must be in a great measure a compilation —
with the same care and accuracy, the whole may vie with any
of those that have of late years been produced either in our
own or in foreign languages. Dr. Flint is already favorably
known as the author of various physiological essays published
in the ' American Journal of Sciences ;' and as he occupies the
important posts of Professor of Physiology and Microscopy in
the Bellevue Hospital Medical College, New York, and in the
Long Island College Hospital, it is natural that he should
furnish his pupils with a text- book as a supplement to his lec-
tures. We may remark in passing that there are some advan-
tages as well as disadvantages connected with the publication of

60 Reviews. [July,

such a work as the present, in parts. On the one hand, it en-
ables the author to round off each portion perfectly, making
every section complete in itself, whilst a sheet or two more or
less is a matter of little consequence. On the other hand, the
exhaustive manner in which he is tempted to treat the par-
ticular subject to which he is devoting his attention, neces-
sarily takes up much time ; and when he has completed it, the
reading, repetition of experiments, &c., required for the next
part, delays the progress of the whole work to so great an
extent, that th6 first sections published are rarely up to the
time, especially in so progressive a science as physiology. A
well-known instance of this occurred in the case of Dr. Todd's
' Cyclopaedia ;' and in spite of the originality as well as the
acumen of the authors, was also perceptible in Messrs. Todd
and Bowman's Physiology, the publication of which extended
over some fifteen or sixteen years. The first volume of Dr.
Flint's work, though published in 1866, has a preface with the
date of October, 1865, and the second, of June, 1867, which,
certainly considering the labour involved, implies very steady
application ou the part of the author; but there still remain
the two most difficult sections in the whole range of physiology,
the nervo-muscular apparatus and reproduction, to be consi-
dered ; these will, doubtless, occupy two if not three more
volumes; and allowing the same space of time between the appear-
ance of each, Dr. Flint will have concluded his labours at the
end of 1870, an interval of at least five years occurring between
the commencement and the termination of the same edition — a
period which is sufficient, as is actually the case with the exten-
sive subject of the nutrition, and microscopic anatomy of muscle,
very materially to modify the statements made in the earlier
parts of the work.

The first volume of Dr. Flint's treatise commences with a
description of the saliva and organic constituents of the body,
which, on the whole, is sufficiently good. The remarks on the
sugars may be taken as an example of the style of these intro-
ductory sections. After giving an account of the composition
and properties of the various saccharine substances met with in
the body and in the food, the several tests are fully given, in-
cluding Moore's, Trommer's, Barreswil's, Maumene's, the fer-
mentation test, and the evidence derived from the growth of
torulse. The origin and functions of sugar are then briefly dis-
cussed, and he concludes by remarking that, in the present state
of science, we are justified in saying that sugar is important
in the process of development and nutrition at all periods
of life, though the precise way in which it influences these
processes is not fully understood. Dr. Flint makes no men-

1868.]

Recent Works on Physiology^ ^c. 61

tion of Dr. Pavy^s observations in regard to glycogene, which
are certainly deserving of consideration, but holds with Bernard,
that sugar is " continually manufactured in the economy by the
liver, whence it is taken up by the blood passing through this
organ. It disappears from the blood in its passage through the
lungs. Sugar is found, then, in the economy constantly in the
substance of the liver, in the blood coming from the liver, and
in the blood of the right side of the heart ; and after the inges-
tion of saccharine or amylaceous articles of food in the blood of
the portal vein. It is not found in other organs, nor does it
normally exist in arterial blood.^^ A few of the details of the
introduction appear to us to be somewhat antiquated ; thus Dr.
Flint still admits the existence of margarine and margaric acids,
though it is now well known that the former is only a combina-
tion of tri-palmitin and tri-stearine. So also the essential albu-
minous constituent of muscle called by Dr. Flint museuline, and
by which we suppose syntonine is meant, is dismissed in a
dozen lines, no reference being made to myosin ; nor do we find
any mention made of myelin. The account of fibrine, again, is
scarcely up to the present time, no notice being taken of C.
Schmidt's important experiments, confirming and extending the
older ones of Dr. Buchanan, of Glasgow, and now very generally
admitted to the efifect that fibrine is composed of a fibrino-
genous and of a fibrino-plastic substance, both of which exist in
a free state in the blood during life ; but after death, or when
the blood has been removed from the body, and under various
other conditions, unite to form the coagulating material.

The remainder of the first volume is taken up with the blood,
circulation and respiration. To each of these is prefixed a
succinct and well-selected historical sketch, though we are
rather in doubt whether the space thus occupied might not
have been advantageously engaged with the consideration of
points of minute anatomy, that are only glanced at, or in giving
more fully the bearings of physiology on pathology and medi-
cine. Dr. Flint, in common with most modern microscopists,
holds that the red blood-corpuscles possess a perfectly homo-
geneous structure, presenting no nuclei or granules, and being
destitute of an investing membrane ; but we are surprised to
find he only alludes, in the most cursory manner, to the crystal-
lisation of the blood, the few lines devoted to it occurring in a
note, and the credit of their discovery being attributed to Sir
Everard Home, whilst their nature is most incorrectly given.
The importance that the forms of the crystals obtained from
blood-spots may possess in medico-legal investigations, apart
from the great interest attached to the crystallisation of a sub-
stance so nearly allied to albumen, should have led to its intro-

62

Reviews.

[July,

duction into the text, and to references to some more recent
chemical handbooks than those of Robin and Verdeil's ' Chemie
Anatomique' and Nysten's 'Dictionary/ published in 1858.
Dr.Flint has paid considerable attention to the various modes
of analysis of the blood, and gives the following as the result of
certain modifications which he has suggested.^ It will be seen
that it differs to a considerable extent from the tables given by
other observers. We have slightly condensed the propor-
tions of the salts. The blood was taken from a healthy male,
aged 27.

Com2)osition of the Blood.

Water

Corpuscles .....

Albumen .....

Fibrin . . .

Serolin ? .

Cholesterine .....

Oleate margarate and sfcearate of soda .
Chloride of sodium ....

Chloride of potassium (a trace) .

Phosphate of lime and magnesia, other salts, carbonate

' of soda being the most abundant
Iron ......

Extractives .....

154-870
495-590
329-820
8-820
0025
0-125
1-400

3-500

2-500
0-550
2-450

1000-000

For purposes of comparison, the fibrin, albumen, and cor-
puscles, were desiccated and weighed, giving the following
proportions of dry residue :

Fibrin . 2-50 parts per 1000 of fresh blood.
Albumen 71-53 „ „

Corpuscles 125-00 „ „

The chapter on circulation commences, as we have said, with
an historical sketch of the subject from the time of Hippocrates
to the present day, the foremost place being jvistly assigned to
Harvey, whose descriptions and experiments are freely quoted,
and acknowledged to be models of simplicity and pertinence.
The physiological anatomy of the heart is fully given, and refer-
ence made to the observations of Hiffelsheim and Robin, who
endeavoured to ascertain the capacity of the cavities by inject-
ing them with wax, in an animal recently killed, subsequently
calculating the amount of liquid displaced by the moulds. He
states that these observers found the capacity of the right
auricle and ventricle to be respectively from one tenth to one
third greater than the left auricle and ventricle; that the
capacity of each ventricle exceeded that of the corresponding
1 See also 'Amer. Journ. of Med. Sci.,' Oct., 1863.

1868.] Recent Works on Physiology, S^c. 63

auricle by from one fourth to one thirds and that the absolute
capacity of the left ventricle is from 4" 8 to 7 ounces ; but, he
continues, all we can say is that from observation on the heart
during its action, it never seems to contain much more than
half the quantity in all its cavities that it does when fully dis-
tended by injection ; but it is the right cavities which are most
dilatable, and probably the ordinary quantity of blood in the left
ventricle is within one fifth or one sixth of its extreme capacity.
In opposition to the statement of Kolliker, but, we think, cor-
rectly, Dr. Flint considers that the fibres of the heart are desti-
tute of sarcolemma; he gives the old drawing from Kolliker,
showing the anastomosing character of the fibres ; but since the
period at which the publication of the work has occurred, Eberth
has proved that the muscular fibres of the heart closely resembles
those of the unstriped variety, being broad, flat fibres, which are
branched and divided at their extremities, but the processes of
which do not actually fuse with one another. Several pages are
occupied with a discussion of Avhat was long ago clearly explained
by Dr. Halford, now professor of physiology at Melbourne,
namely, the apparent elongation and real shortening of the
heart's action, the apparent elongation being due to the elastic
recoil of the vessels at the base of the heart. As regards the
impulse, we are at issue with Dr. Flint, who describes it as pro-
duced by a direct blow from the apex of the heart. " If," he
says, " the impulse of the heart be felt while the finger is on
the pulse, it is evident that the heart strikes against the thorax
at the time of the distension of the arterial system. The im-
pulse is due to the locomotion of the ventricles;" and he quotes
an observation of Harvey's, to tlie effect that at the moment of
systole the heart is erected, and rises upwards to a point, so that
at this time it strikes against the breast, and the pulse is felt
externally. Notwithstanding the high authority of Harvey, we
are convinced, from personal observation, that there is no such
thing as a blow given by the heart against the parietes of the
chest, in the sense of the whole musculature of the organ being
withdrawn from the ribs, so as to leave a space in diastole, and
then being suddenly shot out in systole. It is simply a case of
suddenly increased pressure giving the impression of a blow,
the conditions being almost precisely identical with those which
are perceived when the finger is placed on the cheek, and the
masseter muscle is caused suddenly to contract. Moreover, the
sensation of a blow is occasioned, not by the apex, but by the
anterior surface of the heart, nearly an inch above the apex, the
apex, as Dr. Flint previously correctly states, being slightly
moved from left to right. The account of the succession and
duration of the movements of the heart is mainly taken from

64 Reviews. [July>

Marey and Chauveau, and he summarises their observations in
the following propositions ;

** Auricular Si/stole. — This occupies two tenths of the heart's
action. It is feeble compared with the ventricular systole, and re-
laxation immediately follows the contraction.

" Ventricular Si/stole. — This occupies four tenths of the heart's
action. The contraction is powerful, and the relaxation sudden. It
is absolutely synchronous with the impulse of the heart.

" Diastole. — This occupies four tenths of the heart's action."

In a recent essay by Bonders, translated in the January
number of the ' Dublin Medical Journal/ the whole period of
activity of the heart is estimated at rather less than one half
of an entire cardiac revolution ; the period of diastole would,
therefore^ be rather more than five tenths, the actual proportion
being as -428 : -572.

Dr. Flint points out what we do not remember to have else-
where seen any notice of — a safety-valve action at the orifice of
the pulmonary artery, which he believes to be as important as
that ascribed by King to the tricuspid valve, and, indeed, even
more important in protecting the lungs than the insufficiency of
the latter. It may be shown by cutting away a portion of the
ventricles in the heart of a large animal, securing the nozzles of
a double syringe in the aorta and pulmonary artery, and forcing
water into the vessels. In performing this experiment it will be
noticed that, while the aortic semilunar valves oppose the
passage of the liquids so efifectually that the aorta may be rup-
tured before the valves will give way, a considerable degree of
insufficiency exists, under a high pressure, at the orifice of the
pulmonary artery.

The relative duration of the sounds of the heart and of the
period of silence is stated to be such that the first sound occu-
pies the period of the ventricular systole or four tenths of the
heart's action, the second sound about three tenths, and the
repose three tenths. Perhaps this is accurate, though most of
the text-books consider the pause to occupy as much time as
the two sounds together.

The causes of the first sound are stated to be complex, and to
include the closure of the auriculo-ven1|ricuiar valves, the mus-
cular sound, and the impulse of the heart against the walls of
the thorax. These statements would drive Dr. Billing and Dr.
Halford nearly wild. These gentlemen would object to the
term " closure of the valves." In their opinion it is the sudden
tension, not the closure which has already occurred, of the
valves that produces the sound ; and they would deny alike the
muscular sound, and especially the impulse, seeing that the

1868.] Recent Works on Physiology, ^c. 65

heart never leaves the inner surface of the chest. There can be
no doubtj however, we think, that the muscular sound is a
genuine element of the first sound ; but we are disposed to
agree Avith them, in opposition to Dr. Flint, in ignoring the
impulse as a cause of sound, and in admitting the tension of the
valves as the essential cause of the first sound.

Dr. Flint, sen., Avhose essay gained the prize of the American
Medical Association in 1858, is of opinion that auscultatory ex-
periments may be made by which all but the valvular element
of the first sound may be eliminated, and the character of the
first sound is thus found to resemble that of the second.
Thus :

" 1. If a folded haukerchief be placed between the stethoscope and
integument, the first sound is divested of some of its most distinctive
features. It loses the quality of impulsion, and presents a well-
marked valvular quality.

" 2. In many instances, when the stethoscope is applied to the
pra?cordia, while the subject is in a recumbent posture, and the heart
by force of gravity is removed from the anterior wall of the thorax,
the first sound becomes purely valvular in character, and as short as
the second.

" 3. When the stethoscope is applied to the chest a little dis-
tance from the point where the first sound is heard with its maximum
of intensity, it will present only its valvular element."

Dr. Flint then quotes Chauveau and Faivre's experiment, in
which the first sound was abolished by the introduction of a
wire ring through a little opening in the auricle into the auriculo-
ventricular orifice, so arranged as to prevent the closure of the
valves. '^But,^' he continues, '' whilst these observations settle
beyond question the fact that the closure of the auriculo-
ventricular valves produces one element of the first sound, there
are other and less prominent elements which serve to give it
its prolonged and booming character.^' This, we confess, we
do not quite comprehend. It seems to us that if the first sound
of the heart is really abolished in Chauveau's experiments, the
heart still continuing to beat, there is no necessity for curiously
investigating the possibility of other causes, since this one, the
sudden tension of the auriculo-ventricular valves, has been shown
to be suiu.-'ient.

Dr. Flint sides with those who maintain that the activity of
the pneumogastrics is not affected by woorara, at least until a
much later period than the motor nerves of the body generally,
and he gives the following interesting experiment in support of
his views :

" Desiring to demonstrate to the class at the New Orleans School
83— xi.li. 5

66 Reviews, [July,

of Medicine the action of the heart in the alligator, a specimen, six
feet in length, was poisoned with woorara, and the heart exposed.
The animal came under the influence of the poison in about thirty
minutes, when the dissection was commenced, and was quite dead
when the heart was exposed, i The pneuraogastrics were then exposed
and galvanised, with the effect of promptly arresting the action of
the heart. This observation was verified in another experiment. "We
were at first at a loss to account for the absence of effect of the
woorara on the motor filaments of the pueumogastric nerves ; but on
reflection thought it might be due to slow absorption of the poison
in so large a cold-blooded animal. AYith a view of ascertaining whether
there is any difference in the promptness with which different nerves
in the body are affected by this agent, we made the following expe-
riment upon a dog. The animal was brought under the influence of
ether, and the heart, the pneumogastrics and the sciatic nerve were
exposed. Galvanisation of the sciatic produced muscular con-
traction, and of the pneumogastrics arrested the heart promptly. A
grain of woorara dissolved in water was then injected under the
skin of the thigh. One liour after the injection of the woorara the
sciatic was found insensible to the action of galvanism, but the
heart could be arrested by galvanisation of the pneumogastrics,
though it required a powerful current, A weaker current dimi-
nished the frequency, and increased the force of its pulsations. In
this experiment, the operation of opening the chest undoubtedly
diminished the activity of absorption of the poison, and consequently
retarded its effects upon the nervous system. Taken in connection
with the observations on alligators, it shows that the motor nerves
are not affected at the same time, and that the pneumogastrics resist
the action of this peculiar poison after the motor nerves generally
are paralysed. This shows a conservative provision of nature which
guards particularly the important influence exerted by these nerves
upon the heart."

In the description of the capillary system, we observe that
Dr. Flint denies the presence of an epitlielial lining to the
capillary, though this was proved to exist by Dr. Eherth in the
early part of 1865, and is now admitted by all microscopists,
since it may easily be shown by llecklinghausen's plan of in-
jection Avith nitrate of silver. He gives some important ex])eri-
nients corroborating the view of Dr. Keid, that in asphyxia the
blood experiences a difficulty in traversing the systemic capil-
laries. If the medulla oblongata of a frog be broken up, and
the capillary circulation of the web be watched, no important
change occurs ; but if the cutaneous surface be then coated with
collodion, excepting only the web under examination, an imme-
diate diminution in the rapidity of the circulation is observable,
and at the expiration of twenty minutes it will have wholly
ceased. If now the entire coating of collodion bo peeled off,
quite a rapid circulation commences, though it soon again

1868.] Recent Works on Physiology, S^c. 67

begins to decline, and in twenty minutes will have almost
ceased. These experiments, as Dr. Flint observes, taken in
connection with observations on the influence of asphyxia upon
the arterial pressure, conclusively show that non-aerated blood
cannot circulate freely in the systemic capillaries. At the same
time he is a disbeliever, and we are much disposed to agree
with him, notwithstanding the ingenious arguments adduced by
Dr. Carpenter and others in favour of the opposite view, that
there is any such thing as a capillary power. He believes that
physiologists generally M^ho have admitted this power have not
appreciated the action of the arterioles, the contractility of
Avhich is competent to produce all the variations which are
observed in the capillary circulation.

The section on Respiration contains little requiring notice
here. The author approves of and corroborates the views of
Dr. Sibson on the functions of the intercostal muscles, holds
with Kobin, we think incorrectly, that the black appearance of
the human lungs is due to the presence of carbon, which has
been inhaled and deposited in the parts where it is found, and
gives various original observations made by his father. In
reference to the auscultatory phenomena accompanying the act
of respiration. Dr. Flint has some interesting remarks, and has
made some original investigations on the location and cause of
the respiratory sense. He observes —

"1. If the chest be opened in a living animal, and artificial
respiration be carefully performed, inflating the lungs sufficiently
but cautiously, and taking care to change the air in the bellows
every few moments, as long as this is continued the animal will
make no respiratory effort, showing that for the time the respiratory
sense is abolished.

"2. "When the artificial respiration is interrupted, the respiratory
muscles are thrown into contraction, and the animal makes regular
and at last violent efforts. If we now expose an artery, and note
the colour of the blood as it flows, it will be observed that the
respiratory efforts only commence when the blood in the vessel
begins to be dark. "When artificial respiration is resumed, the
respiratory efforts cease only when the blood becomes red in the
arteries. The invariable result of this experiment seems to show
that the respiratory sense is connected with a supply of blood con-
taining little oxygen and charged with carbonic acid, to the systemic
capillaries by the arteries, and that it varies in intensity vrith the
degree of change in the blood.

"3. If while artificial respiration is regularly performed a large
artery be opened, and the system be thus drained of blood, when the
haemorrhage has proceeded to a certain extent the animal makes
respiratory efforts, which become more and more violent, until they
terminate just before death in general convulsions. The same result

68 Reviews. [July*

follows when the blood is prevented from getting to the system by-
applying a ligature to the aorta. These facts, which may be suc-
cessively observed in a single experiment, remain precisely the same
if we previously divide both pneumogastric nerves in the neck,
showing that these are by no means the only nerves which convey
the respiratory sense to the medulla oblongata. The conclusions
which may be legitimately drawn from the above-mentioned facts are
the following :

" The respiratory sense has its seat in the system, and is
transmitted to the medulla oblongata by the general sensory nerves.
It is not located in the lungs, for it operates when the lungs are
regularly filled with pure air, if the system be drained of the oxygen
carrying fluid. It is due to a want of oxygen on the part of the
system, and not to any fancied irritant properties of carbonic acid ;
for when the lungs are filled with air, and the system is gradually
drained of blood, though all the blood which finds its way to the
capillaries is fully oxygenated, as the quantity becomes insufficient
to supply the required amount of oxygen, the sense of want of air is
felt, and respiratory efforts take place. The experimental results on
which these conclusions are based are invariable, and have been
demonstrated repeatedly ; so that the location of the respiratory
sense in the general system, and the fact that it is the expression of
a want of oxygen, seem as certain as that oxygen is taken up by the
blood from the lungs, and distributed to the tissues by the arteries.
With this view we can explain all the reflex phenomena, which are
connected with the respiratory function.

" The supposition of Berard, that the respiratory sense is due to
distension of the right cavities of the heart, is disproved by the
simple experiment of sudden excision of this organ. In that
case, as the system is drained of blood, eff'orts at respiration
invariably take place, though the supply of air to the lungs be
continued,"

In the second volume of his work Dr. Flint treats of alimen-
tation, digestion, and absorpiion, and of the lymph and chyle. He
commences -with a general account of hunger and thirst, and of the
nature of the different kinds of food in which the sugars, oils, and
albuminous compounds are again considered, but in reference
only to their dietetic characters; and two excellent chapters follow
on compound alimentary substances in which the comparative
value of meals, eggs, milk, and animal food generally, is con-
trasted ititer se, and with the various kinds of vegetable diet ;
whilst full consideration is given to the various beverages in
common use. He remarks that " the flesh of various non-
domesticated animals is esteemed highly as food. In some parts
of this country buffalo meat is largely used. This is somewhat
coarser and of a more decided flavour than beef, but does not
differ in its physiological properties. Venison is a meat very
highly esteemed. This resembles mutton, but as a constant

1868.]

Recent Works on Physiology, ^c. 69

article of diet is by no means as agreeable. The flesh of the
■svild boar is used as food in many European countries. It is
darker and more highly flavoured than ordinary pork, and is
generally regarded as a delicacy. In tliis country the racoon
(Procyon lotor), the woodchuck (Arctomys monax), and tho
opossum (l)idelpliys Virginiana), are occasionally eaten. These
can hardly be ranked among the delicate varieties of game.
They are not, however, unpalatable, but are excessively fat."

In regard to the use of alcohol. Dr. Flint holds with MM.
Lallemand, Duroy, and Perrin, and in opposition to Dr. Anstie,
that a considerable proportion of alcohol ingested into the
stomach is eliminated by the skin, lungs, and kidneys. He
considers there can be no doubt that it may temporarily give
tone and vigour to the system when the energies are unusually
taxed, and that it retards the destructive assimilation of the
tissues ; but that it cannot be regarded as an alimentary prin-
ciple, that if its use be long continued it weakens the assimilative
power of the system, and that under ordinary conditions, where
the organism can be adequately supplied with food, it is un-
doubtedly injurious. He states that " in many parts of the
United States the manufacture of wine from native gi-apes has
assumed considerable importance. The Catawba wines of Ohio,
the California, and the North Carolina wines have become quite
celebrated. Though these are of rich flavour, and possess many
good qualities, it Avill be many years before wine can be pro-
duced in this country equal in delicacy to the products of tlie
vineyards of the old world."

In his observations on mastication Dr. Flint states that the
upper jaw undergoes a slight movement of elevation in opening
the mouth ; which becomes somewhat exaggerated when the
mouth is opened to the fullest possible extent, and he refers to an
experiment suggested to Monro by Pringle, namely, that if the
blade of a knife be so placed as to correspond exactly with the
line of contact of the teeth, it may be observed in a mirror that
the upper teeth are sensibly elevated every time the mouth is
opened. This movement, he considers, may bo partially effected
by the posterior belly of the digastric, but probably, also, by the
contraction of muscles placed too deeply to be explored experi-
mentally, but is certainly not due to the contraction of those of
the posterior muscles of the back, Avhich have for their chief
function the elevation of the head.

The account of the saliva and of the act of deglutition are very
fully and completely given, and there is little to add to them.

The description of the stomach, gastric juice, and gastric
digestion is exceedingly good, the only point of importance
omitted being, Ave think, the characters of pepsine itself and

70 Reviews. [J"ly>

the mode iii which it may he obtained by precipitation succes-
sively with phosphate of lime and with cholesterine. The
question of the nature of the acid of the gastric juice, which is
treated of at considerable length, is admitted to be still doubtful.
" On what," he remarks, " does the acidity of the gastric juice
depend? This is the simple question to which the foregoing
discussion naturally leads, and it is one which can be answered
almost with positiveness, though it is not settled to the satis-
faction of all physiologists, since there are some conflicting
observations which can be harmonised only by new researches.
Aside from the conditions under which acids, such as the
acetic, butyric, or the lactic are developed from articles of food
taken into the stomach, the evidence is strongly in favour of
free lactic acid as the principle on which the gastric juice
mainly and constantly depends for its acidity. There also exists
a certain proportion of the biphosphate of lime, and this is the
only condition in Avhich a phosphate of lime can exist in the
presence of free lactic acid. The observations of Bidder and
Schmidt indicate apparently a quantity of chlorine in the gastric
juice, not to be accounted for by the pi'oportion of bases obtained
by ultimate analysis. There is evidence sufficiently positive to
show that there is no hydrochloric acid in the gastric juice in a
condition Avhich allows the fluid to present the reactions which
are observed when the acid exists in a free state. If there be
any hydrochloric acid not in combination with metallic bases, it
is united with organic matter in such a way as to prevent the
manifestations of its ordinary properties, excepting that of
acidity. The fact that some of the mineral acids can be made
to unite in this way with albuminoid substances lends colour to
this supposition ; although further investigations are necessary
to demonstrate that this takes place in the gastric juice."

The section on the nature and properties of the bile is very
well drawn up, and some valuable experiments, which it is
interesting to compare with those of Dr. Dalton, are given. In
one case, after the formation of a biliary fistula in a dog, the abdo-
men was somewhat tumid, with some rumbling in the bowels for
five days. " The first alvine discharge took place on the even-
ing of the second day. The faeces seemed in all regards normal.
After that time they became very infrequent, though the animal
ate very well every day. The fseces that were passed after the
third day were of a greyish colour and moderately soft. They
had an exceedingly offensive and penetrating odour. At about
the fifteenth day the faeces became more frequent, and from
that time were passed three or four times a day. Generally
they were clay-coloured, but on one or two occasions Avere
quite dark. They ahvays had a peculiarly offensive odour ; the

1868.] Becent Works on Physiology, S^c. 71

weight of the animal remained stationary for about four days."
It then, with some interruptions, progressively diminished until
death occurred thirty-eight days after the operation, the loss
of weight amounting altogether to 37|^ per cent. His appetite
was good throughout, and towards the later periods ravenous.
He also became very cross, snapping at every animal that came
near him ; but there never was any icterus, foetor of the breath,
or falling off of the hair.

In reference to the variations in the flow of bile with diges-
tion, he gives a table in which are set doAvn the quantities of
bile discharged in thirty minutes at various periods after feeding,
and he gives the following conclusions. Disregarding slight
variations which might be accidental, " it may be stated in
general terms that the bile commences to increase in quantity
immediately after eating, that its flow is at its maximum from
the second to the eighth hour, during which time the quantity
does hot vary to any great extent; after the eighth hour it
begins to diminish ; and from the twelfth hour to the time of
feeding it is at its maximum. The experiments of Dr. Dal ton,
made on a dog with a fistula i"nto the duodenum, show that the
bile passes into the intestine in by far the largest quantity imme-
diately after feeding, and within the first hour." Dr. Flint
adds in a note that, according to Bidder and Schmidt, the flow
begins to increase about two hours after feeding, its maximum
being from twelve to fifteen hours after ; whilst Arnold found
the maximum to occur soon after feeding, decreasing after the
fourth hour, and Kolliker and Miiller found the maximum to be
between the sixth and eighth hours.

We observe that Dr. Flint does not mention Dr. Brinton's
views on the nature of antiperistaltic action, but he gives a good
account of vomiting ; and here, as elsewhere, he seems to have
very conscientiously referred to original authorities, and is thus
enabled not unfrequently to rectify errors that have appeared in
edition after edition of other well-known works.

Considering the importance of the epithelial cells covering
the villi, Ave are somewhat surprised to find no description of
their peculiarities. It is a subject that is at the present time
attracting much attention, and recent researches and micro-
scopical investigations Avill, doubtless, lead to very important
modifications of the modern views respecting the nature of
absorption.

After noticing excretine. Dr. Flint gives an interesting de-
scription of a new substance, to Avhich he has applied the term
''stercorine :"

" This principle, which we discovered in the faeces in 1862, was

72 Reviews, [July^

described by Boudet in 1833, as existing in excessively minute
quantity in tbe serum of the blood, aud Avas called by him seroline.
As we found it to be tbe most abundant and characteristic consti-
tuent of the stercoraceous matter, we proposed to call it stercorine,
particularly as our researches led us to the opinion that it really
does not exist in the serum, but is formed from cholesterine by the
processes employed for its extraction. Stercorine may be extracted
in the following way : the fseces are first evaporated to dryness, pul-
verised, and treated with etber. The ether extract is then passed
through animal charcoal, fresh ether being added until the original
quantity of the ether extract has passed through. * * * The ether is
then evaporated, and the residue extracted with boiling alcohol.
This alcoholic solution is evaporated, and the residue treated with a
solution of caustic potash for one or two hours at a temperature a
little below the boiling point, by which all the saponifiable fats are
dissolved. The mixture is then largely diluted with water thrown
upon a filter, and washed until the fluid that passes through is
neutral and perfectly clear. Tbe filter is then carefully dried, and
the residue washed out with ether. The ether solution is then
evaporated, extracted with boiling alcohol, and the alcoholic
solution evaporated. The residue of this last evaporation is pure
stercorine.

" When first obtained, the stercorine is a clear, slightly amber-
coloured, oily substance, about the consistence of the Canada
balsam used in microscopical preparations. In four or five days it
begins to show the characteristic crystals. These are few in number
at first, but soon tlie entire mass assumes a crystalline form. In
our analysis we obtained from seven and a half ounces of normal
human fajces (the entire quantity for the twenty-four hours), 10'417
grains of stercorine, the extract consisting of nothing but crystals.
This was all the stercorine to be extracted from the regular daily
evacuation of a healthy male twenty-six years of age, and weighing
about 160 lbs. In the absence of other investigations, the daily
quantity of this substance excreted may be assumed to be not far
I'rom ten grains. In many regards stercorine bears a close re-
semblance to cholesterine. It is neutral, inodorous, and insoluble
in water and in a solution of potash. It is soluble in ether and hot
alcohol, but is almost insoluble in cold alcohol. A red colour is
produced when it is treated with strong sulphuric acid. It may be
easily distinguished from cholesterine, however, by the form of its
crystals. It fuses at a low temperature, 96*8 Fahr., while cho-
lesterine fuses at 293° Fahr. Stercorine crystallises in the form of
thin delicate needles, frequently mixed with clear rounded globules,
which are probably composed of the same substance in a non-crys-
talline form. When the crystals are of considerable size, the borders
near their extremities are split longitudinally for a short distance.
The crystals are frequently arranged in bundles. These crystals^
cannot be confounded with excretine which crystallises in the form

* Of which Dr. Flint gives drawings.

18G3.] Recent fVcrks on Physiology, ^r, 73

of regular 4-sided prisms, nor with the thin rhomboidal or rectan-
gular tablets of cholesteriue. They are identical with the crystals of
seroline figured by Eobin and Verdeil.

" There can be no doubt with regard to the origin of the sterco-
rine which exists in the faeces. We have found that whenever the
bile is not discharged into the duodenum, as is probably the case,
for a time, in icterus, accompanied with clay-coloured evacuation,
stercorine is not to be discovered in the ejections. In one case of
this kind in which the faeces were subjected to examination, the
matters extracted with hot alcohol were entirely dissolved by boiling
for fifteen minutes witii a solution of potash, showing the absence of
cholesterine and stercorine. In another examination of the faeces
from this patient, made nineteen days after, when the icterus had
almost entirely disappeared, and the evacuations had become normal,
stercorine was discovered. Taking the estimates which have been
made of the entire quantity of bile discharged into the intestine in
the twenty-four hours by Bidder, Schmidt, and Dalton, a com-
parison of the total quantity of cholesterine contained in the bile,
with the quantity of stercorine actually discharged, shows a cor-
respondence which serves as an additional argument in favour of the
view that stercorine is formed from a modification of cholesterine in
its passage along the intestinal canal. These facts show conclu-
sively that the cholesterine of the bile, in its passage through the
intestine, is changed into stercorine. Both of these principles are
crystalline, non-saponifiable, are extracted by the same chemical
manipulations, and behave in the same way when treated with
sulphuric acid. The stercorine must be regarded as a slight modi-
fication of cholesterine, the excrementitious principle of the bile.
We have found that the change of cholesterine into stercorine is
directly connected with the process of intestinal digestion. If an
animal be kept for some days without food, cholesterine will bo
fo;ind in the fseces, though for a few days stercorine is also present.
It is generally recognised by those who have analysed the fseces,
that cholesterine does not exist in the normal evacuations ; but
whenever digestion is arrested, the bile being constantly discharged
into the duodenum, cholesterine is found in large quantity. For
example, in hybernating animals cholesterine is always present in
the fseces. The same is true of the contents of the intestines during
foetal life ; the meconium always containing a large quantity of
cholesterine, which disappears from the evacuations when the digestive
functions become established."

The following extract from an official report by Dr. Jones,
dated Oct. 19th, 1864, respecting the condition of the Federal
prisoners in the Southern prisons, is so interesting and instruc-
tive, not only in a physiological but in a medical point of view,
that we shall not hesitate to extract it :

"Immediately after the brief report upon hospital gangrene had
been forwarded to the surgeon general, Dr. Jones repaired to Camp
Sumpter, Andersonville, Georgia, and instituted a series of investi-

74 Revieios. [July»

gations upon the diseases of the Federal prisoners. The field was of
great extent and of extraordinary interest. There were more than
5000 seriously sick in the hospital and stockade, and the deaths
ranged from 90 to 130 each day. Since the establishment of this
prison on the 2ith Feb., 1864, to the present time (19th Oct.,
1864), over 10,000 Federal prisoners have died ; that is, nearly one
third of the entire number have perished in less than seven months.
Dr. Jones instituted careful investigations into the condition of the
sick and well, and performed numerous post-mortem examinations,
and executed drawings of the diseased structures. The medical
topography of Andersonville and the surrounding country was
examined, and the waters of the springs, streams, and wells, around
and within the stockade and hospital carefully analysed. Diarrhoea,
dysentery, scurvy, and hospital gangrene, were the diseases which
have been the main causes of the extraordinary mortality. The
origin and causes of the hospital gangrene which prevailed to so
remarkable a degree and with such fatal effects amongst the Federal
prisoners, engaged his most serious and earnest consideration. More
than 30,000 men crowded upon twenty-seven acres of land, with
little or no shelter from the intense heat of a southern summer, or
from the rain and dew, with coarse corn bread from which the husk
had not been removed, with scant supplies of fresh meat and vege-
tables, with little or no attention to hygiene, with festering masses of
filth at the very doors of their rude dens and huts, with the greater
portion of the banks of the stream flowing through the stockade, a
filthy quagmire of human excrements alive with working maggots,
generating by their own filthy exhalations and excretions an
atmosphere that so deteriorated and contaminated their solids and
fluids, that the slightest scratch of the surface, even the bites of
small insects, were frequently followed by such rapid and extensive
gangrene, as to destroy extremities and even life itself A large
number of operations had been performed in the hospital on account
of gangrene following slight injuries and mere abrasions of the sur-
face. In almost every case of amputation for gangrene, the disease
returned, and a large proportion of the cases terminated fatally. * * *
The rations consisted of one third of a pound of bacon with one pound
and a quarter of meal. The meal was unbolted, and when baked the
bread was coarse and irritating, producing diseases of the organs of
the digestive system (diarrhoea and dysentery). The absence of
vegetable diet produced scurvy to an alarming extent, especially
among the old prisoners. * * * From the sameness of the food, and
from the action of the poisonous gases in the densely crowded and
filthy stockade and hospital, the blood was altered in its constitution,
even before the manifestation of actual disease. In both the well and
the sick the red corpuscles were diminished, and in all diseases
uncomplicated with inflammation the fibrinous element was defi-
cient. In cases of ulceration of the mucous membrane of the
intestinal canal, the fibrinous element of the blood appeared to be
increased, whilst in simple diarrhoea, uncomplicated with ulceration,
and dependent upon the character of the food and the existence of

1868.]

Recent Works on Physiology, 3fc. 75

scurvy, it was either diminished or remained stationary. Heart-clots
were very common, if not universally present, in the cases of
ulceration of the intestinal mucous membrane, whilst in the uncom-
plicated cases of diarrhoea and scurvy the blood was fluid, and did
not coagulate readily ; and the heart-clots and fibrinous concretions
were almost universally absent. From the watery condition of the
blood, there resulted various serous efi"usions into the peincardium,
into the ventricles of the brain, and into the abdominal cavity. * * *
The Federal prisoners, as a general rule, had been reared upon wheat
bread and Irish potatoes, and the Indian corn so extensively used in
the South was almost unknown to them as an article of diet previous
to their capture. Owing to the impossibility of obtaining the
necessary sieves in the Confederacy, for the separation of the husk
from the corn meal, the rations of the Confederate soldiers, as well
as of the Federal prisoners, consisted of unbolted corn flour, and
meal, and grist. This circumstance rendered the corn bread still
more disagreeable and distasteful to the Federal prisoners. Whilst
Indian meal, even when prepared with the husk, is one of the most
wholesome and nutritious forms of food, as has been clearly shown
by the health and rapid increase of the Southern population, and
especially of the negroes previous to the present war, and by the
strength, endurance, and activity of the Confederate soldiers, who
were throughout the war confined, to a great extent, to unbolted
corn flour ; it is nevertheless true that those who have not been
reared upon corn meal, or who have not accustomed themselves to
its use gradually, become excessively tired of this kind of diet, when
suddenly confined to it without a due proportion of wheat bread.
Large numbers of the Federal prisoners appeared to be utterly dis-
gusted with Indian corn, and immense piles of corn bread could be
seen in the stockade and hospital enclosures. Those who were so
disgusted with this form of food that they had no appetite to par-
take of it, except in quantities insufficient to supply the waste of the
tissues, were of course in the condition of men slowly starving, not-
withstanding that the only farinaceous form of 'food which the
Confederate states produced in sufficient abundance for the main-
tenance of armies was not withheld from them. In such cases an
urgent feeling of hunger was not a prominent symptom ; and even
where it existed at first it soon disappeared, and was succeeded by
an actual loathing of food. In this state the muscular strength was
rapidly diminished, the tissues wasted, and the thin skeleton-like
forms moved about with the appearance of utter exhaustion and
dejection. The mental condition connected with long confinement,
with the most miserable surroundings, and with no hope for the
future, also depressed all the nervous and vital actions, and was
especially active in destroying the appetite. The eflfects of mental
depression and of defective nutrition were manifested, not only in
the slow feeble motions of the wasted skeleton-like forms, but also
in such lethargy, listlessness, and torpor of the mental faculties, as
rendered these unfortunate men oblivious and indifferent to their
afflicted condition. In many cases even of the greatest apparent

76 Reviews, [July,

suffering and distress, instead of showing any anxiety to communi-
cate the causes of their distress, or to relate their privations and their
longings for their homes and for their friends and relations, they
lay in a listless lethargic uncomplaining state, taking no notice
either of their own distressed condition or of the gigantic mass of
human misery by which they were surrounded. Nothing was so
appalling and depressing as this silent uncomplaining misery. It is
a fact of great interest, that notwithstanding this defective nutrition
in men subjected to crowding and filth, contagious fevers were rare,
and typhus fever, which is supposed to be generated in just such a
state of things as existed at Andersonville, tvas unlcnown. Neuralgia
and malarial fever were also very rare."

What a picture of the horrors of war ! Dr. Flint also quotes
another report by Prof. Wallace, by which it appears that the
rations in the Southern prisons, when at the maximum, con-
sisted only of half a pint of soup, containing about ^ oz. of
beans or peas or sweet potatoes, 10 oz. of bread, and 6 oz. of
beef; whilst the minimum amounted to 4 oz, of bread and 1 oz.
of beef, a quantity far too small to sustain life. One of the
most remarkable effects produced by this diet was the feeble
power of resisting cold — frostbite and gangrene of the extremi-
ties being very frequent even in the mild climate of the south.

We must here conclude our notice of Dr. Flint's work. The
description we have given of it, as well as the numerous extracts
we have taken from it, will enable our readers to judge not only
of its plan and scope, but also of its execution, and we trust
soon to see the remaining parts. It is printed on agreeably
toned paper \A'ith good type. It is singular amongst modern
works on physiology in containing only some half dozen wood-
cuts, the reason of the introduction of which, to the exclusion
of others of at least equal value,we are unable to see.

Respecting Dr. Dalton's work, which has reached its fourth
edition (a tolerably good evidence of the estimation in which it
is held) our comments must necessarily be brief. In many parts
excellent, and in some superior, to any other treatise on phy-
siology, it is with regret that we find some of the sections
dismissed with a brevity Avholly disproportioned to their im-
portance. Thus the entire subject of the circulation, including
the physiology of the heart, arteries, capillaries, and veins,
occupies only forty-two pages ; as a consequence, some very
important topics are omitted altogether, whilst others are
scarcely more than alluded to. Not a word is said respecting
the nervous supply of the heart, and the experiments of Weber
V. Bezold, Ludwig, and a host of other writers, are wholly
ignored. The account of the venous system, again, is singularly
imperfect. The author unintentionally, no doubt, leaves the

1868.] Recent Worlcs on Physiology, &^c. 77

impression that the heart has little to do with the passage of the
blood through the veins, the circulation in this part of the vascular
system being stated to be essentially maintained by the combined
action of the following forces : 1. The force of the aspiration of
the thorax, the influence of which in the normal movements of
respiration extends to the farthest extremities of the venous
system; yet he admits that in forced or laborious respiration the
movements do not assist, and may retard, the flow of blood ;
^3. The contractions of the voluntary muscles ; and, 3. The force
of the capillary circulation, which he considers to be the most
important of all, as it is the only one which is constantly and
universally acting. We presume that Dr. Dalton refers the
force of the capillary circulation to the force primarily derived
from the heart ; but as many physiologists still hold that there
is a certain force in the capillaries derived from a mutual action
and reaction taking place between the blood and the tissues, the
importance of the cardiac force should have been more clearly
expressed. We do not find any notice of the pressure of the blood
in the veins, nor any remark on the eff'ects of the introduction
of air into them, one of those points of physiological interest
which has so immediate a bearing on surgical practice that it
should at least have been alluded to.

The whole subject of respiration is despatched with equal
brevity with that of the circulation in barely twenty pages, and
there are some inaccuracies. The bronchial ramifications are
stated to be l-25th instead of l-50thof an inch in diameter, and
the average size of the air-vesicles is given at 1-75, though this
is really the maximum. Dr. Dalton holds that the external and
internal intercostals alike minister to the act of inspiration, which
is in accordance with the older views, and is now admitted by
most writers of eminence. The estimate given for the total
amount of air inspired per diem, 600,000 c. i., is certainly below
the average, or at least holds only for a man at perfect rest. He
adopts the curious and wholly unnecessary supposition that the
interchange of air entering, with that already contained within
the lungs, is assisted by the vibratile action of the cilia lining
the tubes. It may indeed be assisted, but it must be to an
infinitesimal extent only, since the cilia are extremely short and
are immersed in the fluids which cover the bronchial membrane.
The old experiments of Magnus, which are very incorrect, are
referred to in speaking of the amount of oxygen and carbonic
acid in arterial and venous blood respectively ; whilst no allusion
is made to the more recent, and far more trustworthy, observa-
tions of Meyer, Schrofier, Setschenow, and others ; and it is stated
that both these gases are in solution in the blood-globules, and
not in the plasma ; whilst it is now well known that it is only

78 Reviews. [July^

the oxygen that is combined with the corpuscles, the carbonic
acid being contained in the plasma, either in the state of bicar-
bonate of soda or as a compound of phosphate of soda and
carbonic acid. Lastly, the experiments of Dr. Edward Smith
appear to have been entirely overlooked, though without question
they constitute, on some points in the physiology of respiration,
the most important that have as yet appeared, and materially
modify the conclusions arrived at by Andral, Gavarret, and
others, whose calculations were made at a time when animal
chemistry was almost in its infancy. We have noted these
defects in Dr. Dalton's work somewhat pointedly, because the
remainder of the book is ftir above the average.

The subject of the bile and the whole section of reproduction
are admirably written, and the woodcuts, of which no less than
266 out of a total of 274 are original, are extremely well done.
The section on reproduction embraces eighteen chapters, and
commences with a short account of the nature of reproduction,
and of the origin of plants and animals, in which he makes a
vigorous attack upon the doctrine of spontaneous generation.
He states, on Prof. Wyman's authority, that although infusoria
will make their appearance in infusions of animal and vegetable
substances which have been boiled at the ordinary temperature
of the air, for periods varying from fifteen minutes to two hours,
in glass vessels so arranged that the atmospheric air could only
gain access to their interior through tubes filled with red-hot
iron wire, yet that the appearance of such infusorial life is
absolutely prevented by exposure of the organic solution to
ordinary boiling for four hours, or to boiling for fifteen minutes
under a pressure of five atmospheres. The observation of Dr.
Mitchell which is also referred to is curious, to the effect that
vibriones will grow and thrive in the venom of the rattlesnake,
Avhen beginning to putrefy, and when it is still a deadly poison
to all the higher animals.

To this follows a description of the egg in the various classes
of the animal kingdom, and the mode of its discharge ; the
structure of the spermatozoa, and the function of menstruation ;
the formation of the corpus luteum is excellently described and
depicted as it presents itself both in the virgin and in the
impregnated uterus.

Then comes an account of the segmentation of the vitellus
and the further process of development in the frog, the mode in
which the umbilical vesicle appears in fish, and the amnios and
allantois in the chick, and finally the development of the
chorion in the human subject. The remainder of the section is
occupied with the changes that take place in the uterus, the
formation of the placenta, and lastly the development of the

1868.]

Recent Works on Physiology , §-c. 79

several organs. This, in our opinion, is the proper way to teach
this difficult subject, and we venture to make one extract from
Dr. Dal ton's work, Avhich Ave are sure will induce many of our
readers to purchase the work for themselves and master its
contents :

" Amnion and AUantois. — We sliall now proceed to the description
of two other accessory organs which are formed, during the deve-
lopment of the fecundated egg, in all the higher classes of animals.
These are the amnion and allantois ; two organs which are always
found in comj^any with each other, since the object of the first is to
provide for the formation of the second. The amnion is formed
from the external layer of the blastodermic membrane, the allantois
from the internal layer. In the frog and in fish, as we have seen,
the egg is abundantly supplied with moisture, air, and nourishment,
by the water with which it is surrounded. It can absorb directly all
the gaseous and liquid substances which it requires for the purposes
of nutrition and growth. The absorption of oxygen, the exhalation
of carbonic acid, and the imbibition of albuminous and other liquids,
can all take place without difficulty through the simple membranes
of the egg, particularly as the time required for the formation of the
embryo is very short, and as a great part of the process of develop-
ment remains to be accomplished after the young animal leaves the
egg. But in birds and quadrupeds the time required for the deve-
lopment of the foetus is longer. The young animal also acquires a
much more perfect organization during the time that it remains
inclosed within the egg ; and the processes of absorption and ex-
halation necessary for its growth, being increased in activity to a
corresponding degree, require a special organ for their accomplish-
ment. This special organ, destined to bring the blood of the foetus
into relation with the atmosphere and external sources of nutrition,
is the allantois.

" In the frog and the fish, the internal blastodermic layer, forming
the intestinal mucous membrane, is enclosed everywhere, as above
described, by the external layer forming the integument ; and, con-
sequently, it can nowhere come in contact with the investing mem-
brane of the egg. But in the higher animals the internal blastodermic
layer, which is the seat of the greatest vascularity, and which is
destined to produce the allantois, is made to come in contact with
the external membrane of the egg for purposes of exhalation and
absorption, and this can only be accomplished by opening a passage
for it through the external germination layer. This is done in the
following manner by the formation of the amnion.

" Soon after the body of the foetus has begun to be formed by the
thickening of the external layer of the blastodermic membrane, a
double fold of this external layer rises up on all sides about the edges
of the newly-formed embryo, so that the body of the foetus appears
as if sunk in a kind of depression, and surrounded with a mem-
branous ridge or embankment as in fig. 1. The embryo c is here
seen in profile with the double membranous folds above mentioned,
rising up just iu odvance of the head and behind the posterior

80 Reviews. [July,

extremity. It must be understood of course that the same thing
takes place on the two sides of the foetus, by the formation of lateral

Fia. 1.

Diagram of fecundated egg, sliowiug fonnation of amnion,

a. Vitellus. b. External layer of blastodermic membrane, c. Body of embryo.

d d. Amniotic folds, e. Vitelline membrane.

folds simultaneously with the appearance of those in front and
behind. Aa it is these folds which are destined to form the amnion,
they are called the ' amniotic folds.'

" The amniotic folds continue to grow and extend themselves for-
wards, backwards, and laterally, until they approach each other at a
point over the back of the foetus (fig. 2), which is termed the
' amniotic umbilicus.' Their opposite edges afterward actually come
in contact with each other at this point, and adhere together, so as
to shut in a space or cavity (fig. 2 b), between their inner surfaces
and the body of the foetus. This space, which is filled with a clear
fluid, is called the amniotic cavity. At the same time the intestinal
canal has begun to be formed, and the umbilical vesicle has been
partially separated from it by the constriction of the abdominal walls
on the under surface of the body.

" There now appears a prolongation or diverticulum (fig. 2 c)
growing out from the posterior portion of the intestinal canal, and
following the course of the amniotic fold which has preceded it,
occupying it as it gradually enlarges and protrudes the space left
vacant by the rising of the amniotic fold. This diverticulum is the
commencement of the allantois. It is an elongated membranous sac,
continuous with the posterior portion of the intestine, and containing
blood-vessels derived from those of the intestinal circulation.
The cavity of the allantois is also continuous with the cavity of the
intestine.

" After the amniotic folds have approached and touched each
other, as already described, over tlie back of the foetus, at the
amniotic umbilicus, the adjacent surfaces thus brought into contact
fuse together, so that the cavities of the two folds, coming re-
spectively from front and rear, are separated only by a single mem-
branous partition (fig. 3 c) running from the inner to the outer
lamina of the amniotic folds. This partition itself soon after atrophies
and disappears, and the inner and outer lamina become consequently
separated from each other. The inner lamina (fig. 3 a), which
remains continuous with the integument of the foetus, inclosing the

1868.J Recent Works 07i Physiology, ^c. 81

body of the embryo in a distinct cavity, is called the amnion (fig.
4 b), and its cavity is known as the amniotic cavity. The outer lamina
of the amniotic fold, on the other hand (fig. 3 5), recedes farther
and farther from the inner, until it comes in contact with the

Fig. 2. Fig. 3.

Fig. 2.— Fticundated egg, farther advanced, a. Umbilical vesicle, b. Amniotic

cavity, c. Allantois.
Fig. 3. — Fecundated egg with allantois nearly completed, a. Inner lamina of

amniotic fold. b. Outer lamina of ditto, c. Point where the amniotic

folds come in contact. The allantois is seen penetrating between the inner

and outer laminae of the amniotic fold.

original vitelline membrane, still covering the exterior of the egg ;
and by continued growth and expansion it at last fuses with the
vitelline membrane, and unites with its substance, so that the two
membranes form but one. This membrane, formed by the fusion
and consolidation of two others, constitutes then the external invest-
ing membrane of the egg.

" The allantois during all this time is increasing in size and vas-
cularity. Following the course of the amniotic folds as before, it
insinuates itself between them, and of course soon comes in contact
with the external investing membrane just described. It then
begins to expand laterally in every direction, enveloping more and
more the body of the foetus, and bringing its vessels into contact
with the external membrane of the egg. By a continuation of the
above process, the allantois at last grows to such an extent as to
envelope completely the body of the embryo, together with the
amnion, its two extremities coming in contact with each other, and
fusing together over the back of the foetus, just as the amniotic folds
had previously done. It lines, therefore, the whole internal surface
of the investing membrane with a flattened vascular sac, the
vessels of wliich come from the interior of the body of the foetus,
and which still communicates with the cavity of the intestinal
canal.

" It is evident from the above description that there is a close
connection between the formation of the amnion and that of the
allantois. For it is only in this manner that the allantois, which is
an extension of the internal layer of the blastodermic membrane,
can come to be situated outside the foetus and the amnion, and be
brought into relation with external surrounding media. The two
laminse of the amniotic folds, in fact, by separating from each other

83— xLii. 6

^2 tlevieivs, [July,

as above described, opeu a passage for the allantois, aud allow it to
come in contact witli the external membi-ane of the egg."

Such writing as this, we repeat, is deserving of all praise. It
is eminently intelligible, perfectly correct, and, considering the
difficulty of the subject, very concise. If Dr. Dalton would
work up the other sections of his book to the same extent as this
we should be inclined to concede to him the palm of having
written the most readable book on physiology extant.

AVe have read Mr. Marshall's work through with great care,
and we may add with great pleasure. Taking it altogether, it is
one of the most complete treatises on physiology we possess, and it
is surprising how much information is here compressed into the
compass of two moderate-sized volumes. Not limiting himself
to human and comparative physiology alone, as the title of the
Avork might lead one to expect, Mr. Marshall has introduced
a succinct but clear outline of the anatomy of the body of the
various vertebrate and invertebrate classes, a very good account
of the microscopical appearance of the different tissues, and an
excellent summary of the results of modern histo-chemicul
research. Nor is the vegetable kingdom wholly passed over, a
section being devoted to the consideration of the general struc-
ture and functions of plants, which are instructively compared
with those of animals.

The first volume is occupied with the consideration of general
physiology, including the vital properties of the tissues and the
relations of man to external nature ; with the minute anatomy
of the textures ; and chiefly with the animal functions, motion,
and sensation, including voice and speech. The second volume
embraces the vegetative functions and reproduction. The plan
adopted in regard to each section is to give first the general
anatomical features, then the physics and chemistry of the
organ Avhen practicable or requisite, then the pure physiology
with the relations that may exist to pathology, and finally the
comparative anatomy. Thus, under the head of respiration, we
find successively considered the organs of respiration, includ-
ing the general and minute anatomy of the thorax, trachea,
bronchi, and lungs ; the mechanism of respiration, where we
may note in passing that Mr. Marshall agrees with those who
hold that the external intercostals and a small portion of the
internal are muscles of inspiration, whilst the remaining pos-
terior portion of the internal intercostals, including the greater
part of their fibres, are muscles of expiration ; the movement
and sounds of the air in respiration and the capacity of the
lungs ; the changes in the air resulting from respiration ; the
effects of respiration on the blood and tissues, in which Prof.

1868. J Recent Works on Physiology, ^c. 83

Stokes' experiments are capitally summed up; the geneial
theory of respiration, including the consideration of the two
points, in what part of the circulation, and at the expense of
what constituents of the hlood and tissues does the oxygen
absorbed in respiration become united with carbon to produce
the carbonic acid given off; the conditions which modify the
chemical processes of respiration, as purity of the air, age, food,
exercise, &c. ; the nature and treatment of asphyxia and sus-
pended respiration and animation, the rules of the Humane So-
ciety, as drawn up by Dr. Silvester, being given ; the effects of bad
air and imperfect ventilation; the chapter concluding with a very
full account of the organs and function of respiration in animals.
As every great division of physiology is treated in neai'ly the
same fashion, our readers will see that Mr. Marshall's book is
one of no ordinary character. Everywhere there is evidence of
its being written with care, and we are especially disposed to
praise the lucid manner in which the numerous topics cognate
to, and yet scarcely forming a part of physiology, are treated;
we allude to such subjects as osmosis, spectrum analysis, the
description of various instruments used in physiological re-
searches, as the galvanometer and sphygmograph ; the cardiac,
and respiratory pathological sounds,.&c.

The section upon locomotion in man and animals, which
occupies fifty-five pages, is one that is rarely introduced into
English works on physiology, and is here very interestingly
given. After describing the various forms of joints and the
kinds of levers employed in the body, the modes of progression
on solids and in fluids, both in man and animals is described at
length ; and we will transcribe the section on walking, which is
a fair sample of the whole :

" The act of walking is accomplished by means of alternate un-
Bymmetrical movements on the two sides of the body, performed at
the ankle, knee, and hip-joint, the trunk being kept as nearly as
possible in a state of equilibrium, though, as we shall immediately
show, its centre of gravity is not merely carried forwards, but under-
goes both vertical and lateral oscillations. One leg is first lifted
from its base of support with a slight flexion of the knee and foot,
so as to prevent the latter from touching the ground, and is
advanced a certain distance, chiefly by swinging, as will be presently
mentioned, but also by flexion of the thigh upon the pelvis, and by
extension of the leg and foot ; it is soon permitted to touch the
ground in advance of the body, the centre of gravity at the same
time descending a little, as well as advancing forwards, and also
inclining over in the direction of the advanced limb. As the forward
foot advances, the hinder one inclines in the same direction, and the
centre of gravity, now moved beyond the original base of support, is

84 Re.vk'ws. [Jub'>

sHglitly curved. "VVheu the forward foot has touched the ground,
the hinder one is raised by extension of the foot, which continuing to
press on the ground, assists in urging the centre of gravity forwards,
a little upwards, and still more over to the opposite side. The
centre of gravity having now reached a secure point of support
over the advanced and stationary limb, the hinder limb com-
pletely leaves the ground ; the thigh is slightly bent upon the
pelvis ; the leg is a little beiit on the thigh, and the foot some-
what on the leg ; in this position of the segments it is shortened
by about one ninth part of its length, so that the toes may keep
clear of the ground. The limb in its turn is now swung forwards,
to be planted on the gi*ound in advance of the body, the centre of
gravity being again carried forwards, downwards, and over to the
same side, and the foot being finally planted on the gi'ound as before.
* * * In rapid walking almost every muscle of the body is exer-
cised : the duration of the step is shortened, and so also is the length
of time during which both feet touch the ground together ; the
length of the step may be either shortened or increased. In the case
of a man walking at the rate of four miles an hour, and whose legs
were thirty-four inches in length, the number of steps taken in fifteen
minutes was 2000, the length of each step 2G4< feet, and the period
of eacli step "45 of a second (Vasey). In very quick walking the
rate has been nearly 5| miles per hour, or about 79 feet per
second." * * *

The chapter on " Animal Statics and Dynamics " is also ex-
ceedingly good, and gives a resume of all the recent physiolo-
o-ical researches occasioned by the important observations of
Fick and Wislicenus, which have led to such material modi-
fications of the older views of the nature and mode of development
of muscular force. After recounting the details of these w^ell-
known experiments, and the further investigations of Frank-
land and of Parkes, Mr. Marshall continues —

" There are many facts which indicate the necessity for large
amounts of non-nitrogenous food for the due performance of mus-
cular work. It is in the larval stage that insects generally consume
the most albuminous food, and perform the least amount of work,
whilst in the perfect condition, as in bees, butterflies, and moths,
their muscular activity is remarkable, altliough their food is ahnost
purely saccharine or non-nitrogenous. The goat, chamois, gazelle,
and many other ruminants, are singularly swift and active creatures;
their food, however, is not highly nitrogenous, but chiefly consists of
carb-hydrates. It is not probable that the muscular work in any of
these cases is performed by the oxidation of albuminoid matters
only ; for in that event the muscles, especially the minute ones of
insects, would soon be entirely oxidised, and could not be restored
by the scanty supply of nitx'ogen in the food. The remarkable pro-
visions for digesting the carb-hydrates, and rendering them absorbable,
appear therefore to have reference, not only to their use as heat-

1868.]

Becent Works on Physiology, ^c. 85

givers, but also as sources of motor power. The production of sugar
from starch is a universal action of the saliva of all animals, and
long-continued digestion in the ruminant stomach will even change
the cellulose. It has beeu remarked that the chief food-manufac-
tures are concerned with non-nitrogenous articles of diet, that eggs
contain, when dried, forty per cent, of fatty matter, that fat is
always present in meat, that the poor consume much bacon fat and
the rich, who eat most albuminoid food, likewise take more butter,
sugar, and alcohol (Lawes and Gilbert). The use of bacon by the
agricultural labourer has given rise to a familiar epithet for him.
The chamois hunters prefer a store of bacon-fat and sugar to any
other provisions on a hunting expedition ; and Tick and Wislicenus
ascended the Faulhorn on non-nitrogenous diet, without special
fatigue. But on the other hand, Parkes found that, on the second
day of severe exercise, on a non-nitrogenous diet, healthy soldiers
complained of unusual fatigue. Practically it would seem that
sufficient nitrogenous food, being supplied for the nutrition of the
muscular and nervous system, then the most effective diet for a
labourer is that which, contains a large proportion of non-nitro-
genous substances. Athletes should train on meat, but enter
into their contests upon amylaceous, saccharine, or fatty food."

As a means of showing the mode in which Mr. Marshall deals
with the comparative anatomy he has introduced, we take at
random his account of the circulation in moUusca, which runs
thus :

" Mollusca. — The most perfect condition of the circulatory system
in the non-vertebrate animals is met with in this sub-kingdom, and
in the class Cephalopods. In the cuttle-fish, for example, there is
found a systemic ventricular heart, provided with valves at its orifice ;
it is usually rounded, has strong muscular walls, and even internal
columnte corneae. Arteries proceed from it to all parts of the body,
excepting to the branchiae or gills, the liver even receiving branches.
The blood is returned into a large vein, or venous sinus, which is
surrounded by a remarkable cellular organ filled with blood, and
from which symmetrical lateral branches, two or four in number,
according to the number of the gills, proceed to those organs, each
presenting, as it enters the gill, a pulsating dilatation or so-called
bronchial heart, which helps to propel the blood through the gills.
Prom the gills the blood is returned into large venous sinuses, which
being contractile, act as auricles, and thence passes into the systemic
ventricular heart already described. In the Pteropods, and in the
Grasteropods, there is but a single heart which is always systemic,
distributing its contents by one arterial trunk and numerous
branches to the body and liver, from which, having passed through
lacunce or spaces, it is again collected by veins, and by them con-
veyed to the respiratory organs ; from these it is collected by other
canals, the branchio-cardiac veins, and is so brought to tl)e heart
again. In the Terrestrial Pulmo-gasteropods, as in Helix, the

86 Reviews. [July,

venous blood from the body passes througb small vessels on the
walls of the pulmonary air-sac, and is then collected into a larger
vessel, which conveys it to the heart ; vrhilst in the aquatic Branchio-
gasteropods, as in Doris, the blood returning from the body is
carried by special vessels into the gills, and is then conveyed by
other vessels bade to the heart. In both kinds of Grasteropods, the
lieart consists of an auricle and ventricle, between which there is
found a minute but distinct valve, which serves accurately to direct
the course of the circulating fluid. In the Lamellibranchiata, the
heart, usually single but sometimes double, in correspondence with
the bilateral arrangement of the parts of the body of these animals,
and often perforated by the intestine, is placed in a pericardium
situated near the adductor muscle, which closes the shell; when
single it has sometimes one and sometimes two auricles connected
witii its simple ventricle ; when the heart is double, each has only
one auricle."

In like manner, a short exposition is given of the vascular
system of the several invertebrate and of the vertebrate classes.

Here and there some slight corrections might be made : thus,
after the careful researches of Dr. Anstie and Dr. Dupre, it can
scarcely be said that after the injection of alcohol " a great
portion escapes vmchanged by the lungs, skin, and kidneys."
The proportions of gases in the blood is given on the old state-
ment of Magnus, which, as has been shown by many succeeding
observers, are very incorrect — he, in fact, only obtaining about
three fourths of the actual quantity present. We do not find
any reference to the peculiarities of the circulation in erectile
organs. We can hardly agree with Mr. Marshall that the milk
is most abundant, as well as most nutritious, in nursing women
from the age of fifteen to twenty. Had we to select a wet-nurse
on purely physiological grounds, we should prefer one of from
twenty to thirty ; and so on. These, however, are but trifles ; and
on the whole, Ave are bound to say there are very few alterations
or emendations needed. We may remark in conclusion that the
topography of the book is excellent, and that it is embellished
by 122 woodcuts, some of which are original. It fairly represents
the existing state of physiological science, and whilst cordially
recommending it to all our readers,we would most strongly do so to
those students who are reading for the physiological examination
of the University of London, to whom the section on comparative
anatomy will render it extremely valuable.

The physiology of M. Otto Funke, which is founded on the
older treatise of Wagner, and of which the fourth greatly ex-
tended and improved edition has, after several years' delay, been
completed, is a fine work, and is as deserving of translation into
our language, as was the philosophical treatise of Johann
Miiller. Dealing lightly with the subjects of alimentation, cir-

1868.]

Recent Works on Physiology, ^c. 87

culation, and respiration, the purely vegetable functions of our
bodies, it enters most elaborately into all the important points of
the nervo-muscular apparatus. His description of the nerves of
special sense is very complete, and especially is this the case with
the eye, Avhich occupies more than three hundred closely printed
pages, or one seventh of the whole work, being at once an
indication of the inexhaustible field of research presented by this
wonderful organ, and the extraordinary perseverance with which
it has been worked out by a multitude of inquirers.

We have taken the trouble to epitomise the section on the
sympathetic nerve, which shows well Prof. Funke's mode of
dealing with a difficult subject, and will, perhaps, prove of
service to some of our readers. He commences by pointing out
that the work of Bidder and Volkmann was the commencement
of a new era in the history of the sympathetic nerve. These
observers showing by actual counting, in opposition to
Valentin and Remak who held that it was to be regarded
as merely an offset of the cerebro-spinal system, that it was
fairly impossible that all the fibres of the sympathetic could take
origin in the brain and spinal cord, but that the ganglia were
properly to be considered as centres of origin for new fibres.
Again, whilst Valentin considered tlie rami comraunicantes as
being exclusively composed of fibres passing from the spinal
cord to the sympathetic. Bidder and Volkmann assured them-
selves that the greater part of these fibres turned at the point
where they joined the spinal branch towards the periphery, a
small number only bending towards the spinal cord, which last
could alone be regarded as the spinal root of the sympathetic ;
and they further maintained that many even of these fibres pro-
ceeded from the ganglion on the posterior root of the spinal
nerves, since an examination of this root on the proximal side
of the ganglion showed that it contained only about 2 per cent,
of fine or sympathetic fibres, which is much below the propor-
tion found in the mixed nerves, and still less than in the sympa-
thetic branches. The work of Bidder and Volkmann received
important support from the excellent researches of Kolliker;
but, at the same time, much correction and extension. Kolliker
corroborated the origin of the nervous fibres from the spinal and
sympathetic ganglia, and indeed not only indirectly by com-
])arative enumeration, but directly through the discovery of
their origin from the cells of the ganglia. He denied, it is
true, the specific nature of the sympathetic fibres, and con-
sequently regarded the independency of the sympathetic, as
caused not by any peculiarity of its elements, but essentially as
a result of the origin of its fibres; whilst he yet rightly
attributed to it, in consequence of a portion of its fibres being

88

Reviews.

[July,

derived from the spinal and cerebral jyanj^lia, a certain degree
of dependency upon these centres. Kollikcr's modification of
Bidder and Volkmann's theory received very general acceptation,
and even A'^alentin felt constrained to modify his views in
accordance with them. More recently the question of the de-
pendency of the sympathetic has again become the subject of
dispute, some endeavouring to establish the original theory of
Valentin, others exerting themselves to prove the entire in-
dependency of the sympathetic as . regards the cerebro-spinal
system. We shall here take into consideration the anatomical
points of the controversy, only reserving the physiological for
subsequent discussion. Axmann's results are best explained
by a reference to the accompanying figure. In the cells of the

Fia. 4,

spinal ganglion (s) fibres originate, which partly run towards
the periphery and emerge with the spinal nerves (a), or enter
the sympathetic through the ramus conmiunicans (b), and
partly pass towards the centrum either through the anterior (d)
or the posterior root (c). From the nerve-cells of the sympa-
thetic ganglion fibres originate, which partly remain in the
sympathetic nerves (e, e), partly pass to the spinal nerves through
the ramus communicans, in order either to course downwards
peripherically (f), or to pass upwards without communicating
with the cells of the spinal ganglion, aud to enter the spinal
cord either through the anterior or the posterior root (g, h).

1868.]

Becent Works on Physiology, S^c. 89

This scheme of Axmann's contains many propositions of an
unproven and doubtful nature. At the first glance it is obvious
that Axmann only admits a unipolar origin of the fibres from
the sympathetic ganglionic cells ; as also in the spinal ganglia,
although he himself has especially observed the existence of
bipolar cells with the fibres arising from their pursuing opposite
directions in the spinal ganglia. On this ground his description
of the fibres marked cA and yh appears particularly doubtful,
since he attributes their origin to the ganglionic cells ; whilst
he regards the spinal cord as their peripheric terminal organ."

After some further criticism of Axmann's views, Funke con-
tinues : " The scheme proposed by Kiittner, founded on micro-
scopical sections and experiments on the living animal, is
Avholly different. Previously to the observations of Kiittner,
the degeneration of the distal part of a nerve which follows its
section established by Walter and Budge, had been employed
by Schiff to decide the question whether the sympathetic speak-
ing generally Avas an independent system or a derivative and
sectional portion only of the spinal cord. Schiff took for granted
that destruction of the spinal cord would certainly be followed
by this peculiar degeneration of all the fibres of the sympathetic
if the spinal cord constituted their central organ. Experience
con-oborated this supposition, but whether this circumstance is
to be regarded as incontestable proof of the origin of all the
ganglionic nerve-fibres from the medulla appears to us extremely
doubtful, since other observers who have repeated the experi-
ment have not been able to discover such degeneration. Kuttner
has indeed gone to the other extreme. He denies that any
communication takes place between the fibres originating in
the sympathetic ganglion and the spinal cord, especially any
passage of fibres to the sympathetic in the path of the ramus
communicans, Avhilst he admits that a communication occurs
between the nerve-cells of the special ganglion and the spinal
cord, but does not reckon the ' broad ' fibres originating from
them as sympathetic fibres. He maintains, also, that the
peripherically directed fibres remain in the proper spinal nerves.
He founded his statements on the following experiments. He
divided in frogs either the ramus coimmmicans (c, fig. 5), or
the nerves of the spinal cord on this side {g), or on that side
(h) of the point of insertion of the former, or the roots v h ; and
after a certain time made examinations, Avith the view of deter-
mining the presence of degenerated or of normal ' fine ' fibres,
which, in common with Bidder or Volkmann, he regarded as
specifically sympathetic and easily recognisable as distinct
from the spinal fibres ; upon whichever side of the section the
degenerated fibres were observed, he attributed their centre

90

Reviews,

[July,

of origin to the part beyond or on the opposite side of the
section. After he had convinced himself that in the frog tlie
fibres contained in the ramus communicans, at the point of
union with the spinal nerves, were directed partly peripherically
in these, and partly turned towards the centre (in point of
fact, in the upper spinal nerves chiefly centrally, and in the
lower almost exclusively peripherically) ; he divided the ramus
communicans c at its middle ; after the lapse of three months
the fibres of the part still in connection with the sympathetic
ganglion were normal in appearance, Avhilst the fibres of the
portion attached to the spinal cord were degenerated, as were
also even the finer fibres of the spinal nerves themselves at a
and b. On the other hand, in the roots v and h, KUttner could
neither discern normal nor degenerated fine fibres ; he thence
came, in direct opposition to Bidder and Volkmann, to deny their
existence in these roots. If the spinal nerves were divided
between the entrance of c and s at d, degeneration was observ-
able after three months, even to the naked eye, in the peripheric
segment. Under the microscope, all the broad fibres appeared
degenerated ; whilst, on the contrary, all the ^ne fibres, both
here and in c, were perfectly normal. In v and h he was unable
to find either normal or degenerated thin fibres. In another
frog Kuttner divided on the right side both, on the left the
posterior root of the ninth spinal nerve. Subsequent examina-
tion showed in c, a and b all ihejine fibres on both sides normal.

Fi&. 5.

The remarkable difference in the behaviour of the roots them-
selves, the degeneration of the central part of the posterior and
of the peripheric portion of the anteiior root, is fully discussed
in another part of the work.

Kiittner concludes from these facts that all the fibres con-

1868.] Recent Works on Physiology, S^c. 91

tained in the ramus communicans originate in the sympathetic
ganglion which constitutes their centre ; that those which, after
the junction with the spinal nerves, pass towards the spinal cord
neither terminate in the spinal ganglion of the posterior root,
nor iu the ganglionic cells of the spinal cord, but enter the dorsal
branch of the spinal nerve (d), and are distributed peripherically.
He considers that the centripetally coursing fibres originating iu
the bipolar nerve-cells of the spinal ganglion pass to the spinal
cord, whilst those that run peripherically are distributed with
the spinal nerves ; but since he finds in the dorsal branch (d)
of the lower spinal nerves a far greater number of fine fibres,
the majority of which run peripherically, than can proceed from
the ramus communicans, he maintains, in opposition even to
his OAvn statements, that the greater number of these fine fibres
arise from the spinal ganglion, the cells of whichj lie elsewhere
states, give origin only to broad fibres.

Kiittner claims, therefore, for the fibres of the sympathetic
the most complete independency in an anatomical point of view ;
still more complete, even, than that maintained by Bidder and
^^olkmann, who at least admit that a few of the sympathetic
fibres course in the roots of the spinal nei'ves. M. Funke else-
where already indicates the grounds on which he is disposed to
doubt Kiittner's theory and the physiological considerations
which are opposed to it.

The theory of Remak stands in strong opposition to that of
Kiittner. According to this, the whole of the sympathetic fibres
proceed immediately from the brain ; all pass through either the
anterior or posterior roots of the spinal nerves and enter the
multipolar ganglion cells of the sympathetic, through which they
are continuous, with fibres passing either with the peripherically
distributed branches of the sympathetic, or with those of the
spinal nerves. Ilemak denies the existence of fibres primarily
originating in the sympathetic, and also the existence of cerebro-
spinal fibres in the sympathetic nerves, which have proceeded
directly from these cerebro-spinal centres without communication
with the sympathetic ganglion cells. This theory is, however,
as one-sided, and rests on foundations as unsatisfactory, as
those of Kiittner or of Axmann. So stands the controversy
respecting the anatomical relations, and especially concerning
the origin of the sympathetic. In view of physiological facts
which indisputably point to a communication between the
sympathetic and the cerebro-spinal system, we regard the theory
of Kolliker as incontestably the best established and most pro-
bable. According to this, the rami communicantes are to be
regarded as in part branches, in the proper sense of the word,
of the sympathetic, through which fibres originating in the

93 Reviews. [July,

sympathetic ganglion-cells enter the spinal nerves, but in part
also as roots containing fibres passing to the sympathetic, from
the anterior and posterior roots, originating in part from the
spinal cord and partly from the ganglion on the posterior root
of the spinal nerve.

As regards the functions of the sympathetic, M. Funke
remarks upon the difficulty of determining them, in conse-
quence of the close connection that exists between the sym-
pathetic and the cerebio-spinal system, so that doubt and
obscurity exist even in reference to the first and most prominent
question, whether the sympathetic fibres can conduct sensory
impressions. It is certain that the parts supplied by the sym-
pathetic nerves are sensitive, but who is to say whether the
impressions are conveyed through sympathetic or through
cerebro-spinal channels? He himself thinks that impressions
of pain are certainly received through the sympathetic fibres,
though they are incapable of transmitting simple impressions of
touch ; and he further holds that the impressions derived from
the sympathetic system are perceived, not by the ganglia of the
sympathetic, but by the cerebral ganglia or sensory centres of
the brain ; as regards the motor properties of the sympathetic,
it is indubitable that motor impulses can be transmitted by its
fibres, and the independent origin of the impulses is shown by
the continued contraction of the heart removed from the body,
and of the intestines and other parts after the removal of the
entire cerebro-spinal system. It seems, however, that no im-
pulses of the will can be conveyed to the parts supplied by the
sympathetic. The motor impulses, under ordinary circum-
stances, appear to be excited automatically or rcflectorially,
though this explains little or nothing of the nature of the pro-
cess. He then refers to, and corroborates, the remarkable
inhibitory influence exerted on the movements of the small
intestine by galvanisation of the splanchnic, discovered by
Pfliiger ; but admits there is much difficulty in giving any
satisfactory explanation of the phenomena observed. The most
likely, he thinks, is that, as in the case of the heart, the
intestines are excited to contract, rather through automatic, or
reflectorial, or direct excitation of the peripheric ganglia. The
fibres of the splanchnic nerve are in direct continuity with the
same ganglion cells as those which give origin to the motor
fibres of the intestine and the influence exerted by the former
set of fibres, is to effect the inhibition of the motor impulses
developed in the cells.

He then fully discusses the well-known vaso-motor powers of
the sympathetic fibres, giving an excellent resume of the obser-
vations of Bernard, "Waller, Budge, Schiff, Brown-S^quard,

1868.]

Recent Works on Physiology , ^c. 93

and others, in regard to the dilatation of the vessels which
results from section of the nerve in the cervical region, or from
section of the anterior roots of the spinal nerves from the fifth
cervical to the third dorsal, and of the contraction that occurs
on galvanizing the upper cut extremity. The experiments of
Callenfels are also described, founded on the observation of
Schiff, who, however, was preceded by Wharton Jones on the
rhythmical contractions of the arteries at short but variable
intervals (of 6*60 sec), and which propagate themselves towards
the capillaries. Callenfels found that the galvanic stimulus
applied to them when dilated caused their contraction, but
when contracted their dilation. Finally he has a very complete
section on the trophic influence of the sympathetic nerve, /. c.
its influence on nutrition. Axmann's views, of which we have
seen no translation, are thus stated :

" Axinanu came to the conclusion, that the ganglia on the spinal
nerves are trophic centres, whilst the proper sympathetic ganglia
govern the 'vital contractility,' and are therefore to he regarded
only as motor centres. He grounded this opinion on the fact, that
section of the roots of the spinal nerves above the ganglia produced
no change in tlie nutrition of the parts supplied by them, nor was
any alteration visible in frogs after removal of the whole brain and
spinal cord. The animals lived for a long time, wounds healed, and
broken bones united with the greatest facility. It was observed after
section of the posterior roots alone above the ganglia that parts of
the spinal cord soon underwent inflammation and softening, which he
attributes t6 the division of the fibres marked c, fig. 4, which origi-
nating in the ganglia, pass to the spinal cord. So also, when section
of the spinal nerves was made below the ganglia, between them and
the junction of the ramus connnunicans, considerable trophic dis-
turbances occurred. The frogs became pale from retraction of the
processes of their pigment-cells, general anasarca occurred, the fluid
containing uric acid ; relaxation of the muscles took place, and
numerous small extravasations of blood were found in their sub-
stance. The mucous membrane of the small intestines was soft and
injected, the kidneys softened and the liver filled with extrava-
sations. From the seat of the section, these results could not pro-
ceed from the division of the proper sympathetic fibres ; and as they
did not occur after section of the posterior roots above the ganglia,
the only conclusions he could arrive at was, that they were the con-
sequences of the division of the fibres arising from the ganglionic
cells in the ganglion on the posterior root."

Pincus, who instituted an extensive series of researches, to
control the results obtained by Axmann, generally corroborates
them. These, with those of Bidder and Valentin, are likewise
given at length. Our readers will be able to see from these

94 Reviews, [July?

extracts the very full and complete manner in which all the
questions relating to the nervous system are treated. The only
deficiency of the work, taken as a whole, seems to be the almost
entire omission of all English references, standing in this re-
spect in remarkable contrast with the learned work of M. Milne-
Edwards, whose *Lecons,' when completed, will constitute,
perhaps, the most perfect physiological treatise in existence.

We can cordially recommend Kiihne's Physiological Che-
mistry to those of our readers who understand German.

The Avork is divided into five sections, digestion, the chemistry
of the animal fluids, the chemistry of the tissues, the chemistry
of the fluids, and, lastly, the chemistry of the secretions.

The first section is very complete, it is Avritten in a plain and
easy style ; but though worked up to the very latest period,
gives comparatively few references to authorities. It includes
the consideration of the properties of the various kinds of saliva
and their action on starch, the changes that the food undergoes
in the stomach, the chemical character of the biliary, pancreatic,
and intestinal fluids, the constitution of the faeces, and the nature
of the gases contained in the intestinal canal. In the last sec-
tion, special praise is due to the account of the urine. Through-
out the book, the physiological and chemical aspect of each
subject are happily blended ; and it is, in contrast with v. Gorup
Besanez's work on the same subject, not a book of reference
only but one that is eminently readable. As a specimen of Dr.
Kuhne's work, we subjoin a translation of the part relating to
the spectrum analysis of the blood. • /

"the optical relations of the «loou.

" It has already been mentioned that the crystals of haemoglobin
possess double refraction, and are pleochromatic ; and that, when
dried below 0°, they form a red powder. Their solution if prepai'ed
with access of air, is likewise of a beautiful red tint. In order to
determine the influence it exerts upon transmitted light, Hoppe-
Seyler first adapted cells to the spectrum apparatus, permitting
solutions containing various proportions of the colouring material,
but of equal thickness, to be examined. If, in the first instance, a
concentrated solution be placed in the apparatus, the whole of the
red will be found obscured, at most, about three fourths of the
space between the Traunhofer's lines, C and D remaining clear; the
yellow is also obscured. On gradual dilution, clearing up occurs as
far as D, then light appears between the lines E and F in the green.
With further dilution, the part beyond F. clears up, and the
spectrum extends to the violet. . At this degree of dilution there
still remains two absorption-bands in the green parts of the spectrum,

1868.]

Recent Works on Physiology, ^c.

95

betweeu D and E, which are most distinctly seen in a solution rather
less than one third of an inch in thickness, and containing 1-lOOOth
of hsemoglobin, but even in 1- 10,000th they cannot be overlooked.
The first absorption band of the hsemoglobin (a) which lies nearest
to the line D is smaller, darker, and better defined than the second,

Absorption Spectra of the Blood and of its Colouring Matter.

■2»

vb r

Violet.

O.xy-liiciuoglobin and
NO.-Htcino^lobin.

CO-Hu-'inogloliiii.

Reduced Ha;iuoglobIn.

Htcinatin in acid
solution.

Hsematiii in alkaline
solution.

Reduced lieematin.

'I"''i""l""i""l""'°^

Solar spectrum with the
lines of Fraunhofer.

B 10 // IS IS llf.

/3, which is close to E — a clear space intervenes between the two.
With still further dilution, /3 is the first to disappear.

" 8tokes now made the interesting observation, that on the addition
of oxygen absorbing fluids, these absorption bands gradually disap-
peared, whilst coincidently a broad shadow with softened off edges
appeared in the previously clear intervening space (y). By agitation
with air the broad shadow again vanishes, and the strise n and /3 return.
Eor this purpose mixtures of sulphate of iron, tartaric acid and am-
monia, sulphide of ammonium, or ammoniacal solution of tartrate of
zinc oxide may be employed. These fluids, mingled in small proportion
•with the solution of haemoglobin, rapidly produce the changes in the
absorption of light above described. Sulphide of ammonium acts

96 Reviews, [Ju^y^

somewhat more slowly. Since the reducing solutions oxidise them-
selves at the cost of the oxygen in the haemoglobin, and since the
reduced hsemoglobin by agitation with oxygen again presents the
former optical relations, the experiment may be repeated as fre-
quently as may be desired. Even without the application of the
spectrum, it may be noticed'that the application of colourless sul-
phide of ammonium causes the solution of reduced haemoglobin to
assume another tint. It becomes darker, resembling venous blood,
becomes somewhat bluish or violet, and in thin layers green. Thus,
through reducing agents, the mono-chromatic hremoglobin becomes
dichromatic, whilst oxygen again restores its monochromatism. Hoppe
has shown that the reduced haemoglobin absorbs rather less of the
blue part of the spectrum. From all this the conclusion may be
drawn, that the reduced hajmoglobiu represents a colour which is
compounded of red, green, and blue, for these parts of the spectrum
remain clear, whilst the yellow is obscured by the shadow y. But
since this part of the spectrum is the most brilliant, it follows that
the haemoglobin becomes by reduction darker (more opaque),
througli oxydation brighter (more transparent). Similar differences
in the brightness are observed if solutions of hsemoglobin in the
oxidised and reduced conditions are compared with one another, the
concentration of which is so considerable that the absorption bands
a and /3 are imperceptible. In that case all light is absorbed by the
reduced solution, with the exception of the red bands between the
Praunhofer's lines a and /5, and even these are much darker in the
' reduced' solutions of equal strength. The same changes in the
optical relations are all exhibited by haemoglobin after the intro-
duction of COg, CO. and H. CO gas causes only a shifting of the
absorption band a towards E,.but blood thus treated does not become
dark by any of the reducing agents o, the bauds a and ft remain
without the occurrence of the shadow y. " NO gas, with exclusion
of air, passed through reduced haemoglobin, restores the striae a
and ft, but these cannot be again made to disappear by reducing
agents. In blood treated with CO, the transmission of NO
brings back the shifted band o to its original position. Under
all destructive operations which produce hsematine, the optical re-
lations of haemoglobin are modified, as is clearly shown by the
passage of the beautiful red into brown or green. The now
remarkable absorption of light depends upon the presence of
liEematine. As this exhibits different colours in alkaline or acid
solution, its spectrum is different, according to whether it is united
with acids or bases. In order to recognise the absorption bands,
especially of the former somewhat concentrated hemoglobin solutions
must be employed corresponding to the relatively small proportion
(4 per cent.) of haematine proceeding from the haemoglobin. The
simplest experiment consists in the addition of a little acetic acid,
"When this is done, the absorption bands a and ft vanish immedi-
ately, and another absorption band appears which covers the
Fraunhofer's line C (a) and extends towards D.

" Supersaturated with ammonia, or some otlier alkali, tlie stria is

1868.] Recent Works on Physiology, ^c. 97

shifted towards D (/3), so that the part in the immediate vicinity of
C becomes free from shadow. This second band is somewhat less
defined than the former on acidification. /3 readily changes to a.
According to Hoppe's experiments, these appearances are still clearly
visible with a solution of 1 gramme of hagmatine in 6667 Ccm. of
fluid, 1 Ctm. thick.

" If the solution be treated with the above-mentioned iron-
oxide solution, it causes these absorption bands to disappear;
but two new ones appear of dark colour, which, on superficial ob-
servation, might be referred to an exchange for the a and /3 of the
haemoglobin solution. They are, however, the strire of the reduced
haematine, y and h, y commencing with a soft shading between D and
E, in which position a of the haemoglobin also lies. Only the former
(y), reaches nearer to the spot where /3 of the haemoglobin begins, and
is therefore much broader than a of the haemoglobin. The very dark
line /3 of the reduced haematine includes in its centre the Praun-
hofer's line E, On agitation with air these bands disappear, but
those of the original unreduced haematine do not reappear. This is
opposed to the opinion of Stokes, that by the use of reducing agents
haemoglobin can be produced from haematine. As already stated,
solutions are produced with all the optical properties of haematine
under all those circumstances which develope haematine out of
hjEmoglobih, as by long exposure, by drying, by long transmission of
COg, by warming, by coagulation, &c. If dried and decomposed
haemoglobin be extracted with water, a solution is obtained which
gives the band /3 of the acid haematine, because the fluid is acid from
the presence of the products of disintegration (formic and butyric
acids, &c.). Hoppe draws the conclusion, that the haematine is here
combined with the albuminous bodies, which are not precipitable by
neutralisation, to form a peculiar substance called met-haemoglobin,
which possesses similar optical relations to those of acid albumen.
But this solution always still contains undecomposed haemoglobin,
as is proved by tlie presence of its two spectral absorption bands. In
fact, we can artificially out of weak acetic acid solution of albuminate
of alkali, haemoglobin and hydrochlorate of haematine, obtain a
mixture which behaves itself exactly as the so-called met-hae-
moglobin."

The two papers written by Dr. Parkes may be taken as the
types of the kind of work that is required for the advancement
of physiological science. They reflect the greatest credit on
Dr. rnrkes' industry and intelligence, and they show in the
most conclusive manner that were the efforts of original
investigators directed in different paths with some common
object in view, we should soon be rewarded by important
advances.

The subject of the first series of Dr. Parkes' essays is replete
with interest. It consisted in an endeavour to determine whe-
ther during exercise any increase takes place in the amount of

83— xLii. 7

99 Beviews, (July,

nitrogen eliminated from the body on a non-nitrogenous diet.
In a second series, the effect of rest and exercise respectively on
the elimination of nitrogen, when the diet contained a regulated
amount of this substance, was investigated. Throughout all
modern treatises on physiology it is admitted as an undoubted
fact that muscular substance is constantly undergoing degenera-
tion, or, in other Avords, oxidation, and that for the repair and
renewal of their tissues fresh supplies of food are required. The
degeneration is supposed to take place even when the vessels
are at rest, but much more actively when they are brought into
play. A strong argument in favour of this view is drawn from
the fact that the elimination of nitrogen in the form of urea
continues even in complete inanition to the last day of life, and
this was supposed to represent the minimum amount produced
by the heart and respiratory muscles (as well as to a small extent
by other nitrogenous tissues), in their persistent activity ; and
further, the experiments of Lehmann and others seemed to show
that with vigorous exercise more urea was eliminated than when
the body was at rest, due apparently to the increased degenera-
tion of the tissue when in action, which was further exhibited
by consequent increased demand for food. Of late years, and
especially through the observations of Bidder and Schmidt, a
luxus-consumption of the food came to be admitted; that is to
say, it was believed that, although a certain proportion of the
nitrogenous food was applied to the maintenance of the mus-
cular tissue, yet if more food were consumed than was required
for this purpose, it was used up for the general purpose of the
economy, and, probably, chiefly for the production of heat.
In either case, whether the nitrogenous constituents of the food
were applied to the renewal of the muscular tissue, or were
oxidized in the blood, the terminal products were carbonic acid,
water, and urea. Some doubts were thrown on the validity of
these conclusions by the observations of Dr. E. Smith, which
showed that with even violent exercise — such as that of the
treadmill — there was comparatively little increase in the amount
of urea discharged from the body. Several subsequent observers
noticed the same fact, but the most important observations were
those of Fick and AVislicenus which, owing to Dr. Frankland
having given a lecture upon them at the Koyal Institution, are
now well known. These gentlemen endeavoured to ascertain
whether there was any increase in the elimination of nitrogen
from the body during violent exercise on a non-nitrogenous diet.
They climbed the Faulhorn, exerting an amount of muscular
force which, when added to the muscular force employed for
circulation and respiration, was equr.lto 159,637 kilogram meters
for M. Fick, and 184,287 kilogrammeters for M. Wislicenus. In

1868.] Recent Works on Physiology, ^c, 99

accomplishing this severe effort, it was found that during the
ascent, and during six hours after the ascent, only 5'74 grammes
of nitrogen were eliminated, which corresponds to the disinte-
gration of 37" 17 grammes of muscle, and the experiment cor-
roborated upon the whole what had already been stated by
others, and especially by Dr. E. Smith, that active muscular
exertion causes little or no increase in the amount of urea dis-
charged, and, therefore, of nitrogenous tissue used up.

Dr. Parkes' observations are more valuable than those of
MM. Fick and Wislicenus on two grounds : first, because they
extended over a much longer period (seventeen days); and
secondly, because attention was paid to the possible exit of
nitrogen by the bowels, which had been overlooked by the
German observers. The mode of proceeding adopted in Dr.
Parkes' experiment was, that two healthy and remarkably in-
telligent and docile soldiers were allowed for six days a general
diet of meat, bread, vegetables, &c., without any absolute re-
striction. The quantity of nitrogen contained in the urea and
other nitrogenous constituents of the urine and in the faeces
was carefully examined, in the former daily, and in the latter on
one occasion. The tissue-changes were found to be very closely
the same, and the men quite comparable and well fitted for the
experiment.

During a second period of two days, the men were placed on
a non-nitrogenous diet of arrow-root, sugar, butter, and tea,
and were kept at perfect rest. The effects of this diet were very
similar on both, and a satisfactory basis of comparison was ob-
tained for the period of exercise. During a period of four days
the men returned to their former regulated diet and usual occu-
pations, during which their weight, which had fallen away a
little with the farinaceous diet, returned to its usual amount.
In the fourth period, the diet was the same as in the second,
viz., arrowroot, sugar, and butter ; but the men now walked,
on the first day, 23 '76 miles, and on the second 32*78 miles.
In the fifth period (of four days' duration), the men returned to
their ordinary diet and exercise.

The general results obtained by Prof. Parkes were that,
during the four days which followed the period of non-nitro-
genous diet ivith exercise, more urea and more ureal nitrogen
was discharged from the body than during the four days which
followed the period of non-nitrogenous diet with 7'est, as shown
by the following table, in which the quantities are expressed
in grammes.

Excess of urea In four days in after-work period
Excess of total nitrogen do. do.

s.

T.

3-364 .

, 7-700

1-492

. 4-560

100 Reviews. [July,

Whence it would at first sight appear that on a non-nitrogenous
diet exercise does increase the elimination of nitrogen, hut hoth
the men were more hungry after the long walks of the fourth
period, and took so much more food containing nitrogen, that it
is possible the excess was derived from this source. Dr. Parkes,
therefore, believes the conclusion arrived at by MM. Tick and
Wislicenus is certainly borne out, that, on a non-nitrogenous diet
exercise produces no notable increase in the nitrogen of the
urine, although when the whole period is considered it does
produce a slight increase. It may now also, he thinks, be said
that under similar conditions, exercise produces no increase in
the excretion of nitrogen by the bowels. He is careful to add,
however, that,

" Although it is thus certain that very severe exercise can be per-
formed on non-nitrogenous diet for a short time, it does not follow
that nitrogen is unnecessary. The largest experience shows not
only that nitrogen must be supplied if work is to be done, but that
the amount must augment with the work. For a short period the
well-fed body possesses sufl&cient nitrogen to permit muscular
exertion to go on for some time without a fresh supply ; but the
destruction of nitrogenous tissues in these two men is shown by the
way in which, when nitrogen was again supplied, a large amount
was retaiaed in the body to compensate for the previous de-
privation."

There was some probability, also, that the muscles and nerves
of these men were becoming structurally impaired, as shown by
great exhaustion occurring on the second day.

In the second paper, Dr. Parkes considers the variations that
occur in the elimination of nitrogen when the body is at rest,
and where exercise is taken respectively, on a regulated diet of
nitrogen. The course of the experiments precisely the same
as those just described, except that the diet was during sixteen
days exactly the same on each day. During four days the
men were at their ordinary employment ; during two days rested,
returned to ordinary work for four days ; took very active exer-
cise for two days ; and were then for four days more on ordinary
occupation. The food consisted of bread and butter, meat, and
vegetables, and tea and coffee, sufficient in quantity exactly to
maintain the body at its normal weight. The general results
obtained by Dr. Parkes were — 1. That with an unchanged
ingress of nitrogen there was a slight excess of nitrogenous
excretion during rest, as compared with a period of ordinary
exercise. 2. There was a decrease of urinary nitrogenous ex-
cretion during active exercise as compared with a period of rest,
and this was perceptible both when the ingress of nitrogen was

1868.] Recent Works on Physiology, ^c. 101

stopped as well as when nitrogen was supplied in regular amount.
3. There was an excess, not great, but long-continued, in nitro-
genous excretion after exercise. 4. There was a retention of
nitrogen in the system when it was again supplied after having
been cut off after both rest and exercise, and greatest in the
latter case, showing that it is needed in the system, and that an
insufficient supply at one time must be subsequently compen-
sated. In addition. Dr. Parkes observes, we cannot leave out
of account the well known dietetic fact, based on experience,
that much muscular work always demands the supply of a
larger amount of nitrogen. He considers both the old and new
theories of the chemical changes involved in muscular action
are alike insufficient to account for all the above facts. Upon
the old theory, muscle undergoes disintegration during action,
and it is natural to suppose that the amount of action is mea-
surable by the quantity of nitrogen eliminated. The new view
founded on the theory of Fick and Wislicenus is, that the
nitrogenous framework of a muscle is merely the machinery
which allows changes in the non-nitrogenous substances to
take place, and that in itself it undergoes during exercise no
changes.

Dr. Parkes suggests the following as a theory more consonant
with the facts than either of the above.

" When a voluntary muscle is brought into action by the influence
of the will, it appropriates nitrogen and grows ; the stimulus, or
the act of union, gives rise to changes in the non-nitrogenous sub-
stances surrounding the ultimate elements of the muscular substance
which cause the conversion of heat into motion. The contraction
continues (the will still acting) until the effete products of these
changes arrest it ; a state of rest ensues, during which time the effete
products are removed, the muscle loses nitrogen, and can again be

called into action by its stimulus This theory shows why the

muscle requires nitrogen for its action, and why increased action
requires increased nitrogen. The food must either supply this, or
the store of nitrogen in the blood and other organs must be lessened.
It enables us to understand why, in a well-fed body, it may be some
time after nitrogen is cut off before the muscles have any dif&culty in
obtaining what they want, and why in a body ill supplied with
nitrogen, exertion lessens, or if kept up, produces bad effects. If
exertion is persevered in under such circumstances, a failure some-
where is always observed. Frequently the nervous system, or the
heart, shows signs of weakness, a result which could hardly be
explained by the view of the Swiss professors."

The objection that presents itself to our minds to Dr. Parkes'
explanation is the difficulty of conceiving the muscle to appro-

103 Reviews. [July,

priate more nitrogen in contraction, at a time when its supply of
blood is considerably diminished. It seems to us more rational
to suppose that the tissue really disintegrates during violent
exertion, and that the products are thrown out, though not
taken up, by the vessels. When they have accumulated beyond
a certain proportion, the sense of fatigue is induced, rest then
allows of the gradual absorption and removal of these secondary
compounds which are forthwith discharged from the economy
and produce the increase observed in the succeeding period of
rest.

To Mr. Morrant Baker's edition (the sixth) of Dr. Kirkes'
' Physiology ' the merit may be conceded of being, for its size, the
most satisfactory text-book to put into the hands of a beginner.
It is clearly written, it avoids controversy, it is remarkably free
from errors ; and under Mr. Morrant Baker's able editorship it
very fairly represents the broad outlines of the present state of
physiological science. A chapter has been added on the prin-
cipal elementary tissues of the body, which we are sure will
prove very serviceable to the great body of students. A small
text-book of histology seems to be much wanted. With the
exception of the introduction to Quain and Sharpey's Anatomy,
there is literally not one in the language that is at all up to the
present time. Will no one of our professors of physiology fill
up the hiatus ?

The little elem.entary work on Physiology by Prof. Huxley is
well adapted for the purpose for which it is designed. The
general features of the subject are clearly rendered, and few
debatable points, except that of the actions of the intercostal
muscles, which are stated with a refreshing simplicity, are intro-
duced. It is pleasantly written, and will, we are sure, be of
great service to the school-teacher and others for whom it
was written.

The ' Introduction to Quain and Sharpey's Anatomy,' which
has just been published, though unobtrusive in its character, is
yet a very admirable manual of histology. Almost entirely free
from controversy, there may be found in it a plain statement of
facts, which will give the student a thorough insight into the
microscopic structure of the tissues. Nothing can better prove
the care with which this subject was drawn up in the former
edition than the fact that it has been requisite to modify it in so
slight a degree in this.

In the first section, devoted to the general consideration of
the textures, an account of the researches of Prof. Graham on
Dialysis has been introduced, whilst the chemical characters of
the proximate constituents has been much condensed. The
varieties and properties of the vegetable cell are then discussed.

1868.] Recent Works on Physiology, ^c. 103

and from thence the transition is easy to the animal cell. In
reference to the employment of the term cell. Dr. Sharpey
remarks :

" The existence of animal cells destitute of envelope, although
more insisted on of late years, has heen all along recognised in
the study of cell- development, and was expressly pointed out hy
Schwann himself. It has appeared to some that another name
should he used to designate bodies which thus exist in a naked
non-vesicular form. Briicke proposes to call them 'elementary
organisms,' a term too cumbrous for use ; as the first ' shaped'
products of organisation which appear in the development of
all but the lowest organised beings, they might be named
'protoplasts,' or as that name has been already used in a widely
different sense — ' monoplasts,' but after all seeing the universal
currency of the term ' cell,' it is probably most convenient and best
to adhere to it, with the understanding that in many cases it is used
in a conventional sense."

The jDrogress of microscopical investigation has rendered
necessary some modification of the account contained, in former
editions of the production of new cells, which is now reduced to
the following heads :

" 1. The subdivision or fusion of pre-existing free cells, as occurs
in the ovum and white blood corpuscles ; and this may be either into
two or into more than two. A similar process occurs in cartilage,
the chief difference being that the cells are enclosed in a matrix
with which the cell wall of the parent cell is continuous, and which
takes no part in the division. 2. The development of cells from
nuclei, which may either be contained in cells or may be free."

Lister's and Kiihne's observations are referred to as well as
those of Dr. Beale, whose views, however, respecting '' germinal
matter and formed material " are by no means accepted un-
reservedly. Dr. Sharpey remarking that he presumes it is not
meant that " formed material " is incaj)able of undergoing
further organization ; for otherwise the proposition would be
in opposition to well-known facts, such as the formation of fibres
in the matrix of cartilage. A few lines are devoted also to Dr.
Bennett's molecular theory of organization, respecting which
Dr. Sharpey observes, that for his own part he—

" Is disposed to think that in the process of organization, as
distinguished from its result, the cognisable form and mass of the
organisable material, whether as cell or molecular, are of altogether
subordinate consideration to the nature of its substance."

The descriptions of the tissues require no remark here ; they

lot Reviews. [July,

are iidmivably clear, and most of the observations of late years
receive due notice. The best section is undoubtedly that on
bone, to which Dr. Sharpey has, as is well known, paid great
attention. It is embellished by numerous excellent woodcuts,
nearly the Avhole of which are original, though one or two are
copied from Kolliker and the best foreign authors.

M. Durand's work is a series of philosophical essays of such
wide scope and general character, that it is almost impossible,
without going very fully into them, to do more than indicate
the principal points treated of. The titles of the several essays
are as follows : 1. A Coup d'osil of the Physiological Relations
existing between the Organism and the Outer World ; 2. The
Experimental Physiology and Medicine of the Soul ; 3. On
Vital, as compared with Inorganic Properties and Forces ; 4.
What is an Organ ? a Theoretical Investigation in General
Anatomy ; 5. On Function : its Faculty, its Organ, and its
Specific Agent ; 6. An Introduction to the Physiological Theory
of Instinct ; 7. Physiology of the Correlations of Physics and of
Morals. Almost all these topics are treated of metaphysically ;
and we can, therefore, recommend the volume to such of our
readers as are engaged in inquiries of this nature. The mental
faculties are very freely discussed in somewhat of a materialistic
spirit, and broad views are given of the functions appertaining to
the several parts of the nervous system. In the fifth essay on
instinct, M. Durand dwells on the importance of the study of
Comparative Biology ; and after reviewing and sharply criticis-
ing some of the definitions of instinct that have been given by
preceding writers, he gives one which, perhaps, it is hardly fair
to take from the whole of the preceding train of reasoning, but
is certainly remarkable. It is that —

" Instinct, in the proper acceptation of the word, must be consi-
dered as a kind of local hypertrophy of the soul, more and more
localised in proportion as we ascend in the scale of animated beings.
Amongst the lower tribes, it is only perceived by those acts which
tend to the satirfaction of the alimentary and reproductive appetites.
Reduced to its narrowest passional and intellectual limits, to its most
rudimentar}^ simple and uniform expression, it is, in our opinion, the
motor power which has its seat in the ganglia of the sympathetic
system, and which is only rendered apparent in the work of
nutrition."

M. Durand advances some singular views regarding the
nature of the corporeal frame ; thus, after referring to the opinion
of M. Lacaze-Duthiers, to the effect that, in almost all the
invertebrata, the individual is made up of a number or colony
of distinct individuals, which may be designated zoonites, each

1868.] Recent Works on Physiology, ^c. 105

of which possesses its own heart, respiratory orifice, &c., he
proposes to extend this doctrine to the vertebrata and to con-
sider their bodies as being also collections of zoonites, differing
only in degree from those of the invertebrata — that is, in the
existence of a greater division of labour and a greater specialisa-
tion of the individual parts, and he adduces the various arguments
for and against his suggestion. The work will be useful to
those who have devoted themselves to the study of Speculative
Physiology.

We are glad to see that M. Brown-Sequard has again under-
taken to edit a journal, a task for which, as may be concluded
from the success attendant on his former efforts, he is in every way
so well qualified. He has secured the co-operation of two gen-
tlemen, Messrs. Charcot and Vulpian, whose labours in the field
of experimental physiology are already well known, and if, as
appears probable from present results, the work contain papers
as valuable as those written for the ' Journal de la Physiologic,'
of which it is to be regarded as the continuation, there is no doubt
it will prove a great success. The parts already published contain
seventeen separate memoirs, with short accounts of the chief
advances in French and foreign physiological literature. The
second part closes with a bibliographical index of the labours of
our distinguished countryman, Mr. Lockhart Clarke, whose entire
works are here brought into view at a glance, with the dates
of their publication, and the mode (whether in journals or
otherwise) in which they have been published. Amongst the
original treatises we may notice ' Anatomical and Physiological
Researches on the Spheno-palatine Ganglion,' by M. Provost ;

* On Osteitis,' by Dr. Ranvier ; ' On Tubercle,' by M. V. Cornil;

* On the Pathogeny of Cerebral Hgemorrhage,' by MM. Charcot
and Bouchard ; ' On the Pathological Conditions found in
Sclerosis of the Posterior Roots of the Spinal Cord, with Atrophy
of the Posterior Roots,' by M. Vulpian ; ' On the Cardiac
Pulsation of the Frog,' by M. Prompt ; * On the Oidium Albi-
cans,^ by M. Quinquand ; * On the Movements of Certain
Organic Bodies at the Surface of Water, and the Relations of
such Movements to a Theory of Smell,' by M. Liegeois, &c.
If, in future numbers, papers of equal value are contributed,
there is little question but that the Journal will obtain an
extensive circulation, not only in France, but in this country
also.

We have often been surprised that the United Kingdom was
unable to support a journal devoted exclusively to anatomy
and physiology. But the truth is, we suppose, that publishers
turn a deaf ear to propositions involving considerable outlay,
and resulting in the establishment of a serial of a purely

106 Reviews. [July,

scientific character. Everything they conceive must be prac-
tical. We have always seriously doubted this, and we have
great pleasure in seeing that one publisher at least has had the
courage to attempt to cater for the profession on these subjects,
and we vv^ish Professors Humphrey and Turner every success
in their new and arduous undertaking. The first volume of
the new series of their ' Journal of Anatomy and Physiology '
contains, indeed, many interesting papers, and promises well
for the future. Amongst the more important ones in the first
part may be mentioned those of Mr. Gulliver, on the white
and red blood corpuscles, and of Mr. Hair on the arrangement of
the muscular fibres of the alligator, the amusing as well as learned
disquisition of Professor Rolleston on ancient and modern
domestic cats, the excellent paper of Mr. Mivart on the osteo-
logy of the Insectivora, and the contribution to the anatomy of
the pilot-whale, by Professor Turner : whilst the second contains
a suggestive essay by Drs. A. Crum Brown and Eraser, on the
connection between chemical constitution and physiological
action, an account of certain American crania by Professor Huxley,
an interesting paper by Dr. Beigel, on the nature and action of
Indian and African arrow poison, and a carefully dravrn up account
of the myology of the Orycteropus capensis and of the Phoca
communis, by Professor Humphry, besides more than twenty
other shorter communications. Each part contains also capital
reports on the progress of anatomy by Professor Turner, and on
recent English and foreign physiology, by Drs. Rutherford,
Eraser, and Gamgee.

Review VI.

1. Proces-Verbaux de la Conference Sanitaire Internationale,
ouverte a Paris le 27 Juillet, 1851. Tomes I et II. Folio.
Pp. 396 and 412. Paris, 1852.

Proceedings of the International Sanitary Conference opened at
Paris, 21th Juhj, 1851.

2. Proces-Verhaux de la Conference Sanitaire Internationale,
ouverte a Constantinople, le 13 Fevrier, 1866. 4to. Pp.
762.

Proceedings of the International Sanitary Conference opened at
Constantinople, ISth February, 1866.

1868.] International Sanitary Conference. 107

3. Rapports faits a la Conference. 4to. Pp. 379. Constan-
tinople, 1866.

Reports made to the Conference.

In this article we purpose to give a summary of tlie prin-
cipal contents of the proceedings of the late International
Conference held in Constantinople on the subject of epidemic
cholera, in order that the profession may be enabled to form their
own opinion of the practical conclusions which were then adopted,
and of the evidence on which these conclusions are based. The
two volumes in which the proceedings are recorded are as yet
very rare in this country, so that few persons can have an
opportunity of examining them for themselves. It is the more
necessary, too, at the present time, that a connected analysis of
their contents be laid before the reader, as not only several of
the topics discussed and opinions expressed by the Conference
are occasionally being commented on in the press and at medical
meetings, but also, more than once, reference has been made and
questions asked in the Legislature as to what our Government
propose to do in respect of the recommendations which have
been officially made to them. But, before proceeding to our
immediate task, it will not be unprofitable to take a retrospective
brief notice of the sister work, the first on the list at the head of
this article. It was undertaken now seventeen years ago for a
similar object, and under similar circumstances ; yet, strange as
it may seem, its contents have (as far as we are aware) never
been made known to the profession in any medical journal
down to the present day. The truth is that, although printed
as an official document, it was not published or circulated, in
this country at least. The Conference of 1851 was more com-
prehensive in its scope than that of 1866 ; for it undertook to
discuss and determine the whole subject of quarantine, in
respect not of cholera only, but of other diseases, more especially
of yellow fever and the plague. Delegates, medical and con-
sular, were appointed to attend it by the governments of France,
Great Britain, Russia, Austria, Piedmont, Tuscany, the Papal
States, Naples, Turkey, Greece, Spain, and Portugal. The
medical members were Drs. Melier, Sutherland, Rosenberger,
Menis, Bo, Betti, Cappello, Carbonaro, Bartoletti, Costi, Monlau,
and Grande. The conference sat for eight months, and held
forty-three meetings. We shall confine our notice of their
work to what has reference to the subject now in hand.^ The
delegates differed much in opinion as to the necessity for any

^ A full analysis of the proceedings of the Conference will be found in a paper
by Dr. Milroy in the * Transactions of the National Association for the Promotion
of Social Science,' 1859.

108 Reviews. I July>

stringent quarantine in respect of cholera. The French, British,
Austrian, and Piedmontese members were decidedly opposed to
'^ measures of rigour." On the other hand, the Neapolitan and
Papal members urged their necessity as much for the cholera as
for the plague; the island of Elba and many places in Italy
had been, it was alleged, preserved intact by the segregation or
exclusion of all suspected arrivals. The Spanish and Portuguese
members — while admitting that it is mainly by adopting sanitary
measures on board merchant vessels, and also in sea and river
ports, that the spread of the disease can be checked — contended
that, until these measures were universally carried out, quaran-
tine must be continued. Russia, it was stated, had not come
to a definite conclusion on the question ; she awaited further
inquiry. On two points, however, experience seemed to her to
be conclusive, viz. (we quote from Dr. Milroy's analysis) —

" That the disease, when occurring only in sporadic and occasional
cases, is certainly not importable by intercourse; and, secondly,
that the only fomites or articles capable of transmitting the
cholera poison are bed or body clothes fouled with the excreta of
the sick.

" The final decision of the Conference, as carried by a majority of
votes, was that all arrivals whatever from a place where cholera
exists should be liable to a quarantine of observation of five com-
plete days, the voyage being included in this period, before free
pratique is granted.

" If a case of the disease occurred during the voyage, the quaran-
tine to date from the arrival of the vessel ; and, if during the per-
formance of quarantine, a fresh detention to be imposed from the
date of each such occurrence.

" "With respect to cargoes, it was decided that they shall never be
required to be disembarked into a lazaret, or be subjected to any
other measures of purification except free ventilation on board, and
due attention to the cleanHness of the vessel itself.

" These remarks apply to arrivals 'from countries- actually in-
fected with the cholera. A shorter quarantine of observation,
namely, for three days only including the voyage, might be im-
posed on arrivals from countries which a local board of health
should consider to be compromised, either by proximity to an in-
fected place or otherwise, although the disease may not yet have
manifested itself."

To make assurance doubly sure on the side of presumed safety
by these precautionary measures, it was determined that, even
after the certified cessation of cholera in a place, an interval of
ten days should be required to elapse before clean bills of health
should be permitted to be issued therefrom. It need only be
added to this short notice of the Conference of 1851 that the

1868.] International Sanitary Conference. 109

convention, which was drawn up in accordance with the views
of the majority of the delegates, was accepted only by France,
Piedmont, Portugal, Tuscany, and Turkey. Our Government
declined to accede to it, on the ground of the proposed restric-
tions upon freedom of intercourse, from the apprehended risk of
importation of the several diseases, being deemed extreme, and
unnecessarily oppressive. Within a year or two afterwards, the
quarantine regulations of some of the States represented at the
Conference were more rigorous and severe than they had been
previously.

The Conference of 1866 was of larger dimensions, although
the scope, of its inquiry was more limited, than that of its prede-
cessor. The governments represented at it were seventeen in
number ; and the number of delegates who attended was in all
35, of whom 14 were diplomatic, and 21 Avere medical. France
was represented by Dr. Fauvel ; Britain, by Drs. Goodeve and
Dickson ; the Netherlands, by Drs. Van Geuns and Millingen ;
Prussia, by Dr. Muhlig ; Austria, by Drs. Sotto and Polak ;
Russia, by Drs. Lenz, Pelikan, and Bykow ; Spain, by Dr.
Monlau ; Portugal, by Dr. Gomez ; Greece, by Dr. Maccas ;
Italy, by Drs. Bosi and Salvatori ; the Papal States, by Dr.
Spadaro; Sweden and Norway, by Dr. Hubsch; Turkey, by
Salih Effendi and Dr. Bartoletti i Egypt, by Dr. Salem Bey ;
and Persia, by Dr. Sawas. Belgium and Denmark were repre-
sented only by diplomates ', and the United States of America,
which had been invited to join, did not send any delegate.
The first meeting was held on February 13th, and the last on
September 26th, 1866.

The Conference was opened by an address from the Minister
for Foreign Affairs of the Porte. No sooner was this over and
business commenced, than the French delegates (Count Lalle-
mand was the diplomatic member), with an autocratic energy
which characterised them throughout the proceedings, moved the
immediate appointment of a committee to determine what pre-
cautionary measures should be forthwith urged upon the Ottoman
Government for adoption, in the event of cholera again appearing
this year among the pilgrims assembled at Mecca. The scheme
recommended by France was nothing less than the total sus-
pension of all maritime communication and intercourse whatever
between any part of the Egyptian coast in the Red Sea, and
all ports on the Arabian coast, as long as the disease continued
among the pilgrims, and for fifteen days after the occurrence of
the last case among them. Until then, the pilgrims should be
required to remain in the Hedjaz, unless they preferred to
proceed on their return journey by caravan along the desert ; —
whereby the disease was invariably, Dr. Fauvel asserted, got

110 Reviews, [July,

effectually rid of. To carry into effect these measures would of
course require, among otlier means, the posting of ships of Avar
at various ])arts of the coast of the Red Sea, so as to bar the
approach of all vessels to the infected points, and prevent the
possible escape of any of the pilgrims to Egypt by sea. As to
the pilgrims returning to India and other lands to the east of
the Red Sea, they might possibly be allowed to embark at
some port considerably to the southward of Djeddah ; although
it would be wiser on the Avhole, it was thought, to subject all
pilgrims without exception to one general rule until all trace
of the disease among them had vanished.

This proposition at once gave rise to much controversy. Mr.
Stuart, the British diplomatic member, took exception to it as
at variance with the very terms of the original invitation,
addressed by the French Government to England and other
states in respect of the Conference, Avhose object Avas professed
to be —

" De reehercher les causes primordiales du cholera — d'en etudier
les caracteres et la marche — d'en determiner les points du depart
principaux — enfin elle aurait k proposer les moyens prktiques de le
circonscrire et de Tetouffer a sou origine ;"

the ultimate and great object being to prevent, if possible,
the recurrence of epidemic visitations of cholera in Europe.
The present proposal was, he contended, " beginning with the
end;" and, moreover, the consequences, maritime and com-
mercial, involved "in its adoption Avould manifestly be so very
serious, that he declined to take any part in its consideration,
without first consulting his Government. The Turkish and
Persian delegates pointed out the disastrous results that might
ensue from the sudden enforcement of measures of such extra-
ordinary rigour, and this too, Avithout any previous intimation
to the tens of thousands of pilgrims that Avould soon bp assembled
at Mecca.^ Dr. Pelikan contested the necessity of the alleged
urgency for immediate action, on the ground that the past
history of cholera proves that —

*' the pestilence, always proceeding from India, has never followed
two years in succession the same route in reaching Europe, the
reason doubtless being that tJie epidemic development of the cholera is
not explicable solely ly its transinissihility.''^

Moreover,the wide dispersion of cholera-infection already through-

1 In 1865, the number of pilgrims was unusually great, not less, according to
Dr. Gianelli, than 200,000. The majority arrived at Djeddah by sea. In that
year, between 18,000 and 20,000 returned to Suez by sea. The total number of
pilgrims this year, 1866, would probably be considerably over 100,000.

1868.J

International Sanitary Conference, 111

out Europe constitutes, he said, a much more formidable danger
than " the conjectural re-importation " of the disease by the
pilgrims assembled at Mecca. The Committee appointed to
consider the French proposition could not, after much
discussion, arrive at any satisfactory decision; of seven
members only three were in favour of it, and one (Mr. Stuart)
abstained from voting. It was then brought before the full
Conference. Dr. Fauvel again strongly urged its necessity.
M. Kalergi (Greece), quite approved of the suspension of all
maritime communication between the Arabian and Egyptian
coasts ; but he thought that a strict quarantine might be neces-
sary by land also, when the caravans reached Suez, or any other
point of their destination. Drs. Muhlig and Sotto, and other
members, were decidedly in favour of the French proposal. The
former gentleman considered that the proposed restrictions were,
in some respects, less rigorous than they ought to be, especially
in respect of infected or suspected arrivals at Suez from India
and other places beyond the Straits of Babel-mandeb. The
Turkish delegates protested, in the name of humanity, against
the scheme of barring all escape of the pilgrims by sea, when
the means of transport by land were notoriously utterly inade-
quate for the purpose of their removal; and when the due
supply of provisions and of water, for those who were forcibly
detained at Mecca, could not be depended on. Dr. Goodeve
asked what was proposed to be done with the numerous vessels,
bringing not only pilgrims but stores of provisions and other
cargoes, which would congregate at Djedda, the only consider-
able port of the Red Sea ? Were they at once to be compelled
to proceed to sea, whenever it was announced that cholera had
appeared at Mecca ? and, if so, where Avere they then to go to ?
and what were they to do ? Dr. Hubsch, in reply, was of
opinion that the interests of the public health should over-ride
all mere commercial and maritime considerations whatever.
On the question being put to the vote, seventeen of the twenty-
six members present were in favour of the French proposition,
eight were against it, and one member did not vote. The dis-
cidents Avere the British, Turkish, Persian, and Russian com-
missioners. Thus already, and before any evidence had been
taken or examination commenced, the opinions and views of
the majority of the Conference, on a most important practical
point of inquiry, had been distinctly manifested and made known.
In the original programme of the French delegates, it was sug-
gested that the proposed embargo and interdiction upon all
vessels arriving at Suez from infected ports should not be made
applicable to arrivals from ports out of or beyond the Red Sea,
whether they had touched at Aden or not ; and that such arrivals

112 Reviews. [July,

should continue to be merely subject to the practice which had
hitherto been in force there under such circumstances. This
limitation or exception was obviously designed to meet the case
of the Peninsular and Oriental steamers from India, which were
fortnightly arriving at Suez ; and which, it was admitted, during
twenty years and more, had not been known to have introduced
the disease into that port in a single instance. The Prussian
delegates, notwithstanding, insisted upon the necessity, for the
sake of uniformity and consistency in the recommendations of
the Conference, of a much more rigorous quarantine by sea
being now enforced upon all arrivals, witliout exception, from
infected places. INIoreover, tliey contended that, in the event
of any cases of cholera occurring at Suez, a military cordon
should forthwith be drawn round the town, so as to intercept
all communication with any other place in Egypt, with the view
of preventing the spread of the pestilence. Many of the other
members of the majority appear to have taken the same view of
the question ; but as the proposal could never, it was well
known, be carried into execution, it was finally resolved to
omit altogether any notice of this point in the programme.
Neither the British nor Russian delegates took any part in the
discussion, and the former requested that a note of their absten-
tion be entered on the minutes of the sitting. Having deter-
mined this point, the Conference proceeded to nominate com-
mittees to examine and report upon different sections of the
great subject they had taken in hand, and which they sought to
investigate in the most exhaustive manner. The several reports
•were, of course, submitted to the general body of the members
before being finally adopted. It is but right to state that there
was no small discrepancy of opinion on many of the points dis-
cussed, and that this was more especially the case when the
practical application of the restrictive and coercive measures,
proposed for the arrest or subjugation of the pestilence, came to
be considered. But we must not anticipate.

The^rs^ report discusses the questions of the origin or genesis
of cholera, its endemicity and epidemicity in India, and the
propagation of the disease from that country. It is considered
as proved that cholera had its origin in India, where it is still
permanently endemic ; it is extremely doubtful whether it is,
or has been, so in any other land. Nowhere else can it be
shown to have sprung up spontaneously. With respect to the
Hedjaz, or district around Mecca, the disease has invariably
been imported from the East ; and this event has alw ays coin-
cided with the period of the annnal pilgrimages to the Holy
Places. As to India, the mother-seat of the pestilence, it would
seem that the valley of the Ganges has been, and still is, the

1868.]

Tnternational Sanitary Conference. 113

principal habitat of its endemic prevalence. The special con-
ditions which give rise to its spontaneous production in India,
and which occasion its persistence in certain localities in that
country, are as yet unknown. That the pilgrimages to the
many noted shrines in different parts of the peninsula are the
most potent causes of its propagation and increase, can scarcely
however, be doubted. It seems probable that in India, as in
every other region of the world, away from and out of the
endemic foci, the importation of the disease ab extra is the
necessary condition of its epidemic development.

That the cholera is transmissible by human intercourse from
one place to another is demonstrated by indisputable facts.
The general course of each great European visitation has proved
it. The rapidity of the successive epidemics has gone on
increasing with the increased velocity and frequency of the
means of transport ; and the earliest cases in all countries have
usually occurred in sea-port towns. Among the most notable in-
stances in former years are those of the importation of the disease
into Mauritius in 1819, into Quebec in 1832, into New York and
Quebec in 1848, into Varna^ in 1854, and into Madeira in 1856.
The epidemic of 1865 supplied also many convincing proofs, as in
the case of Constantinoi)le, of Odessa and other places in the
South of Russia, and of Altenburg in Saxony. Again, the
efficaciousness of restrictive measures, on many occasions, affords
additional confirmation of the same truth. Both Greece and
Sicily escaped entirely in 1865, and in botli countries a most
rigorous quarantine was maintained. The frequent unsuccess
of quarantine, in defending countries against the incursion of
the pestilence, has been probably due to the insufficiency or
defective application of the proper means to be employed for
this purpose. Moreover, cholera when imported into a place,
is not invariably or inevitably transmissible. For the trans-
mission of the disease there must be adjuvant circumstances,
and these are, happily, not always coincident ; " otherwise the
ravages of the pestilence might soon bring about the extinction
of mankind."

On the important question whether the cholera is ever pro-
pagable to a distance by the medium of the atmosphere, inde-
pendently of human intercourse, it is declared that, although it
has not been always possible to demonstrate an inter-communi-
cation between an attacked locality and one already infected,

^ The statements of the French and British naval medical officers as to the date
of the first appearance of the cholera at Varna, among the allied armies, diiFer con-
siderably. According to Dr. Bryson, the disease had manifested itself there three
or four weeks before the date assigned by Dr. Marrouin, the physician-in-chief of
the French fleet. Moreover, the Danubian provinces had been infected for months
previously, and had sufl'cred in the preceding year, 1853,

83— XTJi. 8

114 Reviews. [July,

still wherever due Inquiry lias been made, such previous inter-
course has been clearly established. And, yet, the atmosphere
seems to be the chief, if not the sole, vehicle of the morbific
element in its diffusiou ; only (just as with the poison of typhus),
it is never wafted to a great distance from a focus of infection.
On no occasion, has epidemic cholera spread from one locality
to another in a shorter time than that in Avhich it might be
conveyed by human intercourse. For an outbreak to occur in
any locality two coincident conditions are requisite, viz., the
arrival of some person or thing from a place already infected,
and. the existence there of favouring circumstances. It has
been long believed, in respect of ships, that the mere lapse of a
few days without any manifestation of disease on board during
the voyage, or after arrival, afforded a sufficient guarantee
against the possibility of their importation of cholera. This, it
has been clearly shown, is a mistake ; for even a long voyage
does not always suffice to extinguish the danger of transmission
of the disease in this Avay. Every ship arriving from an infected
port should, therefore, be regarded as ' suspected,' or capable
of introducing the pestilence. There is, moreover, no propor-
tion between the amount, so to speak, of the imported poison —
or, in other words, of the number of infected persons or
things landed in a place — and the intensity of the subsequent
outbreak. A single case of cholera arriving in a locality may
give rise to an epidemic. The intensity of the epidemic de-
pends on the more or less favouring conditions of the locality,
just as in a conflagration the ravages are proportionate to the
combustibility and quantity of materials the flames encounter.
Nor does it require that the sick person arriving in a place,
liitherto healthy, should be affected with developed cholera. If
he has only premonitory diarrhosa upon him at the time, that
may suffice to transmit the pestilence. As to whether persons
being in perfect health themselves can be the channel of its
transmission, there may be some doubt ; but, be it remembered,
a slight diarrhoea may exist without any visible signs of ill-
health otherwise, or the possibility of its being found out.
And, even supposing the absence of any premonitory symptoms
among all the individuals, are we not entitled, should cholera
break out after their arrival from an infected place, to conclude
that " ce sent ces individus sains qui ont, par eux-memes, importe
la maladie? et n'ont-ils pas pu porter avec eux des objets con-
tamines V

The incubation of the cholera poison, or the period between
its reception into the system and the manifestation of the first
symptoms, is usually short; in most instances, it does not
exceed a few days, and in some cases not many hours. Occa-

1868.] International Sanitary Conference. 115

sionally, however, the period seems to extend to twenty days
and even more. In these exceptional cases, the precursory
diarrhoBa has been probably included in the period of incuba-
tion ; or the reception of the poison may possibly have occurred,
after the sailing of the vessel, from the effluvia proceeding from
contaminated baggage or other articles on board in which it
had been latent.

That the clothes and baggage of persons arriving from an
infected place, particularly if they have been used by cholera
patients, and still more so if soiled with choleraic discharges, can
communicate the disease, is now fully admitted ; yet, it must be
confessed that very few instances of a decisive and thoroughly
demonstrative character can be quoted; "presque toujours ils
se presentent entourees de circonstances qui permettent des in-
terpretations difFerentes." Washerwomen, laundresses, and other
persons who have had much to do with the clothes of cholera
patients, are particularly liable to be attacked.^ Certain facts seem
to show that the disease may be transmitted to a great distance
by articles of clothing, when these have been shut up for several
months from free contact with the air. At the same time, it must
be admitted that the importation of the disease by personal
clothing, sent from an infected locality, is extremely rare. When
exposed freely to the atmosphere, all such articles quickly lose
their infective power.

Although no evidence whatever exists that ordinary mercan-
tile cargoes have ever conveyed the cholera from an infected
port, still such an occurrence may be regarded as possible;
and especially, of course, in regard of such articles as rags,
hides, &:c.

It has been a question whether the corpses of cholera patients
are liable to be the vehicles of infection. Many medical men
have confidently asserted that they are, while others have as
strongly denied the dictum. Certain it is that medical men
Avho have been much engaged in post-mortem examinations,

* The question as to the greater liability to cholera of washerwomen than other
persons in the same social position, &c., has not been worked out with that pre-
cision which its importance demands. At the Marine Hospital of Constantinople,
only one of the persons so employed, during the severe outbreak there, was
attacked ; and this occurred at first, and before the clothes had begun to be
treated with chloride of soda or lime prior to their being washed. Out of 300
women employed in washing the linen of cholera patients in the Paris hospitals,
in 1865, not one died. The articles were always first steeped in a chloride solu-
tion. At the London hospital, in 1866, and where the same precaution was used,
only one of the washerwomen died. She had been engaged at the work for a
fortnight before she was attacked ; she slept out of the house and in a locality where
the epidemic was prevailing at the time. Dr. Goodeve states that the native
washers at the Calcutta hosj)ital,have not suffered more than other persons in the
same condition of life.

116 Reviews. {^^h'y

and the porters in hospital deadhouses, have not suffered more
frequently than other persons.^ Nevertheless, it is prudent to
consider the corpses of cholera patients " comme dangereux."
Another subject of dispute has been whether animals are liable
to become infected with the disease ; and if so, Avhether they can
communicate it to man. From some experiments of Thiersch,
Meyer, and others, it has been inferred that the ingestion of the
matter of choleraic dejections into tbe stomach of animals is
capable of producing- cholera in them.

"Mais tons ces faits sent bien loin d'etre probants, et quand
ineme on admettrait ranalogie de certaines epizootics avec le
cholera, et que les souris blanches empoisonnees par Thiersch aient
presente tous les symptomes de cette maladie, on serait loin d'etre
autorise a conclure a I'identite de nature, et encore moins a la trans-
missibilite de I'aniinal a I'homme."^

Whether the hair or fur of a living animal can serve to retain
and give off the choleraic poison, is not absolutely determined ;
possibly it may.

As to the influence of the different modes of intercommunica-
tion between countries in favouring the spread of the cholera,
maritime transport is unquestionably the most frequent and the
most dangerous in the conveyance of the disease to a distance.
Next to ships, railroads must be regarded as the most common
channels of distant transmission. Sandy deserts usually prove
to be an effective check to the persistence, and to the diffusion,
of the pestilence. Caravans speedily become free from it, after
they had been a few days on their journey in the desert. The
disease has never been imported into Suez or into Syria from
the side of the desert.

With respect to the liability of ships coming from an infected

' During the Paris epidemic in 1865, out of 911 persons employed as bearers
of coffins, or otherwise engaged at the funerals of hospital patients, two were
attacked. No details are given (in the 'Gazette des Hopitaux') respecting the
circumstances of these two cases. Chloride of lime was put into the coffins, and
the corpses were strewn over with sawdust, moistened with carbolic acid.

2 Thiersch's experiments appear to be considered anything but conclusive,
either in Germany or in France. At the Weimar Conference it was stated that
they had been repeated both in Berlin and in Vienna, but without confirmatory
results ; and the Commissioners of the French Academy, in reporting on the
concours in 1866 for the " Prix Breant," confine themselves to the simple state-
ment that some of the authors, including M. Thiersch, in experimenting with
choleraic discharges, " ont determine chcz les animaux des sj-mptomes et des
lesions semblables a ceux que Ton observe sur les hommes atteints du cholera."
Dr. Sanderson's experiments failed in producing any results in dogs, hedgehogs,
antl pigeons. It was only in mice that the choleraic liquid had any decided effects
in a considerable number of the animals experimented upon ; and, when the
experiments were repeated in cooler weather, they were altogether resultless.
Onthe whole, experiments on animals seem to have, as yet, contributed very little
to our useful knowledge of the disease.

1868.] Internai'wnal Sanitary Co'iferatce. 117

port to transport the cholera, it must not he inferred that merely
because they have had no sickness, or, perhaps, only a few cases
of slight diarrhoea during the voyage, and because they appear
to be innocuous on arrival, they are not likely to import the
disease. This would be a dangerous mistake; it has been long,
unfortunately, believed, but is clearly contradicted by several
notable facts observed in the epidemic of 1865.

" The great majority of the vessels from Alexandria remained free
from cholera; but have they the less not propagated it, even when
no choleraic accident could be ascertained to have occurred on
board ? The decisive proof is that nowhere did the disease appear,
except only where such vessels arrived."

Even in respect of the case of the Guadaloupe invasion,
although there has been some difference of opinion Avhether it
was due to a vessel from Marseilles or to one from Bourdeaux,

" the capital fact is, that the outbreak of the pestilence took
place after the arrival of a vessel from a country which was infected.
The immunity of other similar arrivals in other ports proves nothing
against the importation in this case."

All evidence goes to show how much the propagation of the
disease is promoted by the accumulation of masses of indivi-
duals in pilgrimages, armies, &c. ; and how much good may be
done by a timely thinning and dispersing the crowds over suit-
able localities. But however beneficial this niay be to the per-
sons immediately concerned, such dispersion

"ue devrait jamais etre operee dans des localites indemncs ou
elle aurait pour resultat d' importer la maladie, en meme temps qu'elle
serait sans avantage pour les individus contamines ; elle devrait au
contraire rester renfermee dans la circonscription de la localite ou
s'est manifestee I'infection."

The influence of bad hygienic and sanitary conditions of
peoples and places in predisposing to invasions of cholera, and in
aggravating their force and fatality, is now universally admitted.
And as choleraic excreta appear to contain the ' generative prin-
ciple' of the disease, it may be reasonably inferred that sewers,
privies, and

" the contaminated waters of a town may become the channels of
infection. The soil of a locality, once impregnated with cholerai c
dejections, seems to retain for a considerable period the property of
disengaging the morbific principle, and thus to keep up the
continuance of an epidemic, or even to regenerate it after it lias
ceased."

It has been already stated that the atmosphere is the priu-

118 Reviews. [July,

cipal vehicle of the cholera poison, and the chief agent in its
dissemination, the generation of the poisonous element taking
place only by successive renewals and multiplications within the
human body, and never occurring spontaneously. As to the
question how far the morbific poison can be wafted by the air,
facts seem to show that the distance from the focus of infection
is generally very inconsiderable ; it probably never exceeds
100 metres. The statements, which have been made of its
transport through the atmosphere to the distance of one mile
and more, have not been duly authenticated.

That water, whether it be directly polluted with choleraic
excreta, or whether it has become impregnated with the morbific
poison diffused in the atmosphere, may be the vehicle of its
transmission, has been shown by the experience of England.
It is, however, mainly by the respiratory passages that the poison
enters into the system ; but the alimentary canal is, most probably,
also a channel of its admission. It is within the stomach and
intestines that the generation and multiplication of the cholera
germs seem to be effected ; and that the alvine dejections con-
tain them, is incontestable. Whether the morbific principle
may be evolved from the body by the lungs as well as by
the digestive passages, it is not easy to determine :

"Le fait n'a paa et4 demontre, et en outre les phenomenes
morbides de cholera le rendent peu probable."

The last point discussed in this report is the question, for
what length of time may a person affected with precursory
diarrhoea, or with confirmed cholera, be liable to communicate
the disease ? Some of the members held that '' cette diarrhee
infectieuse," may continue for several weeks ; while others main-
tained that in the great majority of cases the duration of the
disease, as well as its incubation, is short — usually not exceed-
ing three days, and very rarely a week — and that, consequently,

"On pouvait, en toute securite, tenir pour nonrcholerique un
individu isole de toute cause de contamination, dont la diarrhee se
serait prolongee plus de huit jours apres son isolemenfc, sans qu'il ait
present^ aucun signe caracteristique de la maladie."

The majority adopted this view of the question, but without
explaining how the " premonitory diarrhoea^' might be discrimi-
nated from other kinds of diarrhoea, prevailing at the same time
during the epidemic prevalence.

The secojid report is devoted to describing " the march and
mode of propagation of the cholera in 1865.^' The professed
object of the Committee which drew it up is declared to be, not
to give a simple historical narrative of the epidemic, but rather,
"de reunir les faits les plus saillants qui se rattachent k sa

1868.] International Sanitary Conference. 119

marche afiii d'eii tirer la preuve de son importation par des
hommes d'un lieu malade a un lieu sain, ou bien, dans le cas
contraire, d'etablir le principe de la diffusion de I'epidemie par
I'air et sans le concours de malades qxx d'objets contamines."

It is of course unnecessary to enter into any of the details of
this report, as the uhole subject has been gone into at length
in a recent number of this journal. AVe shall therefore here
only glance at the practical conclusions, which, in the opinion
of the Commission, are fairly deducible from the evidence which
has been brought together. Premising that the earliest cases
of the cholera, wherever it manifested itself, were (with one or two
trivial exceptions) consequent upon the arrival, by sea or land, of
persons or things from places previously infected, attention is
then drawn to the fact that the disease appeared at Constan-
tinople, at Gibraltar, at Guadaloupe, and at Marseilles, after
the arrival of ships Avhicli had not been subjected to quarantine.
Among the places which, by means of a complete sequestration
of all cholera arrivals (^provenances^) escaped the pestilence, may
be mentioned Cavalla (on the coast of Macedonia), Volo (on the
coast of Thessaly), and the islands of Chio and Crete ; these
places established encampments on small islands which had no
communication with the mainland. At other places, as Bourgas
and Sinope in the Black Sea, at Mytilene and Rhodes, and at
Benghazi (on the African coast), the same fortunate result was
obtained by camping out all persons who arrived from infected
localities at a distance from human dwellings, and strictly
watching them. This experience shows that lazarets, to be a
secure means of prophylaxis, should be established as much as
possible on islands, and with a large amount of airy space round
them. Greece affords a striking instance of exemption, attri-
butable to her system of quarantine, which is more strict than
anywhere else. She refused to admit all arrivals from infected
places into any of her ports on the mainland; they were obliged
to go to the islands of Delos or Skiathos, where no fewer than
25,000 persons performed quarantine in 1865. The islands of
Samos and Sicily also, surrounded, so to speak, with foci of
infection, owed their immunity to the system of repulsion which
they strictly maintained, from the beginning to the complete
disappearance of the epidemic. The experience of New York,
too, confirms in the most conclusive manner the efficacy of
quarantine measures, properly applied, in preventing the spread
of cholera.

To the report is appended a chart, indicating the march of
the epidemic of 1865 from its presumed starting points at
Singapore and Calcutta to Mecca, and thence on to Alexandria.
From this, as a centre, radiate numerous red lines in every

120 Reviews. [J^b'*

direction to the several places to which the disease was con-
veyed directly from Egypt. These, again, are, in like manner,
shown to have become secondary foci, from which it emanated
to other localities, which are designated as tertiary foci. More-
over, the exact course of the pestilence being always shown by
the direction of the arrows affixed, and the precise dates of its
origin in each spot being also given, no traveller's route, when
indicated on a map, could be laid out more definitely or made
more easily intelligible. If the data from which the chart has
been constructed are accepted as thoroughly trustworthy, the
migratory movements of the epidemic of 1865 cannot certainly
be regarded as in any way obscure or problematical. In respect
of Great Britain, the only locality indicated is Liverpool, in
connection with the transmission of the disease thence to Halifax
in the spring of 1866. Southampton and Epping are not
marked as infected localities in 1865.

The third report treats of " the hygienic measures to be taken
for preservation against the Asiatic cholera." These measures
are subdivided into six classes, viz. : — 1. Measures to be adopted
in places or countries deemed to be permanent foci of the disease ;
2. Measures to prevent, as far as possible, the importation of
cholera by sea ; 3. Measures to diminish the chances of recep-
tion of the disease in sea-ports by sanitary regulations; 4.
Measures to diminish the predisposition or receptivity of towns
and dwellings by sanitary regulations ; 5. Measures to arrest,
as far as possible, the spread of the disease in the interior of a
country ; and, 6. Measures to prevent and extinguish foci of
infection by destroying the germs of the disease in the atmo-
sphere, or in contaminated objects, by means of disinfecting
agents.

In reference to the first of these points, allusion is made with
commendation to the great sanitary works that are now being
carried out in the three presidencies of India ; to the improve-
ments which have been, and are being, effected in barracks and
other military establishments; to the regulations relating to
pilgrims and places of pilgrimage in the country ; and to the
regulations aSfecting the conveyance of pilgrims from Indian
ports, under the Native Passenger Act of 1858.

" The transmissibility of cholera having only recently been
recognised in India, as almost everywhere else, it has been within
the last few years merely, that sanitary measures have begun
to be based on this principle." In the Bombay presidency,
pilgrims on returning from their journey are now not allowed
to enter towns or military stations until it has been ascertained
by examination that they are free from diarrhoea or other symp-
toms of cholera; otherwise, they are detained under observation

1868.]

International Sanitary Conference. 121

for forty-eight hours, or longer if need be, and till all traces of
disease have ceased ; due attention being of course paid to main-
taining cleanliness in the encampment, and to providing proper
food and medical treatment. Most satisfactory results have
followed the adoption of these measures. But, however useful
hygienic precautions may be, they will never suffice of them-
selves to extinguish the cholera. " It is obvious that measures
directed against the importation and propagation of the disease
are indispensable, and will continue to be so for a long time ;"
for " its transmissibility may give rise to deadly epidemics as
long as there shall remain a single permanent focus of infection,
— we might almost say, as long as there remains a single indi-
vidual affected with the malady."

On the second point enumerated, which deals largely with
naval hygiene, it is unnecessary to say more than that the
importance of sanitary arrangements in merchant and passenger
ships is fully discussed ; and with respect to the third one, that
which relates to the necessity for the sanitary regulation of sea-
port towns, there can be one opinion. Equally important is
the purification of inland towns, villages, and detached dwellings.
The experience of England, during the last twenty years, is
largely quoted to prove the salutary effects of such measures.
Not a single reference is made to the experience of any con-
tinental country — a fact of no small significance, when coupled
with the relative slightness of the last cholera visitation in Great
Britain, and contrasted with its fatality in Paris and most other
large cities of Europe.

In conformity with the doctrine that the excreta of choleraic
patients alone contain the infective elements of the disease, and
believing that the dejections of a single person, when received
into a common sewer, may suffice to poison the neighbouring
houses which drain into that sewer, through the medium of the
refluent gas finding its way into the dwellings, more especially
during the night when doors and windows are shut, the Com-
m.ission give a decided preference to the system of "fosses
mobiles " during a cholera season over that of ordinary privies
or waterclosets which drain into a common sewer ; as the former
can be immediately removed and disinfected before being buried
in the earth : the risk of spreading the poison is thus greatly
diminished. It would not be unreasonable to go so far as abso-
lutely to prohibit the use of common latrines, and to make
obligatory the general disinfection of excreta, &c. Such a
measure, if rigorously enforced from the beginning of an inva-
sion, might arrest the development of the pestilence, especially
if its adoption was combined with a system of daily house-to-
house visitation. Many facts, related by Pettenkofer and others.

123 Reviews. [July,

attest the power of disinfectants in checking the spread of the
disease.

With respect to the removal and interment of the corpses of
cholera patients, the more quickly it is done the better ; the
burial should be within twenty-four hours of the decease. The
body should be put at once into a pitched coffin, and covered
with a layer of quicklime ; and, when placed in the grave,
quicklime should be sprinkled over it. "The conveyance of
the corpses of persons who have died from the cholera to a
locality free from the disease should be interdicted."

On the question of hospital accommodation for the sick,
special hospitals should be provided. If a house be hired
for the purpose, the adjoining ones should be evacuated. If
general hospitals must be made use of (which, considering the
contagiousness of the disease, should if possible be avoided),
separate wards must be assigned to cholera patients. Special
vehicles for the conveyance of the sick from their homes are
indispensable. For attendants upon the sick, persons who
have passed through the disease themselves are the fittest.

Appended to this report is a special one by Dr. Muhlig, a
member of the Commission, on " disinfection applied to the
cholera ;" also an additional note relating to the treatment of
ships, their cargoes, &c., in epidemic seasons. These need not
detain us.

The ybwr^^ report deals with " the measures to be taken in
the East for the purpose of preventing new invasions of Europe
by the cholera." Against the importation of the disease by sea,
three series of defences or obstacles, " echelonnes sur le trajet
parcouru par le Jleau," are proposed, viz. : — 1. Precautionary
measures at the entrance of the Red Sea ; 2. Measures to pre-
serve Egypt, if the coast of the Red Sea become infected ; and
3. Measures to protect Europe against Egypt if the disease has
penetrated to it. The prophylactic measures by land against
the transmission of the pestilence from India to Persia, and
thence to Europe, are, of course, more difficult than those by
sea ; " et cependant la etait le point stategique de la preservation
g^nerale." As to the measures at the entrance to the Red Sea,
it is recommended that a quarantine station should be esta-
blished there on an island, if possible ; and that all vessels
coming from the East should be required to touch at it for
examination, and, if need be, for detention and purification.
The institution should be of an international character, i. e. be
under the direction of commissioners from different European
countries as M'ell as from Egypt and Turkey.

For the purpose of arresting the spread of the disease to
Egypt, in the event of its being introduced into any part of the

1868.] International Sanitary Conference. 123

coast of the Red Sea, notwithstanding the surveillance proposed
at the above station in the Straits of Babel-mandeb, sanitary
posts should be established at several ports on the African as
well as on the Arabian shore ; and there should be at least two
lazarettos, one for the use of pilgrims exclusively, and the other
for ordinary arrivals of ships and passengers. For the general
superintendence and direction of quarantine and sanitary mea-
sures in the Red Sea, a permanent international commission
should be made resident at Suez, with full power to decide on
all questions relating to the public health. If cholera should
appear in the Hedjaz during the period of pilgrimage, it was
decided that all communication whatever by sea between the
infected part of the coast and the Egyptian littoral at Suez, and
elsewhere, should be suspended during the continuance of the
disease, and for ten days at least after all traces of it had ceased,
as officially declared by the sanitary authority resident at the
spot. The British and Egyptian members of the Conference
objected to this recommendation, but their objections were over-
ruled by a large majority. To the objection that the proposed
interruption of all transit from the East to Europe, via Egypt,
would inflict enormous loss and inconvenience, it was suggested
by one of the delegates that the route by the way of the Cape
of Good Hope would still be open. In the event of the pesti-
lence reaching Egypt in spite of the above precautionary
measures, it is recommended — for then " le danger est aux
portes de I'Europe, et I'importation y est infaillible si des
mesures serieuses ne s'y opposent pas," — that the same heroic
measure of a temporary embargo on all intercourse between that
country and every part of the Mediterranean seaboard should be
at once established, and maintained while the disease lasts.
Again, the British and Egyptian commissioners objected, but to
no avail.

Our limits prevent our going into details respecting the qua-
rantine, and other prophylactic measures, proposed with the
view of preventing the importation of the cholera by land on the
Turko-Persian frontiers, or by the way of Bokara and Tartary,
or on the Russo-Persian frontier ; and with these details the
report closes.

The fifth and last report is devoted to the consideration of
the " Quarantine measures applicable to cholera arrivals {pro-
venances choleriques)P The first questions examined are,
AVhat have been the results of quarantine as hitherto practised
against the cholera ? and then. What are the fundamental prin-
ciples derived from experience which should guide us in the
matter ? It is admitted that, on the first European visitation of
the pestilence, stringent quarantine measures, both by sea and

124 Revieivs, [July,

land, were everywhere tried, and that on the whole they signally
failed ; but, at that time, the knowledge of the disease was noto-
riously inexact and incomplete. From 1847 to 1850, Sweden
made a much more sustained attempt to safeguard herself than
any other country ; " cette fois encore le cholera a franchi ces
barrieres elevees au priz de tres-grandes sacrifices." As to the
recommendations of the International Conference in 1851, what
could be expected, it is asked, from a quarantine of from three
to five days, Avithout taking any regard either of the incubative
period of the disease, or of the premonitory diarrhoea, or of the
influence of contaminated articles, and of bed and body clothes,
soiled with cholera dejections — all conditions which determine,
in the present day, the laws of the transmission of cholera?
At that time, too, lazarets were badly situated, often crowded,
ill-ventilated, and unwholesome, so that they were more likely
to communicate a disease to the neighbouring residents than to
protect them from its assaults. The experience of former times
is deemed, therefore, to be quite inconclusive, Greece, however,
then as now, has afforded a signal example of what may be
realised by stringent quarantine. By the complete sequestra-
tion of all infected arrivals on small islands, duly watched, she
has escaped in every European visitation, except only in 1854,
when she was prevented from carrying out her rigorous system
of exclusion by the Piraeus being occupied by foreign troops.
The experience of 1865 has furnished numerous other strong
proofs to the same effect, as at Crete, Volo, New York, &c.
The conclusion from these facts is that —

*' il est incontestable que des quarantaiaes etablis sur des bases
rationelles et conformes aux progr^s de la science peuvent servir de
barriere effieace centre Tenvahissement du cholera."

With respect to the utility and applicability of sanitary cordons
around infected localities, the Conference, after quoting several
instances of their reputed efficacy in Russia during the epidemic
of 1830-31, and in Syria during the late visitation,^ came to the
conclusion that—

"Employes au milieu de populations notnbreuses et serrees, ils
sont d'un efFet incertain et souvent sont daugereux ; que, par contre,
employes dans lea localites limitees, ou des contr^es dont a
population est clair-semee, comma dans certains pays Asiatiques, les

^ Nowhere has the trial of sanitary cordons been so s^'stematically and re-
peatedly inade, and that, too, under circumstances of very eBective isolation,
arising from the nature of the locality, as by Spain in respect of Gibraltar when
cholera has been in that citadel. The results have hitherto not been encouraging;
a vast amount of distress has been inflicted on the inhabitants, not only of the
Rock but also of the adjacent district of Spain j and, on no occasion, has the disease
been kept out.

1868.]

International Sanitary Conference. 125

cordons sont appeles a rendre de grands services contra la propa-
gation du cliolera."

To cut off all communication with an infected place is un-
questionably, whenever it is practicable, the best safeguard
against the dissemination of the disease ; but the measure is
generally very difficult to maintain for any length of time. To
attempt to prevent the flight of the panic-stricken inhabitants
from a city which has become the seat of the pestilence, would
scarcely be possible ; yet, something requires to be done to
mitigate the evils consequent upon unlimited dispersion. No-
where was the flight of the people from infected localities, in
1865, more conspicuous than in Spain, where some attempts were
made in several places to confine them. A third of the inha-
bitants fled from Valentia ; and nearly the half of the large
population of Barcelona, 190,000, fled from that city for a time.
There were between 30,000 and 40,000 fugitives from Alexan-
dria. The Commissioners recommend that there should be, at
least, a regulation in force restricting the number of persons to
be received on board vessels at such a time; and, moreover, that
a strict examination of them, and of their baggage, should be
enjoined before they are permitted to leave the port.

Minute details are given respecting the suitable sites, and
the proper construction, of lazarets. *' Parloirs," or " parla-
torios," are condemned, because the germs of the disease might
possibly be transmitted by the air from the detenus to visitors,
Avho might thus convey them back to the town. From the
moment, as renlarked by one of the delegates, that the Con-
ference admitted that the choleraic poison may, in certain cases,
be conveyed by the atmosphere to a distance of 100 metres, it
would stultify itself by sanctioning " parloirs." Common privies
or closets in lazarets are disapproved of; and moveable closets,
provided with disinfectants, are recommended. A proposal by
two of the members that each person should have a separate com-
mode, so that '* le medicin a sa visite journaliere put inspecter les
dejections alvines pour reconnaitre la nature, et constater par
ce moyen le debut d'une diarrhee,'' was voted impracticable in a
place where hundreds of persons might be congregated at a time.
The detenus should be arranged in different categories, according
to the degree of suspicion, and the dates of their admission; and
these categories must be kept quite separate from each other ;
otherwise a healthy person would be exposed to contract the
disease, as long as he remained in the lazaret. To every lazaret
there should be three physicians attached : two of them to be
always resident in, and not to leave, the establishment. Two
kinds of lazarets arc required, viz., 1. Lazarets of observation.

126 Reviews. [July,

where vessels having a clean bill of health, but which may be
deemed suspected by the authorities, may perform quarantine
without disembarkation of passengers, or discharge of cargoes ;
and 2. Foul-bill lazarets, where rigorous quarantine, neces-
sitating the landing and systematic purification of passengers
and cargoes, is performed.

With respect to the length of quarantine to be enforced, the
Conference, believing that a detention for two or three days over
and above the ordinary maximum of the incubative period
would afford a sufficient guarantee against the transmission of
cholera, recommend that, as a general rule, all persons arriving
from an infected place should undergo a quarantine of ten full
days, commencing from the date of arrival. Should any case
of cholera, or of choleraic diarrhoea, occur among the dete?ms,
" les personnes saines, apres la separation des malades, devraient
recommencer la quarantaine de dix jours pleins." Some of the
members were of opinion that the period of detention should
not be less than fifteen or seventeen days. As choleraic
diarrhoea is not always distinguishable from ordinary diarrhoea,
all persons suffering from looseness of the bowels should be
regarded as " suspected," and pratique should not be granted
to any one until the medical officer has satisfied himself of the
innocuousness of his case. All contaminated ships must be
kept in strict quarantine for ten days ; if any case or cases of
disease have occurred during the voyage, other rigorous pre-
cautions, including the discharge and disinfection of the cargo,
are declared to be necessary. If the voyage has exceeded
fifteen days, and without any sickness on board, the quarantine
may be reduced to five days ; but no length of voyage can be
deemed sufficient to render a ship, in which a case of cholera
may have at any time occurred, free from the taint of infection,
and, therefore, admissible to pratique on arrival. A ship from
Calcutta, for example, which may have had the misfortune
to have had one of her crew or passengers sick in going down
the Hooghly, although perfectly healthy during the rest of the
voyage, must be considered as " suspected," and be treated
accordingly. Under certain conditions, the period of the voyage
may be taken into account in determining the duration of the
quarantine to be performed. This relaxation was, however,
opposed by several of the delegates, as resting on a false basis,
and likely to frustrate the object of the Avhole system.

In regard to arrivals from infected places bi/ land, (which are
considered to be less dangerous and less liable to transport the
disease than arrivals by sea,) a detention of eight full days is
recommended as a general rule ; but pilgrims, emigrants, and
troops, should be kept in quarantine longer. " Si les prove-

1868.] International Sanitary Conference. 127

nances de terre partaient d'un foyer rapproche d'un a trois
jours de marche, la quarantaine serait de dix jours pleins."
This regulation would, of course, apply to the intercourse
between all the cities on the continent, including Paris, and this
country, during an epidemic season.

Minute particulars are given as to the most efficient mode of
disinfecting ships, and everything on board of them. The
articles of cargoes are divided into " susceptible " and " non-
susceptible," according to their presumed liability to convey
the morbific germs from infected places. Letters and dispatches,
which are exposed to contamination by contact with persons
affected with cholera, should be inclosed in a box, and be dis-
infected with chlorine, but, '* sans etre percees." As ready-made
clothes and such goods are manufactured by workmen who, if
sick, might soil and infect them, they should be disinfected by
aeration, immersion in water, or by fumigation, according to the
nature of the articles. As to ordinary cargoes, always except-
ing rags, hides, &c., their liability to transmit cholera has not
been demonstrated ; and it seems certain that goods imported
from India into Suez, or directly into Europe, have never been
known to introduce the disease. The same degree of doubt
exists as to the liability of living animals to convey the infective
poison, when they have been exposed to it. Nevertheless it will
be prudent to subject them, '' k des mesures restrictives et de
desinfection dans des circonstances dont I'appreciation dependra
des autorites sanitaires."

What time should elapse between the cessation of epidemic
cholera in a place, and the granting of free pratique to arrivals
thence when provided with a clean bill of health ? To grant
free pratique at once, on the mere announcement by the autho-
rities (always desirous to get rid of restrictions on the inter-
course and commerce of their community) that the disease had
ceased in the place, would be an imprudence which might lead
to serious consequences ; as occasional and scattered cases are
often known to occur for some time afterwards. It is, there-
fore, recommended that all boards of health should agree not
to grant free pratique to arrivals from any infected port, until
fifteen days have elapsed after the date of the entire cessation
of the epidemic.

In conclusion, the Conference point out the necessity that
heavy penalties should be attached, on the part of every Govern-
ment, to all evasions or violations of quarantine enactments and
regulations —

"Les reticences, les fausses declarations, rendent illusoires Ic
systeme restrictif le mieux combine, et compromettent la isant^

128 Reviews. [July,

publique. Elles doivent etre severement punies par les lois de
chaque pays."

And with this recommendation the lahours of the Conference
close, and our analysis comes to an end. This, it will have been
seen, has been expository, not critical. A work which has been
the offspring of so much combined labour among medical men
of different nations, and which comes forth with all the prestige
of diplomatic authority, should obviously be well known by the
profession in this country ; for no country in the world is more
concerned, few so much, in the practical questions discussed by
the Conference, and none has certainly contributed more abun-
dant and valuable materials to assist in their rightful solution.
That, moreover, it will in future be much appealed to in various
parts of the continent, and also abroad, as a guide and directory
on many of the points treated of, can scarcely be doubted ; for,
already, its influence has been made manifest in the character
of the prophylactic or defensive measures resorted to for the
exclusion of cholera in several of the Mediterranean ports, and
nowhere more conspicuously than in our own colony of Malta.
On the other hand, exception has been taken in this country to
the accuracy of many of the statements, and to the soundness
of not a few of the conclusions, sanctioned by the Conference.
Some of the former have been clearly shown to be inexact. All,
for example, that relates to the limitation of the endemicity of the
disease exclusively to certain parts of India, and much relating
to the history of its epidemic outbreaks in the East in former years,
are regarded by competent authorities as conjectural and illu-
sory. The narrative, too, of the circumstances connected with
the development of the disease in the Hedjaz in the spring of
1865, tracing that event back to direct importation from one
point, viz., the distant settlement of Singapore, without having
duly ascertained whether it existed in intermediate regions or
localities prior to the arrival of the infected vessels from the
Straits of Malacca, has been deemed anything but satisfactory.
And the same remark has been made in respect of several of
the allegations, put forth as indisputable facts, regarding its
traceable transmission from Egypt throughout the Mediterranean,
and from one point of the continent to another.^ Sufficient

' To take one instance, and tliat from a country which more than any other
exercises a most vigilant surveillance at all her sea ports, and must, therefore, be
the better enabled to communicate exact intelligence of all that occurs in respect
of arrivals from other countries. It is alleged that Barcelona received the infec-
tion from Malta by the British fleet, and that the first case occurred there
(Barcelona) on July 22. No details whatever beyond these two statements appear
to have been given by the Spanish delegates to the Conference. It now appears
that the fleet left Malta harbour on July 1st, and was at sea till the 12th, when
it reached Barcelona, where it remained until the 22nd. On that day, it sailed

1868.] International Sanitary Conference. ]^9

scrutiny, it is maintained, has at least not been exercised in
ascertaining- the accuracy of thr; data made use of. Certain it
is that the entire account of the epidemic has been drawn up
under the dominant influence of an accepted idea, viz., that the
cholera is a virulently transmissible or contagious disease, and
that its propagation and spread are due solely to the transmis-
sion of its infective poison from man to man, either directly, or
through the medium oi'fomites which have been impregnated
with the morbiflc matter. In these respects it resembles, it will
be observed, the cattle plague. Assuming the above proposition
as demonstrated, and coupling it with the annex that the infec-
tive germs of the disease are generated in the alimentary canal,
and are contained in the alvine excreta (whether the ejecta
from the stomach also contain them, appears to be yet unde-
cidedj, the Conference have built up an elaborate superstruc-
ture complete in all its details, alike of theory and of practice,
each part conformable to and supporting tlie others, so that the
whole fabric has the aspect of harmonious consistency. In the
language of the schools, the work is planned on the deductive
method of investigation, in contrast with the inductive method,
followed in the somewhat analogous work of the Royal Academy
of France on the subject of the Plague, about twenty years
before, and to which an incidental reference is made.

As the quarantine measures recommended by the Conference
for the protection, in future, of Europe from visitations of the
cholera lead back to the re-adoptiun of the system that was in
force at the end of last century against the apprehended inva-
sion of the plague, and as grave doubts are entertained among
medical men on the Continent, as well as in this country, as to
the wisdom or the practicability of these recommendations, it
obviously behoves the profession to consider what advice
should be urged upon our Legislature and government with
the view of obtaining a thorough investigation, on a large and
comprehensive scale, of this confessedly difficult and cogent
question of State Medicine.

The memorial on the subject which was recently addressed to
the Privy Council by many of the most eminent men in our
ranks, and which we published in the last number of this
journr.1, sets forth in the clearest manner the necessity there is
for such an inquiry by means of a Rojal Commission appointed

for the Bay of Rosas, arriviug there ou the 27th. The fleet was healthy ou
leaving Malta, and no case of choleraic sickness occurred in any of the ships
before reaching Barcelona, or afterwards. No quarantine was imposed upon it
ou arrival there. It may be added that the disease had appeared in the port of
Valentia on the same coast, about a hundred miles to the southward, a fortnight
before it was discovered in Barcelona, and ten duys before the first case occuiTed
at Gibraltar.

83~XLII. 9

130 - Revieivs. ' [July,

for this purpose. But, notwithstanding its acknowledged im-
portance, both nationally and internationally, no one can be
sanguine that this desirable object will be speedily attained. To
no subject could the attention of the forthcoming meeting of the
British Medical Association at Oxford be more appropriately, and
more beneficially, directed; we commend it to their consideration.

Review VII.

Memoires de VAcacUmie Lnperiale de Medecine. Tome xxviii.
Ire Partie. 4to. Paris, 1867.

It is a considerable period since we noticed in this Review
the publications of the French Academy of Medicine, and
before adverting to the contents of the present volume it may be
of interest to some of our readers if we furnish some account
of the learned body under whose auspices it is published.

The Academic de Medecine is, so to say, the heir or resusci-
tation, after a long interval of abeyance, of the famous Academic
de Chirurgie and the Societe Royale de Medecine, both sup-
pressed during the troublous times of 1792. It was founded by
royal charter in 1820, opened in 1824, and since that period
has pursued the even tenour of its way, undergoing no other
change during the various political vicissitudes that have
occurred, except that of altering its title from "Royal" to
" National," and then again to " Imperial." Within its walls
have been embraced almost all those who have attained repu-
tation in the various branches of medical science since the
period of its foundation, and the honour of its membership is as
highly appreciated and as keenly sought for at the present day
as at any former period. It is true that from time to time
other important scientific societies have been established, corre-
sponding to various sections of the Academy, such as the So-
cietes d'Anatomie, de Biologic, jiud de Chirurgie, but these arc
in no sense rival bodies, having in view only a more active
development of their respective branches of investigation than
could be attained in the academical sections, composed as these
are ratlier of the seniors who have attained their rejjutation
than of those who are still laboriously working.

The Academy embraces medicine under its widest accepta-
tion, and consists of 100 members, who are distributed into
the following eleven sections : — Anatomy and Physiology,
10 members j Medical Pathology, 13; Surgical Pathology,

1868.] Memoires de VAcademie de Medecine. 131

10; Therapeutics and Medical Natural History, 10; Ope-
rative Medicine, 7 ; Pathological Anatomy, 7 ; Obstetrics, 7 ;
Public Hygiene, Legal Medicine, and Medical Police, 10;
Veterinary Medicine, 6 ; Medical Physics and Chemistry, 10 ;
Pharmacy, 10. There are also at present nine " Free As-
sociates," among whom we observe the names of MM.
Chevreul, Milne-Edwards, Littre, Husson, Director of Public
Assistance, and Conneau, the Emperor's physician. Next
we have lists of twelve "National Associates" and fourteen
'* Foreign Associates." These may be increased each to twenty
and it is remarkable that the only English names are those of
Travers, Faraday (both dead), and Professor Simpson. Finally,
there are 120 " National Correspondents," which number is to
be reduced gradually to 100 ; and 61 " Foreign Correspondents"
— to be reduced to 60. The English names are those of Farre,
Owen, Roget, Wardrop, Hodgson, and P. Lee. The respected
physician. Dr. Farre, elected in 1835, has been long dead.
When vacancies occur in any of the academical sections, the
titles to admission of the various candidates are referred to tlie
section in question, which has to make its report to a secret
sitting of the Academy, giving in a list of not less than three,
and not more than four, names arranged in order of merit.
These have to be balloted for at the next public meeting of the
Academy, an absolute majority of the members present being-
necessary to secure election. As a general rule, the Academy
selects the name placed first on the list by the section ; but this
is by no means always the case, for the contest is sometimes
very keen and close, and the custom of the candidates having
to visit and personally solicit the votes of the electors is con-
sidered by many as a very burdensome and objectionable pro-
cedure.

The Academy has two forms of publication, its * Bulletins' and
* Memoires,' both of which have now become long and important
series, constantly consulted. In the ' Bulletins,' commenced in
1836, are furnished authentic reports of the memoirs, correspond-
ence, reports, and discussions of the Academy. Some of these
last reach portentious dimensions, but many of them are of great
importance, and characterised by high ability and deep research.
The ' Memoirs' or ' Transactions,' the first volume of which ap-
peared in 1828, are usually published annually, and besides cer-
tain official reports contain the more elaborate papers that have
been deemed worthy of selection by the committee of publication.
We may here notice that all essays, memoirs, &c., submitted to
the notice of the Academy are referred for examination to com-
mittees, the names of whose members are made public, and that
the reports of these committees upon such memoirs are always

132 Reviews. [July,

published in extenso in the ' Bulletin ;' so that the grounds of
their recommendations as to the ultimate disposal of the memoirs
in question, whether by publication, simply thanking the
author, &c., are made publicly known. Not only are they
known, but they may have to be defended, for some of the most
important discussions at the Academy have arisen upon the
presentation of these reports. In this way the subject becomes
thoroughly ventilated, and complete justice is secured to the
author.

The Academy, being a body supported by the State, has
certain public functions to perform. Thus it conducts public
gratuitous vaccination, furnishing an annual report to the Go-
vernment upon the subject, prepared by M. Depaul, the Vaccine
Director of the Academy, but previously submitted to this body
for its approval or modification. The Academy also possesses a
chemical laboratory, the chief business of which seems to be to
conduct the analyses of the new mineral waters which are con-
tinually being discovered in France. Reports are made con-
cerning these by the director of the laboratory, and upon them
are based the recommendations of the Academy as to the admis-
sion of the new spring into the authorised list of mineral waters.
The body is also frequently consulted by the Government as to
various matters connected with public health.

Before describing the contents of the volume of ' Memoires'
before us, we may for an instant advert to the question which has
at times been mooted as to how far it is practicable or desirable
to establish a similar Academy here. The fusion of the Royal
Medical and Chirurgical and the other Medical Societies has been
suggested as a possible means of accomplishing this. This
might, if properly organized, give rise to much needed improve-
ment in the working , of our medical societies ; but in the face
of the increasing disposition to separation rather than amalga-
mation manifested by the formation of new societies, it probably
would not be practicable. At all events it could never consti-
tute an institution analogous to an Academy, as long as mere
respectability and a willingness to pay a subscription consti-
tuted a claim to membership. This must rest on scientific merit
alone, to be strictly determined by competent judges; and if we
are desirous of an Academy, such an institution can only be
modelled de novo, and not by any attempt to amalgamate bodies
Ibunded on a mere monetary basis. In Paris there are and have
always been numerous medical societies flourishing beside the
Academy, the object of all such societies, in fact, being as much
social as scientific.

1. The first article in the present volume reminds us of the
practice which has always prevailed in the Academy of having

1868.1 Memoires de I'Academie de Medecine. 133

eulogia of its most distinguished deceased members pronounced
by its secretary. Those delivered by M. Pariset, its first secre-
tary, have been collected into two volumes of interesting
reading, although somewhat too eulogistic. Those which have
been delivered by M. Dubois, the present secretary, and M.
Beclard, the assistant-secretary, are more critical and discrimi-
nating productions. Although such orations cannot be always
expected to be characterised by complete soundness and impar-
tiality of judgment, they are of considerable utility in furnish-
ing the authentic facts of the careers of a series of distinguished
men, together with accounts of their writings and some estimate
of the positions they had acquired. Certainly, whether right or
wrong, men of distinguishedmerit on the continent are notallowed
to slip out of the world in the same unnoticed way they do with
us. Where can we point to any properly appreciative account of
the career of Abernethy, Cooper, Brodie, or Lawrence, to say
nothing of lesser men who have yet played an important part in
the progress of science ? It will have to be sought for, even if
then found, in the pages of some fugitive journal, or at the fag
end of some presidential address. The continental practice of
enumerating the merits of their great men at the brink of their
graves or in the halls where their voices once resounded, may be
sometimes too showy and exaggerated, but our own demeanour
is one of indifference and repulsive coldness. The eloffe in the
present volume is that pronounced by M. Beclard on M. Gerdy,
and as he died so long ago as 1856, a sufficient time has elapsed
to allow of a calm appreciation. Although he did much good
work in his day, both in the provinces of anatomy and physiology
as well as in practical surgery, he cannot be said to have occu-
pied the highest rank ; but it is very desirable that an authentic
record of his career should be procured in so accessible a form.
We do not, however, propose to notice this eloffe further than to
transcribe a passage in relation to the concours, the suppression
of which after 1848 excited so much ill-feeling in France.
Before that event the eloquence of Cousin had already threat-
ened the institution, and it is in relation to Gerdy's enthu-
siastic defence of it that M. Beclard refers to the subject
delivered to an approving auditory as his address was in the
presence of such celebrities created by it as Trousseau, Rostan,
Velpeau, and Bouillaud. He says :

" Like all other human institutions, the concours has its defects
and even its errors. But one must feel a strange confidence in the
assurances of renown, that equivocal power, to seek in it for more
serious guarantees than in public trials conducted before competent
judges. Loyal struggles of the intellect will always exert an irre-
sistible attraction. The concours is acceptable, because a sentiment

134; Reviews. [July,

of justice is the principle whence it is derived, its roots stretching
into the very depths of the heart. By the publicity of the struggle,
it exerts a profound influence, and bestows on the aristocracy of
intellect a legitimate and durable popularity. At the epoch in which
we live, when feebleness of moral sentiment is indicated as one of
the signs of the times, what can be more suited to elevate and
strengthen the mind than these noble spectacles which, snatching it
from indolence, excite emulation, and spread, among the youth of
our schools, the beneficent contagion of example, the more certain
and rapid in its operation in proportion to the height whence it has
descended.

" The reproach that has been most especially directed against the
concours is, that it paralyses original work, and that it keeps away
the so-called men with ideas, giving to the clever in speech pre-
cedence over the true savant. Does not such .language seem to
imply that the interests of teaching should be delivered up as a
sacrifice to some exceptional personalities ? How often have we not
seen such men, surrounded as they were by the reflection of a just
celebrity, compromise in a chair without auditors the whole of a
glorious past ? It is too much forgotten that the chief mission of
our schools is not the formation of savants, for savants create them-
selves, but of instructed and useful men, and to assure France as to
the service of the public health. The investigator has his pen, the
press, academies, and the higher professional chairs connected with
his own special researches. As to genius, it raises itself above all
social categories, and institutions are not designed for it. It has
better than all this the glory of the present and the renown of the
future. I repeat, in the words of Grerdy, ' The professor is a man
seldom to be met with, who unites an extensive memory for the
retention of facts, sound judgment for their appreciation, and severe
reasoning for the deduction of the consequences that flow from them.
He is the industrious bee who, accumulating from every side, elabo-
rates from the products of his labour a delicious honey to the profit
of the entire human race.' " (xxxi.)

2. Report ly M. Dubois on the Prizes awarded by the
Academy in 1866. — The Academy performs, through the agency
of committees, a very laborious duty in the award and distribu-
tion of its numerous prizes, most of these being legacies, and
some of them of considerable value. It is the business of the
secretary to state the grounds upon which these awards have
been made, as well as the reasons which have dictated their with-
holdal or postponement. This report is, in fact, a summary of
the various decisions arrived at by the respective committees.
We need not advert to the details of this report, as these were
long since published : but we may observe that the awards of
the Academy are not confined to original memoirs sent in com-
petition, but are often bestowed on the authors of works already
published, which are considered to have advanced the depart-

18G8.]

Memoir es de I'Academie de Medecine, 135

mcnts of medical science they relate to. Whatever may be the
reason, the prize system seems to be much more flourishing on
the continent than with ourselves, judging from the large sums
devoted to it, and the amount of emulation it gives rise to.
But even there the reporters have not infrequently to lament the
insufficiency of many of the essays submitted to them.

3. Report on the Epidemics observed in France during 1865
By M. Bergekon, the reporter of the committee on epidemics. —
This report is addressed to the Minister of Agriculture, Com-
merce, and Public Works, and was approved of by the Academy
at the end of 1866. The material is derived from the reports
of a class of public medical officers distributed over the whole
of France, designated as Medical Officers of Epidemics, and one
of whose duties is to transmit annually to the Academy accounts
of any epidemics that may appear in their respective localities.
Whether from insufficient remuneration or other causes, this
part of their functions seems to be executed in a very imperfect
manner, and it is a standing complaint of the successive acade-
mical committees, that, wliile a few of the reports submitted to
them are creditable and careful productions, the majority of
these officers either send in no reports at all, or these are so
meager as to be of little utility ; so that, what with this defi-
ciency of communications, and the want of authenticity and
uniformity in the statistical information supplied, the Academy
during the forty years it has been at this work has, in the words
of the present reporter " never yet been in the position to present
to the administration a complete and exact representation of
the epidemics prevailing in France." The committee on the
present occasion is anxious to draw the minister's attention to
the fact of how few real sanitary improvements have resulted
from the repeated representation as to their necessity it and its
predecessors have addressed to head-quarters. It is of opinion,
also, that a disproportionate amount of attention has been paid
to epidemic as compared with endemic affections. These latter
are infinitely more amenable to hygienic influences, for while
epidemic scourges are of only occasional occurrence, endemics
are of mucli more constant operation.

" Just as the pathogeny of the greatest number of epidemic
diseases is independent of conditions of locality, so on the other hand
there is an intimate causal relation between endemics and the places
in which they arise. This fact has long been demonstrated as regards
ague, goitre, and cretinism, and there is every reason to believe that
a similar demonstration might be made with respect to phthisis,
scrofula, rickets, and dartres, if, on the one hand, it were established
by irrefutable documents, that one or other of these diseases notably

136 Reviews. [July,

prevailed iu certain localities, and, on the other, the topographical
conditions of such localities were perfectly known." (Iviii.)

It is in this direction, at all events, the committee believes
that attention should be directed for the purpose of obtaining
exact geographical, geological, and ethnological accounts of
these various localities, as well as of the manners, habits, and
occupations, /. e., of the hygienic conditions of their inhabitants.
Sad as are the results of epidemic visitations, the endemic con-
ditions of ill health, more abiding, exert a permanent deleterious
influence from generation to generation, sapping the very vitality
of the race itself.

The reporter passes in review the various epidemics which
prevailed during 1865, as far as the information furnished him
by the reports from fifty-eight departments allowed. The year
was below the average in these visitations, until towards the
end the terrible cholera made its appearance. While speaking
of variola, he says that it has during the last few years been
committing greater ravages than heretofore. This is due to the
diminution in the popularity of vaccination, founded in some
measure iipon the dangerous prejudice that, under its influence,
typhoid fever has been substituted on a large scale for variola.
Then, again, vaccination is too often carelessly performed, and
not sufficiently supervised, while certiflcatesof its performance are
neglected to be enforced as a condition of admission to schools.
In no less than twenty-six departments epidemics of diphtheria
appeared, and in one or two instances they were attended, on a
small scale, with the disastrous effects described by Trousseau
in the epidemics in Touraine in 1819 and 1820.

No official work is complete in France without its medals,
and accordingly the reporter furnishes a long list of Medical
Officers of Epidemics, to Avhom the committee recommends that
silver and bronze medals and honorable mentions should be
accorded. An industrious officer may in this way iu time easily
accumulate a little cabinet of these precious objects.

4. Report o)i the 3Iedical Service of the Mineral Water's in
France during 1864. Addressed to the same minister on the
part of the Committee of Mineral Waters, by M. Guerard. — The
management of the mineral Avaters in France is another of those
State affairs, better carried out on paper than in practice. At all
places Avhere mineral Avaters are authorised to be drank, a *' Me-
dical Inspector of Mineral Waters," Avhose duty it is to furnish to
the Academy reports as to the number of persons frequenting
them, their efficacy, and various other facts desirable to be known.
Formerly these officers were invested Avith a power they do not
now possess of regulating the cases fitted for the use of those

1868.] Memoires de I'Academie de Medecine. 137

medicinal agents. Indeed, the abolition of the office altogether
has been contemplated. In the mean time reports are annually
sent to the Academy, whence the committee compiles its general
account. We may observe that, on the discovery of any new
mineral water, an occurrence Avhich seems of great frequency,
samples are forwarded to the Academy for analysis in its labora-
tory, and upon a favorable report being received, a permission
is granted to " exploiter " the source, such preliminary proceed-
ings being indispensable.

The Academy, through its successive reporters, has often sought
to place some limits on the indiscriminate use of these mineral
waters by patients of their own accord, without the sanction of
the medical inspector, or other medical practitioner. The present
reporter is convinced that much mischief results from this pro-
cedure, and is of opinion that so important an agent in the
treatment of chronic disease ought not to be tampered with by
the ignorant. The absence of any compulsory regulation of
this kind also renders it impossible for the inspectors to furnish
full reports of the number of persons resorting to these places,
or the results of treatment. Moreover many of the inspectors
exhibit gi-eat remissness in reporting, especially from the smaller
places ; and thus, while the present account is drawn up from
reports of some forty establishments, there are more than a
hundred which furnish none at all. From a table given of
thirty-eight establishments sending in reports, it seems that in
these were treated 58,000 paying, and 7000 gratuitous patients,
the various establishments being farmed out by the Government
for sums varying from 1,000,000 francs at Vichy, to 500 francs
at some place in Corsica. The reporter passes in review the
various reports that have come to the hands of the Academy,
the different establishments being classed according to the com-
position of their waters ; and his report forms a useful document
for those to consult who wish to have the latest information on
the repute attached to the various springs. Notwithstanding
the laziness of the great bulk of the inspectors in the matter of
reports, the Academy finds some twenty of the more industrious
of them worthy of medals.

5. Report on Experiments in Animal Vaccination conducted
at the Academy. Addressed to the same Minister by M. Depaul,
Director of Vaccination. — The minister, early in 1866, allotted
to the Academy the sum of 6000 francs for the purpose of con-
ducting a series of experiments upon direct vaccination from the
cow, which, introduced from Naples by M. Lanoix, has been a
good deal patronised of late among the easier classes of Paris.
A committee was appointed for this purpose composed of MM.

138 Reviews. [July,

Leblanc, Blot, Jacquemier, Guerin, Bouley, Reynal, and
Bousquet, having M. Depaiil as its reporter. Heifers were
provided for on the premises of the Academy, and were vacci-
nated through nine punctures made at the lower part of the
abdomen between the udder and the groin, Avhere the skin is not
only very delicate, but is well sheltered from contact with foreign
bodies.

The trials made proved that by this means an ample supply
of lymph might be easily kept up for the use of the public.
The cow-pock employed in them was derived from two sources,
viz., from a heifer furnished by M. Lanoix, to which the lymph
derived originally from Naples had been transmitted through
several animals, and from a recent outbreak of cow-pock at
Beaugency. The results obtained from each of these were
identical — just as fine pustules also being produced by the latest
as by the earliest inoculations. One great advantage of this
direct mode of vaccination, in M. Depaul's opinion, is the
security it furnishes against the transmission of syphilis by
vaccination, a circumstance that may occasionally occur under
the from arm-to-arm vaccination, however carefully the subjects
be selected. On this head we may observe other reports on
vaccination, from the pen of M. Depaul, show that he entertains
very exaggerated opinions, and which, indeed, have been often
rebuked as such in the discussions on the subject at the
Academy. In proof of the non-transmissibility of syphilis to
the lower animals, M. Depaul, after referring to the numerous
experiments already on record, relates some others conducted
on heifers by himself, M. Reynal, and M. Fournier, all of which
were followed by negative results.

It was part of the plan of the committee to institute a series
of comparative trials between the new and the ordinary modes
of vaccination ; and the results are given in this report in great
detail. In the " from arm to arm " vaccinations, the " old
\irus " which has been in course of uninterrupted transmission
for so many years was not employed, for since the prevalence
of " animal vaccination " it has ceased to be obtainable in Paris.
The virus of Neapolitan or Beaugency origin had, therefore, to
be resorted to. After detailing the particulars of each vaccinal
experiment, tabular views of the results are furnished, and from
these we gather the following facts. There were 681 children
submitted to " animal vaccination," but of this number 206
never re- appeared; of the remaining 475, in 54 no pustules had
appeared at the end of the week, and in 421 the results were
quite satisfactory, about four pustules appearing on the average.
Of 885 children vaccinated from arm to arm, o24 were seen no
more, and of the remaining 561, 18 were failures, and 543

1868.]

Memoires de I' Acudemie de Medecine. 139

successes, with an average of 4| pustules. It is to be observed,
however, that while, in this latter category, the children were
all vaccinated on the seventh day from well-developed pustules,
a distinction is to be observed with regard to the 681 submitted
to the new mode. In 406 of these virus, taken from the third
to the sixth day, from heifers perfectly well, was employed,
and (deducting 123 absentees), there were only five failures to
278 successes, the pustules averaging 4^ in number. But
among 275 vaccinations with lymph taken on the seventh day
or later, or derived from a sick animal, not counting the 83
who did not return, there were 49 failures to 143 successes,
only three pustules being produced on the average. While in
the arm to arm vaccination six punctures were made, frequently
only two were made in animal vaccination, in consequence of a fear
of exciting too great inflammatory action, owing to the pustules
which result from this undergoing a greater development.

The following are the conclusions the Committee arrived
at:—

" 1. The transmission of cow-pox by inoculation from heifer to
heifer is obtained without difficulty. 2, We have inoculated forty-
five, and always with the same success. 3. Punctures made either
with the lancet or a needle succeed just as well as do incisions.
4. None of these animals suffered from any accidents that could
properly be referred to the inoculations. 5. For the first three we
employed the Neapolitan cow-pox, and for the other forty-two that
of Beaugency. 6. The results obtained were perfectly identical.
7. Successive transplantations of the same virus do not seem to
influence the development of the pustules. Those observed on the
last animal presented the same characters and dimensions as in the
first experiment. 9. "We have found that the course of the pustules
is a little more rapid than in the human subject. 10. The pimple
almost always began to appear in the course of the third day, and
suppuration was generally set up in the course of the seventh or
eighth. 11. The health of the animals exercised a marked influence
on the development of the pustules, those who became sick exhi-
biting them less developed. 12. Tlie eruption was confined to the
points of inoculation, no pustule ever being met with on other parts
of the skin, or at the commencement of the mucous membranes.
13. Of general reaction there was little or none. In some heifers,
dejection, and a little heat of skin were observed. 14. Our experi-
ments at the Academy demonstrate that it would be possible to
organise and keep up at a moderate expense, especially in the great
centres, sources of animal vaccination. 15. Spontaneous cow-pox is
not so rarely met with as is generally supposed. Two instances of
this occurred during the course of our experiments. 16. The cow-
pox we employed for most of our experiments had an authenticity of
origin of which we had no doubt. 17. The number of inoculations
which may be made are unlimited. The quantity of -virus farnished

140 Reviews. [July,

by each animal is considerable, and more than is required by the
exigencies of the most extensive public service. 18. According to
our experiments, syphilis is not inoculable in individuals of the ox
tribe. 19. In all the instances in which the virus was taken at the
proper period, which is now well ascertained, success has been
almost always constant, and in all cases as frequent as when human
lymph is employed. 20. But wherever it has been taken at too late
a period, that is, after the seventh day, the failures have been more
frequent, and the number of pustules produced fewer. 21. The
results obtained by means of the Neapolitan cow-pox have not been
inferior to those furnished by that of Beaugency. 22. It is not
uncommon to find after the vaccination of children with this virus,
that the period of incubation is prolonged, the eruption not appear-
ing until from the fifth to the twelfth day. 23. Sometimes in the
same infant the course of the pustules is very irregular, some being
much advanced, while others are scarcely visible. 24. The size of
the pustules is considerably greater than that of those derived from
human vaccination. 25. There is more general reaction throughout
the economy produced, especially at the stage of suppuration, when
tlie local inflammatory symptoms assume a greater intensity. 26.
Still, these symptoms have never assumed a serious character in any
of our children. 27. With respect to the number of pustules, very
nearly the same results have been attained with both kinds of virus.

28. After animal vaccination in a certain number of cases, we have
observed two, three, or even four pustules around a single puncture.

29. This phenomenon, though sometimes met with, is observed far
seldomer in human vaccination. 30. All the modes of inserting the
virus have equally well succeeded. The important point is to take
the virus at the proper time, 31. The virus derived from the heifer,
like the ordinary vaccine virus, often fails after it has been kept a
certain time in glasses or in tubes. 32. Without being able yet to
speak positively, the human virus seems to possess some advantage
in this respect over the animal virus. 33. Still we have successfully
employed the latter after it has been kept a month in tubes ; and we
have sent it into the country and abroad with . good results.
34. Whether its preservative action will prove more complete and
durable than the human virus which has passed through several
generations, time alone can show. 35. The number of our
revaccinations has been too few to admit of any positive conclusion.
36. During the prevalence of an epidemic, affecting a great number
of localities, more or less distant from each other, it would be easy to
send one or more inoculated heifers into the infected districts, which
would furnish the virus necessary for the performance of vaccination
and re-vaccination on a large scale." (pp. 51 — 54.)

This last suggestion seems to us to be the most valuable one
of the whole report ; and certainly during the experiments in
vaccination which were made on the occasion of the cattle-
plague, when reliable virus was so diiScult to get, such an
abundant supply would have been welcome. We may observe

1868.] Memo ires de VAcad6mie de Midecine. 141

that when M. Depaul's report was read at the Academy, it
found a severe and able critic in M. Jules Guerin.^ Although
this gentleman, as a member of the Committee, signed the
report, in the belief that it was useful as far as it went, yet he
thought it desirable to protest against the prevalent desire of
seeking substitutes for the present mode of vaccination in place
of trying to perfect the conditions of its performance. He
believes it no slight matter to shake public faith in so admirable
a preservative on the ground that in some very exceptional
cases it may have been the vehicle of syphilis. The immediate
effects of animal vaccination, he adds, are obvious enough, but
its superior preservative operation is a pure hypothesis or
Utopia; and it may even be open to doubt whether virus
which has passed through the human system during succes-
sive generations do not possess superior qualities to that ob-
tained from frequent recurrence to the cow. This investigation
even would have been much more useful had it been confined to a
smaller number of comparative vaccinations, and that the course
oiall of these had been watched over from day to day. It was
found that the course of the arm to arm vaccination was much more
regular, and that the virulent power Avas longer retained, and more
easily preserved. Experiments should have been tried by vac-
cinating infant from infant with the virus derived from the
heifer ; and re-vaccinations ought to have been practised on a
large scale. M. Guerin in vain had sought in the committee
to extend the experimental field, and had even offered to con-
tribute to the expense. He brought also before the Academy a
good deal of evidence of practitioners both in France and Italy
who, having tried the practice of animal vaccination had
abandoned it from disappointment with the results.

6. Report on the Epidemics of Cholera that have prevailed
from 1817 to 1850. By M. Briquet. — A committee consisting
of MM. Bouilland, Barth, Davenne, De Kergaredec, Guerin,
Jolly, Melier, Roche, Tardieu, and Briquet, has been sitting
for some years past, to which all publications and memoirs
received by the Academy relating to the cholera has been
referred. Much dissatisfaction has been expressed at the delay
it has exhibited in furnishing its report. The present document,
bringing down the subject to 1850 (the report on the subsequent
epidemics by M. Barth will, it is said, soon follow), in some
measure explains its own delay. It occupies more than 200 pages,
and exhibits the results of the examination of a vast mass of
material. All the works published in India, and the various
countries of Europe and America had to be consulted, and for

> ' Bulletins de VAcademie,' Aug. 13 and 20, 1867.

142 Reviews. [Ju^y>

France itself, several thousand manuscript documents were
besides submitted to the committee by the Government. The
result is a very elaborate historical and critical account of the
various phases of the disease, which cannot fail to be of great
use to all subsequent inquirers, whether they agree or not with
the opinions expressed. The treatise is divided into five sections.
1. The history of the cholera in India, with the view of ascer-
taining whether it always originates there ; 2. The history of
its appearance in all parts of the world besides France ; S. the
history of the epidemics that have occurred in France ; 4. The
pathology of the disease ; and 5. Its treatment. The itinerary
of the disease has, perhaps, never been placed before in so clear
a light. On the present occasion any critical account of the
work is beyond our scope, and we merely quote the general
conclusions with w^hich it terminates.

" 1, Among the various species of cholera morbus, there is one to
which the name of Asiatic or Indian cholera has been given. Its
etiological character consists in its faculty of being propagated from
one place to another; its anatomical character is psorenterie, and its
pathological character white stools sui generis. 2. It originated in
India, where it has probably existed from time immemorial, but its
well attested outbreaks only acquired importance about 1760, the
period of the contests between the French and English armies in
India. 3, From this period down to 1820, epidemics of cholera fre-
quently occuri-ed in India ; but beyond its limits they have never
been met with, unless it were in the Low Countries in 1665, where
the disease assumed the epidemic form with characteristic symptoms
in the province of Grhent. Holland was at that time the sole power
having very intimate commerce with India. 4. Between 1817 and
1850 three great epidemics were propagated beyond India, all three
originating in Bengal. 5. These epidemics have observed two very
different modes of propagation. When this has taken place by land,
it has generally been through adjoining localities ; but when it has
extended to countries surrounded by the sea, it has taken place at
more or less extensive distances — seaports, and especially mercantile
seaports, being generally the first localities attacked. 6. Its pro-
pagation is facilitated or embarrassed by various circumstances
dependent either upon the atmosphere or upon individuals. The
conditions which, according to recognised documents, in general
favour the propagation of cholera are, the vicinity of places where it
prevails, the proximity of slowly flowing water, inconsiderable alti-
tudes, elevation of temperature, the presence of a large quantity of
water or vapour in the air, great atmospheric vicissitudes, defective
supply of air, the direction of the winds from infected localities,
large assemblages of persons, overcrowding, the presence of great
calamities, as war, famine, poverty, low condition of health, debili-
tating passions, exhausting fatigue, and unsuitable diet. 7. The
conditiona which tend to place an obstacle to its propagation are in

1868. 1 Darwin on Variation under Domestication, 143

some measure the opposite of those enumerated, as distance from
localities where cholera prevails, the absence of water courses, con-
siderable altitudes, low temperature, dryness and freedom from vicis-
situdes of the atmosphere, the free exposure to rapid currents of air,
moderate density of population, general well-being, good health,
calmness of mind, moderate exercise, and a suitable diet. Of these
various conditions, the former do not necessarily lead to epidemics,
nor do the latter offer any absolute obstacle to them. 8. The con-
ditions which predispose, and those which give rise to individual
attacks of cholera, are of the same description as those which favour
the propagation of epidemics. 9. It has not yet been demonstrated
that special pathological conditions are the necessary preludes to
epidemics of cholera. 10. The attack of cholera ordinarily com-
mences with disturbance of the alimentary canal, and especially by the
so-called premonitory diarrhoea. 11. Tlie disease itself seems to be
the result of the influence of an as yet unknown specific agent, the
effect of which is to rapidly exhaust vitality at its very sources.
12. The reactionary phenomena are generally the result of phleg-
masiae having a special form. 13. A specific for cholera has still to
be sought for, and the most rational treatment consists in combating
with a certain amount of reserve, with appropriate agents, the
various symptoms as they appear. In his treatment the physician
should always bear in mind, that in severe cholera every means which
exceeds the bounds of moderation may give rise to very serious
accidents. 14. ^Finally, the mean mortality caused by cholera is
generally about one death in every two patients." (pp. 269 — 271.)

Review VIII.

The Variation of Animals and Plants under Domestication.
By Charles Darwin, M.A., F.R.S., &c. Two volumes.
With illustrations. 1868. Pp. 843.

When the excitement caused by the publication in 1859 of
the celebrated book on " The Origin of Species" had, to some
extent, had time to subside, and the true character of Mr.Darwin's
brilliant theory was beginning to be more clearly recognised, it
was soon perceived that no final decision could be expressed on
its merits, until the promised evidence on Avhicli the theory was
based had been fairly and attentively examined. An interval
of two or three years was at first supposed, by the author, to be
sufficient to enable him to complete the work, of which he had
been urged to publish this now well-known Abstract ; but owing,
as we notice with regret, to continued ill-health, only half of
the anxiously expected and long delayed evidence has been

144 Reviews. [July,

placed before us, and it is further to be regretted that the most
important facts are those which are still unavoidably withheld,
for " it was the consideration of these facts," writes Mr. Darwin,
" which first led nie to take up the present subject ;" and " I
hope," he subsequently adds, " that the reader will pause before
coming to any final and hostile conclusion on the theory of
natural selection. It is the facts and views to be hereafter
given which have convinced me of the truth of the theory."
Consequently, the all-important question of the origin of species
by means of natural selection > which, strictly speaking, requires
for its answer a complete biography of the organic world, can
at present be considered only with reference to the variation of
finimals and plants under domestication.

No date has been, nor perhaps can, consistently with the
unfavorable state of Mr. Darwin's health, be fixed for the pub-
lication of the remaining portion of this grandly planned work,
on which so much of the success of the theory has been admitted
to depend. We have for the present been briefly informed that
the author proposes in a second work to discuss the variability
of organic beings in a state of nature, and it will be shown that
variations occurring under these circumstances are greatly de-
])endent on geographical distribution. An attempt will be made
also to show that whilst it is the large and flourishing genera
which include the greatest number of varying species, those species
which are the most variable are also the most M'idely distributed.
But the main subject of this promised work will be the conver-
sion of varieties into species consequent on an ever-recurring
struggle for existence. For as the author has already stated in
his introductory work, the normal condition of the organic world
is war j and as the strongest in the battle of life must, as a
rule, ultimately prevail, and the weakest fail, it will, conse-
quently, be found that the establishment of distinctly defined
species has been due to the preservation of favored individuals
by the gradual extinction of those intermediate varieties which
do not possess corresponding advantages in structure and in-
stinct. In a third and concluding work, this principle of
natural selection is to be tested by examining how far it will
give a fair explanation of the facts adduced. The evidence of
geology will be cited to prove that new species have come in
gradually one by one, and that " the succession of many dis-
tinct species of the same genus throughout the long series of
geological formations seems to have been unbroken or con-
tinuous." The development of the present from the past and
extinct inhabitants of the world will be shown to be in accord-
ance with the theory of descent with modification by means of
natural selection ; and it will be urged that the facts on which

1868.] Darwin on Variation under Domestication. 145

this theory is based " have as yet received no explanation on
the theory of independent creations." Whilst the great prin-
ciple of inheritance at corresponding periods of life ; the reten-
tion of rudimentary and useless parts; and the remarkable
fact revealed in embryonic growth of the similarity of members
of the same great class in the earlier stages of development — in
consequence of which the embryo, for instance, of a mammal,
bird, reptile, and fish, is barely distinguishable — can admit of
being satisfactorily explained, according to Mr. Darwin, only
by the theory of natural selection.

The first of the two volumes before us is almost exclusively
occupied with illustrations of the extent to which variation
under domestication has been observed ; and not only has Mr.
Darwin exhibited rare power and indefatigable zeal in observing
and recording facts, but, moreover, the vast accumulation of
evidence which he has gathered from almost every available
source is much in favour of his assertion that varieties should
be regarded as incipient species. It would be impossible within
the limits of our proposed review of this valuable work, to
notice the successive variations which have been observed in the
different races of animals and plants since they were first do-
mesticated by man. Their history is for the most part very
defective, and as regards many of those animals which are
know'n to have been domesticated from a very early period, such
as horses, dogs, cattle, sheep, and some other quadrupeds, there
are no records of the date at which their subjection began,
even in those cases in which the genealogy can be traced, with
some degree of probability, to animals at present existing in
the wild state ; Avhilst in other cases there is evidence which
would lead us to infer that the ancestral type, from which the
domesticated varieties have been derived, has become extinct.
The history of the horse, for example, is lost in antiquity; and
the evidence of its domestication, from remains found in the
Swiss lake-dwellings, has been traced with that of the sheej),
the pig, and some other animals, as far back as the latter part
of the stone period ; to which it would, perhaps, be difficult at
present to assign a correct date.

The observations on the domestic varieties of the dog display
an extensive acquaintance with the literature of the subject,
and are rich in interesting facts, many of which will probably
be new to some of his readers. Although fully persuaded that
there has been a large amount of variation under domestication,
Mr. Darwin is strongly in favour of the multiple origin of
domestic dogs, and he suggests that the larger dogs may be
descended from the larger wolves ; the smaller and lighter dogs
from jackals; and that the slim Abyssinian canis sifuensis, with

83— XLii. 10

146 Reviews. [July,

its elongated muzzle, may be regarded as the origin of the grey-
hound. It has been very generally observed that the wolf and
the dog in some countries are so closely allied, that it is not
xmfrequently difficult to distinguish between them; and, although
climate and the various external conditions of life, which con-
stitute endemic influence, may, by equally aftecting both ani-
mals, account in some degree for this approximation in their
form and character, yet it is impossible to accept such external
conditions as a sufficient explanation of all the facts observed.
A very close resemblance of this kind has been noted between
the more northern Esquimaux dogs and the grey wolves of the
Arctic circle ; between the Hare Indian dog and the Prairie
wolf; and between the black wolf-dog of the Indians in Florida
and the wolves of that country. The half domestic dogs of
Asia and Egypt are very similar to jackals ; and it appears that
even the peculiarly offensive odour of the jackal may be im-
parted to a dog by simply feeding it on raw flesh.

It is equally unknown whether the different breeds of do-
mestic cats, like our domestic dogs, are descended from several
distinct species or not. The best authorities on the subject
seem to be in favour of a multiple origin, and their opinion is
to some extent supported by the fact that distant countries
possess distinct races of these household pets. Among the
curious varieties which have occurred under domestication we
can only stop to notice the tailless cats of the Isle of Man, which
occur also elsewhere ; a breed of Chinese cats with drooping
ears ; and the inherited peculiarity of lynx-like tufts of hairs
on the ears of some cats in England and also in India.

With respect to the variations of the domestic horse and the
domestic ass, the most interesting and suggestive fact which
has been noted is the occasional and well-marked tendency in
them to the occurrence of stripes. On this subject of striping,
Mr. Darwin is well known to have bestowed very close and
thoughtful attention; and it is chiefly, as we shall presently
have occasion to notice more fully, on the occurrence of cross-
stripes or bars in the wings and tail of the domestic pigeon, that
he has relied in his argument to prove that our various breeds
of pigeons are all descended from the wild rock-pigeon or
columha livia. The appearance of stripes in the horse does
not, however, according to Mr. Darwin,

" Afford nearly such good evidence of their descent from a single
primitive stock as in the case of the pigeon, because no certainly
wild horse is known as a standard of comparison ; because the stripes,
when they do appear, are variable in character ; because there is far
from sufficient cvideuco of the appearance of the stripes from the
crossing of distinct breeds j and lastly, because all the species of the

1868. 1 Dauwi.v on Variation under Doinestication, 147

genus Equus have the special stripe, and several have shoulder and
leg stripes. Nevertheless, the similarity in the most distinct breeds
in their general range of colour, in their dappling, and in the occa-
sional appearance, especially in duns, of leg-stripes and of double or
triple shoulder-stripes, taken together, indicate the probability of the
descent of all the existing races from a single, dun- coloured, more or
less striped, primitive stock, to which our horses still occasionallv
revert." (vol. i, p. 61.)

The domesticated quadrupeds usually bred for food, includ-
ing pigs, cattle, sheep, goats, and rabbits, have all received their
due share of consideration ; and their variations in distant
countries have been carefully studied. The pig appears to have
been most highly cultivated in China, where it has long been
esteemed as a favorite article of food, and where its domestica-
tion is believed by an eminent Chinese scholar to go back at
least 4900 years from the present time. In this country assi-
duous attention has been bestowed on the breeding of sheep and
cattle ; and the development of any valuable character has led,
by means of methodical selection, to wonderful improvements
in their race. But probably the most satisfactory evidence of
the influence of variation in more or less effectually changing
the character of any breed of quadrupeds occurs in the case of
the rabbit, and Mr. Darwin has in consequence very fully de-
scribed the variations observed, in the several domestic breeds
of this animal, all of which he is of opinion may with safety
be inferred to have descended from the common wild species.
It is a Avell established fact that the wild rabbit, if taken young,
can, though with some difficulty, be domesticated : and that the
domestic rabbit, when turned adrift, readily becomes feral and
reverts to the ordinary grey colour. In the following account
of the Himalayan breed of rabbits, Mr. Darwin has shown us
how in accordance with these facts a new species may be readily
developed.

" The origin of the Himalayan breed (sometimes called Chinese, or
Polish, or Russian) is so curious, both in itself, and as throwing
some light on the complex laws of inheritance, that it is worth
giving in detail. These pretty rabbits are white, except their ears,
nose, all four feet, and the upper side of the tail, which are all brown-
ish-black ; but as they have red eyes, they may be considered as
albinos. I have received several accounts of their breeding perfectly
true. From their symmetrical marks, they were at first ranked as
specifically distinct, and were provisionally named L. niffripes. Some
good observers thought that they could detect a diflerence in their
habits, and stoutly maintained that they formed a new specie?.
Their origin ia now well known. A writer, in 1857, stated that he
had produced Himalayan rabbits in the following mauucr. But it ia

H<8 Reviews. [July,

first necessary briefly to describe two other breeds : silver-greys or
silver-sprigs generally have black heads and legs, and their fine grey
fur is interspersed with numerous black and white long hairs. They
breed perfectly true, and have long been kept in warreui^. "When
they escape and cross with common rabbits, the product, as I hear
from Mr. Wyrley Birch, of Wretham Hall, is not a mixture of the
two colours, but about half take after the one parent, and the other
half after the other parent. Secondly, chinchillas or tame silver-
greys (I will use the former name) have short, paler, mouse or
slate-coloured fur, interspersed with long, blackish, slate-coloured,
and white hairs. These rabbits breed perfectly true. Now, tlie
writer above referred to had a breed of chinchillas which had beeu
crossed with the common black rabbit, and their offspring were
either blacks or chinchillas. These latter were again crossed with
other chinchillas (which had also been crossed with silver-greys), and
from this complicated cross Himalayan rabbits were raised. Fj'om
these and other similar statements, Mr. Bartlett was led to make a
careful trial in the Zoological Gardens, and he found that by yimply
crossing silver-greys with chinchillas he could always produce some
few Himalayans : and the latter, notwithstanding their suddeu
origin, if kept separate, bred perfectly true.'" (vol. i, pp. 108, 109.)

It is useful, moreover, to notice that, although these Hima-
layans when first born are usually quite Avhite, yet when a
single black rabbit is produced in a litter, as sometimes happens,
it becomes, before two months elapse, perfectly white. The
constancy with which tlic characteristic markings are subse-
quently developed in this albino breed of rabbits is considered
by Mr. Darwin to be indicative of long inheritance. For it has
been observed that characters common to many species of a
genus — and a large majority of the species of the genus Lepus
have their ears and the upper surface of their tails tinted black,
and retain these markings when the rest of the body in winter
becomes white — *' are found to resist variations, or to re-apj)ear
if lost, more persistently than tlie characters which are confined
to the separate species." The account of the Porto Santo rabbits
Avhich are the feral descendants of a female rabbit which, with
a litter of young, was turned out on the island in 1418 or 1419,
is in like manner very suggestive ; and Mr. Darwin very truly
remarks that most naturalists would, from the well-marked
variation in this breed, have ranked them as a distinct species.
But far more important than variations in external appearance
are the modifications in the osteological characters of these
animals, which have been very closely observed. Among these
changes in structure, there have beeu noted decrease in the
comparative size and capacity, together with a comparative
narrowness of the skull, from disuse of the brain under domes-
tication : a remarkable diflference in the form and size of the

1868.1 Darwix r>» Vnr'a'io/i ni'-cr Ei.in-> ftcat'on. 110

occipital foramen ; an alteration in the size and character of in-
dividual vertebrse ; and great variation in the shape of certain
parts of the scapuhi and of the terminal sternal bones. These
extensive changes, with some other and less notable modifica-
tions in their osseous development, exhibit a degree of plasti-
city which, it must be admitted, we were somewhat unprepared
to expect.

But however satisfactorj^ the evidence afforded by the rabbit
may appear, the stronghold of Mr. Darwin's argument in the
l)resent as in his earlier work is the well-known variability of
the pigeon ; and it must be frankly acknowledged that his rea-
soning in favour of the rock pigeon, columha h'via, being the
parent of our several domestic breeds of pigeons is throughout
admirably sustained. The wonderful plasticity of the organiza-
tion under domestication, to which we had occasion to refer in
the case of the rabbit, is well illustrated in the varied shape of
the domestic pigeon ; in the great diversity of its plumage ;
and still more in those structural changes which affect even the
number of the bones, as, for example, of the ribs and the sacral
vertebne. In addition to remarkable peculiarities of structure,
there are also to be noticed in some breeds certain inherited
movements, presenting singular differences in their habits, and
of which the most characteristic and interesting is that of
tumbling on the ground, as observed in the Lotcm or Indian
ground tumblers.

The variations of fowls and ducks ; of the goose, turkey, and
guinea-fowl ; of the peacock and canary bird ; of gold fish,
hive bees, and silk moths ; together with the variations of cul-
tivated plants, have all received their share of the author's
attention. But we must hasten to notice a very interesting and
suggestive chapter on bud-variation, with which the first volume
concludes, and Avhich forms, as we shall presently have occasion
to show, a fitting introduction to the great subject of inherit-
ance. In this chapter, Mr. Darwin has, though, perhaps, some-
what unintentionally, succeeded in showing how very difiicult
and sometimes, indeed, impossible it must be, even with the
vast supply of carefully observed facts at his command, to
account for merely common phenomena in organic life ; and,
consequently, how important it is that the scientific inquirer
should avoid the error of hasty generalisation. There is no portion
of the work in Avhich we have felt a deeper interest than in
bud-variation ; and the importance of this division of the in-
quiry may be inferred from the fact that the aim of the author
in this chapter is to show " in how close and remarkable a
manner the germ of a fertilised seed and the small cellular mass
forming a bud resemble each other in function, in their powers

150 Revtetvs. [J«b',

of inheritance with occasional reversion, and in their capacity
for variation of the same general nature, in obedience to the
same laws."

The term bud-variation is applied to all those sudden changes
in structure or appearance which occasionally occur in full grown
plants in their flower-buds or leaf-buds ; and they can generally
be propagated to any extent by grafting, budding, cuttings,
bulbs, &c., and occasionally even by seeds. In speaking of
bud-variation it must not, however, be supposed that the term
should be limited altogether to plants ; for Mr. Darwin is of
opinion that if compound animals, such as hydras, corals, &c.,
had been like plants, which in many respects they closely re-
semble, subjected to a long course of domestication, they would
have varied by buds : and he cites some cases in Avhich varieties
of the hydra and of a true coral have been propagated by bud-
ding. Among the extensive and valuable series of cases of
bvid-variation in plants affecting the fruit, which Mr. Darwin,
evidently after much labour, has succeeded in collecting, may
be cited several instances of peach trees having yielded necta-
rines, and one instance of a nectarine tree having yielded
peaches ; the case of a gooseberry-bush, described by the late
Dr. Lindley, which bore at the same time four kinds of berries ;
and some cases of currant-bushes witli red and white currants
either on the same or on separate branches. Numerous illus-
trations are given of bud-variations in flowers, leaves, and
shoots ; and of subterranean bud-variations by suckers, tubers,
and bulbs. Among the more noticeable of the latter group of
illustrations are varieties of the common potato, produced
sometimes by variation in a single bud or eye ; or, as occasion-
ally happens, by all the eyes of a tuber varying in the same
manner and at the same time, so that the whole tuber assumes
a new character ; whilst among the variations by bulbs is to
be noticed a case in which a blue variety of the hyacinth, for
three successive years, gave offsets which produced white flowers
Avith a red centre. In addition to these illustrations of bud-
variations, some anomalous and apparently allied cases have
been described, of which the most celebrated is that of Adam's
laburnum, a form intermediate between the common and the
purple laburnum, and which Mr. Darwin seems inclined to
regard as a graft-hybrid, which is in accordance with the state-
ment of M. Adam, who first raised the plant. Closely analo-
gous, as reproductive anomalies, to this laburnum, are the cases
in which the orange and the citron have been combined ; as in
the well knoAvn case of the Bizzarria orange, which produces at
the same time leaves, flowers, and fruit, identical with the bittei'
orange and the citron of Florence; and the case of the tiifacial

1868.] Darwin on Variation under Domestication. 151

orange of Alexandria and Smyrna, which differs from the
Bizzarria " in the sioeet orange and citron being blended together
in the same frnit, and separately produced on the same tree."
In commenting on these curious anomalies in the reproduction
of the laburnum and the orange, Mr. Darwin remarks that
"whatever their origin may have been, the two parent species occur
blended together under the form of a sterile hybrid, or reappear
with their characters perfect and their reproductive organs effec-
tive ; and these trees, retaining the same sportive character, can be
propagated by buds." With regard to the causes of bud-varia-
tion, it is evident that many of the cases referred to are simply
due to spontaneous variability; others will admit of being ex-
plained by reversion to characters which have, it may be for a
considerable length of time, disappeared ; and again, some bud-
variations are produced by a cross. It should, moreover, be re-
marked that Avhilst variation is more commonly the result of
sexual generation than of propagation by buds ; yet " all the
plants which have yielded bud-variations have likewise varied
greatly by seed. As it is not desirable, at this stage of the in-
quiry, to notice more fully the several points of interest con-
nected with this subject, it will be sufficient for the present to
state that variability dependent on bud-propagation and varia-
bility dependent on sexual generation are the results of closely
allied forms of reproduction, which appear to be alike subject
to the same laAvs of inheritance ; and that, consequently, the
study of bud-variation is to some extent to be regarded as a
transition stage in the inquiry, through which we pass from the
observation of variations which may be fleeting to the con-
sideration of the influence by which they may become fixed.

But before proceeding to investigate the nature of inheritance,
■which from its importance may be termed the axis round which
the discussion on all other subjects connected with the inquiry
revolves, it is necessary to notice an important digression " on
the direct or immediate action of the male element on the
mother form," which, notwithstanding any supposed relation
the subject may have to that of graft -hybrids, seems to be some-
Avhat out of place in the midst of a chapter on bud-variation ;
and with all due respect for the author, we cannot but express
our opinion that it might with advantage be transferred as an
appendix to the succeeding chapters on inheritance ; since it is
apparently far more closely connected with seminal reproduction
than w*ith propagation by buds. With regard to this subject,
Avhicli is one of the most obscure in the physiology of reproduc-
tion, it has been shown that in the case of flowering plants
when the pollen or male element of one species or variety is
applied to fertilise a distinct kind, that a notable effect can by

152 Reviews. ['^"bs

this means be produced on the mother form, in consequence of
Avhich the succeeding flowers or fruit occasionally present an
altered character. Tlie flowers of an orange, for example, were
fertilised with pollen from the lemon, and it was observed that
" one fruit thus produced bore a longitudinal stripe of peel
having the colour, flavour, and other characters of the lemon."
One of the most remarkable, and at the same time best authen-
ticated examples of this effect of crossing is that observed by
M. Denis who fertilised the ChamcBrops humilis with pollen
from the phoenix or date-palm. In reference to this case, Mr.
Darwin remarks that " the fruit or drupe thus produced was
twice as large as, and more elongated thaii that proper to the
Chamaerops ; so that it was intermediate in these respects, as
well as in texture, between the fruit of the two parents. The
hybridised seeds germinated, and produced young plants like-
wise intermediate in character. This case is the more remark-
able as the Chamaerops and phoenix belong not only to distinct
genera, but in the estimation of some botanists to distinct sec-
tions of the family." In animals, analogous results have been
observed, and first-class breeders are so fully aware of this in-
fluence of the first male on the subsequent offspring of the same
mother by other males, that they are careful to avoid deterio-
rating the race by any cross with a male of inferior breed. It
must, we think, be acknowledged that no satisfactory explana-
tion has at present been given of the abiding effect of a first
impregnation on the subsequent progress of reproductive de-
velopment, although theories of a very opposite description have
been advanced to account for the effect produced ; and, until
more conclusive evidence has been published on the subject, we
should not be disposed to agree with Mr. Darwin in ascribing it
to the direct action of the male element on the reproductive
organs of the female, rather than to any intervention of the
crossed embryo.

In passing from the consideration of what Mr. Darwin has
to a very great extent succeeded in showing to be probably the
origin of many at least of those organic forms which naturalists
have hitherto been in the habit of describing as species, we enter
a field of inquiry in which the evidence of variation under domes-
tication no longer possesses a corresponding value. For although
varieties, as Mr. Darwin states, may be called incipient species, —
and all well-instructed observers would, perhaps, without hesi-
tation, be willing to admit that through hereditary influence
the otherwise transient effects of variation may often become
fixed — yet it is questionable whether sufficient or indeed any
conclusive evidence can be derived from this source to prove
that variation will lead to higher results, and effect such a trans-

1868.] Darwin on Variation under Domestication. 153

formation, tliat pigeons, for example, shall cease after a time to
be pigeons ; or that any of the remoter descendants of rabbits
will nltimately be developed into quadrupeds of a higher class
than themselves. A vast amount of evidence has been accumu-
lated by Mr. Darwin to prove that varieties probably become
species ; and he may be considered to have so far succeeded in 1
establishing his position, that variation can now be accepted as '
one of the chief sources of what have been incorrectly classified
as hereditarily independent forms. But when, as already re-
marked, we attempt to pursue the investigation beyond the >
origin of the so-called species of naturalists, and apply the same i
argument to the origin of the higher groups in natural history,
our progress, so far as variation under domestication is con-J
cerned, becomes simply a leap in the dark. This is chiefly due''
to the ftict that the great principle of inheritance is, in many
respects, unfavorable to the suggested extension of the theory,
and that hybridism is altogether opposed to it. Consequently,
it Avill be found, as the inquiry proceeds, that although by
means of hereditary influence varieties may be raised to the
questionable and unsettled rank of species, yet the change thus
effected is more apparent than real ; for, on the one side, by means
of reversion, temporary characters acquired through variation
may be superseded by the more permanent characters of the
true species ; whilst, on the other side, hybridism, by inducing
sterility, opposes an impassable barrier to the formation of new,
through any intermixture of old and hereditarily distinct, forms.
Before, however, we bestow any special notice on this im-
portant division of the inquiry, we have to express our satis-
faction at the progress which appears to have been made in the
investigation of the " wonderful nature of inheritance," since
the publication in 1859 of Mr. Darwin's introductory work on
the origin of species, in which it was distinctly though some-
what incorrectly asserted that " the laws governing inheritance
are quite unknown." For it must be acknowledged that pre-
vious to this date considerable progress had been made in the
investigation of hereditary transmission ; and that some of the
various influences to which an inheritance might be subject,
and more especially the influence of prepotency in transmission
had been very ably discussed and illustrated by M. Prosper
Lucas in his great work on " Natural Inheritance." But it has
been due chiefly to the recent publication in this journal of a
series of papers by Mr. Sedgwick, in which the influence
respectively of sex, age, and atavism on hereditary disease has
been fully established, that we possess more definite information
on this subject ; and it is gratifying therefore to observe, in the
following summary by Mr. Darwin, the extent of the change

154 Bevinos, [Ju1y>

Avlilcli has been effected by these and other contributions to the
literature of inheritance : —

"Finally, though much remains obscure with respect to inlie-
ritance, we may look at the following laws as fairly well established.
Firstly, a tendency in every character, new and old, to be trans-
mitted by seminal and bud generation, though often counteracted by
various known and iniknown causes. Secondly, reversion or
atavism, which depends on transmission and development being
distinct powers : it acts in various degrees and manners through both
seminal and bud-variation. Tliirdly, prepotency of transmission,
which may be confined to one sex, or be common to both sexes of the
prepotent form. Fourthly, transmission, limited by sex, generally
to the same sex in which the inherited character first appeared.
Fifthly, inheritance at corresponding periods of life, with some ten-
dency to the earlier development of the inherited character. In
these laws of inheritance, as displayed under domestication, we see
an ample provision for the production, through variability and
natural selection, of new specific forms." (vol. ii, p. 84.)

It must be freely admitted that the difficult subject of inhe-
ritance has been investigated by JNIr. Darwin Avith much care
and discrimination, and that he has succeeded in showing the
extent to which the variations from the normal type, if we may
be permitted to use the term, are capable of being inherited.
The illustrations, more particularly of the various inherited
malformations and diseases of the eye, with its accessory parts,
may be referred to as very useful in assisting to prove that even
the most trifling peculiarity or defect may be the heritage of a
family for two, three, or more generations, and that the trans-
mission of the inheritance varies greatly in different cases. In
addition to such affections, it will be as well also to notice some
cases of supernumerary fingers and toes, to which Mr. Darwin
has directed special attention, on account of the occasional
regrowth of these superfluous parts after amputation. The
cases which have been cited in favour of this exceptional power
of regrowth are — 1st. That of a child with a thumb double from
the first joint, and furnished with an additional nail, in which
the supernumerary member Avas removed at the age of three
years, but grew again and reproduced a nail. The newly-grown
thumb in this case was again Avholly removed by its socket-
joint, and again grcAv and reproduced the nail. ^nd. A case,
mentioned by Dr. Struthers, of partial regrowth of an additional
thumb after amputation in a child three months old. 3rd. A
similar case which was observed by the late Dr. Falconer. 4th.
The following case, in which the evidence of regrowth after
amputation is very complete : —

1868.] Darwin on Variation under Domestication, 155

"A gentleman," writes Mr. Darwin, " wlio first called my
attention to this subject, has given me the following facts which
occurred in his own family. He himself, two brothers, and a sister,
were born with an extra digit to each extremity. His parents were
not affected, and there was no tradition in the family, or in the
village in which the family had long resided, of any member having
been thus affected. Whilst a child, both additional toes, which were
attached by bones, were rudely cut off; but the stump of one grew
again, and a second operation was performed in his thirty-third
year. He has had fourteen children, of whom three have inherited
additional digits ; and one of them, when about six weeks old, was
operated on by an eminent surgeon. The additional finger, which
was attached by bone to the outer side of the hand, was removed at
the joint; the wound healed, but immediately the digit began
growing, and in about three months' time the stump was removed
for the second time hj the root. But it has since grown again,
and is now fully a third of an inch in length, including a bone, so
that it will for the third time have to be operated on." (vol. ii,
pp. 14, 15.)

These facts, -whicli have been sufficiently well authenticated,
require to be very carefully considered, for they have furnished
Mr. Darwin -with what he is evidently disposed to think is a very
strong argument in favour of the hiiman race being the remote
descendants of a very inferior type in organization, far below
not only every mammal and bird, but below also every existing
reptile ; a supernumerary digit being in ftict, according to his
vieAv of the case, a finger of scorn pointing to our affinity w4th
a fish. For although he has very justly remarked that all that
can perhaps safely be said about cases of polydactylism is that
they indicate "mere fluctuating monstrosity"; yet he imme-
diately proceeds to suggest, —

" As supernumerary digits in the higher animals, from their power
of regrowth, and from the number thus acquired exceeding five,
partake of the nature of the digits in the lower animals ; as they occur
by no means rarely, and are transmitted with remarkable strength,
though perhaps not more strongly than some other anomalies ; and
as with animals Avhich have fewer than five digits, when an
additional one appears it is generally due to the development of a
visible rudiment ; we are led in all cases to suspect, that, although
no actual rudiment can be detected, yet that a latent tendency to the
formation of an additional digit exists in all mammals, including man.
On this view, as we shall more plainly see in the next chapter when
discussing latent tendencies, we should have to look at the whole case
as one of reversion to an enormously remote, lowly-organised, and
multidigitate progenitor." (vol. ii, pp. 16, 17.)

In reply to this overstrained suggestion it should be remarked,
in the first place, that the regi'owth of supernumerary digits is a

156 Reviews, [-^"1^,

very exceptional fact in the luiman race, for out of an immense
number of cases in Avhich an operation for their removal lias
been performed, and that, too, chiefly, as it is important to
notice, at a very early period of life, there are very few exam-
ples of any reappearance of these abnormal structures ; and,
secondly, that in the exceptional cases in which regroAvth after
amputation has been observed, there is no evidence to show that
such regi'owth was connected with any exceptionally early
period of life at Avhich the operation was performed ; and con-
sequently it cannot rightly be regai'ded as an indication of the
power of reproducing lost parts analogous to what has been
assumed, but on insufficient evidence, to occur occasionally in
the embryonic condition. For although Mr. Darwin is disposed
to infer " that supernumerary digits in man retain to a certain
extent an embryonic condition, and that they resemble in this
respect the normal digits and limbs in the lower vertebi-ate
classes ;" yet it is evident that, since these superumerary struc-
tures undergo development which is to a great extent parallel
with the development of the rest of the body, they must, so far
as growth and regrowth are concerned, acquire a less embryonic
character as age advances. Consequently, instead of havingour
attention directed to any indication of the power of reproducing
lost parts in connection with the limbs of a foetus, as contrasted,
with the fact that " the normal digits in adult man and other
mammals, in birds, and in true reptiles, have no power of re-
growth," evidence should have been forthcoming to show that
the regrowth of supernumerary digits, Avhich have been surgically
removed, has been more commonly observed when the amputa-
tion has been performed immediately after birth than when it
has been delayed to a later period of life. The difficulty attend-
ing any extension of the theory, such as that suggested by an
exceptional power of regrowth in a few cases of polydactylism,
so far, indeed, from becoming less, seems rather to increase as
we proceed ; and a careful study of the comparative effects of
variation on analogous structures in different animals will some-
times conclusively prove that, in attempting to explain such
variations, it has been found necessary, so to speak, to shift the
ground. As an illustration of the difficulty Avhich it is thus
often necessary to encounter, let us examine the evidence which
has been adduced in favour of the spontaneous origin of webbed
feet.

The first and most obvious principle involved in the occur-
rence through variability of webbed feet is that of utility ; and con-
sequently Mr. Darwin has attributed considerable importance to
the fact that in some land animals whicli have become aquatic
in their habits, such as the Newfoundland-dog and the English

1868.]

Darwin on Variation vnder Domestication. 157

otter-hound, there is a decidedly increased development of skin
between the toes. He particnlavly observed in two Newtound-
land-dogs that when the toes were stretclied apart and viewed
on the under side, that " the skin extended in a nearly straight
line between the outer margins of the balls of the toes; wliereas
in two terriers, of distinct sub-breeds, the skin viewed in the
same manner was deeply scooped out;" and a friend, who ex-
amined for him tlie feet of two English otter-hounds, found tliat
the skin in this situation was more developed than in other
hounds ; and it appears also that there is a dog peculiar to
Canada, which has "half-webbed feet, and is fond of water."
From the fact that the skin between the toes in these animals
is usually more developed than in those dogs which are not
accustomed to swim, Mr. Darwin has argued " that as aquatic
animals -which belong to quite different orders have Avebbed feet,
there can be no doubt that this structure would be serviceable
to dogs that frequent the water."

"How inexplicable," exclaims Mr. Darwin in his introductory
remarks, " is the similar pattern of the hand of a man, the foot of a
dog, the wing of a bat, the flipper of a seal, on the doctrine of inde-
pendent acta of Creation ! how simply explained on the principle of
the natural selection of successive slight variations in the diverging
descendants from a single progenitor ! So it is, if we look at the
structure of an individual animal or plant, when we see the fore and
hind limbs, the skull and vertebrae, the jaws and legs of a crab, the
petals, stamens, and pistils of a flower built on the same type or
pattern." (vol. i, p. 11.)

But the occurrence of such a variation as that referred to above
in aquatic dogs, even if it could he shown to be permanently
established — and at present the evidence in its favour is insuffi-
ciently supported by Mr. Darwin's examination of two New-
foundland-dogs, by a friend's examination of two otter-hounds,
and by Mr. Greenhow's observations, published in 1833, on the
Canadian dog — must not be supposed to be due simply to their
acquired habit of frequenting the water, for webbing of the feet
is far from being an uncommon variation in animals which never
acquire aquatic habits. Numerous cases have been observed of
the hereditary occurrence of this variation in the human race ;
but we are not acquainted with any evidence in favour of its
being a more frequent occurrence in the members of those fami-
lies which have been for centuries aquatic by profession than
in others who from constantly living inland have scarcely had
the opportunity of even entering the water. On the contrary,
it might be urged that, from the frequency with which -webbing
of the lingers and toes, with other digital variations, prevails as

158 Tievieuu^, [July,

an hereditary peculiarity amongst the inhabitants of inland and
especially of mountain districts, quite independent of any aquatic
habits, it cannot be regarded as a utilitarian variation in the
human race.

The same argument against this supposed origin of webbed feet
Avill apply to the occurrence of the variation in those birds which
in like manner have no tendency to become aquatic in their
habits ; such, for example, as in certain breeds of pigeons, in
which it is customarily associated with feathered feet ; and it
seems to be very important to notice this exceptional fact in the
pigeon, as it is opposed not only to the argument founded on
utility, but opposed also to the argument which Mr. Darwin has
elsewhere employed with much sldll in favour of reversion to a
primitive type ; for as a very large proportion of the feathered
races are water birds with webbed feet and bare legs, the con-
joined anomaly of webbed and feathered feet in pigeons is opposed
to the supposition that they can have descended, through the
rock-pigeon, from a webbed footed progenitor. It is well known
that, from a very early period in the history of the present inquiry,
special attention has been bestowed by Mr. Darwin on a case of
hereditary peculiarity in some breeds of pigeons, Avhich liave the
two outer toes partially connected by skin when their legs are
feathered. At first this fact is said to have been utterly inex-
plicable ; but it is now understood to be dependent, not on its
utility, as in dogs, for no webbed- footed pigeons have been ob-
served, or have even tried to swim, but on the law of correlated
variation of homologous parts. For these two toes in the pigeon,
which correspond with the third and fourth toes in man, acquire
feathers on becoming partially webbed, because they are, it is
urged by Mr. Darwin, homologous to structures in the pigeon's
Aving representing the third and fourth digits, which are both
feathered and completely united by skin. Now, it is important
to notice, with reference to this peculiarity in the pigeon, that
in other birds, such as marsh- and water-fowl, which possess
either a partial or a complete webbing between the toes, as a
constant because, as Ave have hitherto been accustomed to
assume, it is in their case a normal development, there is no fea-
thering of the legs or feet, notwithstanding the fact that bird-s
' which are thus normally Avebbed footed, instead of presenting
elscAvhere any general deficiency of feathers, have usually a very
dense plumage. Hence it Avould not be otherAvise than alloAV-
able to suppose that the laAv of homologous affinity, Avhicli pro-
vails to a very great extent in normal development, is somcAvhat
exceptionally associated in this case of peculiarity in the pigeon,
Avith the laAV of correlated variability Avhich occupies a pre-
eminent position in Mr< Darwin's argument on the origin

1868.]

Dahwix oil Variation under Domestication. 159

of species ; for he has impressively assured us that '• of all the
laAvs governing variability, that of correlation is the most im-
portant." On proceeding to investigate this subject still further,
it will be found that there are many breeds of birds in which, as
a result of variability under domestication, the legs and toes
become feathered without any corresponding development of
skin between the toes. The feather-footed canaries and the
feather-legged bantams may be referred to as notable examples
of this fact ; and with respect more especially to this interesting
breed of bantams it may be stated that the leg-feathers, which
grow from the outside of the leg, and generally from the two
outer toes, have sometimes been observed to exceed even the
wing-feathers in length, showing that there may be an ex-
cessive development of feathers in this situation apart from any
corresponding development of intcrdigital skin ; whilst on the
other side there are cases in which exactly the reverse of this
has been observed in other breeds of the fowl, such, for example,
as occurs in the case of the golden-spaugled Polish fowls which
are bare legged, and in which the skin between the toes is said,
by Mr. Tegetmeyer and other authorities on the subject, to bo
much developed. It still remains to be noticed that, as in the
bird's wing, the second digit is only rudimentary, and the first
and fifth digits are wholly aborted, the two remaining digits,
which are completely webbed, represent the third and fourth
toes in the foot ; and that, consequently, the limited develop-
ment of web-skin in the foot is strictly homologous to that in
the wing. Hence '" the whole leg tends," says Mr. Darwin,
" to assume the structure of the wing." On referring, however,
to cases of abnormal development of inter-digital skin in other
animals, it will be found that there is occasionally a preference
shown for this digital interspace, apart from any abortion of the
first, second, and fifth digits in the anterior limbs, and alto-
gether independent of any connection with the development of
feathers ; and that in cases of inter-digital webbing in man, to
which we will now more particularly refer, this preference may
be exhibited in the hands and feet, either separately or together.
Mr. Canton has recorded a case of symmetrical webbing, of the
third and fourth toes, in a man who had four sons with pre-
cisely the same peculiarity, and four daughters who were exempt
from it. Dr. Dickie, of Alloa, has recorded a case of webbing
of the corresponding fingers, without any webbing of the toes,
which was observed to be hereditary for more than six genera-
tions ; and it is to be noticed, in this case, that the defect was
on many occasions unsymmetrically limited to one and appa-
rently the same hand, and that unlike, also, the preceding case,
it occurred " move frequently amongst the females than the

IGO Revieivs. [July,

males ;" Avliilst a case has come under our own observation of
partial webbing of the ring and middle fingers and correspond-
ing toes in some members of a family, in which, for five genera-
tions, there had been noticed congenital absence of the terminal
phalangeal bones and nails of the little fingers and little toes.
With reference to such cases, it should be further remarked
that, although a certain degree of preference in abnormal de-
velopment is thus sometimes exhibited for this digital interspace,
yet an equally well-marked limitation to one or more of the
other digital interspaces has been occasionally, though, perhaps,
less frequently observed in other cases; as, for example, in a
case which has been lately brought under our notice, in which
the webbing was limited to the interspace between the second
and third toes of the right foot in a boy whose maternal great
uncle had precisely the same malformation. Many other illus-
trations of such limitation of inter-digital webbing have been
recorded, or have come under our notice ; but it will be sufficient
to refer at once to the fact that the development of abnormal
webbing is not always restricted, even in pigeons, to the third
and fourth digital interspace, for Mr. Darwin informs us that
he had in his possession "a spot and a nun with the skin ex-
tending for a space of a quarter of an inch from the fork between
the two inner toes" (vol. i, p. 160); and from these birds there
might, in accordance with the recognised principles of inheri-
tance, have been bred a race of pigeons with webbing between
the two imier instead of between the two outer toes.

But even if it could have been satisfactorily shown that struc-
tural advance in the organization had resulted from variation, it
would still be incumbent on the author of this theory to prove
that, when from any cause a retrograde change occurs in the
development of an animal which has been thus progressively
improved, intermediate and newly-formed species and genera
ar^ not, as a rule, liable to be altogether passed oVer when re-
version occurs, so as to permit of the degraded descendant being
reduced to a rank peculiar to one epoch only, and that often ex-
ceptionally remote, in its past history ; for if the intermediate
species and genera are in any way entitled to their position and
their name, there is no need for the reversion to extend to a
period always anterior to their development. In the following
remarks on the influence of reversion in inheritance we shall
endeavour to show that the facts Avliich have been observed by
Mr. Darwin are not favorable to the theory which he has
proposed.

Ileversion, or the principle on which depends the reappear-
ance of characters which have been lost sight of or forgotten
through being suppressed for one or more gencratioii?, and

1868.] Darwin on Variation under Domesticaiion. 161

which occupies a very prominent position in the present inquiry,
has often been referred to by many writers as a very curious and
a very mysterious phenomenon ; but it has not, at least until
late years, received much scientific attention. Mr. Darwin, as
might be expected, has been fully aware of its great significance
in relation to his theory of the origin of species ; and he has
accordingly investigated very closely the various forms under
which it may occur, and the various causes on which it may
depend. One of the most common, and, as regards the supposed
origin of species, one also of the most important of these forms
of reversion, is that resulting from a cross in which the offspring
presents the characters proper to either pure parent form. "As
a general rule," Mr. Darwin informs us, " crossed offspring in
the first generation are nearly intermediate between their
parents ; but the grandchildren and succeeding generations con-
tinually revert, in a greater or less degree, to one or both of
their progenitors." This influence of crossing in leading to re-
version has become endowed w'ith peculiar interest, in conse-
quence of its effects in the celebrated case of the pigeon having
been instrumental in first directing Mr. Darwin's attention to
its usefulness in determining the parent forms of our several
domesticated breeds of animals ; and it is deserving of notice
that in the foUoAving evidence respecting the origin of the
domesticated pigeon, which has been given in detail, he carefully
disclaims the merit of having been the first to recognise its effect
in causing reversion to the parent rock-pigeon, or Columha livia.

"My attention," writes Mr. Darwin, "was first cajled to this
subject, and I was led to make numerous experiments, by MM.
Boitard and Corbie having stated that, when they crossed certain
breeds, pigeons, coloured like the wild C. livia, or the common dove-
cot, namely, slaty-blue, with double black wing-bars, sometimes
chequered with black, white loins, the tail barred with black, with
the outer feathers edged witli white, were almost invariably pro-
duced. The breeds which I crossed, and the remarkable results
attained, have been fully described in the sixth chapter. I selected
pigeons, belonging to true and ancient breeds, which had not a trace
of blue or any of the above specific marks ; but when crossed, and
their mongrels recrossed, young birds were continually produced,
more or less plainly coloured slaty-blue, with some or all of the
proper characteristic marks. I may recall to the reader's memory
one case, namely, that of a pigeon, hardly distinguishable from the
wild Shetland species, the grandchild of a red-spot, white fantail,
and two black barbs, from any of which, when purely -bred, the pro-
duction of a pigeon coloured like the wild C. livia would have been
almost a prodigy." (vol. ii, p. 40).

Similar experiments have been made with fowls, ducks,
rabbits, cattle, horses, asses, and other animals, and the results

83--xin. 11

163 Reviews. [July^

obtained have corresponded with those observed in the pigeon ;
the offspring having exhibited the characteristic colour and
markings of what was, in each case, either knoAvn or might
reasonably be assumed to be the wild species. Even instincts
which had been lost were by this means recovered ; such as the
lost instinct of incubation in those breeds of fowls known as
'' everlasting layers." Whilst in other animals the primitive
wildness of disposition, which had for generations been lost
through long-continued domestication, with many other charac-
teristic qualities of the feral state, were by this means restored.
In attempting to account for this reversion to characters
which have in many cases been long extinct, Mr. Darwin has
assumed that they are capable of remaining latent in the orga-
nization for an indefinitely prolonged period, and throughout
an almost unlimited succession of generations ; and in his
remarkable theory of pangenesis,^ to which we may again
have occasion to refer, the marvellous manner in which these
alleged latent peculiarities of structure, — for variations both in

' lu " the provisional hypothesis of pangenesis," which occupies a concluding
chapter of the work, Mr. Darwin has assumed that the whole organisation, in the
sense of every atom or unit, reproduces itself; and its importance may be infen-ed
from the fact that it has been designed to explain the various forms of reproduc-
tion, sexual and asexual ; the development and growth of animals and plants ;
the changes induced in them by variability ; and the great principles of inherit-
ance. Mr. Darwin seems to have been led or rather forced to adopt this theory,
which appears to be founded on Mr. Herbert Spencer's theory of physiological
units, chiefly in consequence of the difficulty or impossibility of otherwise ex-
plaining the various forms of inheritance, and especially those which result from
the peculiar principle of reversion, which he regards as the most wonderful of all.
" In every living creature," he remarks, " a host of lost characters lie ready to be
evolved under proper conditions," their evolution being dependent on the awa-
kened action of dormant gemmules ; and when such gemmules, derived, it may
be, from some remote progenitor, are present in sufficient immber to gain the
ascendancy, they cause the reappearance of long-lost characters. Each of these
gemmules is supposed to represent with exactness the organic unit which was its
immediate progenitor, and from which it has been developed by a process analo-
gous to that of budding, and, consequently, analogous to that ^form of reproduc-
tion in which all other forms may, strictly speaking, be merged; and as each
individual animal or plant reproduces its kind, so each integral cell or unit, of
which the animal or plant is composed, does the same. In like manner also the
ordinary distinction between growth and development, in which the former is
limited to mere increase in size, and the latter is employed to denote change of
structure, is lost, as it were, in the unity of the process by which the work is
accomplished. For, in accordance with this theory, every part of the child, as
of the adult, generates the same part for the next generation, and consequently
"the child, strictly speaking, does not grow into the man, but includes germs
which slowly and successively become developed and form the man." Inheritance,
which " must be looked upon as merely a form of growth, like the self-division of
a lowly-organized unicellular plant," is essentially dependent on a gemmule
attaining its full size ; and the distinction between the various forms of inherit-
ance, direct, atavic, and collateral, is simply due to the occasionally uncertain and
unequal influence of time on their development. In a typical case of direct in-
heritance the development of gemmules in the offspring would be coincident with
the age of a progenitor of the same sex at their birth ; and this is probably the

1868. J Da It WIN on Variation under Domestication. 163

colour and marking are essentially due to structural peculiarities
in development — can be accumulated within an inappreciably
small compass has been very fully illustrated. It will be suffi-
cient, however, at this stage of the inquiry to state that rever-
sion, according to Mr. Darwin's theory of pangenesis means the
evolution of characters which have always been present in a
material form, though for a time present in so rudimentary a
condition and on so microscopic a scale as to be absolutely
beyond our power of detection : and in order that the theory
should be made, as far as possible, consistent throughout, it has
moreover been assumed that since organic forms may have
hereditarily descended from one primeval form, so each of the
descendants may be supposed to retain many, if not all of the
structural peculiarities which have characterised every stage of
their descent ; and that although a progressively larger number
of these characters become latent in each successive generation,
and some may ultimately disappear altogether, and become
irrevocably lost, yet in their latent condition they are always
ready to be evolved under circumstances favourable to their
development. Hence, as there could have been originally no
distinction of sex, it has been assumed that even those outward
distinctions which now characterise the males and females of

prevailing influence, when associated with that of sex, not only in cases of
normal development, in which it would he potent to secure unity of form in the
remotest descendants, hut also in those cases of abnormal development in which
peculiarities and defects are developed in the parents and in the children at a
corresponding age. Whilst in a typical case of reversion in which, for example,
the inheritance is transmitted from a grandfather, through the medium of a
daughter, to a grandson, the gemmules in the intermediate generation are
dormant and remain so till they have passed into the fertilized ovum, when their
development, as in a typical case of direct inheritance, becomes simply, or perhaps
it would be more correct to say chiefly, a question of time. For the gemmules in
the grandson continue dormant till he has attained the age at which in his
grandfather they were produced, and then their development may be said to
begin. In the remoter forms of reversion, in which should be included some at
least of the cases of collateral inheritance, the gemmules will continue dormant
throughout all the intermediate generations; and it would be impossible to
assign any limit to the time during which gemmules might thus remain unde-
veloped; "but there is no reason to suppose," Mr. Darwin writes, "that all
dormant gemmules would be transmitted and propagated for ever," since it is
obvious that in the organism which forms their little world they would neces-
sarily have the same difficulty to contend with as that which in the outer world
leads to the struggle for existence, and consequently undeveloped gemmules
instead of remaining dormant may perish. Finally it may be remarked that
whilst, like the occasional and perhaps progressive extinction of race amongst
animals and plants, the death of gemmules must be supposed to involve the total
loss of any peculiar character in the organization, which had simply disappeared
dm-ing the time that such gemmules were dormant, since some of the vast
number of those which perish leave no descendents, yet there are others which
must possess a pedigree of incalculable extent ; for if they have been hereditarily
derived from the primordial form from which every living thing has been sup-
posed to descend, they are the still surviving representatives of organic units
which were coeval with the very earliest dawn of organic life upon the earth.

164 Reviews. [July*

vertebrate animals must, to a great extent, be looked upon as
unreal ; for every male, according to Mr. Darwin, possesses in
a latent condition all the secondary sexual characters of the
female ; and every female in like manner, possesses those of the
male. When a hen, for example, which has ceased laying,
assumes the plumage, the spurs, and the voice of the cock, there
is in her case simply the evolution of characters which continued
dormant " as long as her ovaria continued to act ;" whilst, on
the other side, a male bird which has ceased, or has been unable
to exercise the reproductive function peculiar to its sex, acquires
the secondary sexual characters of the female bird. In accord-
ance, therefore, with this doctrine of latent characters, all
vertebrate animals may be said to be unequally developed her-
maphrodites, which have lineally descended from a primitively
unisexual, or as it would perhaps be more correct to say, asexual
form ; and that the distinctions of sex, like all other distinctions
in organic nature, are merely the result of divergence of character
from natural variation in the intermediate generations.

Now if we again turn our attention to the case of the pigeon,
we find that it has been very confidently alleged that the com-
bined influence of domestication and methodical selection has
had the effect of establishing such complete divergence of
character that naturalists would be justified in grouping the
various domesticated forms of the pigeon not only as distinct
species, but in distinct genera : and it must, we think, be
admitted that as the organization of the pigeon under domesti-
cation has been wonderfully plastic, that it would be allowable
so far as regards structural change, to make such distinctions.
But when after thus provisionally assuming that not only
species but genera may, in consequence of the anatomical
changes which have been effected in their structural relationship
to each other, be regarded as the natural results of variation
and selection, we pass, as we must do at once, to the considera-
tion of the extent to which such changes are accompanied, as
they should be if the argument on the origin of species be
sound, by corresponding changes in the physiological relation-
ship of these artificially formed species and genera to each
other, we immediately meet with two great obstacles, which
seem to be capable of arresting all further progress in the
inquiry ; their importance being derived from the fact that they
are essentially connected with the reproduction of species.
One of these obstacles is hybridism associated with sterility
from intercrossing in the feral state, and the other is reversion
associated with increased fertility from the intercrossing of
domestic breeds. It has been already noticed that one of the
most interesting, and, at the same time, one of the most

1868.] Darwin on Variation under Domestication. 165

common effects of variation under domestication is that
observed in the secondary sexual characters which properly
belong to the species, and which sometimes either partially or
wholly disappear. In some of these cases the masculine cha-
racters are transferred to the female, and in others the female
acquires the characters and attributes of the male. It is useful
to refer again to these variations in secondary sexual characters
at this stage of the inquiry, as a frequent effect of domestication
for they will, in some degree, prepare us for the results obtained
from the crossing of species artificially formed through the
influence of variation under domestication, as contrasted with
those obtained from the crossing of true species, in relation to
hybridism in the latter, and to reversion in the former case.

With reference to the subject of hybridism in general, Mr.
Darwin appears to be fully convinced, " that the sterility which
almost invariably follows the union of distinct species depends
exclusively on difference in their sexual constitution." In the
application of this important observation to domestic breeds of
animals, which often present differences of structure fully
entitling them, it is said, to be grouped as distinct species, and
sometimes even as distinct genera, it is evident that before we
can proceed any further in the investigation, it has become
necessary to inquire why, in the midst of these remarkable
variations of structures should the reproductive system in the
different breeds, for example, of the domestic pigeon, be specially
exempt from any analogous change. For if, as it has been
lately urged by one of Mr. Darwin's ablest supporters, the
descendants of the wild rock-pigeon have varied so greatly that
they ought to be grouped into at least five distinct genera, con-
taining in all 150 distinct species, it must be allowed either
that domestication, whilst it promotes variation in general
structure, checks in some peculiar manner any tendency to
variation in the reproductive organs themselves ; or, that the
transformation of varieties into species, and of species into genera
has not, through the influence of variation under domestication,
been really effected. With respect to any special exemption from
variation in the reproductive organs of the domesticated breeds of
the pigeon, it should not be supposed that they remain altogether
unchanged ; but, on the contrary, it may be allowed, especially
as the secondary sexual characters usually and readily admit of
being varied under domestication, that they not only increase
or diminish in size simultaneously with any important increase
or diminution in the size of the body generally, but that they
may also vary in other ways to a greater or less extent; just in
the same way that variations of structure amounting to well-
marked defects, which are not unfrequently hereditary, occur in

166 Reviews. [July,

the reproductive organs of the human race, without impairing
or checking reproduction. Variation of structure, however
great it may be in certain cases in which the organisation has
been rendered unusually plastic by long continued domestication
utterly fails therefore in the domestic pigeon to represent those
structural changes in development on which specific and generic
distinctions should be based ; notwithstanding the fact, of which
it would be impossible to overrate the importance, that the
apparent variation in the domestic breeds of the pigeon is gene-
rally speaking greater than in the several members of the
Columbidee in the feral state. Hence it has been candidly
admitted by Mr. Darwin that whilst, on the one side, there is
"perfect or increased fertility " in the several domesticated breeds
of the pigeon when inter-crossed ; that, on the other side, " hardly
a single well-ascertained instance is known of hybrids between
two true species of pigeons being fertile, i7'der se, or even when
crossed with one of their pure parents." It would, therefore,
appear reasonable to conclude that as the variation accumulated
under domestication disappears very quickly under the influence
of reversion developed by intercrossing, the extinction of inter-
mediate varieties, on which great stress has been laid, and
which ought effectually to have secured the isolation of these
breeds, should be regarded as a very questionable fact, since
there is no interruption or arrest in the backward course or
reversion to the ancestral type. For if, in methodical selection,
there has been any general extinction of intermediate varieties,
the hereditary influence of reversion does not appear to have
recognised the occurrence; otherwise, the ancestral form, revealed
by crossing, instead of being always that of tlie wild-rock
pigeon, would be frequently, if not usually, a later-formed
species ; and it would, moreover, be allowable to hope that on
some occasions, the reversion, like the occurrence of a supernu-
merary finger exhibiting piscine affinity in ,our own race,
would extend back not only beyond the C. livia, but beyond
also the ancestral form of all the Columbidae to that of the first
animal which wore feathers. As there is no such evidence of
variation in the reversion of the pigeon, either to an older or
to a newer species than the C. livia, but, on the contrary, a
steady determination to stop in the backward course only when
this particular species, which represents the feral ancestor of all
domesticated pigeons, has been revealed, it must consequently be
admitted that the five genera, and the 150 distinct breeds of the
domestic pigeon, are not entitled to any higher rank than that of
brevet species ; and that there is, at present, no sufficient evidence
to warrant the supposition that time will confirm their promo-
tion, so as to entitle them hereafter to the rank of true species.

1868.] 167

PART SECOND.
IStlilioorapijifal iterortr.

Aht. I. — The Diseases of the Ear, their Nature, Diagnosis,
and Treatment. By Joseph Toynbee, F.R.S. With a
Supplement by James Hinton, M.R.C.S., Aural Surgeon to
Guy's Hospital. 8vo. Pp. 466^ of which the Supplement
occupies 44.

The care of maintaining this treatise of the late Mr. Toynbee
in the high estimation it has acquired, naturally devolves on his
friend Mr. Hinton. The author's modes of thought and views
on aural surgery were familiar to him, and fall, one might
almost say, to his inheritance. He has for some time enjoyed
as wide opportunities for independent observations in the same
field of study, and has earned for himself a like character for
the ardour with which he toils in it. He has presented us with
a supplement which nms in the guise of a series of footnotes
destined for specified chapters of the original work, and which is so
freely drawn from Toynbee's later contributions to the subject,
and so much in the same spirit that the volume may be read as
the record by one mind of thirty years' experience in the treat-
ment of aural maladies, and of explorations of their causes.

Altogether we have a book redundant in valuable matter, and,
we believe, more indispensable to the profession than any other
on the same theme. Yet we doubt whether a volume might not
be composed from a digest of its contents, and information
elsewhere obtainable which might supplant it as a text book.
At, all events it has one great defect for such purpose : It rather
portrays Toynbee's ideas in process of evolution, than incorpo-
rates them in the substance of the work ; and the notes in the
supplement would not always save a docile reader from the
imbibition of precepts which are afterwards relinquished as
erroneous.

According to the preface, the " domains of anatomy and phy-
siology have only been entered upon, when requisite, for the
elucidation of the pathology or treatment," yet in point of fact
the work exhibits the writer as pushing to the front as an ori-
ginal investigator in every division of his subject. He even

168 Biblioffraphical Record, [July>

invents several aural instruments. However, we cannot esteem
him as an equally safe leader in all of these respects. He might
justly plume himself on his unrivalled pathological labours and
his aptitude for treatment ; he advanced our microscopic know-
ledge of the structure of the merabrana tympani ; and, though
Wollaston had found that the faucial orifice of the Eustachian
tube when made to collapse by exhausting the tympanum of
some of its air, was opened by swallowing (an observation not
alluded to in tlie book), and Wharton Jones and Hyrtl had
described it as habitviuliy weakly collapsed, it was left for him
to shoAv that its usual state is closure and not patency, and to
trace out the muscles that open it in the act of deglutition.
It is in his attempts to gain an insight into the physiological
advantages of this arrangement that he fails in success.

In physiological acoustics he is more remarkable for lingering
in untenable positions than for conquests. The announcement
of his discovery in 1853 was associated with his adoption of
the liypothcsis that liearing is effected through the fenestra ro-
tnnda and the air in the drum, jn virtue of the resonant pro-
perties of a jjerfeclly-closed chamber. To this fancy he clings
even to the middle of the treatise whose preface bears the date
of 1830, though he adds as a " second reason" for the closure,
'^that, as specially pointed out by Dr. Jago, sound may be pre-
vented entering the tympanum from the fauces/^ silent as to the
facts and arguments witli which the latter's paper (published only
a ^ow months after his own announcement) was filled, and which
were destructive of the theory uplield by himself. However, in
the course of the volume he is found to have vanished from the
ground lie had so longadhered to,aud undercover of some acoustic
experiments of his own having little new in pi-inciple, encamping
upon that marked out by Johannes Miilier, viz., tliat the fenestra
ovaiis and ossicula chieily conduct sonorous Avaves to the laby-
rintli, the other fenestra and air in the drum somewhat helping.

In physiologicfd mechanics lie continued to propound as his
own oI)scrvation, that air is forced into the drums through the
I'^nstachiaa tubes when we swailovv^ Avith the nostrils closed,
although the writer just named had, two years before, called
attention to the visible depression of tlie lachrymal sacs (the
alie of the nose show the same fact) as manifesting that air is,
on the contrary, withdrawn. After ten years this correction
gains admission to the supplement, where it figures as PolitzerX
who merely verifies it by aid of an air-tight "manometer.^^
Thus, there was promise that Dr. Jago^s remaining correction,
tliat the opening of the tube is not strictly limited to the act of
deglutition, but liappciis also on the occurrence of eructation,
might in due time be allowed.

1868.] ToYNBEE on Diseases of the Ear. 169

With similar reluctancy Mr. Toynbee abandons his view
that an artificial membrana tympani benefits hearing by con-
verting a drum with a perforate (true) membrane into a closed
chamber; being led, he tells us, to do so by witnessing a
demonstration by Dr. Julius Erhard, that hearing might be im-
proved by the pressure of cotton wool on an entire membrane,
and coming now to the conclusion that it was by restoring con.
tact occasioned by some disconnection or loss in the ossicular
chain. Thus, as the supplement points out, he approached the
opinion long held by Mr. Yearsley that the cotton wool supported
the ossicula.

In turning to other topics, we may glean from the supplement
what has been the presumable progress of aural surgery during
the last eight years. In diagnosis we are told that Dr. Von
Troeltsh^s recommendation of employing a mirror to illumine
the meatus and membrane so as to set one's hands at liberty is
universally adopted. Dr. Lucae's proposal for distinguishing
between aflections of the nerve and conducting apparatus is
found of service. He tries whether the sound of a tuning-
fork vibrating on the vortex of the head or forehead grows
louder by closing the meatus. However, it is far from new to
us that vibrations thus arrested in the meatus are heard through
the membrana tympani, and are a test of ordinary hearing power.
Siegler's pneumatic speculum for withdrawing air from the
meatus Avhilst the membrane is kept in sight, is said to have
great value in determining whether there are bands of adhesion
in the drum.

Under " diseases of the meatus,'^ Mr. Ilinton gives us an
important observation of his own ; that, as far as his experience
goes, polypi in the meatus invariably spring from the drum,
though they may also have attachment to the walls of the
meatus ; he finds it better to treat the discharges following their
removal, as well as most of those from the tympanum, by means
of an absorbent powder such as talc, syringing and sending a
current of air by Politzer's method through the Eustachian
tube and perforated membrane. He adds hints from his own
practice on the treatment of boils in the meatus, syphilitic
aflections of the ear, &c. Also, we have an interesting series
of cases from a late paper of Toynbee's on sebaceous tumours in
the ear causing death through caries of the petrous bone.

Under Eustachian tube, membrana tympani, tympanum, ner-
vous apparatus, we have : — Politzer's happy method of inflating
the drums by a jet of air through a nostril at the instant of swal-
loAving, and a description of his apparatus, Weber's nose -douche,
Loewenberg's rhinoscopic observations, not here thought of
wide application, though that writer found them useful in syphi-

170 Bihlingr(qiMcal Record. [July,

litic and scrofulous cases. Dr. Jago's paper in this Journal on the
Functions of the Tympanum being commended to the attention
of the reader as "containing much suggestive" physiological
" matter ;" his " description of the symptoms of patency of the
Eustachian tube^^ is instanced as " deserving a careful study.'"
This is a generous allusion on the part of Mr. Hinton, yet it
is surely an oversight that in a special treatise of this sort this
complaint should remain undescribed, though it may be so rare
that he could only add from his own observation one well
marked case to the two from which Dr. Jago derived its cha-
racteristics ; especially as Toynbee himself had latterly spoken
of it as " proved^^ to be " one of the most unendurable of affec-
tions.'^^ There follows a lucid exposition of Dr. Jago's theory
of the functions of the mucus secreted by the lining membrane
of the drum in keeping us unconscious of subjective sounds
and perfecting the conducting apparatus. Its pathological
groundwork is confirmed from Mr. Hinton's practice, and with
qualifications there is a leaning in its favour. Dr. Jago's opinion
as to the vascular origin of tinnitus is regarded as putting us in
the way of solving the mystery in which this has been involved,
whilst Mr. Hinton suggests that it may often arise from pressure
on the labyrinth caused by irritable muscles of tlie drum or
otherwise. We are told that among the poorer classes hereditary
syphilis frequently destroy s hearing, and that this disease at Guy's
Hospital furnishes one twentieth of the aural cases, and that
" evidently it is the disease, or one of the diseases, which Sir AV.
Wilde described as affecting the ears in early life, subsequently
to, or alternating Avith, an inflammatory affection of the eyes."

Art. II. — A Report on Amputations at the Hip-Joint, in Mili-
tary Surg ei'y. Circular No. 7. War Department, Surgeon-
General's Office. Washington, July 1, 1867. 4to. Pp.
87. With 9 lithographic plates and 30 woodcuts.

A Contribution to the History of the Hip-joint Operations per-
formed during the late Civil War, being the Statistics of
Twenty Cases of Amputation and Thirteen of Resections at
this Articulation in the Southern Service By Paul F. Eve,
M.D., Professor of Surgery in the University of Nashville,
Tenn. Philadelphia, 1867. Pp. 17.

We have had occasion before to call our readers' attention

to the interesting and valuable documents relating to the

medical and surgical history of the late civil war which have

been issued from the Surgeon- General's office at Washington;

'A Vindication of the Present State of Aural Surgery,* p. 12, 1864.

1868.] Amputation at the Hip-joint in Military Surgery. 171

and we should be indeed wanting in courtesy if we did not take
every opportunity of expressing our gratitude and the grati-
tude of the profession in England generally for the great
liberality with which these costly volumes have been distributed
not only to the public libraries and journals, but also to private
individuals in tliis country. We observe, with very great plea-
sure, that the volumes embodying the complete medical history
of the whole war, of which these are but detached portions,
are advanced in preparation, and the first instalment of them
may shortly be expected.

Meanwhile, we turn to the present treatise on one of the
most difficult and most contested points of military surgery.

Every hospital surgeon will readily concede that a compound
fracture laying open the hip-joint, whether from a gun-shot or
from other injury, is as a general rule a fatal accident. The
question on -Nvhicli opinions are divided is what rules of treat-
ment does experience suggest whereby the greatest proportion
can be saved ? By some it is taught that primary amputation
is in these injuries universally fatal, and therefore should be
banished from surgical practice, while secondary amputation
is looked on with favour. Others are in favour of excision,
primary or secondary ; others prefer, as a general rule, the
expectant treatment. The author of the above official report
(Assistant- Surgeon Otis, Curator of the Army Medical Museum,
U.S.) does not affect to settle these questions, but merely to
bring forward materials for their discussion, supplementing these
materials by the opinions expressed by those from whose prac-
tice they Avere collected. The pamphlet by Dr. Eve is, as far
as the statement of amputation is concerned, embodied in the
official report, with some discrepancies which are too trivial to
mention.

The report enumerates and tabulates sixty-one cases of am-
putation for gun-shot wound performed previously to the war
under consideration, and gives the references and results of 111
cases of amputation in civil practice. To these are added more
or less detailed histories of fifty-three operations performed
during the American civil war, all for gun-shot injury, nine-
teen of which were performed by Southern, or rebel, surgeons,
and are included in Dr. Eve's pamphlet. These amputations
are divided by the reporter into four classes. 1. Primary , i. e.
performed before consecutive inflammation had set in, the dura-
tion of which period, he says, will very rarely be found to
exceed twenty-four hours. 2. Intermediary, performed during
the persistence of the inflammatory stage, a variable period,
usually included between the day after the reception of the
injury and some time in the second or third month. 3.

173 Bibliographical Record. [July,

Secondary, or those performed at a period when the inflamma-
tion had abated, and the lesions had become, in a measure,
local and analogous to chronic disease. And, 4. Re-amputation,
after previous amputation lower down. We confess that we do not
see the advantage of the separation between the second and third
classes in cases like these where the notes are so imperfect as to
lead to grave doubts whether so difficult a distinction has been
at all correctly adhered to. Out of the fifty-three fresh cases
included in the report, nineteen were primary. All the patients
were known to have died of the direct results of the operation,
except three. Out of these three, one was in excellent health
at the date of publication of the Report, more than four years
after the operation. The other two were known to be alive,
and in good condition, in one case two months, and in the
other six months after amputation. If all the cases previously
published be added to this list, of which not one is known to
have survived, and we concede the reality of recovery in the
two cases left incomplete,^ we shall have forty-four primary
amputations with three recoveries. Although this is a black
list, it certainly proves that recovery is not impossible, and
encourages the performance of the operation in cases other-
wise hopeless. Such, for instance, was one of the Southern
cases which recovered. The surgeon was close to the man
when he received his wound. The femoral vessels were lace-
rated, and the upper part of the femur smashed to pieces by a
large fragment of shell. Compression was kept up so that the
man did not bleed to death, while hasty preparations were made
for amputation literally sur le champ. The patient recovered
without an unpleasant symptom. But such cases as this can
only occur very rarely, and the most that we can say after
perusing the report is that primary amputation at the hip
is not necessarily fatal, but that it is so so very often that it
ought not to be performed when the slightest prospect of reco-
very exists without it, and this is the general efiiect of the
opinions of the surgeons quoted in the report. In the second,
or '' intermediary'^ category {i. e. those amputations performed
during the presence of inflammatory symptoms) eighteen
American cases are included, which were all fatal ; of sixteen
cases which are added from previously published sources, two
recovered, so that the average mortality, if we could trust to
the classification, would be shown to be about the same as in
primary amputation. In the third class, or that of " secondary''
amputations, in the narrow sense here sought to be introduced

' The official reporter hesitates to admit these as cases of complete recovery,
but the fact is proved from Dr. Eve's pamphlet, for both these cases occurred
La the Southern army.

1868.] Amputation at the Hip-joint in Military Surgery. 173

(when the inflammatory phenomena have wholly passed away)
only nine fresh cases are reported, two of which recovered, and
eighty previously published, five of which recovered. While
unsatisfied of the scientific accuracy of the classification, we
are quite ready to admit that in this, as in every other kind of
amputation for injury, the prospect of survival is better the
more completely the surgical fever following the injury has
passed away. Finally, eight re-amputations are tabulated (all
of which, except one, occurred in this war), and of which one
half recovered. As an appendix, fifty-six miscellaneous cases
(not American) are briefly referred to, the details of which are
imperfect. The total gives 161 cases, with 142 deaths. Of the
nineteen who were not known to have died, the reporter classes
three as uncertain, but, as we have stated above, if this intends
to include the two primary amputations in the Southern
army, the reality of recovery seems in those cases completely
proved.

The result certainly tends to establish the soundness of the
advice given by the best military surgeons of modern times, to
avoid the amputation at the hip-joint as a primary proceeding.
In desperate cases, it is no doubt justifiable, and a life may
here and there be saved by it, but such cases will be of the
rarest. The chief interest of the question, however, now is as
to the value of the operation as a secondary proceeding. In this
inquiry we must distinguish two classes of cases, the one where
the mischief is limited to the upper end of the femur, the other
where chronic osteo-myelitis has invaded that bone in the whole
or a great part of its extent. In the former class it seems pro-
bable that excision will be found to give better results than
amputation. Thus, in Dr. Eve's pamphlet, we find a table of
thirteen cases of " Resections at the Hip-joint,'' of which four
survived entirely, one fell into the enemy's hands, and probably
died, and one would, it was thought, have recovered, but for
want of nourishment, to which he succumbed two months after
the operation. It must be admitted, however, that Dr. Eve's
table is not accompanied by sufiicient details to render it
entirely satisfactory, nor is this surprising, considering the
nature of the service to which it refers.^ As far as it goes,

1 We cannot refrain from giving the last tew lines of Dr, Eve's pamphlet.
Whatever our feelings may be as to the political aspects of the war, no surgeon
can feel otherwise than proud of the heroic exertions of our colleagues to save
life in the dreadful circumstances which surrounded the Southern Army. Dr.
Eve thus compares the Southern statistics, as far as he had been able to collect
them, with those at that time issued from the Surgeon-General's office of the
United States army : —

"In Circular No. 6, Oct. 1865, War Department, Surgeon-General's Office,
Washington City, is given a table of twenty-one hip-joint amputations with three
successful results. One of these is proved to have been erroneous, which reduces

174 Bibliographical Record. [July,

however, it shows that the cases of resection are on the whole
less fatal than those of amputation, doubtless because they are
less often primary. But the most difficult question remains
still for future experience to solve. "We can hardly doubt that
the following opinion is correct, given by Dr. Gilmore of Ala-
bama, who himself amputated at the hip three times, and
performed excision three times (and with one success in each)
during this war :

" I recollect some six cases, that would have required amputation
at this joint, which recovered without an unpleasant symptom. One
case wounded at the battle of Fredericksburg, a Mississipian ; two
cases wounded at Chancellorsville, Georgians, and the remaining
cases wounded at Grettysburg, two of them of Kershaw's South Caro-
lina Brigade, and the other of a Georgia Brigade.

" I believe that one third of the cases of gunshot wounds of the
femur, usually supposed to require amputation at the hip.joint, will
recover if left entirely to the efforts of nature ; and I am confident
that a much larger percentage will die if subjected to either ampu-
tation or resection." (P. 12.)

That this is the correct view of the case is becoming more
and more generally admitted ; but we have little doubt that the
experience of future wars will enable surgeons to contribute
more authentic data than seem to exist at present for deter-
mining the actual results of the expectant treatment in these
formidable injuries. With regard, again, to cases of chronic
osteo-myelitis of the femur, its symptoms and the indications for
amputation, much remains for future inquirers to supply.
Meanwhile, the present volume contains some useful material.

The reader must not imagine that these returns of the Surgeon-
General are complete, and comprise all the cases of each
kind which occurred ; but they bear internal evidence of disin-
terested accuracy, and we believe that they may be trusted to
as unselected and impartial. For statistical purposes a large
and unselected return is nearly as good as a complete one.

The Surgeon- General has also been so good as to send us
his " annual report,^^ comprising the total of deaths to strength,
and such like official details. The only thing which strikes
us in this document is the results of the examination of army

the cases of recovery to one In ten, being precisely double the mortality that my
statistics make it to have been in the Southern service ; and of thirty-two cases
of resection or excision of the head of the femur only four recovered, being a
recovery of only one in eight, a fatality nearly four times greater than on the
Southern side.

" Thus has the investigation of this interesting subject during the past two
mouths, by the request issued from the office of the Surgeon-General, led the
searcher unwittingly to a most favourable result on the side least expected when
•we consider the destitute and Isolated condition of the South during the war.*'

1868.1 Child's Essays on Physiological Subjects. 175

surgeonsj and which we commend to the attention of our own
examiners.

"Number of candidates invited, two hundred and seventy-two
(272) ; number fully examined and found qualified, forty-eight (48) ;
withdrawn before their examinations were concluded, twenty-one
(21) ; rejected after full examination, ninety-one (91) ; failed to ap-
pear, one hundred and twelve (112) — of these, forty-seven (47) were
recommended and appointed, one (1) declined before appointment,
and two (2) declined after appointment."

Thus, out of 160 candidates who appeared to compete, only
forty-four ultimately got into the service. Clearly the U.S.
array board do not err on the side of laxity.

Art. III. — Essays on Physiological Subjects. By Gilbert W.
Child, M.D., of Exeter College, Oxford, M.R.C.P., &c.

On first taking up this small volume we were at a loss to un-
derstand what had induced Dr. Child to republish the few papers
which form it in the shape of a separate volume. The preface,
however, explains the matter. It seems that Dr. Child had
always intended to collect into one body the various essays,
which he might publish, but that he had been compelled '' by
special circumstances^' to do so somewhat prematurely, and
before his collection had reached any considerable bulk. By
these " special circumstances " is, we presume, meant the fact
that the author is a candidate for the scientitic chair vacated
by Dr. Daubeny's death at Oxford ; and that he was desirous of
showing the electors that he had not stood aloof from the phy-
siological questions which have been afloat of late years, but
had taken an active interest in them. This object is, doubtless,
a perfectly justifiable one : and we must admit that this volume,
so far as it goes, is evidence of the fact which we suppose Dr.
Child is desirous of establishing. Although the papers in this
volume appeared originally at various times and in various pub-
lications, they are not devoid of all connection with each other.
The link between them is, indeed, sufficient to give a kind of
unity to the whole book, which might as properly have been
called '^ Essays on Subjects connected with Geueration " as
"Essays on Physiological Subjects," for it is with generation in
some aspect or other that each of the essays is concerned. The
first deals with the fertilization of orchids, the second with the
effects of close inter-breeding, and the remaining two with the
vexed question of spontaneous generation.

The first of the four papers is a reprint from the ' Spectator,'
and consists of a review of Mr, Darwin's admirable work on the

176 Bibliographical Record. [July,

fertilisation of orchids. In his ''Origin of Species," Mr.
Darwin had stated that he entertained a very strong suspicion
that " in no organic beings can self-fertilisation go on for per-
petuity.'^ (''Origin of Species/' p. 101). In that volume he
only gave the general grounds for his belief in the truth of this
law; but having been blamed for propounding this doctrine
without ample facts, he published his book on orchids a few
years later, in order " to show that he had not spoken without
having gone into details." In this work he showed that self-
fertilization is an excessively rare occurrence with orchids.
In the vast majority of these plants, even when they are her-
maphrodite, there exist peculiar arrangements (which he de-
scribes in detail), by which self-fertilization is made impossible,
and the concurrence of two individuals rendered imperative. In
one species, and in one only, so far as is yet known, namely in
in the Bee ophrys are there any special and perfectly efficient
contrivances for self-fertilization ; and even in this case, com-
bined with these contrivances are manifest adaptations for the
occasional transport by insects of the pollinia from one flower
to another. So that in all orchids, hermaphrodite or notj there
is a provision for a more or less frequent intercross with a
distinct individual. " Nature thus tells us in the most emphatic
manner," says Mr. Darwin, " that she abhors self-fertiliza-
tion." Dr. Child, in his review, admits the correctness of all
Mr. Darwin's facts, but objects to the inference which Mr.
Darwin draws from them :

"There exist in nature," says Dr. Child, "three forms of the
reproductive function, namely, the hermaphrodite and self- fertilising,
the hermaphrodite and mutually fertilising, and that in which the
sexes are distinct. These three plans may exist in different pro-
portions, and may be variously modified in different classes of
organisms, but they all exist in the vegetable kingdom, and they
all exist in the animal kingdom. What has been shown in regard
to the tribe of orchidaceous plants is that, though the second method
is that which they mainly follow, all three are to be found amongst
them ; in fact, that in respect of this function they form, as it were,
a microcosm corresponding to the macrocosm of the whole organic
world ; but we must confess that we are wholly unable to see that
this affords the slightest ground upon which to establish the dictum
that 'nature abhors self- fertilisation.' "

The reader will at once see that this is not a fair representa-
tion of Mr. Darwin's doctrine. Mr. Darwin has nowhere said
that nature abhors self-fertilization. His dictum is " Nature
abhors perpetual self-fertilization.'^ The omission of this one
word makes all the difference. The reader will also notice that
though it is perfectly true that in orchidaceous plants all three

1868.] Essays on Physioloyical Subjects. 177

forms of the reproductive function are to be found, yet that
Dr. Childj in the above passage, has passed without notice the
fact that when an orchid generates in the first of the three
methods — namely, the hermaphrodite and self-fertilising — this
mode of generation is invariably interrupted, at more or less
frequent intervals, by the adoption of the second method. Tims
Dr. Child in his divisions really describes inaccurately the first
of the three forms of reproduction in orchids. Instead of
saying '-hermaphrodite and self -fertilising ,^' he should have said
" hei'maphrodite and self -fertilising , with an occasional intercross."
The insertion of these words would be the admission of Mr.
Darwin's dictum, so far as regards this order of plants. How
far the dictum may be true when applied to the whole organic
world is another question, with which we are not now con-
cerned.

Dr. Child's second essay is a reprint from the ^ Westminster
Review.' It deals with a subject of serious practical importance,
the supposed ill-effects of marriages of consanguinity. There is
doubtless a widespread and deep-seated prejudice against such
marriages. Few, however, of the many who entertain this
feeling would be able to give any rational grounds for it. Mr.
Adam is of opinion that one potent cause, which has given rise
to the repugnance with which such unions are viewed, is the
confusion Avhich would otherwise arise in the descent of property
[' Fortnightiy Rqview,' 1865). Dr. Child ascribes the sentiment
to superstition. It is, he thinks, a relic of the time which
preceded the Marriage Act of Henry VIII, when all blood-
marriages were illegal in England, being prohibited by the
Church. We cannot, however, but think that the prejudice
against all blood-marriages is merely the expansion of the more
deeply-felt abhorrence against incestuous unions; and that
the origin of this latter feeling is neither legal nor religious, is
plain from the fact that it is felt by the savages of Australia and
of South America with the same intensity as by ourselves.
'' Yet these savages," as Mr. Darwin remarks, " have neither
pi'operty to bequeath nor fine moral feelings to confuse."
("Animals and Plants," &c., ii, 133). More important, how-
ever, than the origin of this repugnance is the question whether
there are any solid grounds for it. Are the offspring of mar-
riages of consanguinity in any way injuriously affected ? Are
they more liable to degeneracy than the offspring of other
unions? To this practical question Dr. Child does not give
any very decided answer, though we infer from his tone that
he looks upon the danger to which the offspring of blood unions
are exposed as very slight, and as having been ridiculously ex-
aggerated in men's minds. That the danger is a real one
83— XLil. 13

178 Bibliographical Record. [Jwly^

however, there can be no possible doubt. The offspring of
blood-alliances are at least ten times as liable to congenital
idiocy and deaf-dumbness, not to speak of other defects, as the
children of other unions. Dr. Mitchell, deputy commissioner
of lunacy for Scotland, made careful inquiry into the parentage
of every case of idiocy which came under his notice in his
official visitations of nine Scotch counties. He ascertained the
parentage of 519 idiots who were born in wedlock. In 98 of
these cases (that is, in 19 per cent, of the whole) the parents
were blood-relations. Now the exact proportion of blood-
alliances to other marriages is not known precisely. Dr.
Mitchell, however, estimates it as being about one in seventy.
If that be the case, and doubtless it is not far of the mark, the
proportion of idiots from blood-alliances is in those counties
thirteen times as high as it should be. The law of chances
would give 1'43 as the due proportion per cent. ; whereas there
are in reality no less than 19, or more accurately 18'9 per cent.
(^ Mem. of the Anthrop. Soc, ii, 415). '' Of the 98 idiots whose
parents were related, the degree of relationship was as follows :

'' First cousins in . 42 cases.
Second cousins in 35 „
Third cousins in . 21 „

98 ,,;

^' It is probable that more second and third cousins intermarry
than first cousins, yet these last produce a larger number of
idiots. The closer, in short, that the alliance is the greater
appears to be the danger.^' As regards deaf-mutism Dr.
Mitchell obtained a very similar result from inquiry into the
data aiforded by ten deaf and dumb asylums in England, and
Scotland.

M. Boudin has made inquiries on a still larger scale in France
and found that, while consanguineous marriages are only 2 per
cent, of all marriages in that country, the number of deaf mutes
born of such marriages is to all deaf-mutes in a proportion,
which varies in diflPerent parts of France, from 25 per cent, to
30 per cent. He found, moreover, that the danger of deaf-
mutism increases with the closeness of kinship in the parents. It
will be at once seen how nearly these results tally with those of
Dr. Mitchell. The offspring, then, of blood-alliances appear to
be more liable to certain congenital defects than other children.
The question now arises — Is it the mere consanguinity of the
parents which is in itself the cause of this liability ? or is the
explanation to be found in the fact that two cousins or other
blood relations are more likely than two non-related persons

1868.] Essays on Physiological Subjects, 179

to be afflicted with the same morbid peculiarity, which, in
case of their union, is transmitted in an intensified form to
the progeny? The children of two insane, or of two gouty,
parents are of course more likely to be insane or gouty
than the offspring of a union where only one parent is tainted.
It is said, for instance, to have been ascertained that, if a
deaf-mute is married to one who hears, the chances of their
having a deaf-mute child will be 1 to 135, but if deaf-mute
persons intermarry, the chances rise to 1 to 20. There can be
no doubt that much of the evil resulting from unions of blood-
relations is thus to be explained. Dr. Child insists that this is
the explanation of it all. Mere consanguinity in parents, inde-
pendently of any common taint in their blood, is in his opinion
perfectly harmless, and the fear of it is a superstition. Given
in fact, a healthy family, one that is without tainted blood,
nothing could be [better luck for a child than to spring from
the union of two of its members. It would probably inherit the
tendency to healthy existence in an intensified degree. In
support of this view. Dr. Child quotes the " Herdbook'-' and the
" Studbook." He gives the pedigree of the celebrated bull
'' Comet," and shows that this animal, which in no sense could
be called degenerate, was bred with a degree of closeness, any
approach to which in the human race would be quite impossible.
Similar instances might be given in the case of sheep and pigs.
Yet, notwithstanding these undoubted facts, it is the general
opinion of those breeders of animals who have had the most
experience, and especially of those who breed animals Avhich
propagate quickly, that evil does inevitably follow sooner or
later on close interbreeding, but that it does not ensue with
equal rapidity in the case of all animals. The deterioration
consists in the loss of constitutional vigour, size, and fertility,
and not in any falling off in the general form of the body. If
close interbreeding be really perfectly innocuous, it is the most
extraordinary fact that breeders of prize birds, who have every
possible interest in keeping their strain pure, should yet be
almost unanimous in asserting that it is absolutely necessary,
notwithstanding the trouble and expense thus caused, to cross
occasionally their much prized birds with individuals of another
strain, but belonging, of course, to the same variety. Yet Mr.
Darwin assures us that this is the case. Those who have read
the evidence collected by this great authority on the effects of
close interbreeding, and given in the seventeenth chapter of his
recent work, will, we think, agree with him, that it is, if not
proved, yet in the highest degree probable, that interbreeding
prolonged through many generations is highly injurious.
Whether the much more diluted degree of interbreeding, which

18Q Bibliographical Record. \_^^Y ,

alone is possible in the case of man, is also injurious, indepen-
dently of taint in the parents, is a question, in which we agree
with Dr. Child, that the evidence is very defective. As to the
practical question, however, whether consanguineous marriages
are advisable or not, we feel no hesitation. We indorse fully
the following remarks of Dr. Mitchell, " The practical question
is this, should they or should they not be avoided ? And the
answer we are led to give is that they should, for the reason
that they tend to injure the offspring. It matters not practically
whether the injurious influence is the result of some mysterious
effect, intrinsic in the consanguinity itself, or merely the result
of this, that consanguinity increases the risks of finding unde-
sirable or morbid peculiarities transmitted from parents to
children in an intensified and dangerous form. If the results
are disastrous, they will not be less so on one theory than on
another, and the lesson will be the same. If the relations by
blood are liable to possess the same morbid tendencies, and if
by pairing among themselves for procreation, they are likely to
transmit these tendencies in a dangerously increased form to
their children, then it is surely their duty to avoid such unions,
and to seek among strangers alliances with individuals more
likely to possess qualities calculated to modify or counteract
the morbid peculiarities in question. It may be that there is
absolutely nothing whatever in the bare fact of consanguinity,
and that a marriage of kinship should be avoided on the same
grounds as a marriage between any man and woman both pre-
disposed say to insanity. In the case of cousins, though there
may be nothing common to them of so marked a character as
a declared tendency to insanity, still there may be common to
them any one of a hundred transmissible peculiarities, which it
would be very undesirable to send down to their children in an
aggravated form. Even a strong temperament common to both
might thus be intensified into disease in their offspring. It
follows, therefore, that as the chances of possessing similar
peculiarities are great among relatives, and as intermarriage
tends to give a dangerous strength to these in the offspring,
that to avoid such risks the prudent will avoid such unions as
appear to increase them.'''

Our space will not permit us to say more than a very few
words of the two remaining essays in this book. They both
deal with the ancient and still-disputed question of spontaneous
generation. In the one. Dr. Child gives an account of the
controversy between M.M. Pasteur and Pouchet. With this
we need not trouble our readers. They are doubtless well
acquainted with the admirable researches of M. Pasteur, which
most physiologists have accepted, as giving the coup de grace

1868.1 Desgranges' Surgical Lectures. 181

to the hypothesis of spontaneous generation; and no less
with the counter experiments of M. Pouchet. They probably
know also that what was at first a scientific discussion degene-
rated in time into almost a personal squabble. In the other
and last essay, Dr. Child describes a repetition by himself of a
number of Pasteur's experiments. He states that he observed
all the precautions which M. Pasteur himself speaks of as
'' exaggerated," and that notwithstanding this, he obtained
results which entirely disagree with those arrived at by M.
Pasteur, and now, to a certain extent, vouched for by the Com-
mission of the Academy of Sciences. Dr. Child found that
organisms were developed exactly under the circumstances in
which M. Pasteur asserts that their production is impossible.
For this discrepancy. Dr. Child accounts by the fact that M.
Pasteur never examined his substances with any higher power
than one of 350 diameters, while it is, according to his experi-
ence, impossible to recognise the presence of bacteria with any
degree of certainty even with double that magnifying power.
Dr. Child himself made use of a glass with a power of 1500 to
1700 diameters. That Dr. Child really found these bacteria in
his infusions there can, of course, be no doubt. If any such were
possible it would be at once set at rest by the fact that Dr.
Beale assisted in the microscopic examination. The question
can, therefore, only be whether Dr. Child, in conducting his
experiments, inadvertently neglected any precaution. We can-
not say that we can see any flaw in his method of proceeding
as described by him. We should, therefore, be glad to hear
that M. Pasteur had repeated his experiment, using the higher
powers, which Dr. Child says are requisite.

It will have been seen that we by no means agree in all re-
spects with Dr. Child in the conclusions at which he arrives in
these essays. We must, however, admit that this little volume
deals with topics of the highest interest, that it is written in
an easy style, and that the author has not blindly surrendered
himself to the guidance of authority, but has taken pains to
form an independent judgment.

Art. IV. — Legons de Clinique Chirurgicale professees a VHotel
Dieu de Lyon. Par M. A. Desgranges, &c. &c. Paris,
1867. Pp. 108.

I. Tumeurs Abdominales.

II. Corps 'Etr angers du Genou.

III. Tumeurs du Sein.

Monsieur Desgranges' reputation renders any statement of
L his experience at the celebrated provincial French hospital to

182 BibUograpJiical Record. [July,

whicli lie is surgeon most acceptable. The surgical school of
Lyons is looked upon in England as being in many respects in
advance even of that of Paris, and particularly in respect of
ovariotomy, to which M. Desgranges' first paper in this work
chiefly refers. If we are not mistaken, it was from the sur-
geons of Lyons and Strasbourg that those of Paris first learned
to believe in the success of an operation which one of the chief
scientific societies of that capital is still only half inclined to
admit as being justifiable. M. Desgranges relates two successful
cases of ovariotomy, and accompanies them with a commentary
in which he lays down rules for the diagnosis of abdominal
tumours of various kinds. These diagnostic rules are, no doubt,
useful, and in the main correct ; but like most French surgeons
M. Desgranges afi'ects " nettete^' and " precision^^ in his diag-
nosis to a degree that nature will not lend herself to. Thus,
any student who might imagine that he could diagnose the
presence or absence of adhesions in an ovarian tumour by the
precepts which M. Desgranges lays down, would we fear be
exposed in practice to numerous disappointments. We are
glad, however, to see that the operation of ovariotomy is making
its way in France, and congratulate M. Desgranges on his ac-
ceptable contributions to its progress. One curious circumstance
which we have not met with elsewhere occurred in one of M.
Desgranges^ ovariotomies. " During the first six months after
the operation at each menstrual period, a little abscess regularly
formed over the pedicle of the tumour,'^ which had been secured
outside the wound by a clamp. This circumstance is with great
probability attributed by M. Desgranges to the determination
of blood to the parts at the menstrual period, and possibly to
increased traction on the pedicle by the body of the uterus, in-
creased as it is in volume by congestion.

With respect to loose cartilages in the knee, M. Desgranges'
lecture does not seem to us of equal merit with the others.
His explanation of the pain which attends such bodies is neither
supported by any reasoning nor in itself intelligible. Rejecting
the old idea (and as we believe the true one) that this pain
depends on the body being caught between the bones (although
his own case proved beyond a doubt that such bodies can get
between the bones, which Richet and Nelaton deny) and reject-
ing also the exceedingly improbable explanation advanced by
M. Richet, who refers the pain to contusion of the synovial
membrane, M. Desgranges asserts that the pain results from
stretching and twisting of the ligaments, though there is not a
shadow of evidence that any such stretching or twisting
occurs, nor does the analogy of sprains lead to the idea that if
it did it would produce similar symptoms. Again, as to the

1868.] DE^i Anq,v AY on Pneumatoloffy. 183

treatment, Mr. Desgranges says, at page 53, " that only incom-
plete, and insecure relief is to be expected from compression
and immobilisation, and that, therefore, it is expedient to reject
these measures in favour of extraction/^ On page 60, on the con-
trary, he says that, '' the wise precepts of M. Larrey ought to
guide us,^^ the third of which is, that the operation should not
be undertaken till attempts to fix the foreign body have been
made and failed.

The concluding paper in this pamphlet need not be reviewed
at length here. It consists of the history of some character-
istic examples of cancer and of sero-cystic (or tubero-cystic)
tumour, accompanied as in the case of the abdominal tumours
with rules for diagnosis, stated in a tabular form. The paper
is an interesting and a practical one, but contains little for
detailed remark.

At its conclusion is a statistical table of the results of
operation for tumour of the breast at M. Desgranges' Hospital
in the ten years 1852 to 1862. The result gives one an insight
into the reason Avhy important surgical operations find such
slow access to French practice. In fact, the hospitals in France
are so unhealthy from their imperfections in ventilation, clean-
liness and drainage, that none but unavoidable operations are
likely to be performed. As an instance of this, in such a simple
and usually harmless operation as removal of the breast, we
have here the statement that out of 222 operations, 42, or
nearly one fifth died ; and if we limit ourselves to the more
formidable cases, those of cancers, the proportion is greater
still, 39 having died out of 153, or more than one quarter of
the cases ; and if we turn to the statement of causes, we shall
see that they are almost all such as are connected with un-
healthy hospital atmosphere ; three died of traumatic fever ;
ten of erysipelas ; three of pyaemia ; four of haemorrhage ; three
of pleurisy ; three of pneumonia (it is not said in the latter
cases whether pysemic or no) ; one of gangrene : two of diph-
theritic angina. When will French hospital surgeons be in-
duced to admit that cleanliness and fresh air are even more
necessary to success in practice than operative dexterity and
scientific acquirements ?

Art. V. — Essai de Pneumatologie Medicale : — Recherches Phy~
siologiques, Cliniques, et Therapeutiques, sur les Gaz. Par
J. N. Demarquay. Paris, 1866. 8vo. Pp. 861.

Essay on Medical Pneumatology , ^c. By J. N. Demarquay.
Dr. Demarquay here presents us with a work of not far

184 Bibliographical Record. [July,

short of a thousand pages octavo, upon medical pneumatology, a
subject not familiar, we apprehend, or at least not known under
this designation, to many of our readers ; for it does not figure
among the contents of class-books of medicine or therapeutics.
Nevertheless the matters treated of under this heading can
claim no novelty. Every old woman has a practical acquaint-
ance, particularly since excessive tea-drinking has been common,
with that division of medical pneumatology known as wind in
the belly, and every practitioner accustomed to prescribe for
hospital or dispensary out-patients, ought to be duly impressed
with the grievous ills resulting when the " wind and the water
meet,^' a catastrophe so constantly recounted by his patients.
But neither old women nor their doctors will find much to
enlighten them on gastro-intestinal accumulations of gas in the
pages of the work before us. Not but that the subject is con-
sidered. On the contrary the author discusses over a score of
pages the questions relating to the sources of the gaseous
matters : still he has nothing to tell the interested individuals
alluded to how best to cure the windy colic and spasm.

In fact the term medical pneumatology is the peg whereon
to suspend dissertations on several topics having no natural
affinity either in physiology or pathology. To let the author
speak for himself, he says : — " The work is divided into two
parts ; the first, physiological and pathological ; the second,
physiological and therapeutical. In the former we treat of,
1. Gases in the blood ; 2. Sanguineous or rather vascular pneu-
matosis; 3. Gastro-intestinal and genito-urinary pneumatosis."
These matters he has sought to elucidate by physiological expe-
riments. " In the second part, devoted to a physiological and
therapeutical investigation of gases, we have made a particular
study of oxygen, carbonic acid, nitrogen, and protoxide of
nitrogen and of hydrogen, inasmuch as these fluids enter, almost
all, into the composition of the air and of water, and also con-
stitute the nutritive elements in our food.^^ It is this second
part which will be read with most interest, although the diffuse
style, and the attempt, common in French medical works, to be
exhaustive, will make its perusal tiresome.

The author sets out with a general notice, borrowed from
several physiological writers, chiefly fellow-countrymen, of the
gases found in the blood, and next, as a result of bibliographical
researches, gives a collection of cases — many of them reported
with little precision, and consequently of as little worth — where
gas has been found as a morbid product in the circulating fluid.
He remarks on the coincidence of such cases with the existence
of paroxysms of dyspnoea, and with the occurrence of profuse
haemorrhage, particularly with that following child-birth. He

1868.1 Demarquay on Pneumatology. 185

rejects the supposition of the gaseous bubbles found being post
mortem products^ and essays, unsuccessfully we think, to discover
the cause of their presence in relation to difficulty of respiration
and to haemorrhage.

Gastro-intestinal and genito-urinary pneumatoses next engage
attention. Without venturing to deny the possibility of the
secretion or exhalation of gas in the bowels, M. Demarquay
considers that the facts that some at least of the gases have no
existence in the blood, and that different gases are formed in
different portions of the intestinal tube, arc adverse to the
notion of such secretion, and at the same time speak in favour
of the derivation of the gases from the contents of the digestive
canal. Again as to the seat of the gas in tympanitis or meteo-
rism, he is convinced that it is within the intestines and that
no gas enters the peritoneal cavity during life, except there be
rupture of the intestinal walls.

To remove meteorism and its disastrous consequences Demar-
quay sanctions fully the plan of puncturing the distended intes-
tine; urging that the fear of peritonitis is no greater than in
tapping for ascites. The puncture may be made by a trocar,
at any part of the abdominal aponeurosis, or in the median
line, care being taken to choose a point where the tympanitic
resonance is very marked. It is well also previously to make
a small incision through the skin, preparatory to thrusting in
the trocar.

It must, however, be stated that M. Demarquay's personal
experience of puncture is not very satisfactory ; at times only an
insufficient quantity of gas has escaped ; at others, the gas has
soon re-accumulated.

Above 200 pages are devoted to the subject of traumatic
emphysema. He recognises three varieties of the lesion ; —
1. Partial; 2. Diffused; 3. General. The second form implies
the progressive propagation of emphysema fr-om some one part
until it finally occupies the entire body. By general emphy-
sema, he means that which has no particular point of origin,
but is simultaneously developed at all parts ; as, for instance
that consequent on septicoemia. After this long disquisition on
air permeating the tissues, its mode of entrance, its symptoms
and consequences in relation to each organ of the body, M.
Demarquay enters upon the second portion of his comprehensive
work ; the study of gases in their physiological and therapeu-
tical relations. Carbonic acid is first taken in hand, and occu-
pies above 100 pages in its discussion. Much of this space is
occupied by historical notices of the first recognition of carbonic
acid and its properties, and of the opinions entertained by
chemists and physicians respecting its uses and therapeutical

186 Bibliographical Record. [July,

properties. But we are also favoured with records of experi-
ments on animals and on man made by M. Demarquay, and
would wish that this able surgeon had restricted his book-making
chiefly to telling us what he had himself observed, and to Avhat
conclusions he had arrived. In dismay at the scores of pages
of historic matter and of crude hypotheses of past times, the
tendency of the reader of his book is to turn over the pages, at
the risk of overlooking something important, to discover the
resume or budget of conclusions, which, by a kind dispensation,
every Frenchman is fortunately impelled to present his
readers. The conclusions respecting the application of carbonic
acid and its results in the human economy are found at p. 458 ;
but the necessary shortness of this notice forbids their quo-
tation, and must also be accountable for the remaining brief
notice of the contents of this work.

In examining the properties of carbonic acid given internally
Demarquay has largely quoted our old English writers, Per-
cival and Beddoes ; but it is as a topical application that this gas
is of the widest utility, and that the author can speak of its value
from extensive personal experience with it in surgical maladies.
We would direct our readers' attention to the section here
referred to on the topical uses of carbonic acid. (Pp. 499 — 562.)

Oxygen is the next gas examined. Its medical history, and
the notice of its physiological action, of its mode of preparation
and administration medicinally, and of its therapeutical action,
extends over upwards of 250 pages, and might, therefore, of
itself afford ample scope for a review. M. Demarquay is an
original investigator of the properties of oxygen on animal life,
and has himself resorted to this gas as a medicine, using it both
internally and externally. Its curative value in medical cases,
in asthma, consumption, and some other diseases, is attested by
himself in a few instances, but he chiefly relies, for the demon-
stration of the fact to the records of others, particularly to those
of Dr. Beddoes, published in 1798. The advantages of oxygen
in surgical cases are, however, illustrated and enforced by his
own experience as a surgeon. He has used the gas in cases of
senile gangrene, in phagedenic and cancerous ulceration, and
in instances of broken down health and ansemia attendant on
caries. In senile gangrene he envelopes the limb in an india-
rubber bag filled with oxygen, and allows the action of the gas
to proceed for two or three hours. The most striking results of
this proceeding are — the cessation of pain, the excitation of the
capillary circulation ; the decoloration of the limb which rapidly
loses its lividity, and lastly the elimination of sloughs, followed
by cure.

The third and concluding section of the work is occupied by

1868.] Lee on the Movements of the Iris. 187

an investigation of nitrogen^ of protoxide of nitrogen, and of
hydrogen. The employment of these gases therapeutically has
been very limited, and Demarquay can add little to the infor-
mation presented by older writers and experimenters. A M.
Chapelle (of Augouleme) has, we are told, resorted to protoxide
of nitrogen as a cure for epilepsy, and detailed his experience in
a paper sent to the Academy of Medicine in 1865. The number
of cures for epilepsy which have from time to time been vaunted
would suggest the inference that epilepsy ought no longer to be
met with, or else that each discoverer of a cure has been the victim
of delusion. The foregoing observations will suffice to show that
the treatise of M. Demarquay is one of great value, especially as
a book of reference.

Art. VI. — An Explanation of the Movements of the Iris,
by Robert J. Lee, M.B. Cantab., M.H.C.P. London,
1867. Pp. 15.

The object of this little work is to show, as expressed in the
author^s words, '' in a brief and. simple manner, that the strong
analogy which exists between the movements of the heart and
the iris is confirmed by the demonstration of similar nervous
structures in the two organs.'' After certain apposite and
interesting allusions to the progress of our knowledge of the
anatomy and functions of the nervous system ; including refer-
ence to the discovery by his honoured father of the great
system of ganglia and nerves of the uterus and of the heart,
and to the connection existing between the spinal and sym-
pathetic nerves. Dr. Lee proceeds to indicate by examples
that ganglionic plexuses of nerves " are intended to unite the
cerebro- spinal and sympathetic systems.'^ The best example of
this given is in the case of the ophthalmic ganglion, " which
bears the same relation to the ciliary muscle and the iris as
the cardiac plexus bears to the heart, is similarly connected
with the cerebral and sympathetic systems, through the
branches it derives from the third and fifth pair of nerves, and
from the cavernous plexus." The author then proceeds to
refute the opinion held by many physiologists, that such ganglia
are sources of the nervous power of the organs which they
supply with nerves ; and are related to the respective organs in
the same manner as the brain and spinal cord are related to the
voluntary muscles ; and he shows in detail how the nerves from
the spinal cord differ from those in various organs, such as
the heart. After alluding to the difficulty in explaining
the movements of the iris, he draws a parallel between the

188 Bibliographical Record. [July,

actions of tlie heart and iris, and points out liow " both act to
a great degree independently of the brain, and both display
power of movement for some period after death. They both
derive their nerves from a ganglion or plexus situated closely
and externally to them, and they both possess in themselves, when
removed from the body and from connection with the external
ganglion, the same property they displayed before/^ He then
remarks that, as a result of the view taken of the nervous
system of such organs as display in voluntary movements,
it was reasonable to expect '^that ganglia would be found to
exist in the structure of the iris similar to those in the heart
and other organs/^ Dr. Lee then describes the dissections of
the ciliary muscles, and iris, and nerves of the eyes of various
animals which he has made, and by which, in spite of the
difficulty experienced in following the nerves into the ciliary
muscle (especially in animals where it is small, dense, and firm),
he establishes the fact that the ciliary muscle and iris possess a
system of ganglia and nerves similar to those in the heart, and
never before demonstrated ; and he exemplifies the subject by
describing what he found chiefly in dissecting the eye of the
bird : representations of the dissected ciliary nerves being well
shown by photographic illustrations. He concludes that
generally the muscular activity of the iris varies directly with
the number and size of the ganglia and nerves connected
with it.

Dr. Lee's remarks constitute an important addition to our
knowledge of the structure of the eye, and form a very interest-
ing resume of observations evidently carried on with much
industry and carefulness ; and in a spirit which we look for in
a son of the discoverer of the ganglia of the heart and uterus.

Art. VII. — Over cle Uiteinden der Smaakzenuwen in de Tong
van den Kikvorsch. Door Th. W, Engelmann, Assistent
bij het Physiologisch Laboratorium te Utrecht. Met
Plaat. 'Nederlandsch Archief voor Genees- en Natuur-
kunde,' Deel III, 3e Aflevering, 1868.

On the Terminations of the Gustatory Nerves in the Tongue of
the Frog. By Th. W. Engelmann, Assistant in the Phy-
siological Laboratory at Utrecht. Reprinted from the
' Nederlandsch Archief,' Vol. Ill, Part III, 1868. 8vo.
Pp. 26.

In the investigations detailed in the above paper, the author
has had the aid and cooperation of one whose name we are
I'ejoiced to see once more in connexion with physiological re-

1868.] Engelmann on the Gustatory Nerve of the Frog. 189

search. We trust that the young Hccr Schroeder van der
Kolk, Med. Cand., is about to walk in the footsteps of his
illustrious father^ and to maintain the prestige conferred by
the labours of the latter upon the name which his son now
bears.

Billroth had found ^ that only the fungiform papillae of the
tongue are provided with nerves. At the same time he con-
firmed the fact, already observed by Leydig, that the terminal
surface of these papillae is covered with a peculiar epithelium.
From the previous researches of Schultze on the extremities of
the olfactory nerves in the mucous membrane of the nose, he
thought a connexion between the nerves and the epithelial cells
of the terminal surface of the lingual papillae not improbable,
though he could neither trace the nerves into the epithelium, nor
find the analogues of the olfactory cells of Schultze.

rixsen,2 too, could trace the nerves only into the connective
tissue of the papilla. Hoyer^ denies the existence of a connexion
between the epithelial cells and the nerves —

" E. A. Key ^ made an important step in advance. He dis-
covered not only in the epithelium of the papilla peculiar cells,
by him called gustatory cells, but he saw also the dark margined
nerves continued into delicate varicose fibres, which ascended
into the epithelium. Each gustatory cell possesses, according
to him, at its central extremity, a thin varicose outrunner,
which passes into a fine nerve fibre."

Of Key^s researches we gave an abstract in our 29th volume,
April, 1862, p. 422. Our notice was, however, taken, not
from the German paper above referred to, but from an ampli-
fication of the same subsequently published in the form of
an academic thesis, by the author, in his native language, the
Swedish.

Key's important results, obtained under the guidance of
Professor Max Schultze, were subsequently disputed by
R. Hartmann,5 who, unable to find the gustatory cells and the
fine nerve fibres of Key, considered them to have been arti-
ficially produced. Dr. Engelraann is not aware that any recent
investigations have been made respecting the terminations of
the gustatory cells in the frog.

The author's own researches relate to adult specimens of the
Rana temporaria. We shall endeavour, as briefly as possible, to
lay his principal results before our readers.

1 Muller's ' Arcbiv,' 1858, p. 159.

■■^ Carol. Fixsen, • De linguae raninaj textura.' Dorpat, 1857.

=> Hover, in ' Arch. f. Anat. u. Physiol.,' 1859, p. 481.

* Key, in 'Arch. f. Anat. u. Physiol.,' 1861, p. 329.

'" Hartmann, in ' Arch. f. Anat. u. Physiol.,' 1863, p. 634

190 Bibliographical Record, [July,

The epithelium covering the circular terminal surface of the
papilla consists of three kinds of cells, which he calls cup-cells,
cylinder- cells, and fork- cells. All these three varieties are cha-
racteristic of the terminal surface of the papilla ; they are met
with in no other part of the surface of the tongue. They are
well defined, having no transition forms among themselves. So
long as the cells remain in connexion on the papilla we can,
viewing the latter in profile, at most see only two kinds, of
which the cup-cells, constituting by far the greatest mass of the
epithelium, are the most striking. The author found that he
could with glass rods very perfectly isolate the cells in tongues
which had lain one or more days in a mixture of equal parts of
strong glycerine, and of a four per cent, solution of bichromate
of potash.

The cup-cells, the " modified epithelial cells" of Key, which
are found to the number of several hundreds on the larger
papillae, form the outermost layer of the epithelium investing the
terminal surface of the papilla. They consist of cylindrical
bodies standing perpendicular to the surface of the papilla, and
containing in their lower third a globular, vesicular nucleus, of
about 'OOSmm., in which is a central nucleolus of 'OOlmm. in
diameter. There is no doubt that the cup-cells are not the
extremities of the nerves, but only peculiar, indeed essential
characteristic epithelial cells of the gustatory papilla.

The cylinder-cells consist of an ellipsoidal body, situated in
the deepest layer of the epithelium, and continued in a straight
cylindrical outrunner reaching to the external surface of the
epithelium. The body is almost completely filled with an
ellipsoidal vesicle, the nucleus, in the centre of which lies a
small nucleolus. Only a very slight layer of protoplasm sur-
rounds the nucleus.

On a review of his observations, the author comes to the
conclusion, that neither are the cylinder- cells to be looked upon
as extremities of nerves, but as a peculiar kind of epithelial
cells, differing in their properties remarkably from other
epithelial cells ; they are, no doubt, for the most part, the rod-
cells of Key. The drawings given by the latter make it probable
that he had seen them and taken them for the terminal organs
of the nerves. He confounded them, however, with the fork-
cells, of which he seems to have observed only injured
specimens.

Fork-cells. These remarkable apparatuses, scarcely deserving
the name of cells, are, notwithstanding many individual differ-
ences, formed after one and the same type. They all consist of
a body provided with fibrinous outrunners. The body has the
figure of an extended ellipsoid, and is almost completely filled

1868.] 'ENGELMA.ui^ on the Giistatory Nerve of Ihe Froff. 191

Avith a nucleus of tlie form of a vesicle Avitli nearly central nucle-
olus. The outrunners arise at the two poles of the ellipsoidj which
last the author distinguishes as peripheral and central poles.

From the peripheral pole arises an usually forkshaped out-
runner, whose free extremities just reach the surface of the
epithelium. This outrunner is divisible into two parts, the
handle of the fork and the prongs. The longer the former is,
the shorter are the latter, and vice versa. The prongs are
usually two, less frequently three. All the prongs are extremely
slight cylindrical rods. The optical properties of the handle
and prongs are those of very fine, pale nerve fibres : they have
the homogeneous appearance and the dull lustre found, for
example, in the axis- cylinders occurring in the posterior layers
of the cornea of the frog. Chemically, too, they almost entirely
resemble the latter. They are, moreover, flexible and tolerably
elastic.

Outrunners dividing dichotomously arise also from the central
pole. These too agree in their physical and chemical properties
■with minute axis cylinders. They lie in the spaces between the
bodies of the cylinder-cells, and their extremities reach the
surface of the stratum of connective tissue of the papilla. The
latter in this situation exhibits a lamellar thickening, per-
forated by abundant ramifications of very delicate pale nerve
fibres.

The author does not feel in a position to decide whether the
central outrunners of difi'erent fork-cells pass into one another,
or whether each descends separately to the connective tissue
stratum of the papilla. In any case these outrunners form with
their dichotomous ramifications an extremely dense fibrous
network, which almost completely fills the space between the
bodies of the cylinder- and of the inferior fork-cells.

While Dr. Engelmann considers the cup- and cylinder- cells
to be only epithelial cells of peculiar construction, he looks
upon the fork-celb as the extremities of the gustatory nerves, as
will appear, he says, more clearly from the description of the
nerves yet to be given. As to the epithelium investing the
remaining surface of the papilla, it consists of ciliated cells and
non-ciliated cylinder epithelial cells. The first of these form a
small girdle or garland around the circular layer of the nerve
epithelium, a closed ring, as it were, having the breadth of one,
or at most of two ciliated cells, and not extending, as stated by
earlier observers, over the whole surface of the papilla. The
sides of the papilla are covered with ordinary non-ciliated
cylinder epithelium.

The nerve fibres of the gustatory papillce. — The stratum of
connective tissue in the papilla consists of a greater under por-

192 Bibliographical Record. I Julj^

tion formed of loose, and a less upper portion, laminated,
composed of dense tissue. The former contains the blood-vessels,
the terminations of the divided muscular fibres, and the darkly-
defined nerve-tubes. The upper part of the stroma of the papilla,
called by the author nerve- cushion, consists of very dense, nearly
homogeneous-looking connective tissue. Inferiorly the nerve-
cushion is rather firmly attached to the other connective tissue
of the papilla ; upwards and outwards towards the epithelium, it
is sharply defined. It has neither connective tissue corpuscles,
nor nuclei, nor outrunners of muscular fibres, nor blood-vessels,
nor elastic fibres, but a surprisingly large quantity of extremely
fine, pale nerve fibres. It forms the basis on which the whole
nerve-epithelium rests.

" The five to ten medulla containing nerve fibres of the papilla run
in the axis of the latter, undivided, to the under surface of the nerve
cushion. On entering this, or shortly before, they become more
pointed, and suddenly lose their dark contours ; their neurilemma,
however, coalesces with the dense tissue of the nerve-cushion. Im-
mediately after their entrance the nerve fibres, which have already
become very slight and pale by repeated dichotomous subdivision,
form a delicate- nervous netAvork, which extends horizontally through
the whole inferior half of the nerve-cushion, and whence very nume-
rous extremely fine branches, usually again subdividing, ascend in
a tolerably straight direction to the free surface of the nerve-
cusliion. The continuations in the epithelium of these branches,
which perforate the nerve-cushion, are the above described central
out-runners of the fork-cells." — (P. 22.)

This, which appears to be the principal point in the work, we
have stated in the author's own words. Previous observers had
seen the nerve-cushion, but had taken a different view of it.
Key looked upon it as a colossal extension of the neurilemma,
and called it ^^Nervenschale."

Dr. Engelmann does not profess to have absolutely demon-
strated the connexion between the nerve-fibres and the fork-
cells above referred to ; but he shows that such a connexion is
all but certain, though it appears just to escape positive de-
tection through the insufiiciency of our optical instruments.
" We see delicate, pale nerve-fibres reach in very many points
the surface of the nerve-cushion : we see from this surface
equally delicate, extremely numerous fibres, having the same
properties as pale nerve-fibres, issuing and continued directly
into the substance of the fork-cells. If we now assume the
existence of a connexion between the former fibres and these
latter, we do only what is necessary : we assume what is by far
the most pi'obable.'^

Certain physiological questions suggest themselves, such as,

1868.] Tkompbo^ oil Diseases of the Prostate. 193

whether each fork-cell is connected with only one or witli several
dark margined nerve-fibres ? The latter view the author believes
to be the more probable. In addition to the arguments with
which he supports this opinion, we might perhaps suggest, that
such an arrangement is more in accordance with what we
observe in the nervous system generallyj as in the multipolar
cells of the spinal cord. This and one or two questions Dr.
Engelmann leaves, however, for the present undecided, ''Content
with the result, that the peripheral extremities of the gustatory
nerves are organs of peculiar structure : the fork-cells, which
are characteristically distinguished from the peripheral terminal
apparatus of other nerves, a fresh proof of the truth of the pro-
position, that specific functions are connected with specific
forms" (p. 26.) Dr. Engelmann^s valuable paper is illus-
trated with a well executed plate from drawings by the author
himself.

Art. VIII. — The Diseases of the Prostate. Their Pathology
and Treatment. By Sir Henry Thompson, &c. &c. Third
edition. London, 1868. Pp. 360. /.

It would be quite unnecessary to give an extended notice o
a new edition of a work so well known as this. The professiona
public have already marked in the most decisive manner their
appreciation of Sir H. Thompson's clearness, fulness, and
trustworthiness as a writer upon the class of diseases of which
he treats, and we need, therefore, say no more on that subject.
The present edition of this work contains some interesting
matters not included in the preceding, the valuable results of
increased experience and extensive practice. Amongst these
one of the most important is the opinion which a very great
familiarity with cases of stone has led our author to form of
the value of lithotrity, when the prostate is affected with
chronic enlargement. Sir H. Thompson claims for himself a
personal experience in cases of this nature only second in extent
to that of M. Civiale. He points out, in the first place, the
great danger, and often formidable difiiculty, of a cutting opera-
tion in cases of enlarged prostate, and he discusses seriatim the
various obstacles to the successful performance of lithotrity,
when this complication exists. Notwithstanding such obstacles
Sir H. Thompson shows that Sir B. Brodie speaks in favour of
its performance, and relates successful cases ; that Civiale was
also in favour of it, providing the enlargement was not enor-
mous (in which case he would propose the high or suprapubic
operation), and that Dr. Ivanchich of Vienna has recorded
statistics of his own experience, which appear to show a much
83— XLli. 13

194 Bihlographical Record. [July,

more favourable result from lithotrity than has ever been
obtained by the cutting operation in such cases^ and to this
testimony he adds his own experience in these words — " I have
operated upon numerous cases of calculus of the bladder, in
which the prostate was enlarged — certainly in thirty ; and I have
no hesitation in saying that I cannot consider it as lessening
the probabilities of success in skilful hands, or, at all events, to
a very small degree" (p. 344). Such an opinion from so expe-
rienced an operator is gratifying, since there is no question (of
the extreme danger of lithotomy in such circumstances. The
difficulty of seizing the stone Sir H. Thomson regards with Sir
B. Brodie as usually trifling -, unless the enlargement is very
great and the sinus behind the enlarged gland lodging the stone
very narrow, in which case the instrument must be reversed and
the stone picked up with it before being crushed, a difficult and
dangerous manoeuvre. But the common embarrassment is in
getting away the fragments. Two recent improvements in the
apparatus, however, have made this embarrassment less than
formerly. One is the flat-bladed lithotrite, which enables the
surgeon to remove a considerable quantity of debris, and is
provided with a screw, by which the amount of such debris can
be regulated ; so that it is less dangerous than the scoop lithotrite
formerly in use for this purpose. Por details as to this instru-
ment, and the method of employing it, our author refers to a
forthcoming new edition of his own work on lithotomy and litho-
trity. The second aid in withdrawing fragments is the " exhaus-
tion-syringe" recently introduced into practice by Mr. Clover.
Our surgical readers are, of course, all familiar with this
instrument, of which Sir H. Thompson speaks in terms of
deserved favour. He has used it, he says, nearly 200
times, a convincing proof of its utility. He adds, how-
ever, " It is necessary to use all such apparatus with extreme
gentleness, and I should prefer to do without it, if possible, as
its employment is quite as irritating as a sitting with the litho-
trite. Repeated injections, which alter rapidly and considerably
the size of the bladder, are always irritating to that organ."
Finally, Sir H. Thompson believes that in some cases, assistance
may be obtained from the injection of chemical solvents into
the bladder, the composition of the stone being previously
ascertained.

We have selected the above out of the numerous interesting
topics on which this edition of Sir H. Thompson's work bestows
new information, partly in order that our readers may judge
of the importance and value of the book, and also on account
of the interest of the subject. All those who are old enough to
have witnessed much of the practice of lithotomy when it was

1868.] Morris on Germinal Matter, ^c. 195

the only means of treating stone in the bladder, agree in stat-
ing that it was almost uniformly fatal in elderly people with
enlarged prostate. Even in our own limited experience we have
witnessed most gratifying instances of the removal of stone by
lithrotity in such patients, and it is encouraging to hear on such
authority as Sir H. Thompson's that such cases are not excep-
tional. There are few more real advances in modern surgery
than the application of lithotrity as the usual method of treat-
ing stone in the adult.

Art. IX. — Germinal Matter and the Contact Theoi'y ; an Essay
on the Morbid Poisons, their Nature, Sources, Effects, Migra-
tions, and the means of limiting their noxious Agency. By
James Morris, M.D. London. Second edition. 1867.
Pp. 111.

Since we last noticed Dr. Morris's little book he has added
considerably to its size, and has adduced numerous instances
more or less favorable to his views. His argument is that solid
particles may be suspended for some time in the air, and be
borne along to considerable distances by currents in it; that
minute portions of organic matter are constantly thrown off by
animals and men ; and that these floating particles are received
into the body, some passing into the lungs, so as to reach the
blood. Accepting Dr. Beale's nomenclature of germinal matter
and formed material, as expressing the two opposite conditions
of living active matter and dead inactive material, he proceeds
to show how in many instances, if not in all, morbid action is to
be regarded as the result of the contact of the affected organ on
tissue with germinal matter in a similarly unhealthy state. The
cases which are favorable to Dr. Morris's theory are, of course,
those in which infection is admitted by all to take place through
the medium of the air, as in typhus, diphtheria, smallpox,
scarlet fever, and measles ; but we are less able to understand
why no case of syphilis should ever occur through particles of
syphilitic germinal matter floating in the air developing in some
favorable spot for their growth and development. Considering
the frequency of the disease, and the remarkable vitality which
its germinal matter possesses, as indicated by the difficulty with
which it is eradicated from a system it has once contaminated,
we should yet doubt whether Dr. Morris would admit the
validity of his own argument, were a patient with a well-
marked chancre to urge that it had arisen from a few floating
syphilitic particles which had unfortunately alighted on a pimple.
Yet why should this not be so, at least in rare instances, since

196 BihliograpJdcal Record. [July,

every one would allow that the direct contact of that same prin-
ciple with a truly infected surface would almost infallibly induce
the disease. However, Dr. Morris's work, notwithstanding that
a good many difficulties stand in the way of an unreserved
acceptation of his views, is both a thoughtful and suggestive
one. It is deficient in positive data.

Art. X. — Irritability : Popular and Practical Sketches of common
Morbid States and Conditions bordering on Disease, with Hints
for Management, Alleviation, and Cure. By James Morris,
M.D. London. 1868. Pp.114.

" Irritability," which, from the ever increasing hurry and
bustle of modern life, is constantly on the increase, is, perhaps,
one of the few medical subjects that may fairly be discussed in
a popular manner. Certainly it is here treated in all its aspects
discursively, and, we may add, pleasantly enough — facts or argu-
ments or similes being drawn from the movements of the sen-
sitive plant, the case of Nicolai, the bookseller, a storm on the
Alps, the Atlantic Telegraph, the terror of Job at beholding a
spirit, and we know not how many others.

We commend the chapter on remedial influences to the
perusal of the present and the ex-Chancellor of the Exchequer,
though we fear that neither of them would be able to carry out
Dr. Morris's recommendation that before attempting to sleep
''the last occupation should be as little exciting as possible
— anything that requires no thought. If they have been much
excited, perhaps there is nothing better than a stroll, with a
cigar or without it, under the starry sky, when —

" ' From the cool cisterns of the midnight air
The spirit drinks repose.' "

Many a man could cure his own " irritability" without pro-
fessional advice, if he had only time and means at his command,
to take amusement or cultivate his love of nature.

Art. XI. — On the Constituents of Food and their relation to
Muscular Work and Animal Heat. By F. C. Donders.
Translated from the ' Nederlandsch Archief,' by W. D.
Moore, Esq., M.D. Pamphlet, pp. 415. Reprinted from
the ' Dub. Quart. Journ. of Med. Science,' 1866.

In this interesting essay a very admirable summary is given
by Donders, of his own and of various recent investigations on
the difficult subject of the correlation of physical and vital force,
of the relations which exist between the food consumed and the
work done, as well as the heat eliminated by the body. He

1868.] Bonders on Food and Work, ^c. 197

shows that heat can no longer be regarded as developed in the
lungs, but that, as proved by Sachs, it is partly directly formed
by the combination of oxygen with carbon and hydrogen in the
blood, and is partly indirectly produced by electro-motor actions
occurring in all parts of the nervous and muscular systems, as
Avell as by transformation of mechanical work in the latter. In
this respect, he instances the heart which produces, in twenty-
four hours, a work of about 86,000 kilogrammeters, which wholly
changed into heat can warm fully 200 kilogrammes by 1°C., and,
therefore, all the parts of the body by 3°C. (5°*4 F.). So also,
he observes, the movements of respiration and all transitory
muscular action must produce heat, not only through the fric-
tion which the particles of the muscles exerted mutually undergo,
but also owing to the increased activity in the circulatory and
respiratory processes to which such exertion gives rise. He
then shows what are the changes occurring in a muscle during
mechanical work — how this is divided into statical when no
apparent effect is produced, as in pulling against an insuperable
weight j and dynamical when movement occurs, and what is the
relation existing between the production of heat and of me-
chanical work. The remainder of the work is chiefly occupied
with the consideration of the effect of exertion on the disintegra-
tion of the albuminous constituents of muscular tissue ; and he
introduces a most instructive communication from Dr. Verloren,
on the extraordinary muscular energy exerted by insects, and
especially by bees, at a period of their existence when their food
consists almost exclusively of farinaceous and saccharine ma-
terial, and which is considered by Dr. Verloren to prove that
muscular work is attended with no considerable metamorphosis
of albuminous matter. Prof. Donders remarks, however, that
the period of the year when bees consume their stored-up
honey is in winter, precisely at that period when they are most
quiescent ; and he states he is somewhat sceptical as to the com-
pletely non-nitrogenous nature of the nectar of flowers consumed
by bees and butterflies.

The general conclusions at which Prof. Donders arrives are
well worthy of earnest consideration, and are opposed to the
hasty adoption of the view that much muscular work can be
performed on a farinaceous or oleaginous diet. On the Avhole,
he observes, '^We come to the conclusion that animals to per-
form work constantly use, not only a larger quantity of food,
and, therefore, proportionately more albuminous matters, but
that they further require for their labour a more highly albumi-
nous diet. In this way the body attains a definite stationary
condition, and that food is thus consumed and used. Conse-
quently, in the excreted matters, the same quantity of nitrogen

198 Bibliographical Record. [July,

must occur as in the ingesta. The nullity of the argument de-
rived from the slightness of the increase of the urea excreted
during the performance of work is thus made apparent.^*

On Non-nitrogenized Food in a Physiological point of View. By
Messrs. Sella and Stephens. 1867. Pp. 26.

This is a defence of some remarks made in a previously pub-
lished work, entitled, 'Physiology at the Farm/ against a
critical review of their book contained in the ' Field/ accusing
them of valuing foods for cattle in proportion to the amount of
nitrogenous food they contain. We have not had an oppor-
tunity of referring to the original work ; but to their reply
there is certainly nothing to object, and we fully concur in
their opinion, that the speedy death of an animal by starvation,
if fed exclusively on non-nitrogenized food, is to some extent
incompatible with the recent views of Prankland and others,
that the combustion of non-nitrogenized aliment within the
body is sufficient to produce that energy on which muscular
contraction is dependent; and the same view is most forcibly
maintained by Professor Donders in the pamphlet we have just
noticed.

On the Function of the Blood in Muscular Work. By C. W.
Heaton, F.C.S., Lecturer on Chemistry to Charing Cross
Hospital Medical School. Pamphlet reprinted from the
' Philosophical Magazine' for May, 1867. Pp. 6.

The above essay is written in support of the view originally
propounded by Mayer, that all the oxidation takes place in the
blood, and in opposition to that of Liebig and other later
writers, to the effect that it takes place in the tissue of the
muscles ; and evidence is adduced that the quantity of oxygen
which can possibly exude through the walls of the vessels, sup-
posing it to be in solution in the liquor sanguinis, and to be
applied to the oxidation of fat or muscle, will not account for
one sixth of the work done by the muscles. Mr. Heaton is,
therefore, of opinion that all, or nearly all, the force of the body
is generated in the blood ; and that Mayer was perfectly right
in saying " that the muscle produces mechanical effect at the
expense of the chemical action expended in its capillaries."

On the Formation of so-called Cells in Animal Bodies. By
Edmund Montgomery, M.D., late Demonstrator of Anatomy
at St. Thomas's Hospital. London, 1867. Pp. 56.

In this pamphlet Dr, Montgomery has summarised his ob-

1868.] Costa on Medical Diagnosis. 199

servations on the mode in which cells^ or rather cell-like bodies,
may be formed by the imbibition of water from viscid materials
extensively distributed through the animal body. His results
are interesting as showing how closely it is possible to imitate
certain organic forms, and how requisite it is to exercise caution
before giving a definite opinion upon the nature of cell struc-
tures ; but we must altogether dissent from the view that a true
cell can thus be produced, since these " counterfeit" cells, how-
ever precisely they may resemble true cells at certain periods
of their growth, lack their essential characteristics of capability
of further development and of reproduction, and are as different
in their attributes as are the nerve-like myelin tubes from true
nerves.

Art. XII. — Medical Diag^iosis with Special Reference to Prac-
tical Medicine : a Guide to the Knoivledge and Discrimination
of Diseases. By J. M. Da Costa, M.D., &c. Second edition.
Revised. Philadelphia, 1866. Pp. 784.

The uncertainty which has been the opprobrium of medicine
since its birth is, we are tempted to congratulate ourselves, be-
coming less and less an integral part of our science. We look
back to the times when it entered into pathology, diagnosis,
and prognosis, to an extent which although it niay have whetted
curiosity and exercised imagination, must have prevented any real
feeling of satisfaction being derived from their study. " I am
weary of guessing," were the sad words in which the foremost
physician of an age not very remote from our own summed up the
account of a long professional life. It is true that, in practically
the most important department of medicine, we have, perhaps, the
fewest landmarks to guide us. We are not agreed as to the
degree or manner in which morbid processes may be afifected
by remedies, and even the question as to the best mode of com-
bating acute inflammations cannot be said to be finally set at
rest. But even in therapeutics we have advanced some little
way on the road to certainty. Our want of agreement does not
depend upon doubt as to the physiological effect of the remedies
we employ. The absurd poly-pharmacy of 200 years ago
is no longer required as a veil for medical ignorance. We are
no longer in doubt as to the action of ordinary drugs. Our
uncertainties in therapeutics are probably due, to a great extent,
to the theory we unconsciously adopt that the same disease
ought to require and yield to the same treatment, at all times
and in all persons. Of course this fallacy, which is a very
common one, has been more or less protested against by the

200 Bibliographical Record. [July,

greatest masters in physic. But if we at once discarded it a
large amount of the so-called uncertainties in therapeutics would
disappear, whilst experience and skill in choosing and applying
a mode of treatment to an individual case would again be thought
worth striving to obtain.

In no department has the change from uncertainty to certainty
been so marked and decided as in diagnosis. Compared Avith
one hundred years ago, daylight has succeeded the dimmest twi-
light. Of course the advance strikes the student most in refe-
rence to lung, heart, and kidney diseases ; but it is true,
although in a less degree, of diseases of the nervous system, and
of the digestive and assimilative organs. Even in reference to
that class of acute diseases which our forefathers saw more fre-
quently than we do — the so-called zymotic class — we have esta-
blished differences between eruptive and continued fevers which
were unknown to the acute physicians of the last century. On
the whole we believe we are justified in asserting that the pro-
gress of medical diagnosis will bear comparison with that of
most other sciences, even in this age of progress.

In the work before us we have undoubtedly a fair and well-
laboured view of the present state of the art and science by
which disease is discriminated. The author has taken care to
bring together all the latest helps and instruments by which
information can be gained, and he has given a full and clear
description of them. But much more than this, he takes diseases
seriatim, according to a simple arrangement, and one by one he
gives a full account of their symptoms, physical signs, and dif-
ferential diagnosis. In almost every instance the information
is brought up to the latest date. The utility of such a book is
obvious. Diagnosis is, in its very nature, more susceptible of
being reduced to rule than prognosis, or therapeutics. The
two latter are influenced by peculiarities of idiosyncrasy, con-
stitution, and outward circumstances which may baffle the most
sagacious. Diagnosis is far less under such influences; it can
be made in many instances with the certainty of exact science,
and in every case it deals far more with the objective and less
with the subjective, than do the other branches of medicine.
It is for this reason that it is fitting that it should be treated
separately. It is more capable of being systematised ; and
something of its principles may be learned from books before
they are practised at the bedside with more certainty and success
than the other parts of the physician's art. In its present con-
dition it comprises a very large portion of the current absolute
knowledge which the student, whilst a student, can hope to
acquire.

The present edition of Dr. Da Costa's work follows in quick

1868.] Costa on Medical Diagnosis. 201

succession the first. It is enlarged by about ninety pages of
letter-press, and it contains twenty-two new woodcuts. The
chief additions, the author states in his preface, will be found in
the chapters on diseases of the brain, of the larynx, of the
blood, on the urine, and on parasites, and in the section on
abdominal enlargement. It is very difficult in a brief notice to
do justice to a book which contains a large part of all that is
known in practical medicine. Truly, it is for the most part
only a compilation, but it is a compilation bearing the impress
of an accurate student, an observant physician, and a polished
writer. The larger portion of the work, excellent as it is, of
necessity does not present much that is new to the well-read
English practitioner. The sections on physical diagnosis,
whether of cardiac, pulmonary, or abdominal diseases, on the
urine and kidney diseases, and on diseases of the nervous
system present little to need remark, except the fact that
they are very good, and represent fairly the teaching of the
present day.

"We are unwilling, however, to part with Dr. Da Costa so
abruptly, and therefore select a chapter from which to give the
reader an idea of the scope of the author's information, and of
the style in which he conveys it. In the chapter on diseases
of the blood, are contained short but not scanty accounts of the
conditions known as anaemia, leucocythsemia, pyaemia, septsemia,
thrombosis and embolism, scurvy and purpura. The observa-
tions on the diagnosis of thrombosis and embolism are a com-
pendium of our knowledge of the subject. After defining
thrombosis as the whole process of the formation of clots in
vessels or heart, and embolism as the projection onward of the
thrombus, or of fragments detached from it, and the pheno-
mena thus occasioned, the author proceeds to review the mani-
festations by which the presence of thrombi in different situations
in the veins and arteries may be diagnosed. In treating of
venous embolism he selects phlegmasia dolens, on the supposi-
tion that that affection really depends upon coagulum in the
venous circulation of the limb, as presenting an example of
most of the conditions which result from considerable venous
occlusion. In addition, however, he notices that haemorrhage
into the surrounding tissues as in a case recorded by Virchow
may result from the stoppage of a vein. From the peripheral
or other part of the venous system he follows the transport of
the clot into various organs and to the right side of the heart.
From the description of the phenomena which accompany
embolism of the pulmonary artery, we extract the following
as a specimen of the author's manner.

*' But the mode of death, and the symptoms preceding it in em-

202 Bibliographical Record. [July,

bolism of the pulmonary artery, are not always the same, and depend
very much upon the size of the embolus, and where it is arrested.
A large-sized clot, whether it be merely a portion of one occupying
the right heart, or be washed at once into the pulmonary artery,
will occasion much the same signs as those alluded to as indicative
of a large clot in the right side of the heart ; the craving for air is
particularly intense, and this craving is increased by every movement
of the body ; the muscular debility, the lowered temperature, the
cyanosed look, the turgid veins of the neck and their undulations,
the increased, irregular cardiac impulse, though the heart's action is
not sufficiently disturbed to account for the disturbed respiration,
and disordered general circulation, are also noticed ; and, in some
cases, a systolic blowing sound, and where the case is at all protracted
vertigo, albuminuria, and cedema of tlie limbs may observable. The
intellect is always apt to remain clear. As regards the pulmonary
phenomena proper, collapse of the lung, hsemorrhagic effusions,
oedema, or capillary bronchitis, are likely to happen, excepting in
those instances in which the principal trunks of the pulmonary
artery are blocked up, and almost instantaneous asphyxia ensues.
If the fragments be very small, the amount of dyspnoea is not of
necessity great, nor are the symptoms of asphyxia marked ; and in-
flammations of the parenchyma of the lungs may take place, occa-
sioning often, secondary obstructions and metastatic abscesses in
the lungs, from which recovery even possibly may take place. These
kind of metastatic abscesses are observable in pyaemia, and are not
unusual in puerperal fever" (p. 639).

The account of arterial embolism and its eflPects on different
organs will scarcely bear condensing. Dr. Da Costa especially
insists upon the value of pain as a symptom of internal em-
bolism, when taken in connection with the history of the case,
the state of the cardiac symptoms, and disordered function of
the organ to which the pain is referred.

" The presence of emboli in the splenic, renal, and mesenteric
arteries is generally rather to be inferred from the history of the
esse, and does not occasion any obvious discernible signs. But ten-
derness, enlargement of the spleen, and pain in the splenic region
in splenic embolism, or disordered secretion of urine and pain in the
loins in embolism of the renal artery may be quite marked. The
occurrence of pain in these cases of internal embolism must not be
overlooked ; and in embolism of the arteries of the extremities pain
is a symptom of as great or even greater prominence. It may be
like a violent neuralgia, or so constant that it is mistaken for rheu-
matism ; and, as happened in a case of embolism of the right iliac
artery, under the care of Dr. Hutchinson, and which I saw, it may
recur in paroxysms of intense severity, and be referred to the foot,
though this be already in a condition of sphacelus " (p. 641.)

In treating of the etiology of embolism as subservient to its
diagnosis, Dr. Da Costa remarks upon the effect of malarial

1868.] Smith on the Surgery of the Eectiwi. 203

fever in giving rise to the accumulations of pigment in the
bloodj and thus originating a form of capillary embolism which
may be the cause of capillary abscesses, or disturbances of the
hepatic circulation. Such a pathological sequence can, of course,
only be a matter of conjecture based on a close study of the
general phenomena and history of a case.

In conclusion we can only say that Dr. Da Costa's book
seems to us a good text-book for students, and a good book of
reference for practitioners. It is clearly, but not tamely
written, in a style which elicits and fixes attention.

Art. XIII. — The Surgery of the Rectum, being the Lettsomian
Lectures on Surgery, delivered before the Medical Society of
London, 1865. By Henry Smith, F.R.C.S. Second Edition.
London, 1868. Pp. 152.

This little book is a re-issue of some very interesting and
practical lectures, delivered by Mr. H. Smith, on a subject of
which he has made a kind of "speciality." We noticed the
first edition shortly after its appearance, and need say very
little more about the second edition, inasmuch as there seems
little in it beyond what appeared in the first. One thing, how-
ever, is very important, which is just that there is nothing new
in this edition. It will be remembered that the main object of
Mr, Smith's publication was to recommend a method of operating
for piles, not of his own invention, but of Irish origin, and
introduced into English practice by Mr. H. Lee. This consists
in catching the base of the pile firmly in a clamp, cutting it off,
and searing the base with nitric acid or the actual cautery.
The advantages claimed for its method are its greater expedition
— the slighter annoyance and confinement required in the
after treatment, and its supposed immunity from danger of
pyaemia, and other secondary complications.

The following is what Mr. Smith's extended experience
enables him to say about the new mode of operating :

" Since this was written I have had a very large experience of the
use of the clamp in the most severe forms of these diseases. Only
thirty-five cases were recorded in the first edition, but I have now
operated altogether upon one hundred and twenty cases without any
fatality, or even any annoying result whatever. I am so thoroughly
conscious of the safety and value of this plan of treatment, that
since the last twelve months 1 have entirely discarded the use of
the ligature ; and I am glad to say that a large number of sur-
geons in England and in the colonies are adopting the means of
treatment which I so strongly recommend, and against which not one

204 Bibliographical Record. [July,

single objection of any weight has been or can be brought forward."
•—'Preface to Second Edition.

We must leave the respective merits of the new and
old methods to the judgment of the profession. Mr. H.
Smith's experience, though large, is as yet obviously insuf-
ficient to prove more than that the method is one which
may be justifiably used. To say that because 120 operations
for piles have gone off" without a case of pyaemia or tetanus,
therefore the method of operating is free from any risk of such
an event is obviously premature, since the same thing often
enough occurs after the ligature. But to say that 120 cases
have been operated on in this way without after-bleeding is cer-
tainly sufiElcient to show that if the cautery be unsparingly used,
the method is tolerably safe from risk of hsemorrhage. There
ought, however, to be no mistake about thoroughly stanching
all the bleeding points, and for this purpose Mr. Smith's clamp
is a very convenient one. The operation is not nearly so painful
as it looks ; and if the patient is timid chloroform can be given.
We can testify to the efficiency of Mr. Smith's method, even in
severe cases ; but we give no opinion as to its superiority. -

Art. XIV. — On Spinal Weakness and Spinal Curvatures, By
W. J. Little, M.D. London. 1868. Pp. 121.

This little treatise on the various curvatures and other un-
natural states of the spinal column is well worth the reader's
attention, since it embodies the results of many years of prac-
tical observation by one who is admitted to be amongst the
best authorities on the subject which he treats. We shall be
excused from following Dr. Little into all the matters spoken
of in this work, but shall attempt to summarise briefly his
views with regard to lateral curvature.

Before commencing his subject. Dr. Little makes one remark
which should be tested by future observation.

" Many facts have come to my knowledge which tend to show the
existence of a more intimate pathological connection between the
spinal cord itself and lateral curvature than has been hitherto pointed
out .... I cannot avoid entertaining the conviction that as patho-
logists we are accustomed to study the diseases of the osseous frame-
work of the spine as instances of one class of disease, and the diseases
of the spinal cord itself as instances of another class of disease,
instead of studying them, or looking upon them as jointly dependent
upon a common cause" (p. 25).

This is a suggestive observation, and if supported by subse-

1.868.] Little on Spinal Weakness and Curvatures. 205

quent experience, will lead possibly to a more accurate theory
of spinal curvature. The explanations in common acceptance
appear as a rule to be too rigidly mechanical.

The predisposing causes of lateral curvature (rotatory or
rotato-lateral curvature as Dr. Little prefers to designate it)
are placed by the author chiefly in the unnatural confinement
and want of exercise which are enforced by the school educa-
tion of girls in the upper classes, other causes of constitu-
tional debility, and some special causes of local deformity being,
of course enumerated. In this particular Dr. Little is in agree-
ment with most other writers on the subject. In considering
the exciting causes. Dr. Little is certainly to our mind less
satisfactory than in the other parts of his treatise. He has
already laid stress upon the fact that the curve is not merely
lateral, but is due to rotation also, that this rotation can only
be produced by the action of muscles ; that the spinal column
is, as it were, passive in the process (in fact, as Dr. Little forci-
bly puts it, " the affection might with as much propriety be
designated bulging of the right or left shoulder, chest, or hip'^) ;
and yet that the predisposing causes are all of them those pro-
ductive of muscular weakness. Again, he has hinted in the
passage above quoted at some probable central origin of irrita-
tion in the spinal cord in some cases of lateral curvature. Yet
when we come to inquire by what mechanism our author sup-
poses the change of shape of the column to be produced, we
are met with the unsatisfactory statement that

"The exciting causes of lateral curvature need occupy less space.
It is more difldcult to define with certainty what these causes are.
The predisposing causes already enumerated may indeed suflice, by
the intensity of duration of their action, to produce deformity.
Thus, I have indicated that simple debility of muscles of the spine,
laxity of ligaments from their imperfect nutrition and exercise, pro-
bably also a diminished firmness of the osseous tissue itself, enfeeble
the spinal column as an active and passive supporting pillar of the
frame, render it incapable of sustaining itself erect, and cause it to
swerve from the perpendicular" (p. 32).

Surely all this ignores the very observation with which Dr.
Little has stated that the deformity is not simply lateral yielding,
but rotation of the column ; which cannot be produced by mere
muscular weakness, but must be due to muscular action. The
same observation applies to Dr. Little^s explanation of the
usual direction of the dorsal curve to the right, viz. that it is
caused by the weight of the liver, an explanation which seems
to us improbable in itself, and utterly inadequate to explain the
phenomena. Dr. Little^s volume was printed in all probability

206 Bibliographical Record. [July,

before he had had an opportunity of reading Mr. BarwelPs
ingenious papers in the ' Lancet' (Oct. to Dec, 1867) . Had
he done so, we can hardly think that he would have been
satisfied with this meagre and inconclusive treatment of the
theoretical part of the subject of lateral or rotatory curvature.
In one respect Dr. Little utterly difiers from Mr. Barwell, for
he teaches that " in the great majority of instances, if not
always, the lumbar curve precedes the dorsal one" (p. 33),
whereas it is the essence of Mr. BarwelFs theory that in
ordinary cases the dorsal curve precedes and excites the
lumbar, and that it is caused by the action of the serratus
magnus on the ribs, and that this traction is exercised towards
the right side in consequence of the greater weight of the right
arm and the greater volume of the right lung. Whatever weak
points there may be in this theory it does at any rate attempt
to grapple with the facts, while Dr. Little passes them over.

It is in the practical or therapeutical portion of the work
that its chief value seems to us to lie. Here the reader will
find an abundance of information, showing the uselessness and
worse than uselessness of the cumbrous spinal machines so
often employed; the great benefit that may be derived from
properly devised exercises and carefully regulated posture, and
the best kind of spinal supports in such cases as demand some
instrumental assistance. Dr. Little, however, urges upon his
reader that such mechanical devices must rather be regarded
in the light of supports than of instruments whereby the spine
can be mechanically straightened, and we do not doubt that
all experienced surgeons would agree with him.

Especially interesting is the chapter in which Dr. Little speaks
of the success which he has obtained in the treatment of the
simple latural curvature which follows on the deformity of the
chest produced by pleurisy.

The treatment which he recommends in these cases consists
in swinging the body for several hours daily upon a broad band
passing below the sound side of the chest, the head and feet
being just supported on the couch. Thus " the weight of the
head and shoulders above and of the pelvis and lower extremities
below, powerfully, but gently and painlessly, drew asunder the
contracted ribs, and replaced the vertebrae'' (p. 79) . Dr. Little
gives three instances of success in the treatment of this defor-
mity in early life ; and as it is one which is ordinarily regarded
as unavoidable, the suggestion deserves extended recognition
and practical trial.

We heartily commend the book to the careful study of prac-
tical surgeons.

1868.] EcHEVERKiA OH Reflex Paralysis. 207

Art. XV. — First Principles of Modern Chemistry. By N. J
Kay-Shuttleworth. London, 1868. Pp. viiij 214.

This book is at once simple and philosophical. The
introductory considerations, the chapters on heat — specific,
latent, and radiant — the notes on ebullition and evaporation,
on the barometer and thermometer, and on specific gravity, are
all concise and clear. A few only of the non-metallic elements
are discussed in this vokime, but these elements— hydrogen,
chlorine, oxygen, sulphur, nitrogen, and carbon are the most
abundant and the most important.

The author adopts most of the opinions of advanced chemists,
but he shows a tenderness for the difficulties of the young
student, which renders his book easy to read and understand.
He popularises and explains the special chemical notation
adopted by Dr. Frankland, and his brief, interesting, and clearly
written chapters afibrd an attractive yet serviceable introduc-
tion to the completer and more usual text-books of chemical
science.

Art. XVI. — Reflex Paralysis : Its Pathological Anatomy, and
Relation to the Sympathetic Nervous System. By M. G.
EcHEVERRiA, M.D. Ncw York. Pp. 80.

It was our purpose to have included a notice of this work in
an article upon the general subject of paralysis ; but as circum-
stances prevent the appearance of such an article for the present
we take this opportunity of making our readers acquainted with
the nature of the contents of the work. The author was formerly
assistant-physician to the National Hospital for the Paralysed
and Epileptic in London, and the essay itself (divided into two
chapters) is, for the most part, a reprint of observations com-
municated to the ^New York Medical Journal,^ and the
' American Medical Times.^ In the first chapter. Dr. Echeverria
defines reflex paralysis, and gives its etiology and pathological
anatomy. Regarding the causes from which reflex paralysis
arises, he describes them as being,

"Exhaustion of the central nervous incitability — general affections,
and a contaminated state of the blood — disturbed nutrition by con-
ditions other than the above — cold, wet, and atmospheric influences,
although these latter more properly belong to those causes which
act on the blood-lesion of the peripheral nervous system."

Under the term reflex paralysis he ranges those varieties

208 Bibliographical Record. [July,

termed functional, idiopathic, asthenic, and peripheral, guard-
ing against the assumption that the name in any way implies

" Contraction in the blood-vessels of the spinal cord as a necessary
initial cause of the paralysis, or subsequent absence of structural
change in the nervous system as its effect."

The observations in this chapter are copiously supported by
quotations and cases culled from the writings of others, as well
as by several original cases, and have for their aim the

" Pointing out of the histological changes undergone by the
nervous system in reflex paralysis and the facts indicating its rela-
tions to the sympathetic system."

This chapter is also illustrated by plates heliographed by
Baron EgloflFstein^s process.

In the second chapter, besides the influence of the sympa-
thetic system on the production of reflex paralysis, the inor-
dinate sensibility, the changes undergone by the muscles, and
the condition of the urine peculiar to the disease are con-
sidered. The writer shows his reasons, gathered from the
recital of pathological facts as well as from physiological and
anatomical considerations, for looking upon reflex paralysis as
being induced through the agency of the sympathetic, and
dwells on the fact that a material alteration in the structure of
the spinal cord and ganglia, as well as in the nerves and
muscles in fatal cases, has been detected. He believes

" That there are cases such as those of progressive locomoter
ataxy, progressive muscular atrophy, &c., which will probably be
included in the same class of paralysis due to original lesions of the
sympathetic. This classification will be possible when we become
more familiar with their etiology, and the morbid changes they occa-
sion in the sympathetic system."

Dr. Echeverria combats the idea that sensibility of the skin
is not to any degree impaired in reflex paralysis, a symptom
much regarded by Dr. Brown-Sequard as specially characteris-
ing myelitis ; and insists on the existence of derangement of
sensibility in the aflection, forasmuch as he looks upon the
fact as having an important bearing in relation to the con-
sideration of the part which the sympathetic takes in the
production of the paralysis.

The work is one of much interest, as well from the apposite
collection of cases and facts in reference to the views of the
author, as from the practical hints and suggestions which it
contains ; and shows what good use Dr. Echeverria has made
of the opportunities which he has enjoyed of studying aflection s
of the nervous system.

209

PART THIRD,
(©rtflinal Olommunicationg.

Art. I.

Notes on the Geographical Diffusion of Epidemic Cholera m 1866
and 1867. By Gavin Milroy, M.D., P.R.C.P., Vice-President
of the Epidemiological Society.

In the number of this review for last January, I gave a sketch of
the spread of epidemic cholera from the shores of the Red Sea over
a large portion of Europe, and to two points in the New World, viz.,
the harbour of New York and the Trench West India island of
Guadaloupe. Eor the materials I was mainly indebted to Mr.
Radcliffe's very able summary, contained in the last report of the
medical officer of the Privy Council, of the official inteUigence which
had been transmitted by our consuls to the Government, in com-
pliance with the recommendation of the Epidemiological Society to
the Eoreign Office. It is gratifying to know that this source of
valuable information has continued to be available ever since, and
that, in due time, the profession will again have the opportunity of
judging how much may be done by this country in promoting the
science of epidemiology by means of the wide-spread machinery of
her colonies and consulates, scattered as these are over every region
of the globe. It requires but an organised system of continuous
record of this kind, based on authentic data furnished by medical
men resident in each locality, to lay the foundation of a trustworthy
geographical and chronological registration of many epidemic dis-
eases, so indispensable to the accurate knowledge of the natural
history and of the physical relations of these maladies, as well as to
the elucidation of some important problems in State medicine. And
here I would, in passing, allude to the singularly ingenious specula-
tions recently put forth by . Inspector-General Lawson in reference
to the development and cosmical progress of certain epidemics, espe-
cially of fever and cholera — speculations worked out with extraor-
dinary industry over many years of patient research, and animated
throughout by an earnest spirit of elaborative induction. Whatever

83 — XLli. 14

210 Oriffinal Communications. ' [July,

may be the fortune of Dr. Lawson's hypothesis as to the connec-
tion of pandemic waves of disease with terrestrial magnetism, his
researches will not fail to have contributed to the advance of epide-
miological science, were it only by having directed the attention of
medical men to the necessity for far more comprehensive and more
continuous investigations than they have hitherto been willing to
undertake.^ The greatest difficulty he encountered in his labours
has arisen from the want of sufficiently numerous and authentic
data over wide areas of the earth's surface, and during many suc-
cessive years. Until this defect be supplied, no real advance in epi-
demiology as a branch of true scientific inquiry can be looked for.
It is in the hope of exciting more general interest in the profession
in respect of geographical and topographical details relating to epi-
demic cholera, that I now venture to bring before my brethren the
following memoranda, meagre and imperfect as they often must be,
seeing that they have been gathered chiefly from the journals of
pubhc intelligence, unaided by the more ample and authentic in-
struction to be obtained from the channels of official information.

In the early part of 1866 the pestilence existed, in a more or less
developed or active state, in many parts of the European continent,
from the western provinces of Eussia to the Atlantic shores of
Prance and Spain. But, from the want of trustworthy data, it is im-
possible to denote the separate districts, or even regions, far less the
distinct localities, where the disease had abeady manifested its de-
velopment. All that can be said, as far as I am aware, is that it
was then present in various parts of Southern Russia, in the direc-
tion from the Baltic to St. Petersburg, in several places in Saxony,
on the borders of Bavaria with Saxony, and some parts of Rhenish
Prussia and northern Rhineland, as well as in Belgium and Holland.
Beyond this very meagre statement, little or nothing can be affirmed
with confidence respecting the habitats of the dormant pestilence
throughout Central Europe at the beginning, and in the first month
or two, of 1866.

The disease still lingered in Paris, where it had proved so destruc-
tive during the previous autumn, and also in several of the north-
west districts of Prance, about Brest, Caen, and other places in the
departments of Pinisterre, Morbihan, and Cote du Nord. Whether
there had been any spread of the malady from the districts in the
department of the A^osges, which were infected in 1865, and respect-
ing the origin of which no account has, I believe, been published,
seems to be quite uncertain. In Luxembourg, close to the north-
east frontiers of Prance and the adjoining district of Rhenish
Prussia, it early began to manifest itself with virulence. In Spain

' Dr. Law3on's papers will be found in the * Reports of the Army Medical
Department ' for 1861, 1864, aud for the present year. See also the ' Trans-
actions of the Epidemiological Society/ vol. ii.

1868.] ■ Geography of Epidemic Cholera in 1866-67. 211

there is reason to believe, notwithstanding the absence of all direct
information from Spaniards themselves, that the disease existed,
throughout the whole winter, in numerous parts of the peninsula,
from Santander on the north to Seville in the south. I am not
aware whether there were any manifestations of its presence in
Portugal at the same time.

Since the cessation of the outbreak at Gibraltar in November,
there had been no reappearance of the disease in that fortress and
its environs. Malta, too, was healthy throughout the year, in con-
sequence, many persons alleged, of the vigorous quarantine she
maintained. A like immunity seems to have been experienced
throughout the Mediterranean sea-board generally, except at some
parts of the Italian coast, and probably also of Algeria. Neither in
Egypt^ nor in Turkey did the disease ever become epidemic ; and
Greece continued, as hitherto, to remain intact. Whether there
was any recurrence of it during the winter in the Trieste or other
adjoining districts of Austria, does not appear. A reliable history of
the epidemic in that part of Europe is very much wanted ; it could
not fail to be highly instructive in many points of view, and to clear
up much of the obscurity that hangs over its development and
progress in some regions of the Continent.

Respecting the progress of the disease in the New World, very
little can be said. It had, as yet, not extended beyond the quaran-
tine station at New York; and Guadaloupe appears to have been
the only place in the West Indies where the disease had appeared.
But whether Cuba, where the disease subsequently prevailed as it
had done on all previous visitations of epidemic cholera in that
region of the world, was entirely exempt at this time, it is not
possible to find out, from the notorious unwillingness of the Spanish
authorities to publish any information respecting their own territo-
ries, although ever most vigilant in their espionage of disease in all
foreign countries. Guadaloupe continued to be severely scourged
during the early months of 1866. The adjacent British colony of
Dominica remained healthy ; and all that is known about the Ereuch
island of Martinique, immediately to the south of Dominica, and
which, notwithstanding its great commercial intercourse with Mar-
seilles and other ports of Erance, had hitherto escaped, is that in
April and May of the present year (1866) there was a good deal of

1 In March, a rumour of an outbreak in Alexandria reached Malta, and forth-
with all arrivals from Egypt were subjected to a quarantine of thirty days. In
August, a few sporadic cases occurred in Alexandria ; and again the same re-
strictions were imposed. At Mecca, there was a considerable mortality among
the pilgrims and soldiery in May, but the disease did not spread beyond Jeddah.
Sanitary precautions had been taken by order of the Turkish government. It
was stated at the time that a good many cases had occurred also at Masaowah on
the opposite coast of the Red Sea.

212 Original Communications. [July,

choleraic diarrhoea or cholerine among the inhabitants of Port
Royal.

To return to Europe. As was to be anticipated the disease began^
as spring advanced, to manifest greater activity wherever it existed
during the winter. It was then that it was brought over directly
and, so to speak, palpably, to this country, by the landing of sick
and infected persons on our shores from various parts of Holland
and North Germany. The history of these occurrences and the
consideration of their relation to the subsequent development and
diffusion of the pestilence through Great Britain are of the highest
interest to the epidemiological student ; and fortunately he is noAV not
left to mere vague rumours and unascertained statements in fol--
lowing out his inquiries, as he generally is when endeavouring to
trace the course of the disease in any other part of the world. It
will be remembered that the only places in England where the
disease had manifested itself in 1865 w^ere Southampton, and a soli-
tary farm-house near Theydon-bois in Essex.

Notwithstanding the incessant and unobstructed intercourse
between France and this country, it is remarkable that, among the
many thousands of persons who came over from Paris during the
prevalence of the epidemic there in 1 865, one solitary instance only of a
fatal attack occurred in London, and that was of a female who died in
Erith Street, Soho, at the beginning of October. Very many, how-
ever, it may be reasonably presumed, must have had diarrhoea upon
them on and after arrival. In 1866, cholera poison found its way
into England by another channel; and this it did several weeks
before its existence in the country was suspected. Streams of poor
emigrants from North Germany and Holland had been brought over
in March, if not earlier, from Hamburg and Rotterdam to Hull, and
thence forwarded on by rail to Liverpool, for the purpose of being
shipped over to America. No casualties of any sort to excite sus-
picion seem to have taken place, either at the port of landing or on
tlie land journey to Liverpool, or yet in that city, among the
strangers before their embarkation. The first intelligence of the
serious risk that had been incurred was on the 20th of April, when
the news arrived at Queenstown that a dreadful outburst of cholera
had occurred in the emigrant ship '^ England,^' which had sailed
from the Mersey on March 28th. The disease had manifested itself
six days after leaving port ; and so rapidly did it spread among the
crowded mass of wretched humanity on board that, within another
week, ninety-two souls had perished, and the ship put into Halifax
on April 9th for additional medical assistance.^

1 The incidents which occurred at Halifax are so very instructive as to demand
special notice. The sick were removed to the " Pyramus" Imlk, and the rest of
the emigrants were camped out under canvas on an island opposite the southern
suburb of the town, the distance across the harbour being about half a mile.

1868.] Geography of Epidemic Chokra in \Sm-Q>7 . 213

In another emigrant ship, the "Virginia/^ which sailed from
Liverpool on April 4Ah, deaths from cholera occurred at sea eight
days afterwards. When she reached New York^ on the 32nd of
that month, fifty of the passengers had died.

The earliest death from malignant cholera in England was at
Bristol, on April 29th, in a sailor who had come from Eotterdam to
London, and had passed on to Bristol. No other case occurred,
either there or in the metropolis. Hull also remained quite intact.
On May 2nd, two deaths occurred in Liverpool ; both were in poor
emigrants recently arrived from Rotterdam via Hull. On the same
day the "Helvetia," a sister ship to the "England" and the
" Virginia," sailed with 925 steerage passengers, chiefly foreigners,
for America. She was to call at Queenstown for her full comple-
ment; but, before arriving there, two deaths had occurred on board.
" The authorities at Cork refused her any aid, and denied her admit-
tance into the harbour.^^^ She was, therefore, obliged to return to

Many deaths occurred in the " England" and the "Pyramus," and a good many
attacks, several fatal, in the camp. The epidemic declined in about ten days ; the
last case, very slight, was on 30th April. None of the thirty-seven saloon pas-
sengers had suffered at all ; hut of the crew, two sailors, one steward, and three
firemen died. The history of the casualties among some of the inhabitants of
Halifax is of the highest interest. The first attacked were the two pilots who
brought the ship into harbour, but without ever, they declared, going on board
of her; they remained in their boat all the time till she was moored. They lived
at a fishing village about ten miles from Halifax. One (Terence) died of
secondary fever on the 19th ; the other (Purcell) recovered after several days
illness. Of Terence's family, four of the children were attacked and two died.
Three of Purcell's children sickened, one severely, the others slightly, and all re-
covered. Purcell's cottage was altogether very much better than Terence's.

No other cases occurred in the village, nor indeed anywhere else, except in a
poor family living in a miserable cottage near the beach at the southern suburbs
of Halifax. On the 22nd, one of the children, aged two, was attacked with cholera
after having had diarrhoea for nearly a week; it died next day in the City
Hospital, to which all the family were then removed. The mother was attacked
on the 25th, and died on the 30th. It is stated that a quantity of bedding had
been cast overboard from the " England," and had floated ashore near to where
the cottage stood, and that the children may have handled it.

Besides the cases now enumerated, the only other casualty was the sad death of
Dr. Slayter, the quarantine medical officer, who, after eight days of incessant
labour among the sick, was attacked and quickly succumbed. " It was no wonder,"
he said, " that, in the dreadful state of the between-decks, the disease had been so
terribly malignant in the ' England.' "

The above notes are from a valuable paper by Dr. Barrow, in the ' Army
Medical Reports,' 1866.

^ Dr. Trench indignantly protests, and most justly so, against this act of bar-
barity, " How far the selfish precautions of the ofBcials of Co«k were legal is a
question well worthy the consideration of the Central Government ; but there can
be no hesitation in arraigning them as guilty of inhumanity and of a reckless dis-
regard of the duties of charity and hospitality. Apart from the cruelty to the
passengers and crew, some weight was due to the fact that, in the neighbourhood
of Cork, there are open spaces and even islands, where the emigrants might have
been safely lodged without danger to themselves or to the inhabitants of the
town, until the ship had been cleansed, disinfected, and prepared again for sea."
In 1854, the Cork authorities had been guilty of a similar heartless act. What a

214 Original Cotnmunications, [July,

Liverpool, which she reached on the 4th. All the emigrants were
at once removed out of the sickly ship — the sick to a vessel set
apart for the purpose, and the unattacked to another vessel, or to
suitable quarters on shore. A good many cases occurred among
the latter, and several proved fatal. Altogether, forty-seven deaths
took place at Liverpool, the latest being on May 33rd. Among the
victims was the surgeon of the " Helvetia.'' The vessel, after being
thoroughly purified, again sailed with emigrants on May 29th, and
reached New York without a single casualty.

In consequence of these events at Liverpool, Spain, Sicily, Malta,
and Greece quarantined arrivals from all English ports, without
exception.

While these events were taking place in England and on board
vessels from Liverpool, the pestilence had been rapidly spreading on
the continent. In May, it was widely diffused through North
Germany from Pomerania to Ehin eland, the movements of large
masses of troops in Prussia at that time doubtless contributing to
its development and diffusion. Stettin seems to have been the seat
of the disease before Berlin was attacked ; but how or whence that
Baltic port became infected, has never, I believe, been explained.^
Had the attention of the cholera Conference, which met at Weimar
in the spring of 1867, and which consisted chiefly of delegates
from all parts of Germany, been directed to the important questions
of the topography and chronology of the manifestations of the
pestilence throughout Central Europe in 1866 much very valuable
information might certainly have been acquired.

Besides North Germany, Holland, Belgium, and some of the
northern departments of Prance were then suffering severely; and
the whole of the Italian peninsula from Brindisi to Brescia was,
speaking generally, more or less under the pestiferous cloud.
The wide- spread and destructive prevalence of the disease throughout
most of Central Europe told terribly on the Prussian, Austrian,
and Italian armies in the campaign of that summer. Nor were its
ravages confined to the theatre of war ; for, while it was in June

contrast the conduct of Halifax towards the " England" presented ! On neither
occasion, too, did Cork save herself from a visitation of the pestilence. Such a
bad example is never without mischievous results elsewhere. At Kingstown, a poor
sufferer was allowed to die in a cart in the open street, in consequence of being
refused admission into any place for relief; and at Holyhead, the whole of the
crew deserted a ship in which one of their comrades was attacked, and left him
to die without any one near him.

1 Dr. Goeden of Stettin stated at the Conference that the starting point of the
disease in that town in 1866 was in some localities about the mouth of the Oder, and
that it sprang up without any discoverable traces of importation from any infected
place. In two previous visitations of epidemic cholera, the same thing had been
observed ; but, on some other occasions, the outbreak of the disease followed on
its introduction ah extra. The earliest cases in 1866 occurred at the beginning
of June ; and, about the same time, tb.e disease appeared at one or two points on
the Pomeranian coast. Berlin was not infected for a week or two later.

1868."] Geography of Epidemic Cholera in 1866-67. 215

raging at Amiens and other places in Western France, Petersburgli
was at the very same time suffering severely. During the autumn,
it existed in several parts in Hungary, Bosnia, Albania', and Mol-
davia. A partial outbreak occurred at Constantinople, in conse-
quence, it was alleged, of importation from Salonica on the coast of
Thessaly.^

On the other side of the Atlantic, too, the scourge had, about
the beginning of summer, begun to appear in New York (the earliest
cases occurred about the beginning of May in an extremely filthy
locality of the city), notwithstanding the assiduous efforts of the
authorities to prevent its extension from the distant quarantine
station at the entrance of the harbour, and to which efforts its ex-
emption in the previous year had been ascribed. The Western and
South-western States appear to have become deeply infected before
or about midsummer; and many of the cities in the interior of the
union suffered greatly in the course of the subsequent season. But
no attempt to record the progress and course of the pestilence in
America has, as far as I am aware, been made. How far south it
penetrated in the Southern States, is unknown to me. Towards
the close of the year, it had appeared at Greytown, on the Caribbean
shores of the isthmus of Panama; and the island of St. Thomas
had become infected in November or December, if not sooner.
Beyond these simple facts, nothing more can at present be said
with confidence.

But we must leave the region of mere surmise and conjecture,
and return to our own country to trace the history of the epidemic
development in the United Kingdom, subsequently to the events at
Liverpool in April and May. "No case of contagious cholera
among the townspeople,^' remarks Dr. Trench in his admirable
report, ''apart from the emigrants, had been as yet (June 30) re-
corded. It is true that from May 28, when the ' Helvetia' finally
left our shores, no week's registry of deaths, with the exception of
the two weeks ending June 2nd and 23rd, had been without a case of
cholera ; yet, careful inquiry satisfied me either that there had been
errors in diagnosis, or that the cases were of the bilious type, and
so purely sporadic as neither to be due to contagion, nor to have
spread the virus in the families or neighbourhood of the deceased.'^

1 Sicily became the seat of a severe and long-continued outbreak in October.
It is not possible, from the want of reliable evidence, to determine whether the
disease was not in the island previous to the landing of troops from Naples, at the
end of September, at Palermo. More than one of its seaports had been quaran-
tined by other Mediterranean ports in the course of the summer ; and the extreme
rapidity with which the disease appeared, according to report, at Catamia and at
other places far distant from Palermo, after the landing of the troops which were
accused of having imported the pestilence, is not to be overlooked. Very
speedily, nearly the whole of the island seems to have become infected.

That cases had occurred in the avitumn in Rome also, there can be little doubt,
although the disease did not become epidemic there till next year.

216 Original Communications. [July,

Dr. Trench dates tlie commencement of the epidemic outbreak in
Liverpool from July 2, when the first of a large group of fatal
attacks occurred in one of the worst Irish dens, at a distance from
the foreign lodging-houses which had been the seat of disease in
the spring. Xo trace of communication or connection with these
former cases could be discovered. The epidemic lasted till nearly
the end of November, and carried off 1792 victims. The disease
" in its epidemic virulence was restricted to the lowest, dirtiest, and
most squalid streets of the borough; so much so that, although
many fatal cases occurred among respectable tradesmen and artisans,
yet these were on the whole so few as to be considered exceptional."
Dr. Trench adds that the dissemination of the disease was certainly
not due to polluted water supply. Previous to the commencement
of the outbreak in Liverpool, the epidemic had begun to manifest
itself in the metropolis, and sporadic cases had also occurred in
South Wales, in Cheshire, and West Yorkshire, and on board some
foreign vessels at Sunderland and Shields.

The earliest undoubted cases in London are supposed to have
occurred on June 26, in a labourer and his wife, at I3romley at the
extreme eastern limits of the metropolis, in a house on the banks of
the river Lea ; but, prior to that date, suspicious deaths had taken
place in diflFerent directions within the metropolitan area.^ How
and whence the morbific poison was brought, or brought itself, it is
impossible even to conjecture. The persons first attacked had not
recently arrived from, nor had had any discoverable communication
with, any infected place or individual. It was not till J uly 8th that
a death occurred at Bermondsey, in a man arrived the day before
from Rotterdam (between which place as well as Hamburg and the
port of London there had been uninterrupted communication) ; and
the earliest known fatal attack among vessels on the river was not
till July 17th, on board a barge at Deptford. " The outbreak in
the metropolis,^' remarks Mr. Eadcliff'e, " was one of a succession
of phenomena which indicated a wide-spread diffusion of cholera
infection in the kingdom during June.'''

The development and degree of prevalence of the disease in dif-
ferent districts of England, during the summer and autumn months
of 1866, present many puzzling questions to the inquirer, whether
he looks at the late epidemic merely by itself, or compares its topo-
graphical history with that of previous epidemic visitations. We
seem to be as yet quite in the dark, when we seek to account for the
erratic or migratory movements of its course. Human intercourse
alone or communication with infected places — Avhether internally

' " The mortality returns of the metropolis show that the first deaths from
Asiatic cholera in 1866, occurred at Walworth, on May 28th. On June 13th,
another such death was recorded at Newington ; on June 27th, two deaths at
Bromley."— Dr. Letheby, ' Annual Report for 1866-67.'

1868.] Geography of Epidemic Cholera in \%e>Q-^7 . 217

between different parts of England, or externally with foreign
countries — does not suffice to explain the irregular and capricious
extension or dissemination of the poison. The suburbs of London,
and the contiguous districts, were but httle affected during the pre-
valence of the cholera in the metropolis. Manchester remained
comparatively intact, \vhile Liverpool suffered so sharply. The
" black country^^ in Staffordshire, which in former visitations was one
of the chief seats of the epidemic, nearly escaped, while various
places in the coal district of South Wales were severely smitten.
Nothing was; perhaps, more remarkable than the comparative mild-
ness of the morbific agency along the whole of the eastern coast of
England, notwithstanding the great intercourse there was all the
while with the infected ports of North Germany and Holland, and
the frequent occurrence of cases of the disease in vessels arriving
therefrom. And the fact is the more notable as other parts of the
coast, apparently far less exposed to the risk of infection, suffered with
unusual severity. While the deaths from cholera, during the quarter
ending September 80th, amounted in Hull to only 12, in Sunder-
land (including Bishopwearmouth and Monkwearmouth) to 26, and
in Newcastle and Gateshead to only 8 ; the deaths in Southampton,^
in Portsea Island, and in Totness, were respectively 98, 113, and

' The history of the second outbreak in Southampton deserves special notice.
Since the cessation of the first visitation in the previous November, no case
occurred in the town or suburbs, till the middle of June, 1866. During the
spring it was reasonablj" apprehended that, in consequence of the number of
steamers arriving from infected parts on the Continent, the disease would be
introduced, especially as the emigrants were allowed to land and go about the
town. " But there is no evidence," remarks Dr. Parkes, " that any of these
vessels introduced the disease;" moreover, "no emigrant vessels leaving South-
ampton for America suffered from cholera on the voyage." The earliest reputed
fatal cases occurred in the family of a fireman in the " Poonah," one of the
Peninsular and Oriental steamers, which arrived from the Mediterranean on the
10th of June, having on the previous day lost one of the crew from cholera. The
fireman had diarrhoea on him, when he landed and went straight home. His
child, aged three, was suddenly attacked on the 13th, and died the same day.
On the morrow the man became worse, and died on the 15th. No other cases in
the house, or the immediate neighbourhood of it, occurred, although already
several suspicious attacks had taken place in other parts of the town, uncon-
nected with the " Poonah " cases. The epidemic may be said to have begun on
July 6, when one death occurred ; the next was on the 11th, and the third on
the 12th. It lasted till the second week of October. " The outbreak was con-
fined to the low and unhealthy parts of the town. . . . All the upper part of
the town, and the suburbs and surrounding villages, remained free." It was
" entirely unconnected with the drinking water."

The origin of the fatal case in the " Poonah " on June 9 remains a puzzle.
On the voyage from Alexandria and Malta (both healthy at the time), all on
board continued quite well till June 8, three days after leaving Gibraltar, where
no case of cholera had occurred for full six months ; there a supply of water was
obtained. This water was found, on examination at Southampton, to contain an
undue amount of organic matter ; but its use on board had not been confined to
the men who sickened. Altogether, this " Poonah " case is as enigmatical as the
" Theydon-bois " case of the previous year.

218 Original Communications. [July,

92. The little village of Brixham in Torbay alone had 45 deaths
from the disease, in that quarter. Again, whereas Eamsgate
suffered severely, Folkstone, Harwich, and Yarmouth (which were in
daily communication with the ports of Belgium and Holland) re-
mained all but intact. A similar remark might be made in respect
of whole counties. Devonshire was the seat of many fatal out-
breaks, while Cornwall on one side, and Dorsetshire and Wilts on
the other, were scarcely affected. And if we glance at the course of
the disease, during this summer, in Scotland and Ireland, fresh
evidence presents itself to show that there must be some occult
agency or influence affecting its development and movements, besides
the one of palpable and material transmission or communication.
" It would be a very difficult thing," remarks Dr. Stark, " to say
when cholera first appeared in Scotland in 1866. . . A few scattered
cases occurred during May and June, but it was not till towards the
close of July^ that the occurrence of the disease in Scotland was
brought under public notice. It then seemed to prevail chiefly in
the sea-port towns on the eastern coast, and from thence gradually
extended westwards and to the more interior parts of the country.
The disease seemed frequently to be carried to these other places by
persons who had fled from the towns first seized ; but, in numerous
instances, no such connection could be traced. The inhabitants of
many of the sea-port towns were often very anxious to prove that
the disease was imported ; but, in very few instances indeed, could
such importation be traced to communication with infected districts
in England or on the continent. And other parts of Scotland, to
which travellers from infected districts on the continent resorted, re-
mained free from the disease." Of 33 counties, including the
Orkney and Shetland islands, 15 only were affected. The total
number of deaths from the disease to the end of the year, reported
to the registrar-general, amounted to 915, and of this number 480
occurred in the eight principal towns as follows : —

Glasgow. Edinburgh. Dundee. Aberdeen. Paisley. Greenock. Leith. Perth.
53 134 105 62 2 14 95 15

The great mildness of the disease in Glasgow — with its very large
population and immense traffic and intercourse — as compared with

^ One of the earliest undoubted cases was a solitary one in the Perth General
Prison, which occurred in a man who had been imprisoned for eight years, and
had not been out of the building. No course whatever could be discovered: to
account "for this remarkable incident," remarks Dr, Christison, who has recorded
the case. The disease had not appeared in Perth at the time. What adds to the
interest of this event is that no other case occurred in the prison till October 28,
when a prisoner (who had been confined for nearly a twelvemonth), occupying the
same dormitory as the former patient, was attacked and died. Ten other
prisoners were in the dormitory at the time, but none of them, nor any other
inmate of the prison, suffered. The epidemic was, however, in the town at the
time. — ' Edin. Med. Journal,' May, 1867.

1868.] Geography of Epidemic Cholera in 1866-67. 219

Edinburgh and Leith, is a remarkable feature in the visitation of
1866. The stress of the epidemic was felt along the eastern coast
from Praserburgh (a fishing town in Aberdeenshire where forty-six
deaths occurred) and the shores of the Firth of Forth. The extra-
ordinarily fatal outbreak at one part of the Fifeshire coast among
some collier villages, where more than 140 out of a population of
less than 3000 died, while the towns and villages east and west of
the district remained free, is one of the most notable events in the
history of the late visitation in Scotland.

If we now pass over to Ireland we find many similar events
relating to the spread of the disease, which it is equally difficult — if,
indeed, it be possible — to explain. The information to be derived
from the Irish Registrar- General's returns is much less complete
than that which the Scottish returns aflFord. The epidemic appears
to have manifested itself first in Dublin in the last week of July.
The earliest fatal case occurred in a girl, who was attacked within a
few hours after landing from a Liverpool steamer, and died the same
night. This case was followed, during the next four days, by three
other fatal attacks among the inmates of the same room which the
first patient occupied. Thereupon, other cases began to occur in
other unwholesome localities, and soon spread in different directions.
The total deaths in Dublin and its suburbs, registered to the close
of the year, amounted to 371. Several places within a few miles
from the metropolis, and in different directions — as Swords, Cell-
bridge, Bray, &c. — suffered severely. Along the coast to the south,
no town was so heavily smitten as Arklow, where 100 deaths
occurred. Its sanitary condition is extremely bad. "The poor
people allow pigs to sleep in their cabins at night.'-* To the north,
Balbriggan suffered much, while Drogheda nearly escaped; and
Belfast, with its large population and busy intercourse, had but
comparatively few deaths. The isolated outbreaks at Mallow in
the centre of County Cork, and at Westport in county Mayo, during
the quarter ending September 30th, are noteworthy. In one part
of the town of Carlow seventy-one deaths occurred, and in Limerick
there were seventy-seven, whilst Kilkenny lost only nine, and Lon-
donderry appears to have remained scot free. A cholera map of the
epidemic visitation in 1866, upon the plan followed out by Sir D.
Corrigan in respect of that in 1849-50, would be very suggestive in
many points of view.^ It would, doubtless, show not only that the

' Sir D. Corrigan, in republishing his map in 1866, remarks, " It was naturally
to be expected that if contagion, promoted by population, free intercourse, and
the bringing of numbers together in commerce, trade and manufactures, were an
element of much power in propagating the disease, the map would show that
the greater number of towns attacked were in those parts of Ireland where trade,
manufacturers, and frequent intercourse, brought multitudes together. But the
contrary is shown by the map; for in the whole of Connaught, and a considerable
portion of Munster (its western portion), not a town escaped ; whilst in Ulster,

220 Original Communications. [July,

same areas or regions of the country were not proportionately affected
to an equal degree in the two visitations, but also that the morbific
cause was much less widely and extensively diffused, at least in viru-
lence or force, in the late epidemic than it was in 184.9. The same
holds true in respect both of England and Scotland. A good deal
may have been due, in respect of certain locahties, to sanitary im-
provements which had been effected in the interval ; but this will
obviously not suffice to explain the general mitigation and limitation
of the pestilence over the length and breadth of the land. In con-
nection with this point, the exemption of Denmark and also of Sweden
and Norway in the visitation of 1866 deserves to be noted here.

I now proceed to sketch the geographical history of the epidemic
in the following year. It is worthy of notice that, in the spring and
early summer of 1867, several severe outbreaks occurred in northern
India, more particularly at Benares, in various places in the Punjaub,
and in Peshawur, at the north-west corner of the peninsula. A
month or two later, it was reported to be raging at Teheran and other
localities in Persia, and also in Affghanistan ; while several of the
Hill stations on the Himalayas, as Murree and Subatoo, suffered
about the same time.

Neither Russia, with the exception of some districts of Poland,
nor Turkey (proper) appear to have suffered much throughout the
year. A partial outbreak at Pera on the Golden Horn, in August,
was attributed to importation from Salonica, on the coast of Thessaly.
In the early summer, not only the Danubian province of Bulgaria,
but also the provinces of Albania, of Montenegro,^ and Ilerzogovina
(the latter two provinces had been hitherto exempt, it was said),
together with the adjacent Austrian provinces of Dalmatia and of
Sclavonia, were the seats of the disease. A few cases occurred at
Trieste about the same time.

Again, throughout the year, the entire Italian peninsula, from
north to south, continued to be in many parts a hotbed of the pesti-
lence. Calabria was still severely ravaged ; and the Papal States,
if they, indeed, escaped in 1866, were now the scene of most destruc-
tive outbreaks. Notwithstanding repeated official contradictions, un-
mistakeable cases — they were designated by the Pontifical authori-
ties " diarrhoea accompanied with fever " — occurred in Eome in the
early summer ; as the season advanced, they became so much more
numerous and fatal, both in the city and the suburbs, that it was
in vain any longer to deny the existence of the disease. In August
occurred the terrible outburst at Albano, which was attended with

Leinster, and the eastern parts of Munster, where trade, manufactures, and
commerce, brought much greater numbers together, the red dots are considerable
in proportion, showing the number of towns that escaped."

1 Military cordons were drawn round the infected districts in Montenegro, and
persons who dared to cross them were shot. The horrors of famine were thus
added to those of pestilence.

1868.] Geography of Epidemic Cholera in 1866-67. 22l

such fatal effects. At the same time many places in Calabria, as
well as Catania and other districts in Sicily, were most disastrously
ravaged. I'ew provinces of the kingdom escaped. Even the island
of Sardinia became infected, it was currently believed, tow^ards the
latter part of the summer ; for, in September or October, arrivals from
that island were put in quarantine at Malta and some other of the
Mediterranean ports. Altogether, no country in Europe has been
more severely scourged, and that, too, during three successive years,
than Italy — a convincing proof, coupled with the atrocious barbari-
ties committed by an ignorant people in their insane terror, of the
physical and moral debasement that prevails in too many parts of
the southern provinces of that fair land.^

The distance from the south of Sicily to the opposite coast of Africa
is not great j and it is a curious circumstance that Tunis, which it
would seem had hitherto very remarkably escaped in 1865 (notwith-
standing the arrival of many pilgrims from Mecca via Alexandria
and Malta), and also in 1866, become infected for the first time
since 1856. in the course of the present spring. How and whence
the disease came, seems to be quite unknown. It manifested itself
first, it is believed, in the city ; it subsequently extended along the
coast, and was especially severe at Susa, south-east of Tunis. It
also spread into the interior of the country. Algeria appears to
have been suffering, in some degree, about the same time. A still
more important coincidence was the reappearance of the pestilence in
Malta (which had remained entirely free during 1866) about the be-
ginning of July, notwithstanding the utmost vigilance of the autho-
rities and the extreme rigour of the quarantine restrictions.^ The
earliest fatal cases occurred in the lazaret, in persons who had come
from Tunis and Sicily.^ A woman, who with twenty-nine other
passengers from Susa, was taken upon arrival, on June 16th, into
the lazaret, was attacked there on July 5th, and died on the 6th ;
on the 6th another woman, belonging to the same lot, was
attacked and died next day.^ On this day, 7th, the master of a vessel

1 A letter from Florence states that some official reports have been received
there respecting the horrors committed in Calabria from fear of the cholera. It
is impossible to imagine anything more frightful. Whole families have been
murdered. More than eighty persons have thus perished on suspicion of scatter-
ing poison, to which the wretched ignorance of the lower orders in south Italy
persists in attributing the cholera. — ' Times/ September 17, 1867.

2 22 May, 1867. — A quarantine of twenty-one days was imposed on all arrivals
from Tunis.

3 6 July. — The quarantine on animals from the Roman States, Naples,[Calabria,
Sicily, and Tunis, has been increased to thirty days.

* 10 July. — The lazaret being at present full, several vessels with refugees from
Tunis on arrival here have been ordered off the island. With the view of pre-
venting travellers who had passed through infected places in Italy finding their
way to Malta via Leghorn or Genoa, these ports have been included in the
category of ports subject to a quarantine of thirty days. The practice of abso-
lutely refusing admission to ships, having any case of cholera] on board, is main-
t lined with rigor.

222 Original Communications. [July,

from Trani, in Sicily, was attacked on board his vessel (which after
nine days' passage reached the quarantine harbour on June 24th),
and died on the 8th. Sharp choleraic attacks had occurred in some
of the villages around Valetta about the same time as the above cases,
but none had proved fatal. Valetta itself remained free for several
weeks; but, about the middle of August, cases began to multiply
there also. Clean bills of health continued, nevertheless, to be
issued till the first week in September ; but, before that time, Malta
had been placed under strict quarantine by most of the Mediterra-
nean ports, and, among others, by Tunis, which, it was alleged, had
become quite healthy. During a great part of the summer and early
autumn, the British squadron, under Lord C. Paget, was obliged to
remain in the harbour of Spezzia, in consequence of the rigorous
restrictions in force in Malta.

Gibraltar appears to have remained entirely exempt in 1867, as in
3866.^ Whether, or to what extent, the same can be affirmed re-
specting Spain, I am unable to say. Cadiz was declared by the
Lisbon authorities to be " suspected" of the disease in the autumn ;
and there seem to be grounds for believing that it partially existed in
the city and its vicinity at that season. Although no reliance can
be placed on the statements of the Spanish authorities in regard of
the extent or degree in which any pestilential disease may exist in
their country, there appears to be no doubt that there was little, if any,
epidemic cholera through the Iberian peninsula during 1867. The
contrast between Spain and Italy, in respect of the far greater per-
sistance and severity of the disease in the latter than in the former
kingdom throughout the present epidemic, is a noteworthy geo-
graphical fact ; and it is the more interesting as, in some former
visitations, the disease is known to have continued in Spain for two
or three years in succession.

It has been already noticed that the Austrian provinces of Scla-
vonia and Dalmatia, as well as the adjacent provinces of Turkey,
were more or less deeply infected in the summer. Warsaw, Wilna,
and other districts in Poland were, also, more or less, affected about
the same time, or a little later. In northern Germany, too, the disease
continued to manifest itself in various parts, from Breslau the capital
of Silesia, to Cologne and Elberfeld in Ehineland. Two disastrous
outbreaks in emigrant ships, which left Hamburg for New York in
October, attest its presence in the former city at that period.

^ The port of Gibraltar having been declared foul by the Madrid Board of
Health, all arrivals therefore will be refused pratique or communication until
they have first performed quarantine at Vigo or Port Mahon. The quarantine
upon Gibraltar (both by land and by sea), although the health of the Rock is
excellent, is in consequence of Gibraltar not having placed in quarantine arrivals
from Morocco, not that there has been any sickness there, but because the
Moorish authorities have not imposed sufficiently stringent restrictions on arrivals
from Tunis and Algeria.—' Times/ 27th August, 1867.

1868.] Geography of Epidemic Cholera in 3866.67. 228

The most interesting feature in the history of the epidemic in
Central Europe in 1867 was its development in Switzerland, which
had hitherto remained intact, notwithstanding the prevalence of the
pestilence all round its frontiers. In Zurich, which suffered most
from the visitation, it seems to have appeared in July. Rumour
attributed the first case to importation from Eome, by a child whose
mother had died there. At Martigny and other places in the Yalais,
where several deaths occurred in July and August, the disease was
believed to have been imported from north Italy. A few scattered
cases were observed in the cantons of Berne, Lucerne, Zug, Schwytz,
and Argovia ; most of the instances were in persons who, it was
said, had come from Zurich. Geneva seems to have remained
exempt.

As in the case of Tunis, the retardation of the epidemic visitation
in Switzerland for such a long period after the disease had reached
adjacent lands is a very curious question, and one of not easy
solution.

During 1867, the disease at no time existed with epidemic force
in France. Sporadic cases, or small detached groups of cases, oc-
curred in Paris, Marseilles, and also at Chambery, Aix les Bains, and
a few other places ; but nothing more. In our own country, too,
with the exception of an outbreak in the Channel Islands, and also
at Port Glasgow on the Clyde, at the early part of the year, the
epidemic did not reappear, although a few cases of rapidly fatal
cholera occurred in the metropolis, and also on board some vessels
sailing from the port of London, during the autumn. Similar attacks
probably occurred elsewhere.

Passing now over to the New World, we find that the pestilence,
while still continuing its hold on various and distant regions in the
United States, had found its way towards the end of 1866, or be-
ginning of 1867, so far to the south of the equator as to have
reached the mouth of the La Plata in the 35 th degree of southern
latitude. In the early part of ]867, it is known to have been pre-
valent in the city of Buenos Ayres, where it raged with great vio-
lence in the course of the spring. The disease, it appears, existed
along the coast to the northward, and subsequently extended into
the interior along the course of the river Parana to Paraguay .^ The

' By a letter from Dr. Scrivener of Bueuos Ayres, dated May 24, 1867, and
communicated to me by Dr, Archibald Smith, so well known to epidemiologists
by his valuable researches respecting yellow fever in Peru, it appears that the
cholera broke out there in the beginning of April. The disease first showed itself
in Rosario, a seaport town, sixty leagues distant from Buenos Ayres ; it then
passed to the neighbouring villages, and ultimately arrived at that city. Dr.
Smith states that, according to information from another friend just returned
from Buenos Ayres, " the reigning cholera of this year came down the river from
the camp (of the belligerents) to the city, and that its greatest havoc was not in
Buenos Ayres, but in the remote rural populations."

^24 Original Communications. [July,

town of Monte Video, on the opposite shore of the mouth of the
great La Plata, was attacked in the course of the early summer,
notwithstanding the most stringent embargo on all communication
with Buenos Ayres, — in consequence of which the commerce and
trade of both towns suffered enormous losses, and the poor classes
encountered great privations.

Whether Eio Janeiro or otlier ports of Brazil had been the seat
of the disease previously — and, if so, at what period it first appeared
there — I am unable to say. In August, the Lisbon Board of Health
declared Rio to be free from cholera ; it may, therefore, be presumed
that it had been prevailing there for some time previously.

In Nicaragua and other regions of Central America, at some parts
in the interior as well as on the Pacific and Atlantic coasts, it is
known to have been prevailing during the spring ; and, subsequently,
Honduras was reported to have become aifected towards the end of
the year. In the summer, Texas suffered severely both from cholera
and from yellow fever. New Orleans, too, was similarly afflicted.
At several places in the Southern States of the Union, along the
Mississippi and Arkansas rivers, cholera was very fatal. In the
northern States, the disease was much less frequent ; but it was not
utterly extinct.

Among the West India islands, Cuba seems to have been the
principal seat of the disease in 1867. So disastrous were its ravages
there that special allusion was made to the subject in the Queen of
Spain's speech, at the end of the year.

The island of St. Thomas also continued to sufl'cr from cholera,
in addition to the terrible calamities of earthquake and hurricanes.

And now, in closing this very imperfect sketch, I have only to add
that the epidemic has not yet become entirely extinct even in tliis
present year, 1868. It continues to prevail in the La Plata region,
kept up and aggravated, doubtless, by the war which has been going
on for a long time past in that country. Moreover, according to a
statement in the public journals about three months ago, it appears
that several cases of the disease had occurred in Eio Janeiro, and
that it still lingered in Honduras, and in the island of St. Thomas.

A rumour also prevailed about the beginning of the year that it
had broken out in Tangiers, which had previously escaped notwith-
standing its proximity to Gibraltar and Spain, and also to Algeria.
If such has been the case, it affords another instance of the curious
and perplexing vagaries in the movements of this strange pestilence,
while it serves to show more and more the urgent need there is of
an authentic record of all such events being from henceforth esta-
blished, if "we expect ever to dissipate the darkness in which so much
of its natural history is still involved.

1868.] Jago on Entacoustics, !^S5

Art. II.

Entacoustics. By James Jago, M.D. Oxon., Physician to the
Cornwall General Infirmary.

There are various sonorous movements which originate in the
ear itself or adjacent structures. An inquiry into their sources and
conditions of audibility may be called entacoustics.^

In an essay on the " Functions of the Tympanum/' which appeared
as an original article in the first two numbers of last year's ' Medico-
Chirurgical Review/ I ventured to account for the phenomena in
question, as far as they occur in the tympanum, in a peculiar manner.
It was beside my purpose to speak of such as have their seat else-
where in any other than a summary way. On these I would now
make a few further remarks, to be read as an appendix to the essay,
and to be regarded as another step in quest of a method of study
which shall deal with the whole of the phenomena under one title,
though-the entacoustical problems may not be here shown to admit
of like precise solutions as do those in entoptics.

Preliminarily, I must embrace this opportunity of enlarging a
little upon certain acoustic phenomena observable in the head or ear,
in order to more exphcitly connect them than I have yet done with
the views I have advanced. The head is made up of many different
structures, and is traversable, more or less, by sonorous vibrations
in any direction. But these progress best in the compact and most
uniform, such as bone (varying, however, in density) and cartilage,
constituting the skeleton or frame of the head, and are comparatively
subdued by passing through such soft substances as muscle, brain,
connective tissue, fat, and skin. The frame receives vibrations best
from an external solid body where it is naked, as at the teeth ; next
best where it is most thinly clad, as at the cartilaginous or bony part
of the meatus. It also imparts its own vibrations to a solid body
most readily in such parts. The transitions of vibrations between
the frame and air may be spoken of in much the same terms, with
the exception that wherever there intervenes a watery skin instead
of a dry one the interchange is obstructed. To give a few examples
to illustrate these statements : — Let a vibrating tuning-fork press
the lips against the teeth, and the sound will be heard very Aveakly
compared to that yielded when it is in contact with the teeth ; and
it is heard somcAvhat better by way of the under jaw, which carries
it close to the labyrinth by a denser medium than the zygoma or

* To group certain phenomena for the ear, as the word entoptics has long done
for the eye. And as entoptics commonly treats of phenomena contributed by the
conjunctival fluids, eyelids, and eyelashes, so entacoustics has been made to em-
brace phenomena which do not originate strictly in the ear; but it is not meant
to be applied to sounds propagated to the head from other parts of the body and
within its tissues, and which may be localised by auscultation.

83— XLli. 15

SSQ Original Communications, [July,

deeper bone that conducts it from the upper teeth. Vibrations im-
parted to the tragus are loudly audible^ their short path to the labyrinth
being through uniform cartilage and dense petrous bone ; whilst vibra-
tions imparted to the mastoid process, a spongy bone, reach the
labyrinth with much less force. In the same manner vibrations
falhng from the atmosphere upon the head and face (the membrana
tympani being excepted from consideration) would more thoroughly
penetrate to the said frame at the meatus than elsewhere ; (the thinly
covered nasal bones have no massive holdfast on the denser bones of
tlie skull) . Conversely, vibrations circulating in the frame would
more readily pass from it into the air at the auditory canal than else-
where. This would be found to be so if the radiating vibrations
were collected from equal areas of the head or face. Then, again,
the whole cylindrical wall of the meatus (an extensive superficies) is
lined Mith mere skin, and our ear placed against another person's, or
a stethoscope encircling its orifice, or a tube fitting into it, would
catch all the issuing vibrations, so that vibrations circulating in his
head would on this account also, if listened for, appear to the aus-
cultator to proceed, pm' excellence, from this source. If the tragus
be pressed over the orifice, or this be otherwise stopped, the ra-
diating vibrations will be reflected back into the canal, and will
resound in it, so as to strongly affect the tympanic membrane of the
person in whose head the vibrations circulate.

But I must remark that the vibrations thus issuing from the
meatus are not only those of the person's own laryngeal sounds, or
his guttural or oral, such as accompany the acts of swallowing or
chewing, but that none are heard better by the person (in mode men-
tioned) or auscultator than such as enter the frame from the teeth,
about its most distant point from his labyrinth and the meatus where
the auscultator listens, and more especially those that enter at the
tragus, on the distal side, with respect to the labyrinth, of the mem-
brana tympani. Hence we must not imagine that such vibrations
as originate in the fauces, or anywhere thereabouts, get to the
meatus through the tympanic air and membrana tympani, transitions
from medium to medium of widely differing densities, against the
best ascertained laws of acoustics, and particularly against my hypo-
thesis of the part played by the fluid on the lining membrane of the
drum. None of these vibrations could reach the tympanum from
the fauces without bridging through solid substance the length of
the shut Eustachian tube, whence they have a highway through
compact bone to the walls of the meatus. All of them must neces-
sarily impress themselves upon the walls of the parts where they are
generated, and these are in close proximity with the base of the skull,
wdiich is ready to conduct them to other portions of the frame. It
is because that the highway of such vibrations is the frame that they
may be used as a mrc criterion, with an intelligent patient, with

1868.] Jago on EntacousHcs, 227

respect to the condition of certain aural structures. Where they
are distinctly heard by him^ when conveyed from his teeth and the
stiff portions of the cartilaginous meatus, the acoustic nerve, and
probably the labyrinthian fluid, are healthy. If, nevertheless, he is
deaf in that ear to external sounds and to the resonance of the said
vibrations imparted to the frame in his shut meatus, the conducting
apparatus, probably the tympanic structures or cavity, are at fault.
No error can result unless there is a flaw in the conducting frame,
and this could be ascertained by testing it at different points ; though
I would advise that the ear should not be stopped by a finger, or by
anything held in the hand, for fear of confusion from the muscular
rumbling alluded to already in my paper. It may be done by a
short stick resting against a solid wall in a still place.^

But I must, in connection with the above remarks, again call
attention to the fact that I could never perceive that the various
Eustachian and tympanic ^sounds I have heretofore described are
intensified by stopping the meatus. A certain portion of the vibra-
tions that pierce the membrana tympani from a tinnitus within it
may be supposed to be emitted into the meatus, and the puff of an
air-current in the Eustachian tube must be impressed upon its walls,
and we might suppose that some of the waves thereof might find a
bony road to the parietes of the meatus ; but the waves that may be
caught in it from either source are not enough to appreciably aug-
ment the sound. We should infer from this that an auscultator must
have more than an ordinarily acute ear to detect such sounds at the
meatus of a patient. Besides, when he listens for the click (dubiously
discernible in one's own ear) of the opening of the Eustachian tube
whUst the patient swallows, he cannot fail to hear the strong click-
ing noise of the passage of saliva, or what not, through the fauces.
And when air enters or leaves the tube, the coincident smacking
or rustling sound of the consequent displacement of the tympanic
membrane is loud to the auscultator. If, however, the membrane is
perforated, or even (according to my hypothesis as to the action of
the mucus on the inner face of the drumhead) dry within, the aus-
cultator's task would be less opposed. I am not aware that any one
has pretended to have auscultated a tinnitus aurium ; yet this feat,
under certain contingencies, seems more realizable than that of dis-
cerning the Eustachian sounds, except, perhaps, the souffie,^ where

1 Much has been published of late on the various foregoing topics; but if the
reader will refer to my early aural papers cited in this Journal, he will exonerate
me from the suspicion of copying anything in these respects from recent writers ;
and their views and mine, on most points, have nothing in common.

2 Toynbee said nothing, in his book, about auscultating the Eustachian " bel-
lows-sound," but afterwards stated that he was in the habit of doing so when
inflating tlie tympanum by Politzer's method; which, however, fills the naso-
pharvngeal tract with a loud blast of that type, as it consists of hlowing forcibly
into a nostril at the instant of deglutition.

2^8 Original Coinmunications. {j^^^y

there is perforation. I am persuaded that auscultators have been
deceived by accompanying noises, in most of the cases where they
have thought that they have detected such sounds. A coarse noise,
like that of air gurgling through a drum filled with mucus or pus,
which lies in contact with the drumhead, is not harder to auscultate
than the movement of that membrane itself. I wish it to be under-
stood that it is a fact worth noting that such Eustachian and tym-
panic sounds as are audible to the ear in which they occur are yet,
unlike faucial ones, but weakly, if not quite inappreciably, com-
municable to the textures of the head.

In turning to another subject, I must remind the reader that one
of the main positions in my essay was that a series of tympanic
sounds are heard through the membrana tympani and ossicula
auditus in precisely the same way that sounds entering the meatus
are heard. Hence, since I also insisted that the membrane cannot
be made tense by any device without impairment of its functions, it
follows that this law should apply as much to entacoustical sounds
heard through it as to others. I neglected to allude to this phase,
however, though I was aware that in such cases as I founded my
reasoning upon the tympanic tinnitus might be kept in abeyance,
both by condensing and rarefying the air in the drum. I now supply
the omission, because every additional test successfully Avithstood is
a corroboration of my central hypothesis. Latterly I have noted, in
several like cases of deafness, that distending the membrane in any
way, for the time being, muffled the tinnitus.

I have drawn such weighty inferences from personal observations
that I cannot refrain from snatching at an opportunity of showing
that like ones may be made by others, especially when they come
from such a safe and acute observer as Mr. Hinton, and who, it will
appear, though usually kind to my views, is not prejudiced in their
favour in this instance. Mr. Hinton says^ — " A little instrument
has been devised by Siegler to exhaust the meatus of air while the
surgeon keeps his eye upon the membrana tympani and observes
the effect produced. It is accordingly called the pneumatic specu-
lum. Its design was to aid in determining the presence of bands of
adhesion in the tympanic cavity, by indicating any spots at which
the outward movements of the membrane might be impeded. In
this respect it has great value. The membrane may be distinctly
seen through it to move, sometimes as a whole, at others unevenly
and in parts.

" But the little instrument has seemed more useful to me, even in
diagnosis, by virtue of its power over some forms of tinnitus. That
this affection very often has its source in an excess of muscular irri-
tability and other causes, leading to an increase of pressure on the

' " An Outline of the Present Methods of Diagnosis in Aural Surgery." By
James Hinton. • Med. Times and Gaz.,' Aug. 10, 1867.

1868.] Jago on Entacoustics. 229

labyrmth, I cannot doubt ; and the more because, in a large number
of cases, slight traction on the membrane, by means of this instru-
ment, allays it for the moment.-"

In another place^ he mentions a fact as shaking his confidence
in this explanation (and which, it will be seen, is agreeable to mine),
viz. ; — " In some cases conditions which must be supposed to cause
great pressure on the stapes, such as an extreme concavity and tension
of the membrana tympani, are found without tinnitus ;" and any one
with healthy ears may satisfy himself, by blowing the breath into the
drums, that a " slight^'' increase of the normal pressure upon the laby-
rinth is not attended wdth tinnitus ; and in the absence of a state-
ment to the contrary, I presume that the tinnitus would have been
equally allayed by condensing the air in the drum, and thus stretch-
ing the membrana tympani, or by accomplishing the same end by
withdrawing some. Altogether, I look upon the fact ascertained by
Mr. Hinton as equivalent to my view, that a tinnitus aurium fre-
quently finds its way to the labyrinth through the membrana tym-
pani ; and I cannot help thinking that, had the other symptoms of
each case been detailed, I should have derived from them support of
my views about the tympanic functions in other particulars, as his
description of the constrained movements of the membrane under the
use of the speculum confirms my notion of the liability of the tym-
panic wall to the adherence of tenacious secretion, and is, in truth,
but a counterpart of other observations of his own on the changed
appearance of the membrane in cases of tympanic catarrh,^ which he
supplies as countenancing my views of the acoustic importance of the
tympanic mucus.

Then, again, there were many of the cases in which the tinnitus
was not appeased by the speculum. I indicated that constricted
vessels in the inner wall of the drum would transmit a tinnitus
immediately to the labyrinth; also Mr. Hinton remarks that en-
largement of the vessels of the labyrinth was very frequently found
on dissection to accompany " even slight inflammatory affections of
the tympanum .^^^ We may assume that a tinnitus may issue from
such vessels, without concluding, with him, that " any considerable
amount of tinnitus seldom exists without a somewhat morbidly in-
creased irritability of the auditory nerve," if this means that the
irritable nerve causes the perception of a sensation of tinnitus which
is not objectively (Avithout respect to itself) produced. If the hear-
ing remain good, notwithstanding the tinnitus, I should believe the
nerve to be healthy, and that the membrane and ossicular chain
are right, and that the peccant vessels were situated in the inner
regions just spoken of. In these cases I believe that the tinnitus
rather subsides gradually, on cure, than suddenly, though a pellicle

* ' Supplement to Toynbee,' p. 463.

* Op. cit., p. 450. ' Op. cit., p. 463.

230 Original Communications. [July^

of mucus may drop from the inner wall of the drum, causing sudden
cure.

I have expatiated so much in the essay on the phenomena of the
tympanum and Eustachian tube, that one of the chief duties that
remain to me is to pursue the subject of tinnitus more generally ;
but in the way of filling up a list of such subjective noises, I may
mention that when the attached muscles move the auricle and car-
tilaginous meatus the rubbing of the displaced structures against
one another is heard; and it may happen, when there lies in the meatus
a plug of wax, or foreign body, or polypus, that a corresponding
friction-sound from the movement of such a thing on the membrane
or sides of the meatus, when its cartilage is moved, may be heard.
Let also what I have stated about tinnitus that may happen in the
meatus be borne in mind.

I casually gave my general views on tinnitus as follows : — " Of
tinnitus as a symptom it is somewhat difficult to speak accurately.
There may be intracranial noises, and even nervous or mental.
These must be diagnosed on other principles ; but confining our
attention to the ear, we must remember that there are many arteries
about it, and that the partial narrowing of the caliber of any one
may produce a noise,^ if the same may not happen in a vein." I
would now remark that if a souffle be produced in the temporal
artery by a due pressure with the finger in front of the tragus, it
becomes much louder if the meatus be stopped ; and I dare say it
may be taken as a safe rule that, when deafness depends upon a
cause as deeply seated as the drumhead, a souffle or vascular tinnitus
from vessels lying external to this is not likely to be heard, and
where no deafness exists such a souffle or tinnitus would be aug-
mented in loudness on stopping the meatus ; whilst I may adjoin
that such a sound issuing from a point more deeply seated than the
bottom of the meatus is not likely, in any case, to be rendered
appreciably louder in this way.

But besides the continuous tinnitus (various in its tones) flowing
and ebbing with the pulse, it is a frequent thing for a deeply seated
loud puff to assail an ear as the heart beats, and this in cases where
there is freedom from deafness. It is generally of a more or less
transitory character, and may depend upon posture or sudden move-
ment of the head, or (vaso-motor) nervous excitement. I can pro-

1 Mr. Hinton says (op. cit., p. 462) of tinnitus, " Scarcely any advance has been
made since the puhlication of this volume (Toynbee's) in the empirical treatment
of this symptom, but there seems a gradual progress towards a better under-
standing of its significance. When of a beating character, and synchronous with
the pulse, it is obviously referable to vascular conditions as its exciting cause, and
among others sometimes to aneurism of the basilar artery. In some cases pressure
over the course of the carotids immediately beneath the ear temporarily arrests it."
In the • Proc. Roy. Soc.,' 1858, I assigned such noises to the circulation, " for they
rose and fell as it was quick or otherwise."

1868.] Jago on Enf acoustics. 231

duce the like at will by a forcible contraction of the abdominal
muscles, and by thus checking the course of the blood through the
descending aorta, subject the carotid to unwonted blood-pressure.
It has been thought the sound may be occasioned by the internal
carotid artery. I am persuaded that it indicates its dilatation beyond
the size of the bony ring in the temporal bone by which it enters the
cranium close to the labyrinth. Such a souffle or tinnitus, if we may
so call it, must, as tried by the tests above suggested, at any rate
arise from some arterial branch deeper than the drum, if not from
the carotid. There may be rare cases in which it might be constant
and aneurismal, or dependent upon some permanent narrowing, com-
pression, or dilatation of the vessel. The very fact of the existence
of the sound is a sign of the healthy condition of the labyrinth and
nerve.

I will now pass on to the intracranial noises to which I have
alluded. It seems to me an interesting question to inquire whether
we have any means of distinguishing noises that arise within the
cavity of the skull from such as we have above described arising
without it or in its wall.

In connection with this question we may note that all the noises
we have been discussing are heard on one ear only ; — that, though a
tuning-fork vibrating on one side of the head may be very faintly
heard on the opposite ear if its meatus be stopped, for all prac-
tical purposes, we may assert that not one of these sounds can by
any device be caught by the other ear; — and that of the ordinary
sounds that reach the organs from the circumjacent atmosphere any
one which is allowed to enter only one meatus is not transmitted
through the head so as to he heard upon the other ear also. In a
word, sounds that affect one labyrinth from without do not pene-
trate to the other. Strictly, of course, no sonorous waves can agi-
tate the liquor Cotunnii without also affecting the petrous bone, and
tending to circulate through the whole frame of the head, and thus
towards the other labyrinth ; but if any attain it in a degree that
would otherwise be appreciable, they must be so strenuous as to
produce a too stunning effect through the first ear to be realized in
the second.

Now, when we speculate whether any of the numerous vessels
which lie within the skull may project a tinnitus upon the labyrinths,
we note that many of these are placed between the two, and that the
majority of them are separated from either by structures of the same
kind, insomuch that, whether they are equidistant from them or
not, we should conjecture that a tinnitus arising therein would be
likely, if it reached either, to affect the other also. I have a curious
observation to relate which illustrates this idea, whatever variety
of opinion there may be as to the actual cause of the phenomenon.

I speak of the phenomenon vulgarly called ringing of the head,

232 Original Communications. [July,

tliat falls within everybody's experience. A patient described it to
me as an electric spark through the head^ attended with noise, causing
him to stagger for fear of falling. Where there are good hearing
and good health, it will invade the head at intervals, may be, of
months, arising without warning and swiftly subsiding. About a
year ago I was alive enough at the instant of such occurrence to mark
that the phenomenon commenced like an explosion going off close
to one ear, and ended by a prolonged ringing in the other. Since
then I have had several capital opportunities of verifying the cor-
rectness of this observation. This sort of tinnitus often frizzes off,
as it were, in contact with one labyrinth, and makes its way after-
loards to the other, affecting it less strongly, and for more instants.
At other times I have heard it hiss or buzz into one, as it were, a
little lengthened out, as if from a point appreciably distant, and yet
not attain the other until after a still more appreciable interval of
time. Again, such an interval may be less and less discernible, or
the two may be plainly attained at the same instant. Pinally, the
ringing, however seizing upon both ears, continues in both for
moments before it becomes inaudible.

Such facts indicate that the phenomenon cannot be primarily a
nervous affection, for we have no reason for supposing that a sono-
rous sensation ever passes from one nerve to the other. Nor is it
observable that the auditory nerves are exposed to be hit in their
paths to the brain by any moving body which assails them separately.
And that there should be an actual resonance within the cavity of
the skull filled up with brain, or that any bell-like ringing (in accord-
ance with the vulgar idea) in such a bony cavity, if containing
nothing but a fluid, could happen, is inconceivable ; yet the tinnitus,
explosive and transitory, has no resemblance to an arterial souffle, or
such a capillary or vascular tinnitus as invades the drum. Nor is
it aggravated by closing the meatus, not having sufficient absolute
intensity to be conveyed thither in appreciable degree from its point
of origin.

To me it seems that anatomy reveals but one apparatus in which
the phenomenon could take place, and this one adapted to all its
phases. I speak of the chain of large venous tubes and receptacles
called sinuses, which connect one petrous bone with the other, and
both with other intracranial parts, &c. It surely does no violence
to probability to assume that in such a blood-current a bubble or
cell may occasionally burst, some fibre snap, some collapsed vein
leading to a sinus be forced open, or some coherent things part.
This being granted, the explanation is palpable.

The two petrosal and the capacious lateral sinuses are actually
supported by the bone that includes the labyrinthian fluid, and the
latter, at least, freely connected with this or the drum by veins ; and
we may infer that a sonorous vibration affecting the blood within

1868.] Jago on Entacousiics. 233

them need not be violently strong in order to find some point where
it may (whether through solid bone or favoured by the course of an
aural vein) penetrate to the labyrinth. Hence should, say, an ex-
plosion take place in either of these sinuses, its sonorous waves
would traverse the Cotunnian fluid on that side immediately, but
would have to circulate all round the tentorium to play upon the
other side of the head, and would thus be heard later upon the
second ear. Such an event might even occur in the beginning part
of one of the internal jugular veins, or, may be, one of the cavernous
sinuses, and the waves have to ripple over one labyrinth in their
course through the lateral sinus, the torcular Herophili, and the re-
maining lateral sinus to the seat of the other. If it happens in
either lateral sinus there will be a difference in the times of their
reaching the two labyrinths, and that difference will be greater as it
happens further from the torcular. Whilst should the starting-
point be in the torcular, or any one of the sinuses lying in the mesian
plane of the head, the two labyrinths will be attained at the same
instant. There may be cases, too, in which the undulations may
find their way back again to the petrous bone they have already
washed, by being reflected, or by winding their way in a circulating
jjianner through one of the small sinuses that help the lateral ones
to keep open a communication between the two sides of the head.
Lastly, we may imagine that the sounds under consideration may, in
certain cases, be increased by resonance; for example, in such a
vessel as the torcular.

Hence I should say that a chief office fulfilled by the numerous
bands which give a spongy structure to the interior of the cavernous
sinus is to intercept sonorous impulses that may, by any chance, be
impressed upon its blood-current by the internal carotid artery which
traverses it, that they may be cut off from the petrosal sinuses.^ We
may conclude that if, notwithstanding, an arterial souffle should be
propagated to these sinuses, so as to affect one ear, it would also
pursue its way to the other.

I have no observation to record on the arterial bruit from an as-
signed intracranial cause ; but the anastomoses of the intracranial
arteries do not furnish a long, broad, tubular communication between
the petrous bones, as the veins do. There is the circle of Willis,
however, to which the basilar artery contributes, whilst this also
sends branches by the side of the auditory nerves to the labyrinths.
It seems too limited linearly for a sound arising in it to reach the
labyrinths in succession with a recognisable interval. A case of

' By placing a finger of one hand on a prominent enlargement of a varicose
saphena vein half way up the thigh, and a finger of the other on any one of several
large branches half way down the leg, the gentlest tap with either finger was
readily felt by the other, so freely are undulations transmitted by the blood in a
full vein without valvular breaks.

234 Original Communications. [^"^yj

aneurism of the basilar artery, said not to be infrequent, I have
never met with ; but I should take for granted that a souffle from
such a source would assail both ears at the same instant, unless the
aneurism involved the origin of one of the branches to the labyrinth.
Beyond this all I can state further is that I regard the brain as such
an indifferent medium for the conduction of sonorous vibrations that
sounds may prevail in it which never reach the labyrinths, but that,
considering the position of the main cerebral arteries, and its general
uniform consistence, I should imagine that an intracranial bruit or
tinnitus is most likely, if audible, to be audible upon both ears,
whereas a cranial or intracranial one is only audible on one.

In the everyday cases in which a throbbing is felt, as it were, all
through the head, and a beating, or, may be, a blowing sound
assaults both ears at each throb, it is palpable that the external
arteries take their full share in the fray, but it can only be guessed
that the central ones furnish their quota of noise.

In seeking to determine whether a tinnitus or other entacoustical
sound is liable to be simulated by a sensation or perception, we must
depend a good deal upon analogies. Unless it be that any of the
substances that stimulate the gustatory or olfactory nerves at their
final distributions may also come in contact with their trunks by
being carried along unchanged in the vascular circulation, the
acoustic nerve is the only special one any point of whose trunk may
directly encounter from without the peculiar stimulus of the nerve.
Yet it will have been remarked that I have always assumed that
entacoustical vibrations affect the nerve through the labyrinth — that
is, where it ends. I have nothing but analogical inferences to justify
me in supposing that they are not likely to act upon it elsewhere.
In the cases of the two other nerves above cited we have no means of
knowing what may happen through the circulation as just suggested,
because it is met by it in all its points, and they do not seem to be
excitable by mechanical stimulus, either at their expansions or in
theii* trunks. But it has been ascertained that nerves of common
sensation, though excitable by pressure or tension at any point of
their course, yet are much more sensitive at their tips than elsewhere.
Light can not only impinge upon the bacillar layer of the retina, but
also on the base of the optic nerve and such portions of its fibres as lie
without it. Hence, as it stimulates the bacillar layer only, we may
take it for granted that the trunk of the nerve is unfitted to directly
receive the stimulus of light. Similarly let us apply a mechanical
stimulus to which this nerve responds. Let us turn the eyes quickly
in their sockets. Hereupon we have two lucid circles projected by
the pinched terminal sentients surrounding the bases of the nerves,
but no other lucidities, though the nerve within the base has been
stretched, and all its fibres, as they radiate therefrom, have been as
sharply bent as the bacillar layer has been. Nor does it appear that

1868.] Jago on Entacoustics. 235

the pulsations of the artery, that runs hke an axis to the nerve, cause
sensations as of light. Thus, without entertaining the question
whether extreme violence to the optic trunk (such as its section by a
knife) may yield a flash of light, we may safely affirm that it is, at
least, difficult to excite the nerve elsewhere than at its terminal
expansion. And even here, as I have insisted in treating of entop-
tics, it is doubtful if any pressure upon the physiological eye pro-
duces lucidities but such as creases the retina towards its centre,
that is, squeezes the very distal ends of the rods and cones. Such
tension of the eyeball as is presumed to arise from excess of the
aqueous or vitreous humours does not, I am satisfied, occasion
lucidities. And when deep-seated inflammation of the eyeball is
introduced by subjective flashes of light (if they be really other than
the lucid circles just mentioned), we may well imagine that in-
flammatory products may irritate or squeeze the said distal ends,
as well as that many of these may be compressed by flexure of the
retina through uneven swelling of the ocular tissues, or by jerking,
impatient actions of the orbital muscles.

In bringing these illustrations to bear on the case of the acoustic
nerve, we note that an artery enters the internal auditory canal in
actual contact with it, running between it and the facial nerve, and
that no rhythmical sounds attend its pulsations, so that the conduct
of the acoustic nerve in this particular resembles that of the optic.
Such is the sole observation we can make on the trunk of a nerve
which is placed out of the reach of experiment ; but we can hardly
err in presuming from this observation, and the deportments of the
other nerves of sensation as above touched upon, that the acoustic
nerve is not liable to be excited by sonorous vibrations impinging
upon it elsewhere than at its terminal points, and that it is not
likely to be exposed to other meclianical pressure or tension capable
of exciting it elsewhere.

Then, as to the labyrinthian expansions of the nerves, spread out
as they are on the walls of a strong vessel, they are exempt from being
pinched by flexure of the wall, nor can the adjoined bristles,
otolithes, and Corti's fibres, be thus disturbed. Such steady pressure
as we can produce upon the liquor Cotunnii through the fenestrse
excites no sensation of sound, and I see no reason to think that a
morbid excess of that fluid would provoke any. The vascular supply
of the labyrinthian membrane and nervous expansion is very far
short of what is furnished to the retina and ocular tunics, and it has
never been shown that those structures are so obnoxious to violent
inflammations as these are. But should abnormal vascular activity
befal them, entacoustical sounds would issue from it, and would
impress themselves upon the nerve as long as it and the labyrinthian
fluid and structures remain uninjured enough for that purpose.
However, we may rest assured that the retina, in its moveable, com-

236 Original Communications. [July^

pressible, and vascular coats, must be far more liable to have its
terminal points pinched or irritated, under such circumstances, than
are those of the auditory nerve.

Again, through whatever portion of the special nervous apparatus
it occurs, very curious lucidities or inequalities of visual power
affect our visual vault just as we awake from sleep, whilst nothing
comparable to such a phenomenon happens to any other special
sense — a phenomenon dependent, possibly, upon the state of the
vascular circulation. The following experiment evinces that some-
thing like it may ensue from such a cause : — Seated in a dark room,
I firmly gripped one external carotid artery, just above the hyoid
bone, and almost immediately a strong tingling sensation ran through
the opposite arm, and marked variously-hued lucidities overspread
the visual field, though the eyes had not been rotated, whilst the
head began to feel so dizzy that I dreaded proceeding with the ex-
periment. Still, I cautiously repeated it on two* other occasions
with characteristic results. I designed it as possibly fitted to modify
the vascular circulation about the middle and internal ears enough
for me to make an observation upon a very faint tinnitus that at
that time occupied one ear, and which I imagined to spring from a
very minute vessel. The unpleasant symptoms were so prompt as
to afford little chance of modification of the current of blood in the
capillaries, nor was the tinnitus either checked or altered. There
resulted no unusual acoustic phenomenon whatever, any more than any
subjective taste or smell. Thus, as far as this experiment goes, it
would appear that when the cerebral circulation is overburdened, as
in this instance, by shutting back an extra volume of blood upon
the internal carotid, sight is the only special sense very obnoxious
to false impressions.

These remarks have regard to such subjective sounds as may
afflict us independent of disease in the acoustic nerve or brain. There
are cases on record, as to each of the special nerves, wherein it has
been apparently the seat of deceptive sensations. In nearly all of
these the proper functions of the nerve were badly performed. AssO'
ciated with such complaints have sometimes been epilepsy, or some
cerebral disease. The acoustic nerve-tract may, I by no means
gainsay, suffer in this way, though I am persuaded that disease in it
by far most commonly produces deafness unconnected with subjec-
tive sounds, and that usually the existence of much entacoustical
sounds should encourage us to hope that the nerve is still healthy,
or that they should be esteemed as a proof of its capability of hear-
ing. The cases which make me doubt the general accuracy of this
statement, are those in which tinnitus and deafness co-exist, and in
which sounds impressed upon the frame are not heard, and which
possibly may not be explicable on the supposition of disease of the
labyrinth only. I waived suggesting that some of the cases alluded

1868.]

Typhoid Fever in the West Indies. 237

to touching other special nerves may have been instances of depraved
secretion coming in contact with the ultimate distribution of the
nerve^ because it is enough that there is a fair probability that there
have been cases free from such suspicion.

In fevers, or when certain narcotic or other drugs are taken into
the system, the mind may ramble and noises in the head ensue, or,
as in the instance of taking quinine, mental stupidity and deafness.
In some such cases, through the influence of the sympathetic and
other nerves, the calibers of the arteries may become irregular, to the
development of souffles ; or the secretion of the mucus in the tym-
panum may become altered in quality or quantity, and tympanic
tumitus or deafness be lience engendered; or the damaged blood
may be less exempt than the healthy from the explosive phenomena
ascribed to the venous sinuses. So that it may be hard to divine
liow far attendant subjective sounds may thus arise. Nevertheless,
in cases like these, where the whole of the nervous structures are
pervaded by a poison, it is so probable that the auditory part of the
apparatus may be somewhere directly teased by it that, in the
absence of evidence to the contrary, it would seem well to suspect
it might be the seat of illusions of audition which might be mistaken
for entacoustical noises. In mania illusions of this sense are no more
or less mysterious than those of any other. Still, in any case what-
ever, a perception ascertained to resemble that from any known enta-
coustical cause, such as the tinnitus of vessels, should be primarily
looked upon as thus originating.

Art. III.

Typhoid Fever in the West Indies. By William H. Stone,
F.R.C.P., &c., late Secretary to the Board of Health in the
Island of Trinidad.

It is scarcely possible to find better evidence as to the im-
portance of studying the geographical distribution of disease,
than is afforded by the epidemic of which I propose to give
some details in the present paper. Typhoid fever, an old
familiar inhabitant of Europe, vs^as allowed on all hands to have
made its first decided inroad into the island of Trinidad in the
end of the year 1866. It was not merely that it then for the
first time obtained recognition. The whole course of the
symptoms and the general character of the malady were
strikingly different from what had previously prevailed ; more-
over, the unanimous diagnosis of many able practitioners
resident in the chief town, some of them recently arrived from
great medical schools in England, was fully borne out by

238 Original Communications, [July^

altered indications for treatment, and especially by novel and
unexpected results of the administration of quinine, a drug
whose peculiar and specific properties endoAv it with the
character of a nosological test, as well as that of a valuable
curative agent.

Admitting, what hardly seems possible to doubt, that typhoid
fever, since its precise segregation from kindred types and its
admission as an independent entity into the list of diseases, had
not before this date been observed in the tropical and malarious
climate of Trinidad, it becomes even more interesting to notice
what modifications it was liable to assume, and how far its
European congener was altered or complicated by the absence or
the supervention of familiar or unexpected symptoms. On this
point I hope to oifer new and trustworthy observations, which
tend to show that typhoid may be blended in several degrees
and manners with remittent fever, producing, by the mixture, a
form of febrile action seldom if ever described. Something
similar has, indeed, been put on record by Casorati, and others of
the Italian physicians, though their examples of remittent action
hardly equal in virulence what occurs on the isothermal line of
greatest heat ; and their conceptions of typhoid, if they existed,
fall far short of the precision which now attaches to the term.

It is not my present object to enter on the question of West
Indian climate, except in a cursory and subordinate manner.
My own meteorological observations, continued steadily through
the better part of a year, were founded on those long taken at
the Botanic Garden in Port of Spain, and which, by the kind-
ness of the curator, I was several times able to consult. They
are being continued by an intelligent resident, and will, I hope,
ere long form the nucleus of an independent communication.
Proof being long, I must be allowed merely to name such
points as seem pertinent to the subject in hand.

The climate of the West Indies, speaking generally, is very
different from what is commonly supposed, and still more at
variance with its old traditional reputation. Professor Parkes,
in his excellent work on hygiene, has already combated ancient
prejudices. The West Indies were indeed a pesthouse of Euro-
peans when every sanitary precaution was neglected, when a
mode of life was indulged in which could hardly fail to be inju-
rious anywhere, and when, moreover, an emigrant was sent forth
with the comforting conviction of his friends that he was com-
mitting a virtual suicide. Much of this prejudice, indeed,
persists ; for instance, in the heavy handicappings with which
insurance companies saddle their West Indian policies, although
a flourishing office in Barbadoes is doing excellent business at
the ordinary European rates. The great majority of Europeans

1868.] Typho'id Fever in the West Indies, 289

can, with ordinary care, enjoy a state of health in no Avay
inferior to what they have at home. Every now and then,
indeed, a person is met with who forms so striking an exception
to this rule as by contrast to show it in a stronger light. One
such case was under my personal observation. Mr. M — , a gen-
tleman of unexceptionable prudence in his mode of living, so
obviously and rapidly wasted and withered under a change from
New Brunswick to Trinidad, that it struck even casual ob-
servers ; at the end of a few months he was obliged to resign a
responsible and lucrative Government appointment and evacuate
the place, fairly beaten by the unsuitableness of the climate to
his constitution.

It is not to be denied that at times the heat is very great.
This is a mere truism in regard of a spot lying in 10° of north
latitude, and over which twice in each year the sun is abso-
lutely and mathematically vertical. But the amount of cold
compatible with these conditions is remarkable, and will pro-
bably be new to most readers. On the loth of February a grass
minimum thermometer, verified, like all my other instruments,
at Kew, marked 57*7° of Fahrenheit, and the shaded mini-
mum, unaffected by radiation, marked 59"6°. This is, I
believe, the lowest recorded temperature for some years, but
during the above month I several times recorded quantities not
far different. For instance, on February 3rd it was 58*7° on
the protected minimum, and, indeed, for the month the minimum
was nearly always close upon the 60th degree.

The maxima for both the days named were 89°, omitting
decimals, thus giving an extreme daily range of 32° and 31°
respectively. It is this large daily range which, in my opinion,
prevents the injurious effects of the great heat. After a noon-
tide heat of 98°, the nightly temperature of 58° or 59° feels so
cool and fresh that most persons, like myself, were waked up by
the cold, and drew their blanket closer over them. My previous
impression certainly was that a blanket would be as unknown
and useless an article on the heat equator as a pair of skates. To
one element of climate I directed very considerable attention,
from its comparative novelty, and for the fact that the instru-
ments which I used for its ascertainment were the first imported
into the colony. The element in question is the radiation
already named. But the minima were not so instructive as the
maxima. By means of Sir John Herschel's excellent ther-
mometer, the blackened bulb of which is contained in a
globular glass vessel carefully evacuated of air and sealed
hermetically, I was able to obtain the actual radiant power of
the sun, free from atmospheric influences. On the two days
cited above the midday maxima Avere respectively 147*3° and

240 Oriyinat Communications. [July,

149°. On the 18th of January it reached the enormous height
of 183-7°, and on the 16th of the same month that of 174°.
These large readings were always on hright showery days, and
fully bore out the connection stated by Professor Tyndall to exist
between the radiation and the amount of watery vapour in the
atmosphere. It is somewhat singular that the only reading of
the radiation maximum at all approaching to those given above
occurred in a far higher latitude. On the deck of the R.M.S.
Atrato, when in the harbour of Peter Island, near St. Thomas's,
the reading at noon was 179°. The stanchions and wood work
of the vessel, where uncovered by awnings, were so hot that
they could not be touched by the naked hand. I hope at some
future period to collect these latter observations, with additions
kindly promised by my friend Mr. Carr, of Port of Spain, into
a coherent series. For the present, I only offer them as out-
lines towards appreciating the " epidemic constitution" of the
locality.

Besides being hot, the Island of Trinidad is decidedly mala-
rious. Unlike most of the other windward islands, its geological
formation is tertiary, whereas Martinique, Guadaloupe, and
others, are, I understand, of volcanic character. In St. Lucia
there is an active volcano, the Souffriere. Perhaps, indeed,
Trinidad should rather be considered geographically as belong-
ing to the great delta of the Orinoko, as a detached portion of
the continent of South America, than as one of the circle of
submarine mountain peaks which rise almost equidistant at
short intervals from the Virgin Gorda group down to Grenada.
Barbadoes, also, has the character of Trinidad in this respect,
and stands even more distinctly aloof from the other Antilles.
The malarious tendency is due to several large lagoons and
marshes, by which the island is intersected. One of the largest
of these, the Caroni Savannah, lies directly to windward of
the principal town. Port of Spain. It is a marsh of great
extent, bordered towards the sea by an elevated belt of mangrove
swamp, which holds back the waters of the Caroni river, the
largest in the island. This swamp is all slightly, though de-
cidedly, above the level of high water in the Gulf of Paria, as
the inland sea is named, and as the tide rises and falls at least
four feet there is abundant room for artificial drainage. A
simple straightening of the devious river, and a few canals
through the fringing swamp, would not only open some hun-
dreds of acres of fine land to profitable cultivation, but would
materially improve the sanitary state of the capital town. It is
somewhat remarkable that this huge storehouse of miasma,
lying just up the prevailing north-easterly wind, does not render
Port of Spain as uninhabitable as Aspinwall or Cayenne ; but

1868.] Typhoid Fever in the West Indies. 24i

such seems not to be the case. It is generally accounted for b)--
those Avho have studied the subject as a result of the configura-
tion of the ground about the town itself. Port of Spain lies in
a basin of hills, which run close down to the Gulf of Paria on
the windward side. Tliese hills, on which are several old forts
dating from the Spanish occupation^ are agreed on all hands to be
deadly even to the acclimatised negro from intermittent and re-
mittent fever, whereas the towu at their leeward foot is only
moderately affected by these complaints. The vegetable poison
is supposed to be diverted by this natural screen and to expend
its force elsewhere. The opposite ridge is equally unwholesome,
a fact locally explained by the down current of the same miasm
settling out of higher regions by its natural specific gravity. It
is difficult to give an opinion as to the truth of this hypothesis ;
a town living in fair health beneath a canopy of poisonous
vapours is at least picturesque in idea, and perhaps not
more singular than some other caprices of malaria on record.
The essential points, however, with a view to the subject in
hand, ai-e the Caroni swamp to windward, the very unhealthy
circle of hills, and the less dangerous basin of alluvial land
which they enclose.

Trinidad has a distinct dry and wet season; but, contrary to the
experience of Europe, the summer is wet, the winter dry. The
wet season usually commences in April or May, the dry season
about October or November. Of course, these limits are sub-
ject to considerable variation in different years. It appeared
that the wet season of 1867 which I passed in the island was
exceptionally dry, and fears were expressed for the following
cane crop in consequence, fears which, I believe, were already
dissipated in some measure before my departure. But although
the quantity of rain falling is considerable, and the showers
sudden and torrential, I was not prepared for the amount of
fine weather which Avas experienced even in the wettest months.
Fifteen inches of rain were the largest monthly fall during my
stay, though I find record of four inches in a single day, and
even of larger quantities.' The beginning and the termination
of the rains have here as elsewhere the reputation of special
unhealthiness. I was able myself to substantiate this fact,
especially at the latter period, when nearly all my patients in
the Belmont Asylum, situated a mile out of the town, had
transient but decided attacks of ague.

The epidemic of typhoid fever does not, however, appear to
have followed any law of season. The earliest cases seem to
have been noticed at the very end of the year 1866, or in

' The largest recorded fall of rain m one day is 6"556 inches on May ISth, 1864.
83— XLii. 16

342 Original Communications. [July,

January, 1867, from which date their number slowly rose until
the character of the epidemic was recognised. On my arrival
in the month of May I found the medical profession fully aware
of the visitation, and with one notable exception acknowledging
its pathological character. At that time the public at large
had not fully taken in the fact, nor was it until the summer
months that the increasing mortality, which rose to seventy,
five in the month of June, produced a disposition to pantic
which Avas fortunately checked by a plain statement of facs.
This the good sense and hearty co-operation of all the resident
practitioners enabled me, as Secretary of the Board of Health,
to lay officially before that body.

The mortality did not immediately decline, but by the month
of September there were evidences of the epidemic wearing
out ; the usual slight recrudescences occurred ; by the end of
the year it may fairly be said to have terminated. The occur-
rence of sporadic cases since then until my departure in March,
1868, struck me as being comparatively infrequent, though on
this point I cannot speak from precise statistics. My friend
Mr. Knaggs, however, in forwarding me by the last mail
(March, 1868), a most valuable report completing the number
of 120 cases, remarks — " The above table probably includes the
whole period of the epidemic (from January 16th, 1867, to
August 28th, 1868), but cases from time to time show them-
selves in all parts of the town. I am attending one now on the
eastern side of the Savannah."

My notes contain a record of about 600 cases, of which some
60 were fatal. This can hardly be considered as representing
the whole epidemic. Unfortunately, the indolence and impro-
vidence of the negro character, even when blended with Euro-
pean elements, render it singularly unfit, among other things,
for the careful treatment of epidemics. And the absence of
any systematic poor-law medical relief for the needy classes
undoubtedly caused many cases to slip through unnoted and
untreated, especially among children and adolescents, who
seem to have suffered most heavily from this disorder.

One other point of a preliminary nature deserves mention at the
present stage, namely, the decided preponderance of cases, both
in number and severity, in the sewered part of the town. I
was in the habit of pricking down each case as it was reported
to me into a block-plan. It soon became evident that one dis-
trict exhibited an unenviable prominence in this respect, and sub-
sequent information showed this district to coincide pretty ex-
actly with a small portion of the town, about a fifth of its
whole area, to which a system of pipe-drainage has recently
been adapted. It should be admitted, however, that the local

1868.] Typhoid Fever in the West Indies. 248

configuration of the town, lying on a perfectly flat alluvial
savannah, with the only outfall into an almost tideless and
stagnant inland sea, is singularly unfavorable for such a
method of purification.

I observe since my return to England that an analysis of
some cases in this epidemic has been communicated to the
Medico-Chirurgical Society by my friend and successor in
oflice Dr. Bakewell. He did not, however, enter into the ques-
tion of climate, and thus rendered an otherwise forcible history of
his own cases somewhat obscure. This Avas, indeed, noticed in
the discussion which followed his paper, and I am, therefore,
tbe more anxious to supply the omission to the best of my
power.

In the subsequent reports of cases I shall have the advantage
of recording many different opinions from independent ob-
servers, and commenting on several lines of treatment which
were adopted by practitioners of distinct schools and nationali-
ties.

244 [July,

PART FOURTH.

(Kfironicle of iHetiical S^titntt.

(chiefly foreign and contemporary.)

REPORT ON SURGERY.
By John Chatto, M.R.C.S.E.

Amputation at the Knee-joint. — Dr. Brinton, in his paper, briugs
forward evidence and several cases with the object of securing a
further adoption of this operation than now prevails. During the
late war it was frequently practised by the American surgeons with
encouraging results. As many as 211 cases are recorded, and of
these 96 recovered, 106 died, one was still under treatment, and in
eight the result was undetermined. Of 191 cases, in which dates are
given, in 111 the operation was primary. Compared with those de-
rived from amputations of the thigh, in the same army, these results
are favourable. Of the latter there were 1597, with 568 recoveries
and 1029 deaths.

Dr. Brinton relates seven cases that came under his own care in
civil practice, and gives abstracts of 38 others operated upon by other
American surgeons, and not hitherto published. He also refers to
a great number of cases which have already been published, either at
home or abroad. Many of these are, however, so carelessly reported
as to be of no use in a statistical point of view, and the author has
drawn his conclusions only from such as exhibited exactitude. The
most important of these is that which shows that the operation has
a very marked superiority over amputation of the thigh, and is even
less fatal than that of amputation of the leg. Another advantage it
possesses over the other amputations is the favorable stump it gives
rise to, the testimony of surgeons, patients, and instrument-makers,
being nearly unanimous on this point. The following are the cir-
cumstances for which this operation is eligible: — "1. In crushed
and compound fractures of the bones of the leg, extending up to or
involving the knee. 2. In gunshot fractures of the bones of the leg,
in the vicinity of or involving the knee. 3. In gunshot wounds of
the knee-joint. 4. In gangrene of the leg, the result of injury to
the great vessels or nerves. 5. In chronic and irreparable disease of
the bones, or for tumours of the leg. 6. In degeneration and abscess
of the knee-joint." — yl«imca« Journal of the Medical Sciences,
April.

1868.]

Quarterly Repoi't on Surgery. 245

Dr. Markoe, of New York, has also published a valuable paper on
the same subject, in continuation of a former one in 1856. The present
paper relates to 51 amputations, performed either in hospital or private
practice, and these were attended with 22 deaths. He refers likewise
to four other successful cases reported to him verbally. The following
are some of the general observations which result from so multiplied an
experience. 1. It is no longer doubtful that the ancient prejudice
against the operation, and the objections to it on the ground of open-
ing so large a joint are unfoimded, at least in a degree, to be of prac-
tical importance. 2. There seems good reason to believe that the
shock to the system and the demand upon its reparative power is less
in the amputation at the knee-joint than in amputation higher up.
3. The condition of the stump during the progress to cure is more
favorable and less distressing to the patient than one made through
the thigh. 4, The bone being unwounded, it is not subject to be
troublesome and dangerous, accidents which sometimes follow the
application of the saw, and the exposure of the medullary membrane
to the air and to the foul secretions of the suppurating surface.
" These considerations, fortified by the observation of a considerable
number of cases, have led me to the conviction that the knee-joint
amputation is in itself a better and safer one for the patient than
amputation of the thigh — a view which statistics, now tolerably
extensive, fairly confirm. But if this intrinsic superiority of the ope-
ration at the knee be judged 'not proven' — if it be insisted on that
it is no better and no safer — it has, in the excellence of the stump
which it leaves, a claim for preference which I think nothing should
defeat but the ascertained fact of its being more dangerous and more
fatal than amputation through the thigh. No one who has ever seen
such a stump, and observed its performances, can have a moment's
doubt as to its very great superiority over any stump which can be
made in an amputation higher up." — Neio York 3Tedical Journal,
March.

On Lithotrity for small Calculi in very Young Children. — M. Mar-
jolin, during a discussion at the Societe de Chirurgie, observed that
he had had under his care several children, from one to four years of
age, having very small calculi ; and in such cases he believes litho-
trity to be the preferable operation. In three such cases, in which
he resorted to it, it was attended with complete success. M. Giraldes
observed that it was not surprising that such young children should
have these calculi, and even be born with them, since, as Martin, of
Jena, has shown, their kidneys are loaded with urate of soda. When
these calculi are very small, lithotrity is the operation that should
be resorted to ; but as they usually then cause little inconvenience
we have to interfere only rarely. When the calculi have attained
a diameter of three or four centimeters, and induce irritation, they
should be removed by lithotomy, which in such cases is a more rapid
and a safer operation. M. Guersant has often had cases of children
of one or two years of age, with calculi the size of a pea, which he
has crushed at a single seance. After three or four years lithotomy
is preferable. He has practised this last 104 times, with eight deaths ;

246 Chronicle of Medical Science. [July*

and in forty cases of litbotrity he has also had seven or eight deaths,
uusually from intercuri'ent diseases, contracted in the hospital. M.
Giraldes maintained that lithotrity was the more dangerous opera-
tion in children. It is long and laborious, as only small and weak
instruments can be employed, which break up the calculus into too
large fragments. The seances have to be multiplied, and, the bladder
being a peritoneal organ in children, peritonitis is easily induced,
while the neck of the organ is excessively irritated by the fragments.
By lithotomy a cure is effected in from ten to fourteen days, and
consecutive fistulge are very rare in children. In thirty-nine opera-
tions performed on children, from one to fifteen years, M. G-irald^s
has met with no instance. In fact, consecutive accidents are
exceedingly rare in children. — i' Union Med., No. 30.

On the Treatment of Anthrax. — M. Eichet, in a recent clinical
lecture, protested against the opinion of those who regarded this
disease as of a malignant nature, and either advocated its entire ex-
tirpation, or the application of the cautery. Still, there are two
forms of anthrax — the simple and that which is complicated 'with
diffuse phlegmon, this last being a very serious, although not a
" malignant" disease. So, too, there are two very opposite conditions
of the system \inder which the disease is developed, one in which the
individual is in the extenuated and exhausted state due to extreme
misery ; and the other where, surrounded by good cheer, he exhibits
an exuberance of health. This is why the Academie de Medicine
and Societe de Cbirurgie take such different views of the disease ;
for while the young surgeons of the latter body have for the most
part only seen the disease in hospitals, the members of the Academy,
in the enjoyment of large practices, have had full opportunity also
of seeing it in civil life.

M. Eichet disapproves of the practices which he designates as
"ferocious," consisting in the ablation of the tumour, or cauterising
it. As to the employment of iodine or the perchloride, it is a detest-
able practice, giving a varnish to the surface, which prevents the
issue of the purulent matters. The subcutaneous incisions advocated
by M. Guerin are ineffective, while M. Velpeau's were needlessly en-
larged. M. Nekton's practice of cleaving the tumour into six or
seven segments, separated like the petals of a tulip, is a much better
one. As long as the anthrax is simple and confined to the skin, M.
Eochet does not interfere ; but as soon as the subcutaneous cellular
tissue is invaded, he incises like N^laton, taking care to cut through
this tissue to the muscles, which should be felt by introducing the
end of the finger between the lips of the incision. Sometimes a true
haemorrhage follows; but gentle compression, made by a pledget of
charpie introduced into the wound, arrests the bleeding in a few
minutes. Afterwards cataplasms and simple baths are ordered. The
general treatment is very important : for the enfeebled and wretched
wine and bark are indicated ; while in the robust a venesection and
a purgative, and perhaps an emetic, are called for. — i' Union Mid.,
No. 38 ; and Gaz. des Hop., No. 41.

G-onorrhceal Hheumatism affecting the Hip-joint, — In an interest-

1868.] Quarterly Report on Surgery. 247

ing case of gouorrhceal rheumatism, M. Eicbet dwelt upon tlie
diagnostic marks of the hip-joint implication. The pain affected the
whole limb, and the knee was exquisitely tender, but M. Richet
pointed out as signs of coxalgia being especially present, the fact
that the patient could not raise the limb, which remained in a state
of forced rotation outwards, the leg being slightly flexed on the
thigh. Then the hollow of the groin was effaced, pressure there was
very painful, and the pulsations of the vessels, raised by a notable
amount of tumefaction, were superficial. This symptom, he observed,
although not mentioned by authors, is of the highest importance.
It is here that exploration in diseases of this joint should be carried
on, for in the region of Scarpa's triangle in the hollow of the groin,
the joint is only separated from the skin by a thin muscular layer, a
layer of subcutaneous cellular tissue, and the femoral vessels. The
remaining soft parts surrounding the joint are also tumified ; and
such tumefaction can best be ascertained between the ischium and
great trochanter in the notch which lodges the great sciatic nerve.
This point and the inguinal hollow ai'e the two regions where the
articulation is most superficial. What was the cause of the tume-
faction observed ? It could not arise from effusion into the joint,
distending the capsule and the soft parts, for this fibrous capsule
offers a considerable resistance, and is not easily distended. The
tumefaction was due to the inflammatory congestion of the tissues
surrounding the joint, a congestion which explains the elevation of
the inguinal hollow, and of the furrow separating the ischium from
the trochanter. Such tumefaction would have sufficed for the diag-
nosis, even without the pain produced during the movements of
the joint, especially on rotation outwards and abduction. The limb
was measured, and neither elongation or shortening was detected.
M. Richet has never in such cases met with elongation due to a
propulsion of the head of the femur by fluid effused into the joint." —
i' Jlnion Medicale, No. 53.

On Forcible Compression of the Knee in JECygroma and Hydrar-
throsis.— Professor Volkmann for the last ten years has employed
compression in the treatment of hygroma of the patella and chronic
effusion into the knee-joint, and has found it of advantage in propor-
tion to the amount of pressure he made. Professor Billroth has
also for some years adopted the same procedure, with a like bene-
ficial result. This procedure is the same whether the bursa patella
or the knee-joint is concerned. A splint from three quarters to one
foot in length, made of very smooth wood, and filled with padding is
placed in the ham in order to protect the popliteal vessels from tho
pressure about to be exerted on the rest of the joint. This splint
is bent at its middle, and therefore corresponds to the bend of the
knee, to such an extent as to allow of the leg resting on the splint
in a condition of moderate flexion in place of complete extension. The
patient is much more sensitive to the compression when this is made
upon the limb in a state of complete extension. The splint must be
very carefully adjusted, the angle in the ham being so rounded oft"
that the longitudinal portion forms a part of a very large circle.

248 Chronicle of Medical Science. \^^^Y)

The pad, too, must be so arranged as to prevent all pressure against
the bare splint. This done the whole joint is enveloped as far as the
splint extends, in a flannel or strong cotton bandage, every turn of
the roller being applied with increased force. The bandage is re-
applied every second day. The application causes a good deal of
pain, and the first, if not the second night, is usually sleepless. The
foot becomes swollen and cyanotic, and the patient complains of
formication and is much discontented. The arteries of the foot,
however, continue to pulsate, although often very feebly, and the
inconveniences gradually diminish. How far we may venture to
carry this obstruction and compression is a matter of personal expe-
rience, and at first most persons will be induced to loosen the
bandage for fear of gangrene. But they will soon learn that unin-
flamed parts can bear an immense amount of pressure without any
harm resulting.

As regards the results of his own experience, Professor Volkmann
pronounces this means to be an almost unfailing and quickly operat-
ing remedy in simple chronic eff'usion into the bursa patellae —
housemaid's knee, that used to be when housemaids knelt. By
simple hygroma he means where there is no thickening of the walls
of the bursa, and when it does not contain free bodies. And this
simple form is by far the commonest. Of fifty-eight cases of prepa-
tellar or infrapatellar hygromata that he has treated in all but one
the efiusion was absorbed in from four to seven days, and in the
smaller swellings, only two days were required. In no case has
relapse occurred, which may be due to slight adhesive inflammation
being induced by the compression. In all cases the author con-
tinues the forcible compression for at least two days after the total
disappearance of the fluid, and orders a roller to be applied for
some time after recovery.

The treatment lias not been so completely successful in chronic
efi"usion into the joints, the fluid often not completely disappearing,
or returning again. kStill it is the most eflicacious means we possess,
except the injection of iodine, which may liave to be resorted to in
obstinate cases. In some cases, however, it is attended with a remark-
ably rapid absorption, and even when it is insufficient alone, it is an
excellent adjunct to simple puncture or the injection of iodine. —
Berlin Klin. Woch., No. 15.

On the Treatment of Bupture of the Lig amentum Patellce. — M.
Sistach of the French army, has founded an elaborate and useful
essay on two cases of this accident, which came under his care, and
the following are some of the conclusions he arrives at : — 1. The
efiicacy of the inclined plane employed to the exclusion of all other
means in these two cases, complicated the one with a transverse
fracture of the patella, and the other with a complete detachment of
a bony lamella of the tibia, seems to demonstrate the inutility
of the various bandages and apparatus usually employed 2.
The mode of reparation after these accidents is by a true
regeneration of tendon which takes place by the same succes-
sive transformations witnessed after subcutaneous sections. 3. A

1868.]

Report on Surgery. 249

good position of the limb, and its immobility continued until such
regeneration is completed are necessary conditions. 4. During the
first days after the accident, the gradual diminution of the tumefaction
allows of a nearer approach of the ligament to the crest of the tibia,
and even when all inflammation has gone, and the patella has
resumed its normal position, no apparatus exerts any effect on the
retraction of the ligament, while it may keep up or reproduce inflam-
matory action or induce atrophy of the limb. 5. The duration of the
treatment entirely depends upon the amount of consolidation of the
tendinous blastema ; and any premature movements of the limb may
lead to defective formation, elongation, or abnormal adhesions of the
ligaments, and may be followed by loss of power of the limb. 6.
In transverse fractures of the patella the diminution of the articular
tumefaction also primarily induces the progressive approximation of
the fragments. At a later period, the fractured surfaces are brought
into immediate contact under the influence of retraction, probably
produced by the surrounding fibrous tissues. 7. The plan of treat-
ment now indicated obviates most of the causes to which the stiff"-
ness of the joint after this accident is attributable. 8. The regular
and exact consolidation of the fracture in one of these cases, confirms
the success attained by Professor Jarjavy in treating fracture of the
patella by position, unaided by any bandage. — April, Recueil de
Mem. de^3IM. Mil.

SUMMART.

Air Passages. — Bourdillot. Foreign Bodies in the Air Passages.
(Gaz. Med., No. 15. Tabular view of 300 published cases.) ,

Anchylosis. — Gross. Osseous Anchylosis of the Knee treated by
Subcutaneous Intra-Articular Drilling and Disruption. (Amer.
Journ. Med. Sci., April.) Details four successful cases, and refers
to twenty-six other cases, four of which proved fatal.

Aneurysm. — Gosselin. Case of Diflrused Aneurysm. (L'tJnion
Med., No. 43. Prom spontaneous rupture of an atheromatous
popliteal artery in a patient set. G8. Digital compression seemed to
have efiected a cure when the patient died from exhaustion. An
interesting autopsy.) — Demarquay. Cirsoid Arterial Tumour.
(Gaz. des Hop., Nos. 30 and 32. Perchloride of iron successfully
employed after preliminary ligature of the radial and ulnar.) —
Gueniot. Case of Cirsoid Arterial Tumour successfully removed by
Ablation (Ibid., No. 39.)

Bone. — Eauvier. Description and Definition of Osteitis, Caries,
and Tubercle of Bone. (Arch, de Physiologic, No. 1.)

Broncliocele. — Delore. Goitre Suffocant. (Bull, de Therap., No.
5. Calls attention to a form of goitre described by Bonnet, which,
though small, impedes respiration by being moveable, and passing
behind the sternal depression during inspiration. A figure given of
the instrument employed for transfixing the tumour before caute-
rizing it.)

Carotid Artery. — Pilz. Ligature of the Common Carotid.
(Langenbecli's Archiv. f. Chir., b. ix, h, 2. A colossal paper, refer-
ring to and tabulating 586 published cases.)

250 Chronicle of Medical Science. [July,

Dislocation. — Schiuzingei'. Cases of Disloeatiou. (Prag. Viertelj,
b. i. States that his plan of reducing dislocation of the humerus by
forced rotation outwards has received much additional sanction from
his own experience, and that of several distinguished surgeons.) —
Demarquay. Case of Dislocation of the Sternum, (L'Union Med.,
No. 47. Displacement of the first on the second portion of the
sternum through a thrust from the pole of a carriage. Eeduction
and treatment accomplished by posture alone.) — Huguier. Luxa-
tion of the Foot forwards. (Arch. Gen., May).

Sar. — Schwartze. Artificial Perforation of the Membrana Tym-
pani. (Arch. f. Ohren., 1867, No. 4.) — Bonnafont. Case of Exos-
tosis obstructing the Meatus. (L'Union Med., No. 64). — G-ruber.
Eare Form of Separation of the Membrana Tympani. (Allg. Wien.
Med. Zeit., Nos. 15, 16, and 18.)

Enceplialocele. — Eipoli. Congenital Encephalocele. (Bull, de
Th^rap., No. 7.)

Eoccision. — Bergmann. Cases of Excision of the Upper Jaw,
followed by Plastic Operations. (Petersb. Med. Zeit., 1867, No.
8.) — Konig. Excision of the Knee. (Langenbeck's Archiv., b. ix, h. 2.
Considers the relative advantages of amputation and excision after
gunshot injury.)

Exostosis. — Sistach. The Nature of Subungual Exostosis. (Gaz.
M^d., No. 15 )

Eye. — Berlin. Foreign Bodies in the Vitreous Humour. (Arch,
f. Opht., b. xiii, a. 2.) — Bergmann. Extraction with the Capsule.
(Ibid.) — Classen. Inflammation of the Cornea. (Ibid.) — Von
Graefe. Eemoval of the Lens in Modified Linear Extraction.
(Ibid.) — Knapp. Eeport on a Second Hundred of Cases of Linear
Extraction. (Ibid., b. xiv., a. 1.): — Wecker. Parallel and Criticism of
Operations for Cataract. (Annales d'Ocul., March.) — Cohn.
Injuries to the Eye among Metal-workers. (Berlin Klin. "Woch.,
No. 8.) — Fano. Case of Living Filaria in the Vitreous Humour.
(Gaz. Heb., No. 13.)— Wecker. Emboli of the Vessels of the
Eetina and Optic Nerve. (Gaz. Heb., No. 19.) Von Hasner. On
the Construction of a New Artificial Eye. (Prag. Viertel, b. 2,
with "Woodcut.)

Fistula in Ano. — Borelli. New Method of Operating in Fistula
Ani, when situated high up. (Gaz. Med. di Torino, No. 17.)

Fracture. — Burlingham. Compound Fracture of the Sacrum.
(Amer. Journ. Med. Sci., April. Urine was discharged tlirough the
wound. Recovery). — Champenois. Diagnosis of Fractures at the
Upper End of the Radius. (Recueil de Med. Mil., March.)— Volk-
mann. On the loss of Pronation and Supination after Fracture of
the Forearm. (Berlin. Klin. Woch., No. 18.)

Hcemorrhage. — Horteloup. Treatment of Haemorrhage of the
Hand. (Gaz. Hebd., No. 13.)

Hare-lip. — Broca. Application of Osseous Suture in double Hare-
lip complicated with projection of the Intermaxillary Bone. (Bull,
de Therap., No. 10, and Gaz. des Hop., Nos. 53 and 54.) — Sedillot.
On the same subject. (Gaz. des Hop., No. 56.)

1868.] Report on Surgertj. .251

Hernia. — Marie. Case of Obturator Hernia easily reduced.
(L' Union Med., No. 59.) — "Wimmer. Strangulated Hernia in
Children. (Ploss, Zeit. f. Med., No. 2. Analysis of forty-eight
cases, chiefly Gi-erman, already published.) — Doutrelpont. Operation
for Hernia without opening the Sac. (Langenbeck's Arch., b. ix,
h. 2. Has met with twelve cases, all but one recovering. G-ives
the history of the operation without mention of the name of the
Luke.)

Hospital Gangrene. — Lewandowsky. On Hospital Grangrene.
(Deutsche Klin., Nos. 14 and 15. Gives an account of an outbreak
in one of the Prussian Military Hospitals. There occurred thirty-
seven cases among 400 soldiers, and all recovered.)

Joints. — Yolkmann. Treatment of Diseases of the Joints by the
aid of Weights. (Berlin Klin. Woch., Nos. 6, 7, and 8. The author
confirms, by additional experience, the accounts of the good results
from this procedure which he formerly published. Its effects in the
relief of pain, and contraction of muscles are very remarkable ; and
it also prevents the ulcerative process which results from prolonged
contact of diseased surfaces.) — Charcot. Arthropathies dependent
on Lesions of the Brain and Spinal Cord. (Journ. de Physiologic,
Nos. 1 and 2.)

Laryngoscope. — Turck. Laryngoscopic Communications. (Allg.
Wien. Med. Zeit., Nos. 1, 3, 4, and 5, with woodcuts. Published
not long before his lamented death.) — Hohl. A new Laryngoscope.
(Deutsche Klin., No. 1, with woodcuts.) — Tobold. Pixation of the
Epiglottis. (Ibid., No. 3.) — Schrotter. Contributions to Laryn-
goscopic Surgery. (Med. Jahr. d. Wien. G-es., No. 1.) — Foumie.
Case of Polypi of the Larynx and Trachea, and Tumour of Pharynx.
(Gaz. des Hop., No. 56.) — Eossbach. Constriction of the Larynx
from Adhesion relieved by Operation. (Langenbeck's Arch., b. ix,
h. 2, with illustrations. States that there are only twelve other
cases on record.)

Ovariotomy. — Dittel. Caseof Successful Ovariotomy. (Allg. Wien.
Med. Zeit., Nos. 4 and 7.) — Gusserow. Two Cases. (Berlin Klin.
Woch., Nos. 12 and 13. One fatal, with autopsy.) — Simon. Two
Cases; (Deutsche Klin., Nos. 1 and 3. One recovered. In the
other the operation not completed on. account of adhesions, and at
the autopsy the case was found to be one of enormous hydro-ne-
phrosis.) — Stilling. Three Cases. (Ibid., Nos. 3, 4, 7, and 11. Two
fatal.)— Koeberl^. Nine Cases. (Gaz. des H6p., Nos. 29, 33, 38,
47, 58, 63, 66, and 67. Pour fatal.)— Scharlau. Two Cases at
Stettin. (Monats. f. G-eburt, Feb. One fatal.) — Maslowsky. Case
of Double Ovariotomy with Recovery . (Langenbeck's Arch., b. ix,
h. 2. Illustrations of the new instruments employed. He gives an
historical account of the operation in Kussia.)

Penis. — Saurel. — Treatment of Phymosis by Dilatation. (G-az.
des Hop., No. 31. Woodcut of the dilating forceps employed.) —
Bourguet. New Mode of Amputation of the Penis, with prevention o f
Atresia. (Bull, de Therap., No. 8, and Gaz. Hebd., No. 15.)

Profhesis. — Hermann. Mechanism of Progression with Artificial

252 Chronicle of Medical Science. [July*

Legs. fPrag. Viertcl, B. 2. Description of a new artificial leg, with
numerous woodcuts.)

Syphilis. — Sigmund. Report on the Syphilitic "Wards of the
Vienna Hospital. (Deutsche Klin., Nos. 1, 5, and 6. He insists
that syphilis is much on the increase, and that it is very urgent that
good syphilitic clinics should be established in all medical schools.)
— Sigmund. Primary Syphilis of the Mouth and Lips. (Wien. Med.
Woch., Nos. 9 and 19. Sigmund says that cases of this description
are increasing in number. During seven years he has met with
seventy-three examples among 5551 syphilitic patients.) — Despres.
Phagedsenic Chancre of the Anus and Eectum. (Arch. Gen.,
April. An interesting essay founded on seven cases at the
Lourcine.)

Tracheotomy. — Hasse. Twenty-six Cases of Tracheotomy in
Diphtheria. (Berlin Klin. Woch., Nos. 1 and 5.)

Tumours. — Forget. On Odontoma, or Dental Tumours. (L'TJnion
Med., Nos. 50 and 60.) — Richet. Diagnosis of Tumour of the
Groin. (Ibid., No. 30.)

Urinary Organs. — Liegois. Case of Urethral Calculus. (Gaz. des
Hop., No. 37.) — Leudesdorf. On a new Lithotome. (Langenbeck's
Arch., b. ix, h. 2.)

REPORT ON MIDWIFERY

By Robert Baenes, M.D. Lond., F.R.C.P.,

Lecture)' on Midwifery &c., St. Thomas's Hospital; Examiner in Midwifery to the Royal College of

Surgeons,

I. PfiEaNANCT.

1. A Fallopian Gestation cured hy Ptmcture. By Dr. Edouaed

Mabtix.

2. A Case of Tuho-uierine Gestation. By Dr. Poppel.

3. A Case of Abdo7ninnl Gestation. By Dr. Dbeessen,

4. On the Becognition of the Seat of the Placenta before Labour. By
Dr. Peeiefer.

5. On the Etiology of the Normal Position of the Foetus. By Dr.
Coiinstein.

6. A Case of Diphtheria of the Mucous Membrane of the Bladder and
consequent Discharge of a Portion of the Mucous Membrane ;
Retroversion of Gravid Womb. By Dr. Haussmann.

1. A woman, set. 29, pregnant for the first time in January, 1867.
On the 25th of February, after exerting herself in moving furniture
she felt a sudden acute pain in the abdomen ; a choking sensation
and vomiting set in, with straining at stool and urine. The vagina
was narrowed, the uterus anteflexed, the body enlarged, the os hard
to reach in the hollow of the sacrum. Some days later along with
considerable haemorrhage a piece of decidua came away, and there
was felt a small circumscribed swelling behind the abdominal wall
projecting over the left horizontal branch of the pubes. The bleeding

1868.]

Report on Midwifery . 353

returned profusely on the 16tli of March, a fresh attack of paiu having
preceded. On examining now there was decided latero-version of the
uterus, the fundus being pushed to the right, the os to the left. In
the left side of the pelvis a spindle-shaped swelling was felt through
the vaginal wall, and the same swelling was distinguished through
the abdominal wall externally. Moving it caused acute pain. These
symptoms and the decided growth of the swelling, led to the con-
clusions that it was an extra-uterine gestation, and that the further
development ought to be arrested. Dr. Martin punctured the
swelling with a fine trocar. A few drops of watery blood followed.
Eight days later it was ascertained that the swelling had not in-
creased ; but a sharp rigor set in. Some days later the tumour was
smaller, and the uterus had recovered its normal direction. On the
4th of May the patient was considered well. — Monats. f. Geb.,
February, 1868.

2, Baart de la Faille has collected twenty-three cases of this kind.
Dr. Poppel's is as follows ; a woman, aged twenty-nine, had borne
two living children. She menstruated on the 1st of May, 1867.
On the 20th of June, she fell ill with severe abdominal pains. The
uterus was found enlarged, and there was a small show of blood,
suggesting abortion. Next morning the abdomen was greatly dis-
tended, fluctuation was plain. There was acute anaemia aud deep
collapse, although the haemorrhage per vaginam had not increased.
Fifteen hours after the onset of her illness, death ensued. The
diagnosis was acute perforative peritonitis with internal haemorrhage.
Autopsy. — Much free fluid blood was found in the abdomen. The
uterus was enlarged, of irregular shape ; its right side was strongly
arched at the fundus, and exhibited on its upper and hinder surface
two irregular rents, through which portions of a placenta and of a
foetus protruded. The right tube was inserted a little higher on the
body of the uterus than the left. On opening the uterus lengthwise
two cavities were exposed. The lower one, which was the uterine
cavity proper, was clothed by a thick decidua. The upper cavity
was divided from the lower by a partition of muscular nature, but
communicating with it by a hole admitting the finger ; it contained
a. fresh dead fcetus corresponding to a development of five months.
The cavity was clothed by ovum-membranes and placenta. A corpus
luteum was found in the left ovary. It followed that there had been
a transmigration of the ovum, but whether extra or intra-uterine
could not be determined. — Ibid., February, 1868.

3. A woman, set. 35, had had three living children. Pregnant
again, abdominal gestation was diagnosed by Professor Litzmann.
She dated conception from the middle of June, 1860. Pains and
ha3morrhage occurred about the middle period of the presumed
pregnancy. The abdomen and breasts enlarged, vomiting often
attended the pains. Foetal movements were felt. She then got
better ; but in March, 1861, pains lasting a whole week, different
from labour pains, aud foetal movements recurred. These movements
grew more feeble, and ceased on the 30th of March. A sensation of

254 Chronicle of Medical Science, [July,

burning in the stomach remained, with severe vomiting of grass-
green matter. Shortly before the death of the foetus a discharge of
blood took place from the genitals, and lasted ten weeks, during two
of which it was accompanied with dark coagula, but no membranous
shreds. After four weeks, the burning sensation was lost. She was
now unable to exert herself. The circumference of the abdomen
diminished after the death of the child. Menstruation did not
return. The position of the foetus was made out by external mani-
pulation. At a later period menstruation returned. In October,

1866, the patient had been obliged to keep her bed on account of
severe abdominal pain, and menstruation ceased again. In January,

1867, she suffered from frequent mucous diarrhoea, through which
she became much emaciated. The encysted foetus was felt as a hard
knobby mass, the size of a four-year old child' s-head in the left side
of the abdomen quite immoveable. On internal examination the
entire brim of the pelvis was found filled with a fixed, hard mass.
The OS uteri was pushed over towards the right pubic bone — much
pain was caused on examination per rectum. She sank on the Ist of
February, 1867. Autopsrj. The cyst was found adherent by nume-
rous points to the omentum. The bladder bounded it and was
adherent to it in front. The uterus was not generally enlarged.
The mucous membrane looked normal. The left Fallopian tube ran
across the wall of the sac. The left ovary could not be discovered.
The right tube was found free. The right ovary was also distinct.
In the sac was found the remains of the foetus macerated. The
placenta could not be made out. The inner wall of the sac was
covered with a smooth serous membrane. At the point of connection
with the rectum there was a fistulous opening. — Ibid,, February,
1868.

4. Dr. Pfeiffer adverts to the fact that the seat of the uterine or
placental souffle may sometimes be felt by the hand, a peculiar
vibration or thrill being perceived. He then observes that under
favourable circumstances, as thin abdominal and uterine walls, by
applying the hands flat to the uterus one may find a smaller seg-
ment of a ball, as if seated on a large spheroid, and that this smaller
mass has a peculiar stretched elastic consistence differing from that
of the parts of the uterus which contain the child. This is the seat
of the placenta.

Professor E. Martin, commenting on this, said he had subjected
the proposition to repeated trial, and thought it required further
observation. — Ibid., Feb., March, 1868.

5. Dr. Cohnstein begins his memoir with a full historical sum-
mary of the theories hitherto advanced as to the causes which deter-
mine the position of the foetus in uter6. His own conclusion is that
the position is to be sought in the foetus itself, not in the active or
passive movements. It is the circulation-relations in the foetus which
until the end of the sixth mouth determine the breech-presentation,
and after this period causing the substitution of gravity of the upper
half of the trunk, cause the head presentation. This proposition

1868.] Report on Midwifery. 255

Cohnsteln illustrates by the developmental history of the foetus. —
Ihid., Feb., March, 1868.

6. Dr. Haussmanu refers to other known cases of casting off of
portions of the vesical mucous membrane, and relates the fol-
lowing : — A woman, aged 39, who had borne a child, was seized when
three to four months pregnant with retention of urine requiring
frequent use of catheter. The uterus was found retroflexed. This was
relieved. The temperature and pulse had risen. The urine was at times
alkaline, and showed cells of epithelium falling into decomposition, and
vibriones. There was at times extreme pressure to void the bladder,
which the patient could not satisfy. She several times passed the
catheter herself. She recovered. A substance which at one time
seemed to have choked the eyes of the catheter was passed, some
blood following. This substance corresponded in size to about the
fourth part of the area of the bladder. It had several small holes, most
probably artificially produced, but one of which possibly answered
to the opening of a ureter. One surface was tolerably smooth,
the other surface showed numerous beam-like processes, which pene-
trated the entire membrane. It consisted of fibre and elastic fibres,
many epithelial cells exactly like those of the bladder.— iitW., Feb.,
March, 1868.

The following contributions are referred to by the title only, on
account of want of space :

A Case of Retroflexion of the Gravid Uterus. — Spontaneous Jtecii/i'
cation. By Dr. Behm. — Monats.f. Gel., April, 1868.

On the Mechanism of the Obstetric Forceps. By Dr. Dietebich.
^lUd.

II. Labofe.

1. Spondylolisthesis in consequence of Lumbosacral Caries. By
Dr. Blasius.

2. On Osteomalacia. By Dr. Casati.

3. Pelvic Deformities affecting Labour. By Dr. Casati.

4. Obstetric Operations. By Dr. Casati. Forceps, Craniotomy
Cephalotripsy, Csesarian Section, Induction of Labour.

5. On the Symptomatology of Incomplete Bupture of the Uterus.
By Dr. C. Heckee.

1. Dr. Blasius describes the pelvis and lumbar vertebrae taken
from the body of an insane patient. It was not known whether she
had ever borne a child. She died at forty-nine, of phthisis. The pelvis
was well formed, but the bones were porous and very fragile. The
union of the basis of the sacrum with the last lumbar vertebra had
undergone considerable destruction through caries ; the upper ante-
rior angle of the first false vertebra was completely destroyed, and
in its place was a rough sloping surface. The last lumbar 'vertebra
was in great part destroyed, and had slipped forward on the altered
base of the sacrum so as to hang as a projection in the pelvic cavity.
A year before death the patient had suffered from sacro-coxalgia,
which was followed by psoas abcess; abscesses also appeared

256 Chronicle of Medical Science. [July*

in the vagina ; and Dr. Koppe, examining during life, had felt &n
easily readied prominence in the vagina, which he took to be the
lumbar vertebra slipped down. — Ibid., April, 1868.

(This case seems a clear proof that spondylolisthesis is not
always of congenital origin. The history of the disease a year before
death explains the deformity ; and congenital or even infantile
anchylosis of the sacral joints invariably induces characteristic pelvic
distortions and modifications of development. — E. B.)

2. In the report of the Milan lying-in hospital, for 1866, under
the direction of Professor Lazzati, is an interesting case of osteo-
malacia. This disease appears to be unusually rife in the neighbour-
hood of Milan, and is attributed to extreme indigence and bad
sanitary conditions. A woman, set. 34, had three natural labours,
but had begun to suffer some pains in the pelvic bones in her first
pregnancy. These had seriously increased in her fourth pregnancy,
and the pelvis was then deformed. Labour set in prematurely, and
was ended by turning. The osteomalacia was suspended after deli-
very. Again pregnant three years later, the disease returned ; and
again labour came on fortunately at seven months, and ended easily.
When pregnant for the seventh time, the pelvic pains and the
distortion returned in an aggravated form, the whole skeleton
being involved ; so that the circulator)' and respiratory organs were
seriously impeded. There was intense dyspucea, cough, difficulty of
speech, the slightest movements caused excruciating pains, the face
became cyanotic and livid, threatening suffocation. Although she
was hardly six months gone, Professor Lazzati, moved more by the
general condition than the pelvic deformity, punctured the membranes.
Uterine action set in immediately, and the thoracic distress seemed
aggravated by the effort of labour. A live child was born in thirty-
eight hours. The patient died twenty-seven hours after delivery.
The thorax was much compressed ; the sternum projecting forwards,
assumed the shape of a keel ; there was passive congestion, and oedema
of the lungs, concentric hypertrophy of the heart. The spinal column
was distorted. The pelvis was triangular at the brim, and extremely
contracted. As proof of the brittleness of the bones, there was a
fracture of the right femur, caused by moving the patient in bed.

Dr. Casati points to the purely obstetric aspect from which osteo-
malacia is commonly regarded, and dwells upon the effects of this
disease upon other parts of the skeleton besides the pelvis. —
Annali TJniversali di Med. Milano, 1867,

3. During 1866, out of 478 women, 47 exhibited pelvic deformities.
These are divided into three degrees. In the first degree the conju-
gate diameter of the brim measured from 3'3 in. to 29 in. This
was always determined by the finger, and compared with external
measurements with Baudelocque's compas d'epaisseur. The external
conjugate almost always corresponded with tiie internal measure-
ments taken with the fingers. In the women belonging to this series
labour was completed in some naturally, in some by instruments, in
some by induction of labour.

1868.] Report on Midwifery. 257

The defects of the second degree comprised cases in which the con-
jugate was reduced to 2*8 in. to 2'3 in. Six such cases were observed.
In all labour was either instrumental or provoked.

Cases of the third degree included two only, and required Caesarian
section.

All the forty-seven cases, excepting three of osteomalacia, were due
to rickets. All remembered to have begun to walk at three, four,
five, or six years old ; that when they began to walk alone they were
seized with the disease called acute fever, which rendered them
infirm. Most had lived in damp, unhealthy places, and had been
badly fed.

It is interesting to observe under what indications and rules the
forceps is used in labour. This instrument was resorted to twelve
times in 478 labours. In nine to the head, at brim _^of the pelvis ;
in three when the head was in cavity. The blades were applied
over the temporo-parietal regions of the head, so as to seize in the
most reducible diameter, and keeping the pelvic curve directed
towards that part of the foetal head which had to be conducted under
the pubic symphysis. The instrument used is that of Professor
Lovati, preferred on account of its length, and its power of compress-
ing the head, and thus avoiding turning or craniotomy. The range
of pelvic deformity in which the forceps was used was from 2*9 in. to
3 "2 in. conjugate diameter.

Three of the children were born dead ; of the mothers, four died,
namely, three of puerperal fever, one of eclampsia.

The mode of performing craniotomy was by means of Smellie's
scissors, applied whilst the head was held in the forceps, which in-
strument afterwards served for compression and extraction ; but
sometimes, these slipping, Simpson's cranioclast was resorted to.

Cephalotripsy was performed with Depaul's instrument, being
always preceded by craniotomy,

CcEsarian section was performed twice, both times on account of
pelvic deformity of the third degree from rickets. Consecutive
haemorrhage occurred, and death the following day.

Induction of labour was performed in twenty-three cases ; and it is
remarkable, as evincing the care with which the patients are ex-
amined, that thirteen of these were primiparse. In twenty cases thfe
indication was pelvic contraction. The means employed were simple
puncture of the membranes, sponge-tents, laminaria, and the elastic
syringe. Fourteen children were born alive.

The proportion of still-born children was about eight per cent., which
exceeds that which prevails in England. — Annali Univ. di Med., 1867.

Dr. C. Hecker relates two cases of laceration of the uterus during
labour, in illustration of a proposition submitted by him that, " When
during a labour, which, perhaps, has already exhibited a suspicious
character, a quickly increasing smooth elastic swelling forms in the
anterior wall of the vagina, and which cannot be regarded as due to
prolapsus or cystocele, the existence of an incomplete rupture of the
uterus is highly probable." This is due to the collection of blood in

83— xLii. 17

258 Chronicle of Medical Science. [July,

the cellular tissue uniting tlie bladder to the cervix uteri ; an extra-
peritoneal ante-uterine hsematocele.

Case 1. — A woman was in labour with her ninth child. The mid-
wife felt no presenting part, but she perceived a peculiar swelling in
the anterior vaginal wall. In the evening a copious haemorrhage
took place. The swelling persisted after the bladder was emptied by
catheter. On passing the hand into vagina the head was felt ;
the pains were strong and regular ; the countenance calm, but the
pulse was over 120. Hecker felt a rent in the left side of the lower
segment of the uterus. Turning was readily accomplished, but the
head enlarged by hydrocephalus had to be perforated. After labour
the pulse rose to 140. Delirium set in, followed by rapid collapse,
and death thirty-six hours after labour. No autopsy.

Case 2. — A woman, in her eleventh pregnancy, had frequent
haemorrhages. The posterior lip of the os was carcinomatous. In
labour the head presented. When the waters had escaped, a smooth
elastic swelling was felt in the anterior vaginal wall. This was not
affected by emptying the bladder by catheter. The patient sat
upright, her legs hanging over the edge of the bed, and strained
forcibly with the quickly -recurring strong pains. These were attended
by haemorrhage. Her countenance was tranquil, breathing but little
hurried ; but the hands were cold, and the pulse small and 156. She
sank undelivered. The child was delivered by turning afterwards.

Autopsy. — The uterus was large and flaccid ; a large extravasation of
blood was found under the peritoneum, extending upwards to the
right kidney. An incomplete rupture of the uterus was seen proceed-
ing from the vagina. In the cellular tissue, between the bladder and
uterus, was an extravasation of blood.

Hecker insists upon the occurrence of rapid small pulse as a sign
of diagnostic value in incomplete as well as in complete rupture. —
Monats.f. Gel., April, 1868.

III. — The Puerperal State.

1. A new Case of Fatty Degeneration in a Puerperal Woman. By
Dr. C. Hecker.

2. Puerperal Diseases. By Dr. Casati.

Beferring to a previous case reported in this Journal, Dr. Hecker
relates the following : — A woman, aet. 32, had been delivered,
easily and without aid, of a mature living child, on the 13th July";
was seized, twenty-eight hours afterwards, with shortness of breath-
ing, and died suddenly. The body was well nourished. When ex-
amined, twenty-three hours after death, there was no trace of
decomposition, of oedema, or of jaundice ; but in the skin of the
abdominal wall were numerous ecchyraoses, which might raise sus-
picion that there was acute fatty degeneration. In the thoracic
cavity was a yellowish transudation in considerable quantity. The
lungs were sound, somewhat oedematous, and spotted with numerous
sub-pleural blood-extravasations. Tlie muscular structure of the
heart was fragile, showing many eccliymoses under the endocardium.

1868/| Report on Midwifery. 259

Valves sound. No embolia iu the pulmonary arteries. The liver
v/as very yellow, not shrunken, soft, and fatty. The spleen was
enlarged, rather hard, looking very fatty. The kidneys were plainly
in the second stage of parenchymatous degeneration ; the capsule
very easily moveable, parenchyma swollen, cortical substance yellow.
The uterus was well developed ; the entire mucous membrane could
be easily scraped off by the knife when its fibres were bared ; there
was a considerable blood-coagulum on the mucous membrane. In
the cervix uteri, all round it was an enormous fresh blood-infiltration
without a trace of loss of continuity.

The outer aspect of the peritoneum showed a bluish colour, which
answered to a colossal mass of extravasations in the entire mucous
membrane of the rectum. There was no blood in the canal of the
rectum. The small intestine was empty; its mucous membrane
pale, but containing in the duodenum numerous blood-effusions in
the mucous membrane. Microscopic examination showed fatty de-
generation very plainly in the heart, liver, and kidneys. The signifi-
cance of this case, Hecker thinks, lies in the fact that its anatomical
character shows an obvious transition-stage towards the peculiar acute
yellow atrophy of the liver. — Monats.f. Qeh., Feb., 1868.

The experience of the Milan lying-in hospital is not such as to
redeem the character of similar institutions in respect to the pro-
pagation of puerperal fever. Out of 478 labours there were twenty-
three cases of puerperal fever, twelve of metritis, and twenty of
" miliary fever." Thirteen ended fatally. This result is considered
favorable, and credit is taken, and certainly due, to Professor Lazzati
for the rigorous care he had exercised in isolating patients on the
first appearance of illness, and in enforcing other hygienic measures.
Owing to this care the hospital was preserved free from any epi-
demic during the first eleven months of the year. It is true that
several sporadic cases occurred during the year, and that eight ended
in death ; but before December there was no spreading. In this
month twelve cases occurred, of which five died. The rise of the
epidemic is ascribed to the admission of a case, at the end of Novem-
ber, of a patient in labour, who had to be delivered by cephalotripsy.
She was admitted iu a state of extreme prostration with tympanitis.
Labour had been in action for forty-three hours ; and a dirty-brown,
fetid liquid was discharged from the vagina. The foetus had been
dead some time. She died twenty-three hours after the operation,
with symptoms of puerperal fever. Suppurative peritonitis was
found. The influence of the zymotic or hospital miasm is seen in the
history of the diseases attending the prevalence of undoubted puerpe-
ral fever. Dr. Casati says puerperal fever represents the prototype of
all the zymotic diseases of puerperse ; that is, metritis, not permanent,
inflammatory, mostly accompanied by miliaria, essential miliary fever,
phlebitis of the lower extremities, represent simply a minor severity
of the evil, but depend upon the same zymotic cause. These affec-
tions are found to prevail simultaneously with puerperal fever. When
puerperal fever breaks out, these affections appear in the hospital.
When the fever is driven out the afltections described vanish. The

260 Chronicle of Medical Science, [July,

same treatment had similar effects. The children born of women
affected with puerperal fever, or these cognate diseases, were equally-
liable to sicken and die, or to be born dead. — Annali Universali de
Medicina, Milano, 1867.

IV. The New-boek Child.

1. On the Point of Insertion of the Umhilicus in the Different
Months of Gestation. By Dr. C. Heckee.

2. Asphyxia of a New-lorn Infant caused hy congenital Struma.
By Dr. C. Heckee.

1. Dr. C. Heclier, having measured many foetuses at different
stages of development, draws the following conclusions : — The seat
of the umbilicus is never lower than in the lower third of the space
between symphysis pubis, and the extremity of the xyphoid cartilage.
It is so low as this only in the third month. From this time we find
it gradually rise until the sixth or seventh month, from which time
there is no remarkable change, the proportion of I to 1'6 being
maintained. — Monats.f. Gel., Feb., 1868.

2. A child was born normally, and cried several times, when
suddenly, after the tying of the cord, it died in spite of energetic
restorative means. The thyroid gland was remarkably enlarged, and
flattened the trachea against the oesophagus. Its tissue was sound,
in state of pure hypertrophy. The lungs were partly emphysema-
tous.— Hid.

CHRONICLE OY PHYSIOLOGY.
By Heney Powee, F.E.C.S., M.B. Lond.,

Ophthalmic Surgeon to St. George's Hospital.

Digestion.

1. R. Heidenhain. Essays on the Saliva in the Stodien des Physio-

logische Instifuts zu Breslan. Heft iv, 1868, pp. 1-125.

2. F. BiDDEE. On the Influence of the Sympathetic on the Parotid of
the Sheep. ' Reichert's Archiv. f Anatomie,' 1867, No. 6.

3. P. AccoLAS. Essay on the Origin of the Biliary Ducts. Thesis.

Strasbourg.

The experiments of Heidenhain were chiefly made upon the sub-
maxillary glands of the dog, but also on those of the rabbit and sheep.
Nearly 120 animals were experimented upon. He considers that con-
siderable diflPerences in structure, corresponding to differences in func-
tion, may be traced between different salivary glands in the same
animal, and in the same salivary gland of different animals. The
sub-raaxillary gland '^of the rallit is more simple in structure than
citlier tliafc of the dog or of the sheep. The cells in the alveoli are
soft and ill-detined, darkly granular structures ; they possess a nucleus,

1868.]

Chronicle of Physiology. 201

and this alone becomes coloured with the carmhie solution. No differ-
ence is observable between those lining and those situated near the
centre of the alveoli. The alveoli have no proper investing membrane,
but are separated from one another by connective tissue, in the meshes
of which are a few lymph-corpuscles. All micro-chemical reactions
show that the cell protoplasm is rich in albuminous compounds ; but
no evidence can be obtained of the presence of mucus. The applica-
tions of weak acids renders the protoplasm turbid. Stronger acids, in
addition to this, cause it to shrink. Strong acetic acid occasions con-
siderable enlargement, and renders it transparent.

The submaxillary gland of the dog is a mucus gland, iu which a
continuous development of mucus-cells occurs, which break down to
form the mucus, whilst their place is supplied by others. On superfi-
cial examination, no diiference at first appears between the cells con-
tained in the alveoli and those already described as occurring in the
rabbit ; but on the application of the carmine solution the greater part
of each acinus is found to contain large transparent (not granular, as
in the rabbit) cells, which remain uncoloured, though the nucleus
becomes red ; and besides these, at one and sometimes at two spots of
the circumference of the alveoli, a semilunar or sickle-shaped mass of
darkly granular material may be seen, the presence of which was first
described by Giannuzzi. This becomes deeply coloured with carmine,
and is composed of cells in close contact with one another. The dis-
tinction between the two sets of cells is still more distinct in the cat.
The clear central cells of the alveoli of the submaxillary gland of the
dog are, for the most'part, of pear- or club- shape, possess a distinct
investing membrane, and one or two highly refractile prolongations,
which become tinted with carmine, chloride of gold, or osmic acid. In
no instance, even with the greatest care, was Heidenhain able to trace
a connection between the nucleus of the cells and these prolongations.
The contents of these cells were poor in albuminates, and consisted
almost completely of mucus ; and in this respect, as well as in their
distinct cell-wall, flattened nucleus, and caudate prolongations, formed
a marked contrast to the cells in the interior of the alveoli of the same
gland in the rabbit. Acetic acid precipitates the contents of the mucus
cells in every degree of concentration. Mineral acids, when dilute,
precipitate them, but redissolve them when concentrated. The " mar-
ginal cells" constituting the semilunar mass of Giannuzzi are ill defined,
and contain material rich in albuminous compounds, with a round
nucleus.

The submaxillary gland of the sheep presents two cell forms in its
acini, but the granular albuminous cells are relatively far more nume-
rous than the clear mucus-cells.

The submaxillary gland of man agrees with that of the dog in its
structure, and is, tlierefore, essentially a mucus gland.

M. Heidenhain next enters into the consideration of the chemistry
of that kind of saliva which is secreted under the influence of the
chorda tympani nerve. The exciting agent employed was a magneto-
electric instrument of ordinary size, rendered active by a small Groves'
element. When the nerve was irritated by this means the secretion

2C2 Chronicle of Medical Science, [J«Vi

never continues to be cliseliargotl for auy length of time, but after
diminishing can, with a short pause for recovery, be again induced
to take place with considerable activity.

The chorda-tympani saliva of the rabbit is thin and watery, decidedly
alkaline, and no reactions indicative of the presence of mucin can be
obtained from it. Its solid residue amounted to 1'239 ))er cent.

The chorda-tympani saliva of the dog contains mucin, and a very
small proportion of albuminous compounds.

In the sheep the amount of proteids, in the same saliva, is much
more considerable than in the dog, whilst the proportion of mucin is
very variable ; and these characters of the saliva in the different
animals correspond with the structure of the glands as already
mentioned.

An interesting result was obtained from the examination of this
saliva in the dog, thjit the per-centage proportion of solid constituents
diminishes with the duration and rises with the strength of the nervous
excitation, the difference being chieily noticeable in the organic con-
stituents ; hence it might be said that the latter are formed by the
gland during the period of rest, and, at the moment of excretion, are
dissolved in the fluids poured forth b}-- the blood ; and Ludwig so
explained the phenomenon ; but Heidenhain shows that the increase is
really due to the fact that the rapidity of secretion of the solid con-
stituents rises in a greater ratio than the secretion of the water, that
the nature of the solid which really augments is mucin, and that con-
sequently, instead of the diminution on protracted irritation of the
nerves being due to an exhaustion of the gland of all its stored-up
solids, it is rather due to exhaustion of the nerves, which are no longer
able to act as exciters to the glandular elements.

Heidenhain proceeds to give a full and accurate account of the mor-
phological elements of the saliva, amongst which he enumerates mucus-
cells of the acini, peculiar transparent spherical bodies of variable size,
and proper salivary corpuscles, possessing the well-known characters of
amfcboid cells. He has not found that the latter occur in greater
numbers on excitation of the sympathetic than on irritation of the
chorda t3'mpani.

After continuous excitation of the chorda-tympani remarkable
changes occur in the substance of the submaxillary gland itself. It
becomes softer, its per-centage proportion of water increases, and its
solid constituents diminish.

We have not space to follow Heidenhain closely through his experi-
ments with the sympathetic ; but some of the more important con-
clusions which he believes his experiments establish, may here be
mentioned. Instead of admitting, with Eckhard, that excitation of
the chorda tympani produces a secretion of saliva differing in kind from
that secreted when the sympathetic is irritated, ho believes that the
difference is only one of degree. The saliva in both instances becomes
more watery in proportion to the duration of the irritation, the quantity
of mucus diminishing.

Both kinds of saliva become richer in salivary corpuscles as the
irritation is continued. Both are indebted for their production to

1868.]

Chronicle of Physiology, 263

impulses which cause a greatly increased pressure of blood in the
capillaries. The chemical and morphological changes are, however,
greatest in the chorda-tympani saliva. On irritation of either nerve,
increased development of heat occurs in the gland. Certain marked
differences, however, do exist between the two kinds of saliva. That
produced by irritation of the sympathetic is more concentrated, richer
in solid constituents, than that obtained by irritation of the chorda-
tympani. The morphological elements of the sympathetic saliva only
appear for a short time after it is first excited ; they then gradually
diminish and disappear, and the quantity of saliva thus obtained is
also less, whilst it contains more mucus.

Heidenhain was at first disposed to think this was to be explained
by the action of the sympathetic on the vessels occasioning their
extreme contraction ; but this explanation is not satisfactory, since, if
the current of blood be checked, and the chorda tympani excited, an
abundant flow of blood still occurs. On the whole, he is disposed to
admit that the formation of mucus and the secretion of fluid are asso-
ciated, or simultaneously occurring processes, each of which is induced
through the action of a special class of nerve fibres. Both sets of
fibres, which for the sake of convenience may be termed respectively
mucus-forming fibres and secretory fibres, are contained alike in the
sympathetic and in the chorda tympani, but in unequal proportion.
The chorda contains very numerous, the sympathetic very few secretory
fibres, relatively, to the mucus-forming fibres. Heidenhain considers
he has positively shown that, by excitation of certain nerves, pro-
cesses and metamorphoses may be induced, which occasion lively cell
formation.

2. Bidder found that on the application of a galvanic stimulus to
the upper part of the cervical sympathetic detached from the vagus
causes an immediate increase in the flow of saliva from Steuo's duct in
the sheep. According to V. Wittich (' Virchow's Archiv.' bd. xxxvii
and xxxix), this is due to increased secretory activity of the parotid
gland, whilst Eckhard (' Henle's and Pfeuffer's Zeits.,' bd. xxix, and
Beitrage, bd. iv, heft ii, Giessin, 1867) considers it to be the result
of the expression from the gland of the store of the saliva which has
accumulated in the ducts. F. Bidder, however, is disposed to agree
with V. Wittich from the results of his experiments on sheep, since
he finds that galvanic irritation of the cervical sympathetic occasions
not only an increased flow of clear and transparent saliva from Steno's
duct, but causes a much greater quantity of blood to traverse the
gland, whilst the pressure of the blood in the veins is augmented,
and the veins themselves pulsate.

3. Accolas agrees with Morel in believing that the biliary ducts en d
in blind extremities at the surface of the acini of the liver. The
investigations of Turner, Eberth, and Kolliker, however, substantiate
Hering's view that the biliary ducts appear as an intercellular network
in the acini.

364 Chro7iicle of Medical Science. [July>

Blood Cieculation.

1. Dr. N. FuiEDEEiCH. On tlie Life History of the Blood.

(' Virchow's Archiv.,' 1868, bd., xli, p. 395.)

2. Dr. E. Metschnikow. On the Development of the Red Corpuscles

of the Blood. (' Virchow's Archiv.,' 18G8, p. 523.)

3. Theodore AiiirsER and Adolphe Lohe. Researches on the

Duration of the Circuit of the Blood during Excitation and
after Section of the Vagi, (' Henle and Meissner's Zeits. f. Rat.
Med.,' bd. xxxi, 1868, p. 33.)

4. Dr. Laknelongue. Researches on the Circulation in the Walls of

the Heart, (' Brown-Sequard's Archives de Physiologic,' 1868, vol.
i, p. 22.)

5. Felix GrtrTON. On the Arrest of the Circulation in the Carotid

Artery during Prolonged Muscular JExertion. ( ' Brown-Sequard's
Archives de Physiologic,' t. i, 1868, p. 56.)

6. M. C Legeos, Note on the Epithelium of the Bloodvessels.

(' Eobin's Journal de I'Anatomie,' No. iii, 1868.)

1. M. Friedreich observes that the occurrence of contractile move-
ments has of late years been observed in the constantly widening circle
of elementary morphological elements, so that it might almost be
regarded as a common characteristic of organic substances, yet that
the red blood corpuscles in this respect occupy a somewhat exceptional
position, since no movements have been observed to occur in them
under ordinary circumstances even by the most practised microscopists.
He then relates a case apparently of albuminuria in which the red
corpuscles discharged with the urine presented at a temp, of 12° R. =
6^^ Fahr. singular and various forms, underwent division, threw out
amoeba-like processes, after which the mass of the corpuscles travelled ;
and which movements persisted for no less than fourteen hours after
withdrawal from the body. Preyer ('Virchow's Archiv.,' Bd, xxx,
1864, p. 426), Rollet (' Sitz. d. k. Akad. zu Wien,' 1864), Beale
(' Trans, of the Micro. Soc.,' xii, 1864, p. 36) had all observed similar
phenomena: Preyer with a moist chamber, Rollet with electrical
currents, and Beale with a temperature of 100° Fahr. Kolliker and
Kneutinger had seen similar effects on the application of a solution
(8 — 11 per cent.) of urea to blood corpuscles, and to the presence of
this substance Friedreich is inclined to attribute the movements he
observed. He noticed remarkable deviations from their usual form
in the corpuscles of a leuksemic man, that could only be explained on
the corpuscles possessing a certain contractility, which after careful
examination, he actually detected. On the whole, he thinks that contrac-
tile movements, though, perhaps, only slight, will hereafter, on further
examination, be found to occur naturally in the red-blood corpuscles.
That the red corpuscles of the blood possess a certain amount of con-
tractility is a fact so often proved in England that one wonders what
Professor Freidreich is driving at. Many instances of apparent con-
traction are merely the effect of an altered condition, as of evaporation
of the liquor sanguinis, in which the corpuscles swim in the minute
drop of blood under the microscope ; the corpuscles may be olten seen

1868,] Chronicle of 'Physiologij . 265

altering their shapes, as Mr. Gulliver has figured during the examina-
tion and particularly at last.

2. No one, says M. Metschnikow, has as yet furnished proof that
the so-called nucleus of the red corpuscles in birds and in cold-
blooded vertebrata is really a structure analogous to the nucleus
of a typical cell, as for instance, an embryonal cell. The ne-
cessity for such a proof has become so much the more pressing
since a great difference exists between the nuclei of the blood cor-
puscles and the Furchungskerne of these animals, and secondly,
because the nucleus of the adult red corpuscle has scarcely anything
analogous with that of the youngest blood-cells of the chick depicted
by Remak. In the hope of obtaining sure standpoints for determining
the significancy of the several parts of the blood corpuscle, he followed
the stages of their development in fowls, which were the animals most
at his disposal. The following are the results he obtained : — On the
third day of incubation the blood corpuscles possess an irregular form.
They are clearly devoid of an investing membrane, but contain in their
interior a round perfectly clear and transparent nucleus, with a few
very small corpuscles (nucleoli). These refract the light more strongly
than the nucleus, but show generally the peculiarities of cell contents.
The corpuscles present a faint yellowish coloration. The protoplasma
containing only very few of tlie granules, exhibits contractile move-
ments, sending out pseudopodia at various points.

These blood-cells undergoing movements were first observed by Max
Sehultz, and increase by division (fission) as was long ago shown by
Remak.

On the fourth day of incubation, the movements of the corpuscles
are shown, and their form becomes consequently more determinate. At
a further stage of development they become more or less oval, pre-
senting a close similarity to the fully formed corpuscles, but he was
unable to convince himself of the presence of a cell wall.
. On the sixth day of incubation, the blood-corpuscles cease to exhibit
any movements at all. The nucleolus increases in size, and sometimes
assumes an oval form.

On the twelfth day, if the corpuscles have assumed their usual flat-
tened oval form, the nucleolus almost completely fills the nucleus, and
this is still more apparent on the fourteenth day.

On the sixteenth day the previously visible boundary line of the
nucleus vanishes, the blood-corpuscles assuming coincidently their cha-
racteristic features.

The result of this frequently and easily repeated investigation is that
the so-called nucleus of the corpuscles is not a nucleus at all, but an
an enlarged and persistent nucleolus, which proves again that the
nucleolus may play as important a role in the cell formation as the
nucleus and weakens the generally received view of the occasional
absence and general unimportance of the nucleus.

3. The experiments of MM. Ainser and Lohe were made on dogs,
and in Hering's method as modified by Vierordt, which consists in the
injection of a small quantity of a 2 per cent, solution of ferrocyanide of

366 Chronicle of Medical Science. [July,

potassium. Each proof quantity of blood taken corresponded to 0*6
of a second in point of time. The total duration of the circuit varied
from 14 to 59 seconds. The injection was thrown into one jugular,
and the blood taken from the other jugular. Under normal conditions
they found the duration of the circuit about 18 or 19 seconds, the heart
beating about 24 or 25 times. When the vagus was excited with an
interrupted current of electricity, for about 10 or 12 seconds before the
injection was made, so that the hydraulic conditions produced by its
excitation were established, the pulse fell in one instance from 76 to
50, whilst the duration of the circuit rose from 30"6 seconds to the
number of the beats of the heart, being therefore 25*6. In two other
cases the time of the circuit rose to 639 and 59'6 seconds. Only one
experiment was made on the effects of section of the vagi, and it was
then found that the normal pulse was 102 and the respirations 28 per
minute, whilst 10 minutes after the section the pulse was 231, the
respiration 15, and the duration of the blood circuit 17'32 seconds, not,
therefore, materially different from its duration in a healthy animal.

4. Dr, Lannelongue commences his essay by remarking that the
circulation of the walls of the heart is not accomplished in quite so
regular and uniform a manner as is generally supposed. There is a period
antecedent to the contraction of the several cavities, during which there
is an increased quantity of blood in the vessels of the muscular tissue.
When the contraction occurs the vessels are emptied of their contents;
it is obviously necessary that no obstacle should exist to the return of
the blood, and in order to facilitate this there exist " canals of deriva-
tion" proper to the auricles which transmit by several channels at
once all the blood they have received from the auricular arteries.
The ventricular arteries are deeply situated and tortuous, are covered
by the cardiac veins, and often dip into the muscular tissue before their
size is much diminished. On the contrary, the auricular arteries are
superficially placed beneath the pericardium ; they give off only capil-
lary branches to the muscular tissue of the auricles, they run in a
straight direction, and are unaccompanied by any vein. The arterial
distribution of the heart is very constant, but the venous is singularly
variable. That of the ventricles is totally distinct from that of the
auricles, and it presents, moreover, some peculiarities that distinguish
it from every other part of the economy'. As regards the veins of the
ventricular walls, all discharge themselves into the right auricle, and
all, with the exception of the veins of Galen, which, receiving the blood
from the right border of the heart, open by one or two orifices into
the right auricular appendix, converge to the great coronary sinus.
With the exception of the valve of Thebesius at the mouth of
this last, there are no valves in the ventricular venous system. The
veins of the auricular walls, with the exception of a few that discharge
themselves into the left auricle, open into the right auricle, but they
present marked peculiarities in their course, structure, and orifices.
On examining the interior of the right auricle, amongst numerous
smaller, three larger foramina are conspicuous by the constancy of
their position ; one of these is situated just below the opening
of the superior vena cava, a second exactly opposite the opening

1868. J Chronicle of P/ii/siology. 267

of the coronary vein, and the third is situated in front of the left
extremity of the auricle. The orifices of these channels are obliquely
placed, and one border is guarded by a kind of valvule formed by
the projection of the endocardium, and an incomplete ring of mus-
cular fibres. On passing a probe from the interior of the auricle through
the opening it enters at once into a large funnel-shaped cavity, which
receives a few small veins, and the outer surface of which is covered
by muscular tissue, whilst on its internal face it presents the orifices of
certain vessels termed " canals of union of the Foramina," or inter-
muscular channels, which course through the fleshy fibres, separated
from the endo-cardium by one and sometimes two muscular planes ;
the calibre of these is not everywhere the same, and as they pass
along they receive numerous small veins. The object of these "canals
of union " appears to be to prevent any hindrance to the circulation of
the auricle during its alternate changes from fulness to emptiness, as
they receive neady all the small veins of the auricle. The arrange-
ment of the muscular fibres in their vicinity is peculiar since the fasci-
culi are at first parallel to them, but subsequently are arranged more
and more perpendicularly, so that the contraction of the muscle tends
to separate their walls, an arrangement that is only elsewhere found in
the uterus. The walls of the canals of union are composed of three
layers : an internal epithelial layer ; then a layer composed of four or
five series of broad flattened nucleated cells, imbedded in a fibrillar
matrix ; and an external layer of ordinary connective tissue, with much
elastic tissue ; but it does not appear that any muscular tissue enters
into the formation of any of the coats ; they are therefore passive. It
appears from all this that the venous blood of the auricular walls
discharges itself into the canals of the auricles by two methods. A
small portion enters it directly b}' small veins ; the greater portion
discharges itself into the canals of union of the foramina which are
open at both extremities, terminating at both ends in a venous am-
pulla. Since the contraction of the auricles and ventricles succeed one
another it remains to be asked what is their influence on the venous
circulation. Muscle in contraction becomes anaemic, less blood enter-
ing by the arteries, and more being delivered by the veins : hence, as
regards the ventricles, their contraction would efiect the repletion of
the coronary veins, and the blood which courses through them finding
the auricle relaxed, enters it with ease. During the diastole of the
auricle the blood coming from the walls of the ventricle will mingle
with the venous blood of the body generally, but the venous blood of
the auricular walls is placed under conditions that are essentially dif-
ferent in consequence of the peculiar anatomical arrangements of the
part. It cannot here enter during the diastole, since at that moment
the walls of the auricle are soft and flaccid, eff'acing the calibre of the
vessels, off'ering a real passive resistance, rapidly augmented by the
internal pressure exerted by the rising column of blood which, when
the auricles are full flattens the canals, and obstructs their auricles.
Now follows the contraction of the auricle, and in consequence of the
adherence of the walls of the vessels to the muscular fibres, the con-
traction of the latter will shorten and dilate the vessels, and cause

268 Chronicle of Medical Science. [J"ly>

their orifices to open. Consequently it is during the systole of the
auricle that the blood coursing through its parietes will empty itself
into the cavity, just as the venous blood of the ventricles is expelled
an instant afterwards during the contraction of the ventricular walls.
The following table shows the concomitant phenomena : —

v«,.+»!«„i„» o,r»4.„i« /•'^"SDmia of the ventricular wall.
Ventricular systole -s t) i i.- a j.\. • ^ it

*' L Repletion of the auricular vessels.^

Aiu-icular systole . j i"""^^}^ °^ the auricular wall.

•' L Kepletion or the ventricular vessels.

5. M. Guyon has made the remarkable observation that during
violent and prolonged effort, the circulation in the carotid artery un-
dergoes quite a peculiar arrest ; the pulsations in any of its branches,
as, for instance, the temporal or facial becoming at first more feeble
and more rapid, and finally ceasing altogether ; when the effort ceases,
and a full inspiration is made, the pulsations of the artery return, but
their re-appearance is not immediate, and the first pulsations, though
sufliciently full are rapid and a little irregular in rhythm. If, during
the same effort, the pulse in the radial be examined, it will be found to
be feeble and hurried, but it does not altogether cease. On examining
the pulsations in the temporal and radial during parturition, he found
that so long as the pains were accompanied by cries little or no effect
was produced either as regards the force or the frequency of the pul-
sations but that as soon as the pains were violent and prolonged, and
no cry was uttered, suspension of the pulsations in the temporal
occurred in one instance for four seconds, in an effort which lasted ten
seconds, and in another for seven seconds, in one that lasted fifteen or
sixteen seconds, though during this period the pulsation in the radial
was only hurried and feeble. In yet another case when two efforts
succeeded one another rapidly, the arrest of the carotidean pulsation
occurred almost at the commencement of the second effort, and per-
sisted no less than twelve seconds. In endeavouring to determine the
cause of this remarkable phenomenon, his attention was at once directed
to the thyroid gland, the anatomical relations of which to the carotid
had already been carefully described by M. Maignien, and all his
observations tended to refer the arrest to this vascular gland ; for, in
the first instance, it is in contact with the artery for above half an
inch. It is also covered by muscles by which it can be compressed
against the artery. Both its arteries and veins are very large ; its
volume varies greatly under different circumstances, and finally its
large size in women, and especially during pregnancy, is well known.
Moreover he found that mere cessation of respiration produced no
effect on the arterial beats. As regards the utility of this arrange-
ment, he suggests that inasmuch as in all effort the discharge of blood
from the head is more or less obstructed, the arrest of the carotid cir-
culation by the repletion of the thyroid gland, and its compression
against the artery, is a special provision to cut off the supply of arterial
blood to the brain, and thus to prevent what would otherwise certainly
occur, the over-distension of the cerebral vessels,

G. M. Legros recommends the use of solution of gelatine, to 400 parts,

1868.]

Chronicle of Physiology. 269

of which one part of nitrate of silver has been added in order to demon-
strate the epithelium of the blood-vessels ; when the blackening effect
has been produced the preparation, should be subjected to the action
of hypo-sulphite of soda, and finally washed out with distilled water.
The details are then beautifully seen. The epithelium is of the pave-
ment variety, as is also the case in that lining the air-sacs of the lungs ;
the cells are very elastic, with sinuous outlines, but of various form,
usually more or less elongated ; lozenge-shaped, or fusiform in arteries,
and shorter aud broader, with better-marked angles in veins, and, in
both instances, all or nearly all possess a nucleus. In the epithelium
lining the lymphatic canals, the cells do not appear to possess a nucleus.
He states that in the normal condition there is no desquamation, the old
cells disappearing by molecular absorption ; but he has not been able
to ascertain how the cells are developed.

Neeve.

1. Bbown-Sequabd. On the Immediate Arrest of Violent Convul-
sions by the Influence of Irritation of certain Sensory Nenies.
(' Archives de Physiologie,' t. i, 1868, p. 156.)

2. V. WiTTiCH. On the Rapidity with which Impressions are Propa-
gated by the Sensory and Motor Nerves in Man. (' Henle und
Meissner's Zeits. f. Eat. Med.' 1868, bd. xxxi, p. 87.

1. M. Brown-Sequard states that he has met with several cases
which presented features in common with those described in the fol-
lowing case. A young American was aflfected with paraplegia depen-
dent upon an inflammation of the spinal cord at the level of the fifth
or sixth dorsal vertebra. The lower extremities were completely des-
titute of sensibility, and there was no power of voluntary movement in
either of them ; but the slightest touch applied to any part of the
skin of these parts was sufficient to bring on a violent tetanic spasm
in the muscles, in which the legs were so rigidly extended that no
efforts of M. Brown-Sequard and of his servant were capable of flexing
the joints of the ankle, knee, or hip. The servant, however, discovered
that if the great toe were grasped, and forcibly flexed, the whole limb
became supple, and passed into the condition which follows death, and
precedes rigor mortis. In this state the patient remained for a length
of time sufficient to enable him to be dressed ; but if too long a time
were allowed to elapse a fresh attack occurred when the stockings
were drawn on, which could again be reduced by forcibly flexing the
great toe.

2. V. Wittich describes an apparatus he has constructed for this
purpose. For the sensory nerves he found the rapidity of propagation
to be on the average 41 "3 meters in one second when electrical excita-
tion was used, and 37'56 meters when mechanical excitation was em-
ployed, whilst for motor nerves the mean rapidity was 303 meters in
one second. As regards the physiological time occupied by the eye
and ear, i.e., the time that intervenes between the occurrence of a
spark or a sound, and the voluntary movement required to open or

270 Chronicle of Medical Science. [July,

close an electrical current he found the mean time through ear to brain
and down to hand was 0*179 sec, the maximum being 0"199 and the
minimum 01625 sec. The mean time occupied for the perception and
registration of the occurrence of a spark was 0*194, maximum, 0223
sees., and minimum 0*163. For the nerves of taste mean time 0*167
sec. The following table gives the results of some other observers, the
numbers representing the physiological time in seconds : —

For Sight.

l''or Heaving.

For Common Sensation.

Hirsch .

. 0*2

0149

0*182, hand.

Hankel .

. 0*2057

0-1505

0*1548, hand.

Doaders .

. 0*188

0*18

0-154, neck.

Witticli .

. 0*194

0*182

0-1301, forehead.

That the perceptions obtained by means of the auditory should be
capable of being registered more quickly than those received through
the optic is not surprising, since the course of the former is much
shorter than that of the latter, but the great rapidity of the transmis-
sion of impulses through [the skin or ordinary sensory nerves as com-
pared with the nerves of special sense is remarkable. By subtracting
the physiological time for auditory impressions from those for optical
impressions, an approximation may be obtained of the rapidity of the
passage of impressions through the optic nerves and their amounts : —

In Hirsch's experiments to . 0-051 sec.

„ Hankel's „ . 0-0552 „

„ Donders's ,, . 0 008 „

„ Wittich's „ . 0012 „

which gives a rapidity in the optic with —

Hirsch of . . 1-156 meters per sec.

Hankel „ . . 1*068 „ „

Bonders,, . . 7*375 „ „

Wittich „ . . 4-916 „ „

But V. Wittich thinks his estimate and, a fortiori Bonder's, is too
high.

Muscle.

W. KoSTEE. The Determination of the Maximum of Force in a
Living Muscle. (' Archives Neerlandaises,' 1867, p. 89.)

"Whilst Weber in his well-known essay on muscle found the force
not to equal more than 2 2 lbs. for a square centimetre of transverse
section of a muscle, Knorz (' Henle und Pfeuffer, t. xxiv), found for
the flexor muscles of the arm, biceps, brachialis anticus, supinator
longus, a force of from 18 to 20 lbs., whilst for the flexors of the foot
it amounted only to about 13 lbs. The results of the experiments of
M. Koster are as follows v — As a mean of all experiments the absolute
muscular force may be estimated at 17*6 lbs, (8 kilog.), for each
square centimetre of transverse section ; moreover in some indi-
viduals the muscles of the calf of the leg are probably stronger than

1868.]

Chronicle of Micrology . 271

the muscles flexing the forearm or the arm, and these last are a little
stronger than the flexors of the foot. After special exercise of one
side of the hody, any particular group of muscles may acquire a degree
of energy very much superior to those of the opposite side. Under
any circumstances, however, the absolute muscular force is not esti-
mated, but only the degree of force that a muscle can exert under
given conditions.

CHRONICLE 0"P MICROLOGY.
By J. P. Steeatfeild, F.R.C.S.,

Assistaut-Surgeon to tlie Royal London Ophthalmic Hospital, and Ophthalmic Surgeon to
University College Hospital, &c.

PaET I. — PsYSIOIiOGICAL MiCEOLOGT.

On the Presence of Flat Muscular Fibres in the Lung Vesicles of
the Vertelrata. — Professor Gr. Piso-Borme, of Cagliari, who has worked
with Moleschott, was induced, the first time in 1845, supported by
Moleschott and confirmed by Gerlach, to undertake a fresh proof of the
existence of flat muscular fibres in the lung vesicles of mammals, and
at the same time also to extend the investigation to the lungs of other
vertebrated classes. For this purpose he made use of the means here-
tofore recommended by Moleschott, namely, the treatment with acetic
acid mixture, in order to facilitate the distinction between the connec-
tive tissue and the flat muscular fibres, as well as the treatment with
solution of potash, so as to isolate the flat muscular fibres.

It is determined that in the lung vesicles of the mammalia, amongst
the elastic fibres of the wall of the vesicles are to be found, here and
there dispersed, flat muscular fibres, which are remarkable in their rod-
like nuclei. That is to say the nuclei of these fibres resemble in their
elongated form (= 0*014 — 0'016 mm.) decidedly a little rod, whilst
those nuclei which belong to the wall of the capillaries (=0.007—0009
mm.) are more or less swollen in the centre, and thus are more or less
elliptical. The appearance of the nucleus is, therefore, the most cha-
racteristic fact, because, on the one hand, by that way of treatment
the muscular fibres become sometimes very transparent, so that their
outlines among the elastic fibres are hard to be made out, and, on the
other hand, because by that treatment the substance of the muscular
fibres often becomes unequally attacked by the reagents and a dis-
integration in the direction lengthwise brought about, whereby the
impression of a fibrillary formation is easily made, and a confusion
with the fibres of the connective tissue may be induced.

When, with use of reagents, the flat muscular fibres of the lung
vesicles have undergone no real changes, then these appear more or
less transparent and gelatinous, with fine wavy outline ; their ends are
generally rounded — at least never so slender and so pointedly lengthened

272 Chronicle of Medical Science. [Jiily>

as are the flat muscular fibres of other parts. One meets with fibres
which are divided as a fork at one end, whilst less frequently there are
such also, in which the furcated arrangement takes place at both ends.
Non-nucleated or poly-nucleated fibres never seem to have fallen in the
author's way.

The length of these muscular fibres is left behind always after
those of the muscular fibres of the trachea and bronchise ; they, in this
respect, approximate to the flat muscular fibres of many mucous mem-
branes. In all animals the number of elastic fibres and the abundance
of the muscular fibres stood in inverse proportion to each other.

The disposition of the contractile fibres in the wall of the lung
vesicles cannot be reduced to a precise type. Where they are very
scanty, passing off" separately, to appear dispersed irregularly among
the elastic fibres, bent generally towards the wall of the vesicle. One
seldom sees them deviate from their original direction, and with the
elastic fibres pass over from the wall of a vesicle on to that of another,
as in human beings. Where they are somewhat more numerous one
finds them in close proximity to the inner surface of the vesicles, then
also set near each other, so that they form little bundles of few fibres,
with smaller or greater distances between the bundles. Finally, the
bundles also end together, so that they appear in the innermost part
of the wall of the vesicle as a delicate muscular coat. — Schmidt's
Jahrlucher, 1868, p. 147.

Sheath of the Optic Nerve. — Professor Sappey, in a paper on the
structure of the fibrous envelope of nerves, says, " the outer sheath of
the optic nerve is specially remarkable for the multiplicity of elastic
fibres which enter into its composition, and for the numerous nervous
twigs which it receives. It was, therefore, a great mistake that by
the ancients it was considered a mark of union between the dura mater
and the sclerotic ; that is to say, as if it partook of the intimate texture
of both of them. It notably differs from them, 1st, by its elastic fibres,
which in both are wanting ; 2nd, by its nervi nervorum, which are
extremely rare in the dura mater, and of which, in the sclerotic, one
sees nothing whatever. Anatomical examination, far from confirming
the analogy which so many anatomists have thought they discovered,
shows, on the contrary, that the outer sheath of the optic nerve is dis-
tinguished from the two membranes with which it is continuous by
characteristics altogether peculiar to itself" — Bohins' Journal de
V Anatomic, &c.. No. 1, 1868, p. 51.

Part II. — Pathological Michology.

Pus-formation. — Bottcher considers that he has found an explana-
tion of the development of the pus-corpuscles in the uncertain modes
of grouping of the discharged manifold cell-forms of an abscess of the
gum. Large vesicles, filled with finely granular cells like pus- corpuscles
he takes to be mother cells of the pus-corpuscles. As an earlier stage,
ho points out cells in which were contained coarse-grained globules of
various sizes. In the latter is sometimes observed a brighter nucleus,

1868.]

Chronicle of Micrology, 278

which is considered by the author to be formed probably by a thicken-
ing of the protoplasraa around the nucleus, which is said to proceed by
division of the original primitive nucleus of the pus-corpuscle.— JZiezY.
f. Mat. Med., 3rd series, vol. xxxii, p. 19.

General Serous Tuberculosis. — Dr. Perrond analyses a paper of M.
Humbert Molliere, in which he has recorded two cases of this disease,
"in which the lesions were localised in the serous membranes, leaving the
parenchymatous parts almost intact." The former author, moreover,
refers to a case in which, besides the various serous membranes, the
urinary mucous membrane was affected in a similar manner. He writes
that " The microscope, in the granulations of the serous tuberculosis,
reveals the same structure as in those incontestably tubercular ; there
are the same connective elements disposed in three consecutive zones,
the outermost little differing from the normal connective elements, the
middle showing these same elements somewhat increased in volume,
furnished with many nuclei, and in course of proliferation, and the
innermost, as results of this exaggerated proliferation, presenting masses
of nuclei and little incomplete cellular elements, destined to an early
death and to that series of retrograde changes which tend to the
caseous state, and finally to softening and elimination, and to become
cretaceous and encysted."

The disease is called by him only a variety of the parenchymatous
tuberculosis. It sometimes finally appears in the tissue of the lungs.
— Gazette Medicale de Lyon, 1st Dec, 1867, p. 511.

Healing hij first intention. — This is a history in detail by Dr.
Wy vvodzoff, especially as it concerns the blood-vessels in tJiis event. The
author observes in the preliminary notice of the results of his investiga-
tions, that he has made his experiments on the tongue of the dog, the
rabbit's lip, and the membrana nictitans of the frog. According to his
experience, the tongue of the dog proved to be better than any other
for such researches, for it is a part so rich in capillaries, and, separate
from the body, is so easily injected. As the basis of his investigations,
the author divides the whole process of healing by first intention into
five periods, each of which, in different individuals, is much varied.
Indeed, not unfrequently one can, in various spots in the same scar,
perceive dififerent phases of the reparative process.

1. Stagnation period, lasting twelve hours (in the dog's tongue),
twenty-four hours (in the tadpole). This is minutely described by
Wywodzoff, as it has been previously by Billroth and others : it is
marked by a stagnation of the blood in the vessels all around the edges
of the wound, and by thrombus formation in the divided ends them-
selves. The finest lymphatics are by coagulation or by swelling of the
neighbouring tissue also obstructed.

2. Loop-formation period, lasting about from the twelfth to the
forty-eighth hour after the injury. In those parts of the vessels not
thrombosed the circulation has not re-established itself, the force of the
blood in them is heightened ; whereby the acute and obtuse-angled
vascular offshoots have become rounded, they are loops originated,
which yet by the same elevated force of the blood broaden and lengthen,

83— XLii. 18

$y4 Chronicle of Medical Science, [July*

until at last the outermost wall of the arch turned to the edge of the
wound yields and gives occasion to the formation of looped processes.
At the same time, the edges of the wound have united by a gluey
material — coagulated lymph, fibrinous exudation — between them is a
great quantity of new-formed cells deposited. The latter either pro-
ceed from a division which takes place in the connective tissue corpus-
cles situated within the edges of the wound or from white blood-cells ;
possibly they owe their origin to both together. Wy wodzofi''s obser-
vations at least make it highly probable that the blood confined in the
wound goes through the same changes as have been described by
Billroth as characteristic of the organization of thrombus, i. e., the red
corpuscles are gradually dissolved, and blend with the coagulable
lymph in the intercellular substance of the recent scar, whilst the
white blood-corpuscles multiply, and so at all events give occasion to
the formation of those little white round cells which afterwards
become spindle-shaped.

3. Canalization period, in the between-substance, which, for the most
part, consists of newly-formed round cells, channels are opening out
from the looped processes, which, without definite arrangement, with-
out uniform law of continuance, are carried on separately in all direc-
tions. These are only visible by use of very high powers, as bright
streaks bounded by granulation cells ; the current of the injection
advances only as far as the beginning of these channels in the looped
processes : this period ends on the fourth day at the wound.

4. Vascularizi?iff period, from the processes of the loops, progressive
organization of the channels into blood-vessels, of very large diameter
relatively, so that it forms a network of very small meshes. Proceed-
ing from spindle-shaped cells, which, arranged in rows, give intima-
tion of connective tissue disposition. This period generally lasts up to
the tenth day.

5. Consolidation period, characterised by this, that the between-sub-
stance as regards firmness takes on always more the character of proper
connective substance, bounds to the vascular dilatation shortly being
arranged, but then the lumen of the newly-formed capillaries little
by little to about a third diminish. That some of them are again in
this way brought wholly to obliteration, as one has generally hitherto
assumed, is said not to be the case according to Wywodzoff''s obser-
vations. The lymphatics are first formed in the scar when the cicatricial
tissue is transformed from spindle cells into connective tissue fibres and
the vascularisation is come to a stand. — Schmidt's Jahrhucher, 1868,
p. 39.

Tlie Parent Oland-cells and the causes of Rheumatism. — Professor
Salisbury, of Cleveland, Ohio, as the results of investigations begun in
1859, and of which he has already given some account, says — " So
long as the parent gland-cells organize normal products, in the
normal quantity, no such pathological state as rheumatism can
occur. But little control can be exerted over the cell-elements and
the filamentous tissues formed by the metamorphoses of the cells
after they have been organized and have escaped from under the
influence of the parent gland- cells."

1868,]

Chronicle of Micrology, $75

The author goes on to describe, of parent gland-cells in the human
body, six types — the parent epithelial, fibrin, involuntary muscular
fibre, connective tissue, voluntary nerve, and sympathetic nerve gland-
cells. And of rheumatism four types — the lithic, oxalic, cystinie,
and phosphatic types.

In the incubative stage of lithic rheumatism ** the blood gene-
rally becomes ropy, and the colourless and coloured corpuscles
plastic and adhesive, the former tending to adhere together in
groups, forming masses too large to circulate freely through the
capillary system of the firmer tissues. In it also occur the spores
and filaments of a minute algoid vegetation." In the acute stage
" the blood is ropy and adhesive, the colourless corpuscles adhering
together in little masses. The coloured discs become aggregated
more or less in groups and rows, haviug a tendency to adhere to the
meshes of fibrin. Spores and filaments of a minute algoid vegetation
are discovered more or less abundantly distributed through the
blood. These either float in the blood-stream singly, or in ragged
aggregations, in balls or in loose knots or skeins. The filaments
have a wavy appearance, and are highly translucent and refractive.
These, with their spores, become almost invisible after being a short
time between the slides." In the chronic stage, "as the patient
recovers, the blood loses its ropy adhesive character, and the algoid
vegetation disappears."

" The fibrin-filaments are adhesive, and the fibrin-cells and fila-
ments, and the spores and filaments of the algoid vegetation, have a
tendency to form little plastic masses or emboli, which slowly flow
along the capillary vessels in the firm, unyielding fibrous tissues.
In the blood of this variety occur masses of minute algoid spores,
and ropes and knots of algoid filaments. I have designated these
minute cryptogams the Zymotosis translucens. The spores are very
minute, and highly translucent and refractive. The filaments are
also highly refractive, and wind in among each other more or less,
and occur in all stages of development, from a filament double the
length of a spore to three and four inches when magnified 300
diameters. The spores are from slightly larger to two and three
times the size of the fibrin-cell-granules. The sudoriparous gland-
ducts and plane surfaces of the skin are covered with an algoid
vegetation resembling that which is found developing in the blood.
The urine also contains similar vegetation."

In oxalic rheumatism "there is a tendency for the fibrin to
aggregate and become ropy, and the coloured and colourless cor-
puscles to take on an adhesiveness which tends to the forming of
thrombi and emboli. These, when examined, are found full of either
stelline, granular, and crystalline cystine, or oxalate of lime. There
is also more or less of a fermentative tendency excited, probably, by
the development in the blood, secretions, and excretions, of a mmute
species of algoid vegetation {Zymotosis translucens) ^

" In all forms of rheumatism the sweat, urine, and secretions are
more or less acid, and the skin and mucous membranes are covered
more or less with algoid vegetation. There seems to be a peculiar

276 Chronicle of Medical Science. [July,

fermeutative state of the excretions and secretions. The blood
contains masses of minute spores and bundles and knots of minute
algoid filaments."

" This algoid vegetation jjrobably has something to do in giviug
plasticity to the colourless corpuscles, and causing them to adhere
in masses, as described under lithic rheumatism. Two, more, or all
of the types of rheumatism may be combined in the same person,
in which case the ti-eatment should be varied to suit the conditions
present."

" The masses of granules in the blood — of either cystine, of
oxalate of lime, or of phosphates — are readily distinguishable from
the masses of algoid spores. The granules of phosphates, cystine,
and oxalate have a well-defined outline, and do not become less and
less visible as the blood stands longer and longer between the slides,
as is the case with the algoid spores ; besides, the spores are more
uniform in size and more highly refractive, and have a fainter out-
line."— American Journal of the Medical Sciences, October, 1867,
p. 359.

Pseuclo-liypertropliic muscular Paralysis. — Dr. Duchenne, of Bou-
logne, continues his researches into this large subject, and he has
thus summarised his own observations as far as they are anato-
mical.

1. The hyperplasy of the interstitial connective tissue, and pro-
duction of a more or less abundant fibroid tissue is, in this kind of
paralysis, the fundamental anatomical lesion of the muscles.

2. It is seated in all the paralysed muscles which have or have
not increased in size.

3. This it is which produces the considerable aud sometimes mon-
strous increase of size of the muscles, in exact relation to the amount
of hyperplastic connective aud fibroid interstitial tissue.

4. The connective aud fibi'oid interstitial hyperplastic tissue is
combined with or joined to a Aery few or moderate quantity of fatty
vesicles ; according to observations made in G-ermany, it is replaced
by a considerable quantity of adipose tissue.

This last stage appears, in the pseudo-hypertrophic paralysis,
to be the most advanced stage of the alteration of the interstitial
muscular tissue.

5. According to observations, the cross-streaking is maintained
throughout the length, or in a more or less considerable part of
most of the muscular fibres : but it becomes very fine and diflicult
to be seen. In the parts at which the transverse striation has dis-
appeared, one sees the longitudinal striae ; sometimes even these lon-
gitudinal striae are eftaced, the sarcolemmae seeming then to contain
adipose vesicles, which really have their origin in the surrounding
interstitial tissue, and which otherwise essentially differ, in their
aspect and their confluence, from the fatty granulations which are
characteristic of the fatty muscular degeneration.

6. The hyperplasy of the interstitial connective tissue generally
only appears in the second stage of the disease ; it seems to

]868.] Chronicle of Mi crolofpj. 277

be preceded by an inflammatory state of the muscles, which may
also produce some slight increase of their size. At this time the
cross-streaking of the muscular fibre is already of extreme tenuity. —
Jrcliives Generales de Medeciiie, March, 1868, pp. 317-8.

In a former paper Dr. Duchenne has given the conclusions arrived
at by M. Ordoiiez, to whom he had referred various specimens
obtained from a patient during life, by the use of the emporte piece-
histologique of the author. This new example of the disease was in
the case of a boy ; the specimens were got, at long intervals, from
various parts of the body where the pseudo-hypertrophic muscles
were most marked. M. Ordonez was referred to, and his obser-
vations quoted in reference to the difterences of observations that
have been made on this subject in Germany as compared with those
of the French histologists. M. Ordonez says, " The muscular fibres
were found united in a close network of bundles of fibrillary tissue
which made it very difficult to isolate, even partially, the muscular
element."

" These fibres, or rather these primitive bundles, did not
appear to be sensibly diminished in volume ; their margins were
somewhat puckered. The cross-streaking of these bundles was not
uniform ; in some parts it did not exist, and at others a greyisli
serai-transparent colouring of the substance of the muscular bundle
was demonstrable ; its margins were puckered ; some fatty vesicles
aiid a few molecular granules were to be found in its course. Else-
where the streaking, which was tolerably distinct, showed a remark-
able delicacy, and finally there were parts in which the cross-streaking
liad been replaced by a longitudinal striation."

" The fibrillary tissue in which the muscular bundles were enve-
loped was made up of fasciculi for the most part of no great size,
delicately wavy, varying as to dimensions from three to eight thou-
sandths of a millimeter ; they had very variable course which made
isolation of the muscular bundles very difficult.''

" The chief characteristic was the great amount of the interstitial
hyperplasy of the fibrillary tissue among the primary muscular
bundles. After protracted investigation, I have found nothing ana-
logous to it, in the muscles of men or of animals. It is known that
the muscular bundles are united by a little amorphous transparent
matter, and by fibres of fibrillary tissue, but they are easily isolated,
and, above all, they are not, as it were, overwhelmed, in a close net-
work of areolar tissue."

" As to the adipose vesicles pointed out by some Germans in such
cases, I must say that I have here and there indeed met with some
small collections or groups of them, but I must add that they were
disseminated in the network of the fibrillary tissue, and not among
the muscular bundles, as they are in cases of fatty transformation
of the muscles. This it is which exactly defines the myo-sclerosis of
M. Duchenne as contrasted with the fatty and fibrous transforma-
tions which are commonly called muscular degeneration." — Archives
Ginirales de Medecine, February, 1 868, pp. 208-9.

Primary diffused Cutaneous Cancer. — Dr. Vald. Rasmussen reports

278 Chronicle of Medical Science. [Jwiy>

a case of this nature in a widow, aged sixty-nine. In the first place
there was a swelling of the skin over the outer half of the great
pectoral muscle. The breast was secondarily affected. There was
no ulceration. " In the infiltrated parts of the skin the lardaceoua
mass was found to consist of alveoli filled with numerous irregularly
formed flat cells, with one or two nuclei. In the tubercles situated
both outwards towards the epidermis and inwards towards the ribs,
the trabeculae which formed the stroma were thin, the alveoli were
large, containing numerous and fresh cells, while the middle, firmer,
almost fibrous parts, exhibited the alveoli much limited in extent by
great development of the trabeculae of the stroma, so that in some
places there were found only inconsiderable heaps of fat-granules, as
remains of former alveoli. No active participation of the elements
of the epidermis in the cancerous formation was discoverable. In
the places where the infiltration extended out to the epidermis, the
papillae were found rather compressed, and the epidermis itself some-
what attenuated. The tubercles which projected on the surface of
the skin consisted only of dense connective tissue. The other
deposits had the usual structure of medullary carcinoma." — Edin-
lurgJi Medical Journal, April, 1868, p. 876.

Phosphorus Poisoning — Olianges in the Kidneys. — Dr. Banvier
begins by observing that there are sometimes albuminurise, but that
in other cases the presence of albumen in the urine has not been
proved during life. Most frequently, the kidueys of those poisoned
with phosphorus (men or animals) show the characters of complete
and generalised steatosis. The twisted tubuli of the cortical sub-
stance are then filled with granular matter and fatty droplets close
together. The straighter tubes of the cortical substance and those
of the medullary substance are often also attacked by the fatty
change. But it is irregularly distributed, and mainly consists in a
more or less abundant deposit of fatty granules within the epithelial
cells. To the fatty granules proteine granules are not added, so
that the cells preserve a certain degree of transparency. In the
Malpighian pyramids, the different tubes are unequally affected ;
and in this form, as in that above to be described here, one can ordi-
narily verify the fact that the reflected (Henle's) tubes are much
degenerated, whilst the large straight tubes are much less granular.
Thus, in some preparations, one can, aided by this kind of patho-
logical injection, follow exactly the course of these different con-
duits.

Other times, the kidney tubules, instead of being filled with fatty
droplets, are occupied by a sort of exudation composed of fine fatty
granules, and an albuminoid substance moulded together; so that
the fatty granular matter, instead of being free as in the first kind,
and escaping easily from the tubuli which contain it, are bound to
each other by an albuminous substance which moulds itself on the
uriniferous tubes. The alteration does not invade all the tubes of
the cortical substance in a regular manner. In some parts it is so
marked that the epithelial cells have entirely disappeared ; in others,

] 868.] Chronicle of Micrology. 279

these cells remain and have become dull by an internal deposition
of albumen and fine fatty granular matter ; finally, some tubes
appear lined with normal epithelium.

The diiFerent canals of the Malpighian pyramids are none the more
equally changed. The alteration always appears more complete in
the tubes of Henle. In fact, in ordinary albuminuria, the fatty casts
are composed of a central transparent part covered by granular matter.
Here the cylinders have the same composition at all parts of their
mass ; as one can at once determine, especially when broken ends of
these cylinders show themselves successively in all their aspects in
the field of the microscope. These cylinders are generally very
abundant, the fatty granular matter that they contain is very fine
and not very evident without acetic acid. In some cases, besides
these casts, one finds hyaline cylinders (said to be fibrinous), but
always in small number. — Mdbivls Journal de V Anatomie, &c.. No. 2,
1867, p. 221.

Croupous-diphtTieritic Irtflammation of the (Esophagus. — E. "Wagner,
in his contributions to the pathology of this part, having described
the normal epithelium, speaks of the uncomplicated diphtheritis, so-
called, of the oesophagus. Microscopically, he says, the relations of
the so-called diphtheritic deposit, in all its essential attributes, are
much th3 same as those of laryngeal diphtheritis and croup, which
I have already depicted. In my case the fibrous network was as
delicate as in crouj), or at least but little thicker, but never as thick
as in an ordinary case of laryngeal diphtheritis, which, moreover,
was as clear, homogeneous, and bright, but of somewhat more uni-
form extent and thickness than these. Their proportionately large
spaces contained in greater number the same corpuscular elements,
especially numerous, large, one-nucleated pus -corpuscles. On the
surface one sees either the same network, but which there shows
abundant irregularities — sometimes interspersed with numerous
fungous filaments, which mostly resembled the O'idium albicans.
Or, the surface showed a one- to threefold layer of very smooth,
indistinctly nucleated epithelium, to which, in opposition to the
following statements of other authors, I particularly draw at-
tention. As soon as these are separated (a fibrinous degene-
ration seems to be not possible) there probably soon begins the
irregular destruction of the deposit. On its under surface the
diphtheritic network in recent cases generally still shows a manifold
layer of epithelial cells, which show no particular change, so that for
the most part a two to fourfold layer is to be met with over the
points of the papillse, and manifold where it lies between them.
Between these cases and those in which a fibrous network is formed
in the place of the whole epithelium, all possible transitions are to be
found. These were formerly described by me as cases of laryngeal
diphtheritis and croup of a primary kind, hardly ever occurring, whilst
subsequently I found the same circumstances in secondary cases
observed. Moreover, the boundary between normal and fibrous,
degenerate epithelium is generally clear enough, not only in the
direction of the perpendicular, but also of the horizontal diameter.

280 Chronicle of Medical Sc'tence. [J"ly,

Here also especially I often found thicker depositions of the net-
work lie at its edge over normal or little changed epithelium.

Of the oesophageal diplitheritis coDiplicated tvith epithelial suppura-
tion the author says that, microscopically, investigation showed a
combination oj" suppuration in the ejnthelium and in the mucous mem-
h'ane, with diphtheritic change of the former. The yellow longitudinal
streaks, visible with the naked eye, appeared on cross section as
more or less regular wedges of a ver}-^ delicate network, of the same
nature as in ordinary croup, containing in its little spaces almost
always a round nucleus or a pus-corpuscle. These wedges for the
most part extended through the whole thickness of the epithelial
layer through it even to the outer surface of the mucous membrane,
their small side turned to the latter. Laterally, also, they were
sharply outlined ; tbey seemed, as already remarked, to become most
conspicuous with the cataract needle. Near these microscopic diphthe-
ritic wedges the epithelium, which was inconsiderable, and only in the
upper parts, is found to be more extensively distributed. The highest
of all the epithelium was much flattened when it was as usual pre-
sent, not diphtheritically degenerate. In the situation of the non-
fibrous-transformed parts the epithelial cells were found medium
sized, free nuclei and pus-corpuscles lying so closely together that
no other structure thereabouts was visible in most places. Although
the mass was so firm, it could be employed so well in the hardened
preparations to the finest sections, and the latter were so very fine
to separate that one must perhaps assume a connective substance to
be present between those elements. Only here and there between
the above-named bodies were the elements visible, which appeared as
non-nucleated, altogether flattened epithelial cells. At all separate
points unaltered epithelial cells were visible. The formation of pua-
corpuscles I did not see in them. The uppermost epithelial cells
were unchanged, not engaged in suppuration, but easily separable in
fine cross sections.

The tissue of the mucous membrane was in most parts so thickly
set with pus-corpuscles that its outer limit (towards the epithelium)
could not be seen. It was found that where the diphtheritic dege-
neration of the epithelial cells afiected the whole thickness thereof,
as in finely fibrillated preparations, in these but few connective-tissue-
fibres were visible ; only in few places could one still see the origi-
nation of the pus-corpuscles from the connective- tissue-cells. The
muscular coat of the mucous membrane showed here and there
series of pus-corpuscles between its elements. The submucous coat
was interspersed with numerous pus-corpuscles, lying almost always
but sparsely and singly, exposed at the edge of the ulceration. The
epithelial cells within the enlarged acini of the scanty mucous glands
of the oesophagus seemed in part only increased, in part engaged in
a process of endogenous cell formation. Tlie proper muscular coat
was normal.

The ulcers were situated, as could be seen with the naked eye, on
the inner surface of the circular fibre layer of the muscular coat, and
even with it. Everywhere remains of the .'-ubmucous coat were found,
' especially of the elastic fibres.

1868.] Chronicle of Microloffij. 281

So far as a conclusiou is deducible from the anatomical iuvestiga-
tiou of the morbid process in the oesophagus, the result is the follow-
ing. The epithelium showed in every respect the greatest and
most extensive change. This was transformed for the most part into
pus, in a less degree into diphtheritic false membrane. Next the
proper mucous membrane seemed to be attacked. It showed only
purulent infiltration. Later this showed itself in the scanty connec-
tive tissue between the contractile cells of the muscular coat of the
mucous membrane. Last of all, the submucous coat became involved.
—Archiv der Heilkunde, 1867, No. 5, pp. 449 — 68.

Congenital Sclerotico-corneal Tumour containing Hairs. — Drs.
Lainati and Visconti have examined minutely a tumour, small,
rounded, reddish, firm, covered with a quantity of fine, curved, short
hair, closely connected with, the subjacent tissues (which were found
to be perfectly healthy), and removed from a girl of fourteen years
of age. " The mass of the tumour was composed of connective tissue,
in the meshes of which were found groups of fatty cells. Elastic
fibres in it were very rare ; on the other hand, nuclei were in almost
all parts of it very numerous. The tumour was covered by a pretty
thick envelope, formed of layers of epidermoidal cells, with a fine
nucleus of reddish-yellow colour, slightly reflecting light. Some
layers of conjunctival epithelium, found at the borders of the
tumour, were the only elements of conjunctivitis of which one could
assert the existence. A vertical section showed distinctly the bulbs
of the hairs with which the surface was covered. On specially
observing these hairs with their bulbs they were found to resemble
in all points those of the skin. Beside the hairs were found fine
sebaceous glands ; in one of the preparations especially was found a
hair with, on one side, a compound grape-like sebaceous gland, and
on the other a simple utriculated gland. No vestige of sudoriparous
glands could be found" —(' Italian Journal of Ophthalmology.')
Archives OdnSrales de Medecine, September, 1867, p. 350.

Corneal tumours. — Molluscum. — At the Berlin Medical Society
M. Grraefe spoke of some very extraordinary tumours formed on the
two cornese of a patient. These tumours had commenced as yel-
lowish, elongated patches : at the base of one of these patches was
situated a prominent tumour, of a dirty yellow, which covered
nearly all the cornea. The skin of the patient was strewn with a
number of little tumours (molluscum), very probably analogous to
those of the cornea. These tumoui's were of a dark brown colour.

The little corneal tumour was excised — it was composed, in the
centre, of embryo-cells and j)artly of large cells, ramified and having
a considerable nucleus. It was probably a sarcomatous production.
The base of the tumour was infiltrated with fatty granulations.

M. Graefe has twice observed fatty tumours developed on the
cornea, but the patient showed no alteration of the cutaneous sur-
face.— Archives Oendrales de Medecine, March, 1868, pp. 378-9.

Fungi in the Kidneys. — Dr. Morris Tonge reports this in a case of

383 Chronicle of Medical Science. [July,

phthisis. No microscopical examination of the urine had been made,
and the mouth was not examined.

*' The pelvis of the left kidney was very nearly filled with a yellow-
ish-white pultaceous substance, adherent to the apices of many of
the pyramids." " Microscopical examination of the pulpy matter
proved it to consist of the sporules and mycelium of a microscopic
fungus, apparently a species of o'idium, possessing the following
characters :

" 1. Eound or oval vesicles, single or grouped, containing one or
more globules (probably oil- globules or minute sporules), and some-
times granular matter.

" 2. Elongated vesicles, united at their ends, so as to form continu-
ous cylindrical tubes, branching dichotomously, sometimes terminated
by strings or groups of round or oval cells, lateral development of
such cells being also not uncommon. The tubes contained oil-glo-
bules and granular material; here and there the contents had es-
caped, and an empty tube was seen. The white portions of the me-
dullary cones were penetrated by the fungi for a varying depth, gene-
rally one twelfth to one sixth of an inch." — Archives of Medicine,
April, 1867, p. 314.

2few Gryptogamic Skin Diseases. — Dr. J. H. Salisbury of Ohio, U. S.
describes two skin diseases (1) Trichosis felinis, and (2) caninia,
which he distinguishes from Trichosis furfur acece. Both are readily
transmissible to the human subject. Of T. felinis the author says
it is produced by a species of fungus that develops in the fermen-
tation of cat's milk — first around the lips, nose, face, and eyes, and
spreads to the head and body. It forms, with the epidermic cells,
circular patches of thin rusty scurf on the face, nose, lips, and head.
The hair soon sickens, curls up, dies, and crumbles away. On infants
and young children it spreads rapidly, attacking all parts of the body
alike. The cells of the hair-follicles and of the epidermic layer be-
tween them are shrunken and shrivelled, and the hairs, diminished in
size, become brittle, and break off and crumble away. The deeper
parts of these follicles become enlarged often, and the hairs die,
shrink, and fall out. The capillary vessels in the papillary layer of
the skin beneath the diseased surface, become congested and enlarged,
producing a reddening of the skin and a slight elevation of the dis-
eased surface.

In ordinary ringworm the fungoid cause exists mostly in the spore
state. The plant does not advance beyond its cell condition. Its
growth seems to be confined simply to cell multijjlication by pullula-
tion. In this disease the plant-cells multiply by pullulation, and
these advance to the filamentous stage of growth. These filaments
are found running through among the cells of the epidermic layer.

T. caninis, the author says, differs from the former in that the
fungus is more luxuriant, large, and more confined to its filamentous
stage of development. It attacks less tlie hair-follicles than the
felinis, and extends more generally to all parts of the epidermic cell
Bur^sLces.— American Journal of the Medical Sciences, April, 1867,
pp. 379-83.

1868.J

283

BOOKS, PAMPHLETS, &c., RECEIVED FOR REVIEW.

Clinical Lectures on the Principles and
Practice of Medicine. By J. Hughes
Bennett, M.D., F.R.S.E., Senior Professor
of Clinical Medicine in the University of
Edinburgh. Fifth Edition. Edinburgh,
Black and Co. 1868. pp. 1037.

Address before the Alumni of the Medi-
cal Department of the University of New
York. By G. T. Elliott, juu., M.D.
Pamphlet.

On the Desirability of the National
Education for the Deaf and Dumb Poor.
By James Hawkins. Longmans and Co.
1868. Pamphlet.

The Principles and Practice of Obstet-
rics. By G. T. Bedford, M.D., Professor
of Obstetrics in University of New York.
New York, Wood and Co. 1868. pp. 763.
* • A Practical Treatise on the Diseases of
Women. By T. G. Thomas, M.D., Pro-
fessor of Obstetrics, &c.. College of Phy-
sicians, New York. Pniladelphia, Lea.
1868. pp.625.

Sanitary Memoirs of the AVar of the
Rebellion. Collected and published by
the United States Sanitary Commission. — •
Contributions relating to the Causation
and Prevention of Disease, and to Camp
Diseases, &c. By A. Flint, M.D. New
York. 1867. pp. 667.

The History of Anaesthetics from an
American Point of View. Extracted from
' Surgical Observations,' &c. By J. M.
Warren, M.D., Surgeon to Massachusetts
General Hospital. Edinburgh. Pamphlet.

The American Eclectic Medical Register
for the year 1868. Edited by R. S. New-
ton, M.D. New York.

A Dictionary of Chemistry and the Allied
Branches of other Sciences. By H. Watts,
B.A., F.C.S., assisted by eminent Con-
tributors. In 5 vols. London, Longmans
and Co. 1868.

The Drainage and the Water Supply of
Towns. A Lecture. By W. Newman,
M.D. Stamford. Pamphlet.

Thomson's Conspectus, adapted to the
British Pharmacopoeia. Edited by E. L.
Birkett, M.D., F.R.C.P. New Edition.
Longmans and Co. 1868. pp.248.

The Morbid States of the Stomach and
Duodenum, and their Relations to the
Diseases of other Organs. By S. Fen wick,
M.D., Lecturer at London Hospital Medi-
cal School. London, Churchill and Sons.
1868. pp. 394.

The Essentials of Materia Medica and
Therapeutics. By A. B. Garrod, M.D.,
F.R.S. Third Edition. London, Walton.
1868. pp.479.

A Scheme of Medical Education. By E.
A.Parkes,M.D., F.R.S. London, Churchill
and Sons. Pamphlet.

On the Reforms of the Out-patient
Department of our Hospitals. By Dr.
Bieveking. Pamphlet.

Clinical Lectures and Reports by the
Medical and Surgical Staff of the London
Hospital. Vol. IV, 1867-8. Edited by Dr.
Clark,Dr. Down, Mr, Hutchinson, and Mr.
Maunder. London, Churchill and Sons.
pp. 525.

On Diseases of the Chest : being Con-
tributions to their Clinical History, Patho-
logy, and Treatment. Part. I. Diseases
of the Lungs. — Part. 11. Diseases of the
Heart and Thoracic Aneurysm. By A. T.
H. Waters, M.D., F.R.C.P., Physician to
the Northern Hospital, &c., Liverpool.
1868. London, Churchill. Liverpool,
Holden. pp. 418.

On Anaesthetic Leprosy. By 'J. N.'
Reprinted from the ' Indian Medical Ga-
zette.* Calcutta, Jan., 1868. Pamphlet,

A Manual of Materia Medica and The-
rapeutics, l&c. By G. F. Royle, M.D.,
F.R.S., and F.W. Headland, M.D., F.R.S.,
&c. Fifth Edition. Churchill and Sons,
1868. pp. 824.

Army Marriages. By Brown Beaa.
Belfast, Mayne. 1868. Pamphlet,

Contributions to the Study of Thoracic
Diseases. By J. Cuming, M.D., Professor
of Practice of Medicine, Queen's College,
Belfast. Reprint from ' Dublin Quarterly
Journal of Medical Science,' Feb. and May,
1868. Pamphlet.

The Contagious Diseases Act of 1866,
and its Extension to theiCivil Population
of the United Kingdom. By J, B, Cur-
genven, M.R.C.S. Reprint. Pamphlet.

On the Action, Use, and Value of
Oxygen in the Treatment of Various
Diseases otherwise Incurable or very In-
tractable. By S. B. Birch, M.D., &c.
Second Edition, London, Chxirchill and
Sons, 1868. pp. 149.

The Causes and Treatment of Lateral
Curvature of the Spine. By R. Barwell,
F.R.C.S., Surgeon and Lecturer on Ana-
tomy at the Charing Cross Hospital.
London, Hardwicke, 1868, pp. 179.

The Surgical Treatment of the Diseases
of Infancy and Childhood. By T. Holmes,
M. A. Cantab., Surgeon to the Hospital for
Sick Children, Surgeon and Lecturer on
Surgery to St, George's Hospital, Surgeon-
in-chief to the Metropolitan Police. Lon-
don, Longmans and Co. 1868. pp. 648.

A Compendium of Practical Medicine

284

Books, i^c, received for Revieiv. [July, 1868.

and Morbid Auatomy. By W. Dale, M.D.
London, Churchill and Sons. 1868. pp.
475.

A Collection of the Published Writings
of the late T. Addison, M.D., Thysician
to Guy's Hospital. Edited for the New
Sydenham Society by Dr. Wilks and Dr.
Daldy. 1868. pp. 242.

Hoarseness, Loss of Voice, and Stridu-
lous Breathing in relation to Nervo-
muscular Afifections of the Larynx. By
Morell Mackenzie, M.D., &c. Second
Edition. London, Churchill and Sons.
1868. pp. 74.

Diseases of Children : a Clinical Treatise
based on Lectures delivered at the Hospital
for Sick Children, London. By T. Hillier,
M.D., Physician to the Hospital for Sick
Children, &c. London, Walton. 1868.
pp. 402.

First Principles of Medicine. By A. Bil-
ling, M.D., F.R.S., &c. Sixth "Edition.
London, Bell and Daldy. 1868. pp. 714.

On Consumption, and its Treatment by
the Hypophosphites. London and Dublin.
Second Edition. Pamphlet.

Transactions of the Obstetrical Society
of London. Vol. IX, for year 1867. Lon-
don, Longmans and Co. pp. 307.

The Law of Human Increase or Popula-
tion based on Physiology and Psychology.
By N. Allen, M.D. Lowell, Mass. New
York. Pamphlet.

On the Pathology of the So-called
Eczema Marginatum, and of Sycosis. By
Dr. M'Call Anderson. Edinburgh, Oliver
and Boyd. Pamphlet.

Principles of Forensic Medicine. By
W. A. Guy, M.B., F.E.S., Professor of
Forensic Medicine, King's College. Third
Edition. London, Eenshaw. 1868.
pp. 655.

Braithwaite's Retrospect of Medicine.
Jan. to June, 1868. London, Simpkin,
Marshall, and Co. pp. 407.

A Manual of the Pathology and Treat-
ment of Ulcers and Cutaneous Diseases of
the Lower Limbs. By J. K. Spender,
Surgeon to Bath Mineral Water Hospital.
London, Churchill and Sons. 1868. pp. 89.

Nouveau Dictionnaire tic Medeeine et
de Chirurgie pratiques. Tome viii, Clav.
— Comp. Bailliere. pp. 801.

Leqons Ciiniques sur lea Maladies Chi-
rurgicales des Enfants. Par M. J. Giral-
des. 2e Fascicule : Tracheotomie — Ances-
thesiques — Hemostatiques — Tumeurs.
Paris, Delahaye. 1868.

Resume de I'Histoire de la Medeeine
durant les XVe et XVIe Siecles, &c. Par
M. Daremberg. Pamphlet.

De I'Emploi du Speculum Larynglcn
dans le Traitemeut de I'Asphyxic par
Subiuersion, &c. Par A. de Labordette.
Paris, Bailliere. 1S68. Paiiiphlcl. -

Etude Bur le Cholera. Manifestation de
I'Epidemie, Anatomie Pathologique. Par
le Dr. Nicaise, Proseeteur des H6pitaux
de Paris. Bailliere. 1868. Pamphlet.

Du Diagnostic des Maladies des Yeux,
par la Chromatoscopie Retinienne, Pre-
cede d'une Etude sur les lois Physiques et
Physiologiques des Couleurs. Par X.
Galezowski, M.D. Bailliere. 1868. pp.
267.

Deutsch. Archiv f. KlinischeVMedicin.
Eedigirt v. Dr. H. Ziemssen u. Dr. F. A.
Zenker. Bd. IV, hft. ii, 1868. Leipzig.

Molestias Vcuereas e Syphiliticas, &c.
PeloDr. J. A. Marques. SegundaEdi^ao.
Lisboa. 1868. pp. 1052.

0 Tratemeiito da Angina Diphtherlca
Pelas Flores de Euxofre. Por A. M, Bar-
bosa. Lisboa. 1868. Pamphlet.

Reports, Journals, Reviews, Sj'C

The Journal of Anatomy and Physiology.
Conducted by G. M. Hemphry, M.D.,
F.R.S., and W. Turner, M.B. No. II,
May, 1868.

Journal of Cutaneous Medicine and
Diseases of the Skin. Vol. II, No. 6,
April, 1868.

Journal of Mental Science. April, 1868.

The Dublin Quarterly Journal of Medi-
cal Science. May, 1868.

Edinburgh Medical Journal. April,
Mav, June, 1868.

Ihe American Journal of the Medical
Sciences. April, 1868.

New York Medical Journal. March,
April, May, 1868.

Cumberland and Westmoreland Lunatic
Asylum Report for 1867.

Seventeenth Annual Report of the Wilts
County Asylum, Devizes.

Report of the Sussex Lunatic Asylum,
Hay ward's Heath.

Third Annual Report of the Cambridge-
shire, Isle of Ely, and Borough of Cam-
bridge Lunatic Asylum, for year 1867.

Twelfth Annual Report of the Asvlum
for County and Borough of Nottingliam.
1867.

Report of Lunatic Asylum for North
Riding of Yorkshire.

Annual Report of the Royal Edinburgh
Asylum for tlie In.sanc, for 1867.

Report of I^lannging Committee of Dub-
lin House of Recovery and Fever Hospital.

Twelfth Annual Report of the Somei'set
Lunatic Asylum.

Journal of the Scottish Meteorological
Society. Jan., 1868.

The New Orleans Journal of Medicine.
April, 1868.

The Royal London Ophthalmic Hospital
Reports. April, 1868.

The Amerioau Jotu-nal of Obstetrics and
Diseases of Women r.nd Children. Edited
by E. Nocggerath, ALD., and B. F. Daw-
son, M.D. May, 1868.

THE

BRITISH AND FOREIGN

MEDICO-CHIRURGICAL REVIEW.

OCTOBER, 1868.

PART FIRST,
^nalgtlral anti (ttritical Itiebietos.

Review I.

A System of Medicine. Edited by J. Russell Reynolds,
M.D., F.R.C.P. London, Professor of tlie Principles and
Practice of Medicine in the University College, Physician
to University College Hospital, &c. Vol. II, containing
Local Diseases. London, 1868. 8vo. Pp. 990.

In a former number, reviewing the first volume of this
work, we pointed out the characters by which it is intentionally
distinguished from other collections of medical knowledge. Of
these the most valuable is that it presents a real life-like sketch
of the current opinions of the most vigorous portion of the pre-
sent generation, so that we may not only know the present,
but we may predict from it what will be the future opinions,
for the next twenty years or so, of those whose talents and
inclinations are imitative rather than creative, that is to say,
of the most numerous, useful, and generally popular part of the
profession. It is not so much that Dr. Reynolds' book will be
a guide, as that the men whom he has selected as his ministers
(including himself) will certainly be the guides of English
practitioners ; and we are glad to be able to learn how they are
to be guided, Tl\\e personnel of this new staff of contributors to
literature is smaller, indeed, than was exhibited in the first list,
but certainly not less weighty : the fresh names are Dr. Anstie,
Dr. Bastian, Dr. Chambers, Dr. Wilson Fox, Dr. Gull, Dr.
Hughlings Jackson, Dr. Maudsley, Dr. Radcliffe, Mr. J. N. Rad-
84— XLir. 19

286 Reviews. [Oct.,

clifFe, Dr. Ramskill, Dr. Roberts, Dr. Sanders, Dr. Sutton ; while
Dr. Gee, Dr. Begbie, Inspector-General Maclean, and the editor
himself, may be mentioned as contributors on both occasions. The
reason of the large influx of new names is that an entirely new
class of diseases is taken in hand, those, namely, which are
capable of a classification following in some degree that of the
historians of the healthy body, the physiologists and the anato-
mists ; maladies with respect to which we can say at once that
they are diseases of tlie nervous system, of the digestive appa-
ratus, and so on. Now, each of these subjects is best handled
by men who have had leisure to collect all the physiological
knowledge extant on one or two subjects, as well as to take
that general view of all physiology as demanded by the subjects
of the first volume. Special investigators, though not special
practitioners, have been selected by the editor to set before u.s
the state of knowledge on the matters each one's inclinations
and opportunities have led him to know most.

The principle of division thus established in regard to all
diseases, viz., that of limitation or localisation, is again applied
by Dr. Reynolds as a means to be employed for the primary sub-
division of the large group of diseases occupying the greater
part of this volume ; " Diseases of the Nervous System " are
ranged under two headings, " General Nervous Diseases" and
*' Partial Nervous Diseases." Under the first, for example, come
epilepsy, alcoholism, insanity, hysteria, diseases exhibiting them-
selves in altered functions of the brain, cord, and nerves ; while as
a transition to those in the second heading we find Avasting palsy,
writer's cramp, &c., which, although they exhibit the maximum
of their obvious symptoms in particular parts of the nei'vous
system, are yet of such uncertain pathology that we shrink
from describing them as diseases of either brain, cord, or nerves
exclusively. It may be that some readers of the hyper-
anatomical school will object to this, and wish to see greater
prominence given to certain favourite hypotheses, which refer to
more accurately defined localities the origin of these diseases.
But we think on the whole the editor has exercised a wise dis-
cretion in demanding a multipliration and verification of
observations, both in death and life, before asci-ibing these
diseases to particular kinds or localizations of tissue change.
Scientific accuracy might be speculated for at a risk of possi-
ble loss of truth, by ranking them under more anatomical
headings.

In the second group of diseases of the nervous system, the
principle of arrangement is sufficiently obvious to need but
little elucidation. In the first place, a subdivision is made upon
simply anatomical grounds into affections of the cranium, the

1868.]

Reynolds' System of Medicine. 287

spinal cord, and the nerves ; and each of these is again subdi-
vided on an anatomical basis according as the various tissues
constituting them exhibit the primary lesions. The next prin-
ciple of division is that determined by the nature of the anato-
mical change which these tissues undergo respectively. Here
an attempt has been made to place in close proximity those
diseases which have the most highly marked clinical similitude
— such, for example, as getting together concussion of the
spine, compression of the cord, caries of the vertebral column, &c.
— an attempt which certainly would save a certain amount of
repetition of diagnostic differences, were it fully carried out, but
which is too generally found inconsistent with the demands of
the other principles of classification. Thus we find " Ecstasy,"
*' Catalepsy," and " Somnambulism," though declared to be of
the same nature as " Hysteria," separated from it by a gulf
wide enough to include " Wasting Palsy," " Mercurial Tremor,"
and " Writer's Cramp ;" while before Ave get to " Hysterical
Paraplegia" we have to pass through " Cerebral Haemorrhage"
and several hundred pages of other tissue lesions. We think
the editor had better not have attempted tliis element of arrange-
ment, or at least have concealed his atterhpt, which then pro-
bably would not have been found out.

We have been particular in describing Dr. Reynolds' classi-
fication of nerve-diseases, because he has evidently bestowed
much time and thought upon it, and certainly with good effect.
We trust he intends to do the same witli affections of the diges-
tive, respiratory, and circulatory system, but this volume only
takes us as far as diseases of the stomach, commencing with
the functional disorders and ending with the tissue lesions of
that organ.

Dr. Maudsley's article on '* Insanity" begins the volume, and
gives, within the compass, we are glad to say, of a very mode-
rate number of pages, a very broad view of the subject. For a
specialist to accomplish this task involves an unsparing amount
of the labor limce. But Dr. Maudsley's mind is apparently
one eminently fitted to exercise the literary pruning-knife ; he
has what Aristotle so much values in the philosopher — the
faculty of seeing resemblances stronger than that of seeing differ-
ences ; and, consequently, instead of trying to distinguish himself,
as so many specialists do, by magnifying varieties into species,
and giving a distinctive name to the disease of almost every
patient, he applies himself to showing how the variations are
the outcome of a common principle. Thus, while he recog-
nises the two well-marked groups of insane persons — those in
whom the feeling or affective life is chiefly perverted, and those
in whom Xkm ideational or m^e/Zec^waZ derangement predominates

288 Reviews. [Oct.,

— he points out that moral alienation is the fundamental fact,
and that it precedes hallucination, both in order of time and
logical sequence. " To insist," he says, " upon the existence of
a delusion as a criterion of insanity, is to ignore some of the
gravest and most dangerous forms of mental disease." Again,
he points out that the delusion is not the cause of the impression
of misery in melancholia, or of the exaltation of self-feeling in
mania, or of the silly acts of craziness (dementia), but is simply
its expression, determined by accidental circumstances of dis-
position, education, and worldly estate. This leads him to a
most valuable and practical guide to prognosis ; namely, that
insanity, however abnormal or however slight its manifestations
may be, is curable in an inverse ratio to the fixedness of a defi-
nite type of morbid action of a chronic nature. Hence in me-
lancholia, where there is a fixed idea that the cause of misery
is in some external agency, the prognosis is unfavorable ; and
hence monomania, which takes its name from the unvarying
monotony of the direction of the morbid ideas, is far less curable
than mania. The expression of this leading idea contributes a
most useful page of illustrative prognosis.

Dr. Maudsley's treatment of insanity rests on the principle of
removing the causes — the physical causes by calming physical
excitement with opium, henbane, and bromide of potassium, and
the moral causes by taking a patient away from the sights,
sounds, and associations of the home where the disease has come
on. This last is the most painful part of the business for all
those whose daily life has not inured them to the idea; for
though the exceptional wealthy may be able to take Dr. Mauds-
ley's advice of travelling in the early stages, or removal to
another residence, yet for the great majority of our patients,
we can attain the desired object only by sending them to an
asylum.

Now, it is a severe struggle to a non-specialist, not only to
risk losing sight of his patient, but also to affix to the family the
stigma of having a relative in a madhouse, especially when it is
an incipient, curable case, capable of easy concealment from all
except the attendant physician. We will, therefore, in the in-
terests of non-specialists, go a little out of our way to quote,
from a lecture on an allied subject, a scheme which strikes us
as capable of being adapted to the treatment of early insanity :

" One good plan that can sometimes be adopted, to the saving of
pride and pocket together, is to negotiate an exchange of patients,
where two famihes of about the same social standing are simulta-
neously afflicted with an hysterical member. The relative of A can
take charge of B, and the friends of B repay the debt by their care
cf A. Mere kindness even may induce people to receive on a visit

1868.] Reynolds' System of Medicine. 289

such inmates, when it is pointed out how valuable the kindness
really is, and what a high office of Christian charity is thus fulfilled,
when a sick person, incurable at home, is rendered curable by
removal." ^

The adoption of some snch arrangement would be most ad-
vantageous to that large class lying between hospital patients
and those in completely easy circumstances.

The next article, on "Alcoholism," is by Dr. Anstie, whose
long devoted attention to the physiological action of so-called
" stimulants" is well known.2 From that physiological action
(which, he points out, in the way they are generally used, is that
of a depressant), he deduces the pathology of the condition
named :

" The exciting causes of alcoholism may be understood, then, to
be the repeated direct action of blood strongly impregnated with
alcohol on the tissues of the nervous centres and branches, rendering
them physically incapable of the due performance of their functions,
and the influence of an insufficiently oxygenated blood-supply cou-
sequent on a morbid condition of the blood-corpuscles."

He therefore treats it by a conjunction of moderate elimina-
tion and continuous ample nutrition ; and he entirely dispenses
with the employment of alcohol, finding no ultimate harm to
accrue from its immediate disuse.

Dr. Anstie, however, strongly dissuades from the administra-
tion of violent eliminants, such as, for example, tartar emetic.
He says that, though it is possible that sudden improvement
may in some cases have followed its powerful effect, yet that it
is perilous in the extreme to the forces of circulation. There
is some dry humour in the suggestion by which the author
would restrict its employment. He thinks it should not be
used till a diagnosis has been made between the vigour of a
really strong pulse and the false shadow of it exhibited in the
glaring eyes and delirious jactitation — a diagnosis to be accom-
plished by the calm application of M. Marey^s delicate sphygmo-
graph to the raving patient. In most cases we should prefer to
forego the advantage, though Dr. Anstie prints a tracing thus
obtained.

The three next short articles by Dr. Chambers are on the rare,
and, therefore, less important, diseases, "Ecstasy," "Catalepsy,"
and " Somnambulism." They endeavour, however, to give a
practical turn to the subjects by tracing their connection with
hysteria, mesmerism, nocturnal incontinence of urine, seminal
emissions, and other defects of semi-voluntary power.

^ ' Chambers' Clinical Lectures,' page, 385 (fourth edition) ; " Hysteria."
' ' Stimulants and Narcotics.' Anstie. 1864.

290 Reviews. [Oct.,

" Chorea" is treated of by Dr. Radcliffe as a disease of
debility, whose natural tendency is towards recovery. He gives
a full description of the ordinary and exceptional features of it
and of the means of diagnosis, and ends with a list of about
thirty remedies, between Avhich he leaves the reader to take his
choice. We should have been glad of a more critical analysis of
these remedies, and of some opinion as to how far their great
number is to be accounted for by the fact of all the moderately
severe cases getting well of their own accord, while the fatal
examples seem quite unaffected by any measures. A philoso-
phical examination of the history would also have been interest-
ing, to trace, if possible, how a disease, originally remarkable
for its hysterical and ecstatic phenomena, should have become
so changed in character, that we iind chorea and hysteria less
frequently united in the same patient than the doctrine of
chances would lead us to expect, when two such common
ailments are concerned. Such critical inquiries should be
suggested by the writer, not left to the reader.

Dr. Maclean's article on " Sunstroke" is interesting, from the
great mortality whicli has at sundry times and places occurred
from that agency to British armies under the old regime, and
because we believe this is the first occasion on which the suc-
cessful treatment has been inserted into a systematic work on
medicine. He traces its pathology to the depressing effects of
excessive heat, aided by other corroborative circumstances, such
as dampness, tight clothes, &c., on the circulation separately, or
the nervous centres separately, or on both together (Morehead's
cardiac, cerebro-spinal, and mixed varieties). In the first,
sudden death takes place by instantaneous syncope ; in the
second, the patient passes through a stage of raving fever into
coma ; in the third, there is a combination of minor degrees in
each.

We should have been glad to have seen, as an appendix to
this article, some remarks on the local effect of other kinds of heat
than that of the sun on the nerve-centres. We have witnessed
phenomena exactly the same as those of insolation, from the
exposure to a hot gas-burner of a bald head engaged in making
up railway accounts : and we have heard of the same results
happening to steel puddlers, from the great heat evolved by the
furnace. We are sorry to say that neither Dr. Reynolds'
System, nor even the Nomenclature of the College of Physicians,
enable us to give a name to this disease, which clearly is not
" congestive apoplexy," because there is no congestion. Would
not " heat-stroke" be a more inclusively correct term for both
together ?

In the article on " Wasting Palsy" the author adds to the full

1868.]

Reynolds' System of Medicine. 291

account of the disease which he published in a monographical
form in 1858/ the subsequent researches of Gull, Lockhart
Clarke, and Luys ; and he announces the important result that
they have changed his opinion as to the morbid anatomy of the
disease. He now considers it proved that the primary lesion
exists in the spinal cord, or at least some part of the nervous
system, and not in the muscle itself; and he thinks that clinical
facts seem to designate as the special parts affected a special set
of organic nerves, having upward connections with the sym-
pathetic ganglia and the cerebro-spinal axis, by no means
identical with the central connections of the motor nerve-fibres,
and which act as nutritive centres to the groups of muscles to
which they lead. For our own part we should have preferred
classing this variety of disease amongst the forms of progressive
paralysis.

Tlie name " metallic tremor" is preferred by Dr. Sanders to
*' mercurial tremor," from an account derived from Dr. Brock-
mann, a practitioner in the Hartz mountains, of a similar in-
fliction befalling the lead-miners of that district. Professor
Schonlein also attributes the disease to the poisonous action of
zinc, arsenic, lead, and bismuth, as well as to mercury. He
differs from the latter pathologist in assigning the nerve-centres
as the seats of lesion instead of the terminal fibrils and the
muscles themselves, which on post-mortem evidence seem to be
accepted in Germany as the locality of the morbid action.

Such articles as that of Dr. Jackson on " Convulsions,"
and that of Dr. Ramskill on " Vertigo," we look upon
as particularly useful in the present day. A symptom com-
mon to many anatomical lesions and morbid states is taken
as the subject, and its bearing upon each discussed, pointing
out how far it may be treated in one common way, however
diverse may be the exciting internal causes, and how far the
diversity of the causes may modify the treatment. We say they
are particularly useful in the present day, and we should be
glad to have more of them, because there is prevalent an over-
strong reaction against the mere symptomatic therapeutics of
our forefathers, and often a diagnostic differentiation is made to
involve an unnecessary variation of treatment. We should be
glad to see a treatise on similia similibus curantur, in the sense
of diseases -which resemble one another being usually best
treated by remedies which resemble one another. Dr. Jackson
is several times unnecessarily apologetic, as if he were going to
be tried by a packed jury of pure morbid anatomists. Let him
take heart ; those excellent pioneers of science are in a minority,

' ' An Essay on Wasting Palsy,' by William Roberts, M.D.

292 Reviews. [Oct.,

even among the critics. We think, for example, that he is by
no means " sacrificing correctness to convenience," when he
divides the subject into (1) fits under seven years of age, and
(2) fits above seven years. The line which separates the two
classes seems dim and roughly defined, simply because the classi-
fication is natural, and arrived at by grouping, rather than
by logical and artificial division. The sets of diseases which
originate convulsions are different at the different periods
of life, and arrange themselves according to their primary
and secondary characters, as the author has done. The differ-
ences and likenesses of those falling together are essential, not
accidental.

By " Epilepsy" Dr. Reynolds means a sudden temporary loss
of consciousness, sometimes with, sometimes without spasm,
originating in the brain as the first material cause. He thinks
it of great importance to restrict the use of the word to that
natural group of cases, with the joint goal of attaining clear ideas
on their rational treatment, and a correct view of their anatomi-
cal pathology. On the latter point the author takes stock of
our knowledge in eleven propositions. Our investigations into
the material cause do not seem to have advanced further than a
suflficiently probable conjecture that the primary and essential
spasm is in the vessels of the pia mater of the medulla oblongata
and upper part of spinal cord. The treatment recommended is
purely empirical — the specific bromide of potassium in large
doses. We are glad to hear from Dr. Reynolds, with regard to this
fashionable remedy for everything, that in his large experience
extending to " many hundreds" of cases, he has " witnessed no
ill effects from its administration." Among ill effects he does not
include a few minor phenomena, scarcely sufficient to induce the
omission of the drug if otherwise beneficial.

There are two methods of trying to make variations of tem-
perature available for preventing fits at night — a bag of ice
down the back and a hot bottle to the feet. Dr. Reynolds has
found the latter the most effectual, the former having proved,
after fair trials, quite useless. Though not epileptic ourselves,
we still feel heartily glad of this comfortable result of expe-
rience.

The article on " Writers' Cramp" we should have been glad
to have seen united to that on " Torticollis," 700 pages later,
and a general essay on the whole subject of local spasms,
including nervous strabismus, stomach cough, asthma, and
stuttering, treated physiologically as a whole.

*' Hypochondriasis " is elegantly and philosophically described
by Dr. Gull as " one of the transformed neuroses which descend
from a parent stock strongly tainted with insanity." The most

1868.] Reynolds' System of Medicine. 293

important point in the management of the disorder is, in the
author's view, to distinguish its phantom subjectivities from the
signs of tissue lesions in the parts indicated. To that he con-
tributes valuable aid. One observation we would take leave to
add, which has often assisted us much in this common dilemma,
namely, the existence of a peculiar suspiciousness in the hypo-
chondriac. Not only is he extremely anxious that you should
believe him, but he has always a shrewd notion that you
do not. The needless tone of advocacy adopted by the patient
has often given us the first hint that his tale was an ignis
fatuus.

The article on " Hysteria " of Dr. Reynolds follows next,
in which the author consistently deduces all he says of
the natural history, causes, phenomena, and treatment of the
disease from its pathology as a condition of the nervous system,
essentially characterised by deficient volition. He divides the
symptoms to which this deficiency gives rise into the inter-
paroxysmal and paroxysmal; and in the former distinguishes
graphically the mental, sensorial, and motorial condition ; where
the morbid phenomenon are all evidently unbridled vagaries of
nervous functions normally kept under control. With this
there is often joined as a powerful ally, often, but not always,
as a precursor, some disorder of the general health, especially
in the direction of defective nutrition. The treatment, then,
may rationally address itself to rectifying digestive and other
imperfections by means of medicines, but the essentially
therapeutical and preventive management of hysteria must be
moral.

"When a street has got rightly or wrongly an evil reputation,
the introduction of respectable tenants is facilitated by a change
of name. This seems to be the reason for the substitution of
" Locomotor ataxy " for the old-fashioned tahes dorsalis, which
was supposed to impute to the patient previous abuse of the
sexual organs. In a good half of the cases the accusation would
be misplaced ', and where it is true, probably points to a symp-
tom rather than a cause of the disease. On this ground we are
quite willing to accede to the new nomenclature, and also to
the omission of Dr. Duchenne's prefix of ' Progressive,' which
is a needless aggravation of the patient's sorrows, a " lasciate
ogni speranza, che intrate " of the consulting room. Dr. E.ad-
clifife's paper seems, however, to show that, though superfluous,
it is unfortunately only too correct an epithet.

The PARTIAL DISEASES OF THE NERVOUS SYSTEM are of course
the section in which the aid afforded by morbid anatomy to
medical knowledge begins to be conspicuous. The first instance
of this is in the essay by Dr. Ramskill, on " Simple Meningitis/'

294 Reviews. [Oct.,

which is made to include the acute hydrocephalus of older
authors, that is to say, all those cases where tubercles are not
the starting-point of the inflammation. These are proportion-
ately so numerous, and present so many individual peculiarities,
that they form the subject of the next article, contributed by
Dr. Gee. We are happy to see that in both simple and tuber-
cular meningitis the inflammation, as it occurs in infancy, youth,
adult, and old age, is treated of as one, and not discussed in the
usual way, which makes medical students reckon it up as two,
if not four, diseases. Pathology suffers as much by being split
up artificially into that of children, and men, and women, as
anatomy would by being taught in the same fashion.

Dr. Gee very properly makes the most elaborate part of his
paper that upon diagnosis, for upon our being happily able to
exclude our patient from the category of a case of tubercular
meningitis rests our only possibility of a favorable prognosis, our
only opportunity for expecting any advantage from therapeutics.
The latter consists in keeping up the strength on the chance of
our diagnosis being wrong, preventing violent measures being
adopted, and if the corneae begin to ulcerate, keeping the eyelids
closed with a piece of sticking plaster.

*' Congestion of the brain " is a very important subject, and
is treated of by the editor himself, with the assistance of Dr.
Bastian. Congestion of the brain is the first stage of two
pathological processes, haemorrhage and inflammation, each of
which is represented in this volume ; yet we are glad it has an
article to itself, because it is the first stage also of a third pro-
cess, more important than either, namely, that of recovery, and
it is peculiarly as the curable stage of acute cerebral affections
that it claims notice. In opposition to the views of Kellie,
Abercrombie, and Reid, Dr. Bastian believes that observation
and experiment alike show the amount of blood existing at
one time in the cranium to be liable to variation, and he con-
siders that too much stress has been laid on the mechanical
peculiarities of the cerebral circulation. He holds, therefore,
that its hyperaemia is a reality, and that it may arise, like
hyperaemia elsewhere, from two caxises, mechanical impediments
to the due return of blood and vital irritation. In accordance
with this pathology. Dr. Reynolds divides the symptoms into
those constituting an apoplectic, convulsive, delirious, and febrile
form of the disease, and apportions the treatment accordingly.
His unprejudiced observations about detraction of blood are most
judicious, as are those about other therapeutical measures. One
hint about bedding we have found so valuable we cannot forbear
from extracting it : —

1868.]

Reynolds' System of Medicine. 295

" Much relief may be obtained by ensuring a position during sleep
which shall prevent not only the head, but the head and shoulders
from sinkiug down to the level of the body. This may be easily
obtained by a simple contrivance placed under the bed or mattress
upon which the patient lies ; such an arrangement being much better
than a mass of pillows, Avhich shift their places, and often maintain
the head in a condition of undue heat."

The same authors handle *' cerebritis," " softening of the
brain," and " adventitious products." The intention of the
first-named paper is apparently to recognise inflammation of the
substance as* arising from meningitis, and to exclude it as neces-
sarily the pathological condition in " red softening." In accord-
ance with this pathology we find here described an " apoplectic,
convulsive, and delirious " form of symptoms in acute softening,
but not a "febrile," as in cerebral congestion. Of chronic soft-
ening, the symptoms are described as paralytic, either sudden
or gradual. As to causes, while it is allowed that alterations in
quality of blood and diminished nutritive activity of tissue
elements may be looked upon as accessory causes of no unfre-
quent occurrence in the production of cerebral softening, espe-
cially in old people, yet practically the etiology of the disease
is to be sought in impediments to the circulation of the blood.
These are classified in the following manner : —

Morbid conditions of
cerebral vessels.

r . , . f Embolism.

Obstructing circula-J * ' ' L T^^^'onibosis.

tion. I Capillaries . . Embolism.

[_ Veins and sinuses . Thrombosis.

Pi'eventing osmosis and uutri- f Diseases of coats of capil-

1^ tive exudation. \ laries and small arteries.

The explanation of non-traumatic red softening as a conse-
quence of mechanical obstructions to the circulation, and the
consensus of evidence to the production of redness and swelling
by this process from the analytical experiments of Cohn, Vul-
])ian, Prevost, Cotard, from the application by Marey and
Weber of the laws of hydrodynamics to physiology, and from
the anatomical observations of Rokitansky, is clearly placed
before the reader in abstract.

The remarks on prognosis are extremely judicious. It is
pointed out that cceteris paribus the lesion is in proportion to
the extent, rather than to the violence or abnormal character, of
the phenomena ; and therefore the prognosis is worse when the
mind, sensation, and motion, are all slightly impaired, than
when either one of them alone is profoundly aifected ; also that
if there is evidence of much collapse or congestion, the disease

296 Reviews. [Oct.,

may quickly pass away, however severe the symptoms ; whereas
the same amount of symptoms without congestion or collapse,
would be of extremely grave import. Altogether, this is
more encouraging than the usual way of treating the same
subject.

" Adventitious Products in the Brain," shortly records what
is known concerning such morbid matters as are not of suffi-
ciently frequent occurrence as to have an article to themselves,
such as cysts, hydatids, nodes, &c. It contains a great many
references, which we trust are all correct.

In "Apoplexy and Cerebral Haemorrhage," Dr. Hughlings
Jackson always keeps in view the two parts of his subject as desig-
nated by the ingeniously constructed title. He confounds them
neither in pathology, prognosis, nor treatment, as is too ofteji
done by both writers and practitioners. We are sorry for the
necessity, we feel sure it was a stern necessity, which forced the
editor to shear this essay down to half its length by the omission
of the illustrative cases. It is worthy of notice that Dr. Jackson
has never seen but one person bled for cerebral haemorrhage, an
innocence from blood-guiltiness which many of his readers will
envy.

Dr. Gull has taken advantage of " Abscess of the Brain "
being comparatively a rare disease, to treat the subject ex-
haustively by a collation of all the cases he could find suffi-
ciently well recorded. We are so glad to get such a good crop
of these that we will not grumble at giving up the ground
(thirty-four pages) to its growth. It will be a classical Memoire
pour servir.

Diseases of the Columna Vertebralis fall into the hands of
Dr. Kadcliffe. Their separate consideration is prefaced by
some excellent preliminary remarks on the physiology of the
part, and on what may be called its physiological pathology,
that is to say an inquiry into the true significance of pain,
spasm, and certain symptoms analogous to pain and spasm
which figure conspicuously in the histories of spinal maladies.
Thus is saved a good deal of digression or possible repetition in
what follows. The revolution which Dr. Browai-Sequard's
observations have made in nerve-physiology, the deposition of
the spinal cord from the throne upon which Marshall Hall had
placed it as the centre of a system, and its re-institution as a
conductor, the reconcilement of the apparently contradictory
results of lateral and vertical sections of the cord, and other
results of the researches of the above-named physiologist, and
of Mr. Lockhart Clarke, have made it needful for us all to go
back to school during tlie last two years, if we would do more
than prescribe by routine. And we think it probable that the

1868.] Reynolds' System of Medicine. 297

great majority of the readers of the * System,' will be thankful
to have these results, albeit not medical, put before them in a
clearer form than an original discoverer can attain to. We
would especially commend the simplification of Dr. Brown
S^quard's diagram.

In the latter part of his preliminary remarks the author
reiterates the conclusions which he placed before the College of
Physicians in 1862, namely, that pain and fever are antagonistic
to one another, and that this warning is evidence of a present
state, which is diametrically opposed to inflammation, though
it often passes into" it, which is in fact the swing of the pen-
dulum in the opposite direction, and also that spasm has the
same significance as pain, and is equally opposed to an inflam-
matory condition.

It is to be remarked that " inflammation " is here held to
mean increased quickness of circulation, combined with an
increased amount of blood in the capillaries. Dr. Radcliffe
does not define it so, but it is evident from the context that he
narrows the word to that sense.

The cases Avhich illustrate the articles on " Spinal Meningitis,
Myelitis, and Congestion," are very good evidence of Dr. Rad-
clifFe's propositions ; pain and spasm ai-e conspicuous by their
inconspicuousness. We think this more striking than would
have been their entire absence ; for in persons so very ill as
these patients, the predominant anaesthesia and paralysis must,
of course, by mere reaction, elicit a certain amount of the
opposite state, during the acute stages of the illness. It is the
predominance of symptoms, rather than their exclusive presence,
which is the test of their being the real outcome of the lesion
they are associated with. We give vent to this suggestion with
some reserve, but still we think it applicable to more diseases
than that immediately before us.

In the cases above referred to the post-mortem appearances
in the spinal cord were clearly enough relics of acute inflam-
mation. " Tetanus," with its absence of special morbid changes
in that viscus, and its exhibition of pain and spasm, comes next
in marked contrast. We think Dr. E-adcliffe's way of taking a
typical case as his text and appending to it what he has to say
on the subject contributes to condensation, and incontestably
adds interest to the matter. In discussing the etiology of this
frightful and fatal complaint, the author does not attempt to
trace any connection between the acknowledged causes, cold and
damp and wounds, and the production of such a fearful conse-
quence in only a few cases. He simply quotes the usual enume-
ration of the prominent circumstances, and the period of the mani-
festation of the results. He does not either point out its relations

298 Reviews. [Oct.,

to hydrophobia, except as regards external symptoms under the
head of diagnosis. We are surprised at this, because in the
therapeutical part of his essay an analogy has suggested itself
to his mind which we have often thought might be Avorked out
into fertility, Ave mean that of snake-bites. He points to the
cases of recovery after poisoning by the cobra and rattlesnake
when excessive quantities of stimulants, such as alcohol and
eau-de-luce, have been administered, as an encouragement to
drench with the same agents, in the same excess, our tetanic
patients. Ought not this suggestion to lead further? May
not the connecting link between chilled Avounds and spasmodic
paroxysms be an animal poison generated in the wound dui'ing
the process of healing ? And, being an animal poison, there-
fore poisonous in extremely minute doses ? And, being an
animal poison, therefore latent in the system for long periods?
And, being an animal poison, therefore specially fatal to the
nervous system ? The greater tendency of punctured and closed
wounds to cause tetanus is \^ery suggestive of the needlelike
serpent's fang, and the frequent triviality of the dog's bite,
which are the more deadly the less blood flows. The inocula-
tion of animals with the matter from the Avound might be an
experiment worth trying in deductive pathology.

The article on " Spinal Irritation," we fear, is a somcAvhat
dangerous one, as tending to erect into a separate class cases
culled from hysteria, hypochondriasis, and neuralgia, and capa-
ble of being successfully treated on the principles already
enunciated under the headings in this volume. Dr. Radcliife
does not give a single symptom pathognomonic of his disease
which is not included in the description of those above named
by Drs. Reynolds, Gull, and Anstie. Equally Avith them, ho
" pours in oil and wine," and uses blisters to the painful spots ;
though Avhy, when recommending this treatment, he quotes
Avithout reprobation Mr. Teale's proposal to employ local deple-
tion by cupping and leeches, Ave cannot imagine.

The most interesting of the remaining subjects treated by the
same author is reflex paraplegia. Of this our knowledge is
almost entirely derived from that form in Avhich lesions of the
urinary organs cause incomplete loss of power in the legs. Its
diagnosis from the paraplegia dependent on spinal myelitis is
deeply interesting, and important to both patient and patholo-
gist, for it is an eminently curable complaint, Avhereas in the
last-named recoA^ery is the exception. The hints given by Dr.
Radcliflb Avill be exceedingly useful to the practitioner, for upon
his diagnosis depends Avhether he shall apply his remedies to
the bladder or to the spinal cord, and Avhether be shall lead the
sick to anticipate restoration of health or make up their minds

1868.]

Reynolds' System of Medicine. 299

to a gradual augmentation of the infirmity. Dr. RadclifFe differs
from Dr. Brown-S^quard in the pathology of this paralysis ; that
physiologist is well known to have considered it as a phenomenon
of " irritation" of the vaso-motor nerves of the exciting organ,
say of the bladder, and to have connected it with a state of
capillary contraction and comparative bloodlessness ; whereas
our author traces it to an inflammatory condition, especially
suppurative, especially chronic. Certainly it would seem a strong
objection to Dr. Sequard's view, that in states where the whole
nervous system is in a state of great apparent activity, as in
tetanus, where it may be presumed that the vaso-motor nerves
participate in this state of irritation, and produce vascular con-
traction and anaemia of the spinal canal, paralysis is precisely
the symptom which is tiof present. Whereas it is long con-
tinued conditions of the bladder, or prostate, or kidneys which
notoriously originate paraplegia.

The article of Mr. Netten Radcliife, on the pestilential nervous
fever which has lately attracted so much attention from appear-
ing as an epidemic in Dublin, ought doubtless to have accom-
panied the other zymotic diseases in the first volume. But it
does not appear to have been ready at the date of that publica-
tion ; indeed some of the valuable information which it puts
before us is on facts too recent to have been then collected. So
it has been placed among " the affections of the nervous system,
to which it bears the closest relationship" muler the name of
** Epidemic Cerebro-spinal Meningitis." We think it would
have been better to have put it in an appendix altogether, for
it has no more business here than typhus would have among
diseases of the lungs. The recent recognition of this as a dis-
tinct fever, and the number of active men who are in various
parts of Europe working at the subject, would have been an
additional reason for delay, for our information is gaining, if
not in quantity, yet at least in accuracy, daily. The laws of
its spread and diffusion are deeply interesting to us in this
island, for hitherto England and Scotland have escaped the
development of the disease into an epidemic, in spite of several
sporadic instances having occurred, and we should be glad to
learn how to retain our purity. The suggestions of Dr. Richard-
son as to the possible generation of the disease by an organic
jjoisonous growth in decayed corn urgently demand investiga-
tion ; for they will certainly create a panic, which, if justifiable,
should be encouraged, but, if groundless, must be instantly
arrested by correct information, as it would raise the price of
food.

Of the articles on diseases of the nerves the most important is
that by Dr. Anstie, on " Neuralgia." Tlie graphic character of

300 Revietvs. [Oct.,

the clinical history of the disease as here given is unconsciously
added to by the fact of the describer being himself a sufferer.
We think too that such a misfortune makes a man's opinions as
to the pathology more valuable ; for he must be conscious of
minor changes and slight symptoms, which would not be
recorded by a non-medical patient, or not observed in another
person, and is thus able to speak with great weight of those
early modifications of function which are the clue to the real
nature of diseases. We should be glad to have a collection of
accounts of their own cases by medical physiologists. As to
treatment we are not so sure that it is an advantage, for the
effect of special remedies on a man's own constitution is apt to
over prejudice him in their favour in spite of the different con-
stitutions of those who consult him. We must have all observed
how a physician of large stomach and appetite will stuff his
patients, how the hard ascetic will starve them, how liberally a
lover of the gifts of Bacchus will dispense them to him that is
ready to perish, how one that has found water agree best with
himself will expect the sick as well as the sound to be tee-
totallers.

To illustrate what we mean, as to pathology, we wouhl
especially point to the author's observation of the previously
anesthetic condition of the parts about to become painful —
to his distinction between the point of tenderness and the seat
of spontaneous pain, to his notice of the modifications of
vegetative life, such as the atrophy of the hair, and the local
epithelial coating of the tongue in the track of the affected
nerves.

Dr. Anstie adds his testimony to the opinion that pain is an
evidence of lowered vitality, not an exaltation, and that painful
parts feel less, in respect of answering the purposes of feeling,
than when in a normal condition. He advocates, also, the
doctrine of an organic change in the centres of innervation,
rather than the peripheries, as the cause of neuralgia ; though
he liberally gives the reader an opportunity by copious references
of seeing the opposite advocated. And he views this organic
change as of an atrophic nature.

On the ansesthesise and spasms which depend on local lesions
of the nerves there is not much to b6 said in the medical trea-
tise, but what there is seems well said by Dr. Warburton Begbie,
except a few pages on " Wry-neck" by Dr. Reynolds.

The rest of the volume is occupied by Dr. Wilson Fox, who
■writes on diseases of the stomach. Of this, about half is
a revised edition which has already been before the public in a
monograph entitled " Diagnosis and Treatment of Dyspepsia,"
which we reviewed in the ' Medico-Chirurgical Review ' for

1868.^ Reynolds* System of Medicine. 301

October last (No. LXXX). We then described it as highly
creditable to its author, and as giving a comprehensive sketch
of the different vievv^s which have been taken from time to time
by the highest authorities in medicine relative to the nature of
the disease, and which are taken at the present of the many
problems on doctrinal questions involved in this dark subject.
The first three chapters of that work, viz., " On the Nosological
Classification of Dyspepsia ;" " On the General Symptomato-
logy of the Stomach ;" " On the General Symptoms and Causes
of 13yspepsia," are here condensed into one article on the " Dis-
orders of Function," with advantage, we think, to the vividness
of the impression produced ; for we do not seem to miss any-
thing, and certainly remember the points of the argument better
in the later work. Then comes an article on " Atonic Dys-
pepsia," in which we see sufficient additions to show that the
author's mind is continually engaged in the practical part of
the subject, which in this most common of all the diseases of
digestion has principal play.

Under atonic dyspepsia Dr. Fox classes all those cases both
where the loss of functional power is an expression in the
stomach of an universal loss of functional power, a generally
depressed vitality, and also where it is the result of local
atrophy or degeneration ; for, as he truly says, " the vital phe-
nomena exhibited are frequently clinically undistinguishable."

The next article " On the Neuroses," or nervous affections of
the stomach, is principally remarkable for the copiousness of the
therapeutical suggestions contained therein ; showing that they
are an eminently curable class of disorders, which while they
reward investigation in that direction, yet are apt to fix a false
value on the means employed. Much more important than this
long list of remedies is the remark by Dr. Fox, that they may
be treated advantageously by modifications of the tonic and
stimulant plan recommended by him for atonic dyspepsia, and
that their cure under this system affords valuable proof of their
true nature.

Under " Acute Gastric Catarrh," the author includes a large
range of cases extending from the embarras gastrique of French
practitioners to ihefebris mucosa of Frank, and actual ery the-
matic gastritis, where suppuration takes place in the cellular
tissue of the parietes of the organs. It seems to be the degree
rather than the extent of the morbid process, which constitutes
the case as one almost absolutely fatal, or so slight as hardly to
require medical attendance. Yet that these slight " bilious
attacks" are of the nature of inflammation, seems sufficiently
evidenced by their being so often the commencement of that
congested thickened condition of the gastric secreting mem-

84— iLii. 20

302 Reviews. [Oct.,

brane, which is here described and illustrated by woodcuts as
" chronic catarrh."

The remainder of Dr. Wilson Fox's contribution has not
been before published. It describes the various organic lesions
found in the stomach after death, and allots to them the various
pathognomonic symptoms by which they may be detected clini-
cally. The headings are " Chronic Ulcer of the Stomach and
Duodenum ;" " Cancer of the Stomach ;" " Haemorrhage ;"
" Hypertrophy of the Walls ;" " Stricture and Obstruction of
the Cardiac Orifice ; " " Obstruction of the Pylorus with
Dilatation ; " " Softening ; " " Perforation ; " " Rupture ; "
" Tubercle." Of these, the most elaborate is the first, to
which that on haemorrhage may be considered as an ap-
pendix ; indeed, for an interesting portion of it (the treat-
ment) the reader is told to "see Ulcer of the Stomach." And
rightly is it made the chief object of attention, for the lesion
that it describes is the only one that admits of cure, and upon
our knowledge of the true nature of the morbid processes in-
volved must rest our hopes of success in that direction. The
next in length is that on " Cancer," in Avhich the great interest
turns upon diagnosis, as in all the rest of the articles which
follow. We think this should have been more borne in mind
by the author, and a due perspective observed in selecting the
amount of information laid before the reader. For the sake of
a few more references to authoritative observations on the
diagnosis of cancer, a matter always of intense interest to the
patient, we would gladly have spared some pages of statistics.
And, on the other hand, on the question of ulcer, we should
have expected to see brought more prominently forward a good
many of the original researches on the pathogenesis of the
disease to which reference is given in a note.

Before we conclude, some notices are due upon the general
conduct of the volume, and we cannot but congratulate ourselves
upon an improvement being manifested in some particulars
which Ave previously ventured to criticise. The foppery of enu-
merating synonyms of diseases which are not synonymous, in a
number of languages which nobody ever reads, is given up.
The references are fuller, and we are not so often startled by
the bracketed quotation of some surname, familiar, perhaps,
to the writer, but unknown to us and to our successors. We
are not quite satisfied with the binding of the volume ; it is
scarcely strong enough for its size, and two of our sheets have
become loosened from the stitches in the act of reviewing.
And we shall be afraid of having it bound, lest the valuable
tables in Dr. Gull's article on " Abscess of the Brain," should
get sewn into the back. Not only in these tables but through-
out, the margin is very narrow.

1868.] Mitchell on the Rattlesnake Venom. 303

To continue our grumbles — with reference not only to this,
but to almost all publications — why cannot the edges be cut?
Who would not willingly pay threepence a volume extra,
and sixpence extra if the tops were gilt in the Fonthill fashion,
to be saved this constant annoyance ? They manage these
things better in America.

Review II .

1. Researches Upon the Venom of the Rattlesnake, lOith an Inves-
tigation of the Anatomy and Physiology of the Organs Con-
cerned. By S. Weir Mitchell, M.D., Lecturer on Phy-
siology in the Philadelphia Medical Association. Published
as one of the Smithsonian Contributions to Knowledge.
Accepted for publication, July, 1860.

3. On the Treatment of Rattlesnake-bites, with Experimental Cri-
ticisms upon the various Remedies now in Use. By S. Weir
Mitchell, M.D., Lecturer on Physiology, &c,, Philadelphia.
J. B. Lippincott and Co. 1861.

3. Experimental Contributions to the Toxicology of Rattlesnake
Venom. By S. Weir Mitchell, M.D., Member of the
National Academy of Sciences, &c., New York. Moorhead,
Simpson, and Bond. 1868.

''Animal Poison.^' This is a term very generally made use
of to indicate certain kinds of animal matter in some septic
stage of decomposition ; but there is, evidently, another sense in
which the term may be applied, and that too with even a more
rigid and appropriate accuracy.

The alarming, the sometimes fatal effects, resulting from the
bites of venomous animals, would seem to require the designate
of " animal poisoning " whilst the material producing such con-
sequences is, in the truest and broadest sense, an " animal
poison."

That the investigation of this poison, or more correctly speak-
ing, that the investigation of these poisons (for, at present, we
have no proof of the poison of the various venomous serpents
being identically the same) should prove a subject of high interest,
and that an experimental inquiry into their chemical composition,
as well as into the mode by which their terrible effects are accom-
plished, should serve a very useful purpose can very readily be

304 Reviews. [Oct.,

understood, for independently of the knowledije to be acquired
by these means, as limited to the bites of venomous reptiles, and
the best method of treating such injuries, it is very far from being
improbable that researches of this description may aid, both
directly and indirectly, in solving some of those problems con-
nected with "blood diseases'^ which have hitherto defied the
questionings of our most astute pathologists.

In Great Britain, fortunately, our personal experience in the
matter of venomous serpents has been of the most circumscribed
character, and hence it has happened, it may be supposed, that
those of our countrymen who have written about them have
confined their observations pretty much to the natural history
and ordinary descriptive anatomy of these creatures ; the general
bibliography of the subject is, nevertheless, a tolerably extensive
one, and includes the names of many of the most distinguished
scientific men of difterent countries and of very ancient dates.
Notwithstanding this, it is worthy of remark that a complete
and, in every way reliable account of serpent venom has been
(until within the last few years) nowhere to be found in the
writings of any single author, nor, indeed, from the writings
of all those who have contributed to the literature of the subject
up to a recent date, collectively, can a full, comprehensive, and
satisfactory account be gleaned. It is not meant by this that
serpent venom, and the effect it is capable of producing in men
and in animals, has not been studied and in written about by many
able men, but simply that the crude and imperfect investiga-
tions made in years gone by require the corrections to be
obtained from advanced science — errors to be erased — facts to be
supported, and cohesion to be perfected between such facts, as
being of a past period, and the additional facts and information
arrived at in this our time, acquired by modern means applied
to modern research.

Upon the subject-matter before us, the writings of Charas,
of Redi, of Mead, and many others during the seventeenth cen-
tury, added no really important knowledge to that furnished
and handed down to us by the Greek and Roman fathers of
medicine ; or if these authors added anything to such know-
ledge, it is not going too far to say the information communi-
cated was purely conjectural in its character; but in 1767 an
admirable and vigorous effort was made by the Abbe Fontana
to exhaust the subject of viper venom, and a record of his
three thousand experiments served to impress the mind with an
idea that he could scarcely have failed in the accomplishment
of his object.

It is nearly impossible to over-estimate the value of Fontaua's
Essays '' On the Venom of Serpents ;" they must be considered,

1868.1 Mitchell on the Rattlesnake Venom. 305

beyond all question, as an indelible record both of his industry
and sagacity, and that they served to clear the way for subse-
quent research, and removed many existing absurd notions and
vain conceits, is past all denial ; still, with their many excel-
lencies, they contain not a few errors, which, however, have
only been proved to be such by the light and advantages gained
(and guided) by, and through, an improved and more perfected
science.

Beyond some desultory communications on the toxicology
of venom, and frequent but unsatisfactory statements as to
what may, perhaps, be called the therapeutics of snake-bites,
nothing of noteworthy interest occurred until 1817, when
Mangili asserted, and proved, that serpent venom when taken
by the mouth is perfectly innocuous : later on (1843), Prince
Lucien Bonaparte pronounced his opinion, and subsequently
verified it by experimental analysis, that the venom of serpents
is of an albuminous nature. From this date there has been
no modern work devoted to the consideration of serpent venom,
and the anatomy and physiology of the venom apparatus, until
1860, when the first of the works of Professor Mitchell, at
the head of this notice appeared. This contribution was pub-
lished for and through the Smithsonian Institution : as all
works so published are submitted to the examination of a
highly competent committee before publication, there is in this
circumstance alone a guarantee that it is a book of no ordinary
merit. It is a large quarto volume of 117 pages, and contains
some excellent woodcut illustrations. The contents have special
reference to the venom of the rattlesnake, and the anatomy
and physiology of the various organs concerned in the secre-
tion and emission of the poison.

The work is divided into eight chapters. The first chapter is
occupied with attentively made observations on the habits of the
*' Crotalus'^ (the particular species of rattlesnake on which all
the professor's observations and experiments were made) when
in captivity; the inactivity of the creature, the difficulty of
getting it to take food, the necessity for artificial feeding and
the best method of effecting this somewhat ticklish proceeding.
It appears that although unwilling to eat when in captivitv,
the creature displays no similar indisposition as regards taking
water ; a plentiful supply of fresh water, every day, is abso-
lutely necessary to preserve the health of the " Crotalus'' when
in confinement.

The process of changing the skin is fully entered into, and
also the question of the loss of the fangs ; our author being of
opinion that such loss takes place during the change of skin,
and, as with some fishes that change their teeth, the loss of

306 Reviews. [Oct.,

fangs occurs several times in the course of the year. Professor
Mitchell considers that, as the outer layer of the cornea is shed
with the skin, it is true that serpents are, at any rate to some
extent, blind during the shedding of the skin.

Lastly, the supposed power of fascination possessed by ser-
pents is discussed : on this subject T)r. Mitchell has formed a
very decided negative opinion, and gives an amusing account
of a variety of instances tending to conclusively refute this, at
one time, very generally believed in faculty.

The second chapter contains a most admirable and carefully
detailed account of the anatomy (general and microscopic) of
the venom apparatus ; the various structures, and even the
weights, particular and relative, of all the parts concerned, are
minutely entered into ; whilst some original observations on the
peculiar formation and functions of the gland duct give an
additional value, and lend an increased interest to this part of
the work.

The third chapter treats of " The Physiological Mechanism
of the Bite of the Crotalus.^' The writer commences the
chapter by remarking that —

" Of the many authors who have treated of the anatomy and
physiology of tlie rattlesnake, and other venomous serpents, no one
has entered fully into the subject of the mechanism of the move-
ments which inflict the bite and inject the poison. Eedi, Pontana,
Tyson, Eanby, Smith, Home, Duvernoy, Soubeiran, and others,
have nearly all in turn contributed something to this subject, but I
find nowhere a full and complete account of the part played by the
various muscles, and of the exact uses of many of the peculiar
arrangements of tissue which characterise the poison apparatus.
Nothing, in fact, can be more admirable than the mode in which the
motions in question are effected, and yet, while they interest the
physiologist, from the wonderful example they aff'ord of a series of
complex acts following one upon another in ordered sequence, to
effect a certain end, they are not less interesting to the physician,
who may learn from their study how he may be deceived as to the
occurrence of poisoned wounds, and how the snake which appears to
strike may really fail in its object, even though seeming to have
inflicted a wound."

He then proceeds to give a very graphic narrative of all the
elaborate movements made, from the period of the snake pre-
paring to strike, up to the actual infliction of the wounds, and
the withdrawal of the fangs ; with regard to this last act, i. e. the
withdrawal of the fangs. Professor Mitchell observes ;

" It happens not unfrequently, that the teeth of the lower jaw
catch in the skin of the bitten animal, and thus prevent the snake
from retreating at once. When this takes place, the serpent shakes

1868.] Mitchell on the Rattlesnake Venom. 307

its bead from side to side, with a motion which, so nearly resembles
the shake a dog gives his prey, that it has been mistaken by at least
one observer for an expression of rage. It is really an attempt to
escape ; nor is it always successful, since a large animal will often
drag a snake until the fangs themselves break loose, and are left in,
or on, the bitten part."

The following sentence concludes the chapter :

" So far as I am aware, it is the only full account of the mode in
which the bite is given, and of the parts played by the different
organs and tissues concerned."

The fourth chapter is devoted to a consideration of "The
Physical and Chemical Characters of the Venom ;" whilst these
characters are fully and ably descanted on in the body of the
chapter, some very lengthy and interesting foot notes afford the
necessary information as to how the venom is procured — the
best method of securing the snakes, and of obtaining the
poisonous secretion. Pr. Mitchell, after enumerating the various
plans adopted by others for securing, without personal danger,
a supply of venom, enters into a description of the course he
himself adopts for the accomplishment of this purpose. He
stupefies the animal with chloroform; about twenty minutes
being the time necessary to effect this. He says if, at the
expiration of this time, —

" The lower jaw hangs relaxed when opened, the neck is seized
firmly, the fang caught on a saucer edge, and the glands stripped
from behind forwards by pressure with the thumb and forefinger.
The venom usually escapes alongside of the fang, from under the
mucous cloak."

The operation is, no doubt, an effectual one ; but from the
danger (real or imaginary) attending its performance, we can-
not look upon it in the light of a very inviting proceeding.

The quantity of venom obtainalsle depends upon two or
three circumstances : the size of the animal, its healthiness,
and the length of time it has been without using its fangs.
Fifteen drops appear to have been the largest amount Dr.
Mitchell ever saw ejected by a natural process, and twenty-
nine drops the greatest amount he ever found a single venom
gland capable of holding.

The colour of serpent venom varies from ''a pale emerald
green to orange and straw colour ;" and when it has remained
any length of time in the gland it is " of a darker hue than
when its ejection follows rapidly upon its formation." No ex-
perimentalist has ever attempted to obtain the specific gravity of
serpent venom ; indeed, the difficulty of getting a sufficient

308 Beviews. [Oct.,

supply for such a purpose is so great as to offer an apparently
insurmountable obstacle. Our author^ however^ has adopted
an ingenious process by which he is enabled to offer an ap-
proximation to this desirable object. He thinks the venom
may become somewhat concentrated by remaining long in the
gland, and fixes the mean specific gravity at about 1035.

The venom of the Crotalus when fresh, is described as being
devoid of either taste or smell, whether in the fluid or dried
state. Some authors, as Mead, and Brainard, speak of the
poison as having " a peculiar and disagreeable odour ;" and
Mead asserts that it has an acrid and caustic taste. Jeter de-
scribes it as tasteless, but having the power to benumb the
tongue when placed on that organ. Professor Mitchell tasted
the venom of the Crotalus upon several occasions but could
not recognise any such action.

Most authorities have represented the chemical reaction of
rattlesnake venom as being acid, and Dr. Mitchell's experience
is confirmatory of this; but he pronounces the reaction of the
mucous membrane of the mouth of the Crotalus to be alkaline;
in fact, so much so, that litmus paper reddened by the action
of the venom became blue when left for a short time in con-
tact with the serpent's jaws. Although the poison is subject
to decomposition, and when kept long in the moist state smells
most abominably, it, nevertheless, still retains its fatal qualities.
It is not a little singular that whilst rattlesnake poison in a
state of decomposition, loses none of its deadly virulence;
vibriones, rotiferae, and other forms of minute animalcular life,
are found to appear in it when in this condition. Professor
Mitchell is not satisfied with the analysis of viper venom given
by Prince Charles Lucien Bonaparte in his essay, and after
stating the grounds on which he bases his objection, explains
the process he has himself adopted, and gives as the result the
following as the composition of serpent poison.

" 1. An albuminoid body. Crotaline, not coagulable by heat of
212° Far."

" 2. An albuminoid compoimd coagulable by a temperature of
212° Far.

" 3. A colouring matter, and an undetermined substance, both
soluble in alcohol.

" 4. A trace of fatty matter.

"5, Salts, chlorides, and phosphates."

In reference to the point which has sometimes been raised as
to whether the poison gland of the serpent tribe is to be re-
garded as a true salivary gland, or not, it is remarked :

" The argument from anatomy alone would certainly teach us to

1868.] MiTCHKLL on the Rattlesnake Venom. 309

respect this view as correct, and to consider the poison gland as a
true salivary organ. Its position and general structure all favour
this idea, just as the appearance and minute anatomy of the pancreas
were once believed to authorise us in placing that organ among the
salivary bodies, and in giving to it the name of the abdominal
salivary gland. But in this case, as in the one before us, the broader
light of physiological inquiry has I'evealed the truth, that anatomical
resemblance, even to the minutest details, does not of necessity
involve physiological likeness." * * * *

And then as to the secretion itself, the writer proceeds to

say—

" Lastly, its singular nature as a ferment, poisonous to other ani-
mals as well as to its owner, constitutes a distinction, which, with
the other points of difference already considered, forbid the physiolo-
gist to regard it, in any true sense, a salivary secretion, or its forming
organ as a salivary gland."

With regard to the effects of various temperatures, and the
influence produced by certain chemical agents on the activity
of the venom, we have in this chapter some interesting and
really valuable information, a considerable amount of such in-
formation being the produce of original research. The experi-
ments described are very numerous, and Dr. Mitchell says that
he planned and executed them for the purpose of increasing

" Our knowledge of the influence of physical and chemical agents
upon the noxious properties of venom."

And he adds,

" They clear the ground for more just conceptions of the real value
and therapeutic possibilities of antidotes."

From the experiments referred to

" It seems that nexihev freezing , nor prolonged iot7»?zy, deprives the
poison of its life-destroying capability."

When the venom was treated with alcohol, oil of turpentine,
solutions of nitrate of silver, ammonia, soda, and potassa (short
of caustic strength), the action of the poison was neither altered
nor delayed ; even when mixed with strong nitric, sulphuric,
and muriatic acid, with ammonia, chlorine water, iodine, &c.,
the potency of the venom was not interfered with.

The fifth chapter relates to the " Toxicology of the Venom of
the Crotalus," and the first observations are addressed to a con-
sideration of the eflfects produced on living vegetable matter,
both iu the lower and higher vegetable existences ; the evidence
as to serpent venom being capable or not of producing any

310 Reviews. [Oct.,

pernicious eflfect upon vegetable life appears to be very conflict-
ing ; for, whilst Dr. Salisbury in the ' New York Journal of
Medicine,' vol. xiii, new series, 1854, p. 337, gives a circum-
stantial and methodical account of having succeeded in poison-
ing four shoots of young lilac, a small horse-chestnut of one
year's growth, a corn plant, a sunflower plant, and a wild
cucumber, Professor Mitchell has signally failed in producing
any such eff'ect upon such plants as he has experimented upon.
The following account appears in a foot note :

" An amusing story, which passed through three persons, reached
the 'Philosophical Transactions,' vol. xxxviii, p. 321, in the tbllowino'
form : Sir Hans Sloane learned from Col. Beverley (' Hist, of Ya.,'
2nd ed., p. 266), that Col. James Taylor, of Metapony, had stated to
him that, having found a rattlesnake, he cut off his head, with three
inches of his body. A green stick, the bark being peeled off, was
put to the head. It bit it, when small green streaks were observed
to rise up along the stick towards the hand. At this juncture,
the colonel wisely dropped the stick, which, in a quarter of an hour,
of its own accord, split into several pieces, and fell asunder from end
to end."

Two sets of experiments made by our author to see whether
the venom of the " Crotalus'^ would, or would not, prevent the
germination of seeds, aff"orded evidence of the poison preventing
germination ; the seeds used were canary and mignonette.

Turning now to the action of venom on animal life. Dr.
Mitchell makes the following appropriate commencement :

" In place of doubtfully deciding as to the cause of death, we are
summoned to witness the operations of a substance which sometimes
acts with a potency so swift as to defy observation, and which has
a power to alter the blood and tissues in a moment, and with a
celerity which is a source of unending wonder, even to one who,
by daily repetitions, has become familiar with the changes thus
produced."

We have then a lengthened series of experiments on cold
blooded animals and on the animal itself; the whole observed
facts of each experiment are thoughtfully and lucidly related and
the results compared with those arrived at by other observers and
experimentalists.

The sixth chapter is occupied with an examination of the
" Toxicological Action of the Venom upon Warm-blooded
Animals." A long list of experiments upon pigeons, rabbits,
and dogs, is given, and a table of symptoms is appended to the
experiments made upon the pigeons and rabbits. In every in-
stance in which death occurred, a post-mortem examination was

1868.] Mitchell on the Rattlesnake Venom. 311

carefully made, and a very ample and clear account of the
pathological condition of each part is given.

The '' Action of the Venom on the Tissues and Fluids/'
forms the subject of the seventh chapter. The power of the
stomach to absorb the venom of serpents is the most important
question here brought forward. The experiments of Harlem,
Mangili, Russell, Davy, and others, are all referred to and
their evidence taken as conclusively establishing that the un-
broken mucous surface of the stomach is incapable of absorb-
ing this poison, " or of admitting it into the system in any
form possessing noxious properties."

The effects of the venom on the pulmonary tissue, on muscle,
on the heart, on the capillary system, upon the intestinal
movements, upon ciliary movements, upon the nervous system,
the sensory and motor nerves, and the nerve-centres themselves,
upon the calorifacient functions, and upon the blood, are all duly
considered and discussed through the medium of well devised
and adroitly carried out experiments.

The eighth and last chapter refers to " Crotalus Poisoning
in Man." Dr. Mitchell begins this chapter in a somewhat
apologetic strain ; and as his own words will best convey an
idea of the difficulties under which he has laboured, when
endeavouring to make this part of the work as complete and
accurate as he wished, we proceed to quote them.

" The cases of rattlesnake poisoning in man have been separated
from the rest of this paper, owing to the difficulty of grouping the
phenomena of human poisoning with those observed in animals.
This diflBculty arose from the imperfect reports of such cases as have
been recorded, and from the fact that, in man, the symptoms were
possibly modified, in some instances, by the remedies used, and were
thus no longer comparable with such as had been seen to exist in
animals submitted to no modifying treatment. *****
Unfortunately, although I have collected at least fifty cases of
crotalus bite, the most of these scarcely deserve the name of medical
reports ; and among the whole number, I have been able to select
but sixteen, which were sufficiently rich in details to be of the
slightest value. The numerous gaps in the accompanying table
show but too well the want of full medical statements of the
order and character of the symptoms, even in these select cases ;
and it is humihating to observe that, of the four post-mortem exa-
minations of the lesions in this mode of poisoning, but.two were made
in this country.

" If, then, in the table of symptoms in man, and in the following
remarks upon them, such a lack of detail is met with as would
disgrace the most ordinary report of ' an interesting case,' the
blame must rest where it belongs, with the physicians of our own

312 Reviews.

country, who have failed thus much in their duty as medical
observers."

After these remarks, the writer proceeds to say that whatever
may be the amount of difference in the virulence of the poison
secreted by the different kinds of venomous snakes, the mode
of affecting the system varies but little whether the injury
be inflicted by the viper, the copperhead, the rattlesnake, or
the dreaded, but not more deadly, cobra. He then gives the
tables referred to in the above quotation, and subsequently
dwells upon the following points: the sex of those injured;
the situation of the wound ; the local symptoms ; amount of
haemorrhage from the wounds ; local results ; the constitutional
symptoms; and the post-mortem examinations he has pre-
viously expressed so much dissatisfaction with.

The remaining part of the chapter is occupied with some
brief allusions to the various antidotes which have from time to
time enjoyed a short-lived reputation. Professor Mitchell
divides these in the following manner :

" lat. Those which remove the poison and the poisoned part —
excision and amputation.

"2nd. Those which partially remove the venom, and more or less
detain it in^ the wounded part :-=-ligature ; scarifications ; suctions ;
caustics.

" 3rd. Those agents which, being injected into the wound, or
wounded part, are supposed to destroy the venom, or to render it
innocuous, as injections of iodine.

" 4th. Local applications of various substances, as alcohol, ammo-
nia, indigo, olive oil, &c."

Of all the above the author seems to think disparagingly,
saving and except amputation, excision, and caustics, when not
too long delayed ; he approves of the administration of stimu-
lants.

At the end of the work there is an appendix (A), which gives
" An Enumeration of the Genera and Species of Rattlesnake,
with synonymy and references," by E. D. Cope.

There is also another appendix (B), giving a most ample biblio-
graphy.

The second work at the head of this article is a reprint from
the ' North American Medico-Chirurgical Review' for March,
1861, and may be considered as a supplement to the first; it
displays the same painstaking and accurate experimental exami-
nation of all the various proposed remedies for rattlesnake bite
that marks the former work, and is, moreover, suggestive on
many topics not mentioned in the larger book. The third con-

1868.1 Mitchell on the Rattlesnake Venom. 313

tribution of Professor Mitchell is also a reprint, in this in-
stance from the ' New York Medical Journal/ for January,
1868. The following extracted paragraphs may serve to show,
perhaps, the motive which gave origin to this publication,
and they may also indicate to those who have read the two
first published communications, the desirability of not neglect-
ing a perusal of this One, containing as it does the most im-
portant of this distinguished physiologist's researches and dis-
coveries in connection with the ultimate mode in which the
rattlesnake venom " affects the economy of animals."

" In the year 1860 I published, through the Smithsonian Insti-
tution, a paper of 117 quarto pages, upon the 'Anatomy, Physiology,
and Toxicology, of the venomous organs of the Rattlesnake.' From
the days of Fontana, 1781, no researches of any moment had
added to our knowledge of the poison of serpents ; and I had, there-
fore, the pleasure of contributing a large amount of completely new
information to the modern history of animal poisons.

" Since the date of my ' Smithsonian Essay,' and of a paper on the
treatment of snake bites which I published in the ' North Amer.
Med.-Chir. Rev.,' March, 1861, I have suspected that in at least
one point I was partly, and in another, altogether wrong, so that it
became an imperative duty to correct my former experiments by a
second, and more careful examination of the dubious conclusions
which I had committed to print.

"As usually happens with those who question nature by the
fertile method of experiment, I was gradually led aside into by-paths,
which proved to be of the utmost interest, so that, besides the ques-
tions with which I started, I have found myself able to answer many
others of equal, and some of far greater interest."

The subjects dealt with are classed as follows :

1 . What is the dose fatal to pigeons ?

2. Why is venom harmless when ingested by animals?

3. What surfaces have the power to absorb venom ?

4. How does it act directly on the tissues?

5. Does it alter the blood, and how ?

6. Is the venom poisonous to the serpent itself?

7. Is it capable of being physiologically neutralized by any
of the agents introduced into practice since 1861, such as the
sulphites and carbolic acid ?

This notice has already been extended beyond the usual
limit ; we cannot, therefore, venture into a seriatim account of
the conclusions arrived at upon the various questions raised
above, but would direct especial attention to the experiments
carried out to determine the manner in which the poison of
the " Crotalus" affects the various tissues as being of the first
importance, and of the highest interest.

314 Reviews. [Oct.,

Dr. S. Weir Mitchell's fame as an original investigator and
physiologist, already places him in the foremost rank; and
we are confident that these contributions to the literature of
a confessedly very difficult subject, cannot fail to add another
leaf to his well earned laurels.

Review III.

St. Bartholomew'' s Hospital Reports. Vol. III. pp. 486.

This volume of * St. Bartholomew's Hospital Reports' con-
tains twenty-five papers, and is prefaced by a memoir of the
late Dr. Jeaffreson, physician to the hospital, who died at the
end of the year 1866. The memoir does no more than justice
to the memory of a most accomplished physician and estima-
ble man, who, although he never lectured on medicine, and,
unfortunately for his contemporaries and for posterity, never
placed upon record the results of his extensive experience, was
nevertheless held in the highest esteem by the students of the
hospital, was consulted by a large circle of patients, and was
beloved by a host of friends. It is satisfactory to learn that,
although Dr. Jeaffreson had barely passed the middle period of
life, his practice had been so successful that he amassed a very
considerable fortune, and was about to retire, at least partially,
from his professional pursuits, when death put an end to his
distinguished career. Although his prospects, on starting in
life, were not brilliant, he never had struggled with adversity :
on the contrary, he was favoured in his youth by the friendship
and active assistance of many persons of influence, and the
advantages thus gained he turned to the very best account, and
fully justified the estimate which had been formed of his cha-
racter by those who were best qualified to form a judgment.

I. Some Statistics of Pt/eemia. By William S. Savory,
F.R.S. — In this paper Mr. Savory has collected the particulars
of what seem to be the main features of 133 cases of pyaemia,
ninety-five of them having been taken from the pages of the
Medical Journals and the remaining thirty-eight having
occurred in the wards of the hospital during three years. All
the cases mentioned occurred in British practice, and no doubt-
ful or questionable cases were included in the tables. Mr.
Savory thinks that in some important facts the records of

1868.]

SI. Bartholomew's Hospital Reports. 315

pyaemia are deficient, as, for instance, in omitting to mention
whether there is any evidence of infection from without, and
whether there has been proximity to other cases. Although
pyaemia is often spoken of as arising from contagion, there is no
evidence to show that it does so in the same manner as scarla-
tina or smallpox. But pyeemia commonly supervenes on foul
wounds, and the emanations from these wounds may impreg-
nate the atmosphere, and may be cai-ried to adjacent healthy
wounds in other persons, and in them create morbid action.
It is generally thought that this disease is specially prevalent
in hospitals, but this opinion may be partly due to the facts
that patients are often admitted into hospitals Avho are already
the victims of the disease, that cases in hospitals are more
carefully recorded than those which occur in the houses of the
poor, and that the great majority of persons who are the subjects
of injuries or operations likely to be followed by pyaemia are
admitted into hospitals. Still there can be no doubt that cer-
tain conditions sometimes prevailing in the best hospitals may
predispose to pyaemia, because it is almost impracticable to avoid
having an undue number of open wounds or sores in a ward,
and then the atmosphere is likely to become tainted, in spite
of the utmost care. The tables yield little support to the view
that phlebitis or even thrombosis is a necessary antecedent of
pyaemia. The earliest symptom of this disease, according to
nearly all the tables, was rigor or shivering, and this symptom
is the more diagnostic when, as is almost invariably the case in
pyaemia, it is immediately or very rapidly followed by profuse
sweating. The rigors appear to Mr. Savory to stamp the rela-
tionship of pyaemia to the specific fevers, and they may be
regarded as indicating the operation of a poison in the blood in
both cases.

II. Practical Observations on the Nature and Medical Treat-
ment of Obstruction of the Bowels and upon Constipation. By
Thomas Head, M.D. — Dr. Head draws a distinction between
obstruction of the bowels, or an entire interruption of their
ordinary functions, and constipation, which is a less serious
affection. The former most commonly arises from intussuscep-
tion and from the lodgment of particles of undigested food in
or near the ileo-caecal valve, and more rarely from hernia and
from malignant disease of the bowels -, the latter has its seat
almost exclusively in the large intestine. In one of the cases
related, which was that of a child five months old, there was
obstinate obstruction of the bowels, and the treatment adopted
by Dr. Head was to inject warm oil and quicksilver into the
bowels, and then to hold the child up by the legs so as to allow

316 Reviews. [Oct.,

the quicksilver to traverse the intestinal tube by gravitation. This
practice, although novel, is described as being successful. In cases
of malignant diseases nothing can be expected from treatment
except the alleviation of the sufferings of the patient. Consti-
pation of the bowels is a common affection, and it is almost
incredible to what an extent the large intestines may be loaded
with scybalous concretions without causing the patient any
remarkable inconvenience. Married women, of middle age,
have sometimes regarded the sense of fulness and weight of the
abdomen as indicative of pregnancy. For the removal of such
scybalous masses, the retention of which in the higher por-
tions of the colon is likely sometimes to produce relaxation
resembling diarrhoea. Dr. Head recommends small doses of blue
pill and podophyllin, with a little acetate of lead, with about a
quarter or a sixth of a grain of opium, and a drop of creosote at bed-
time, for several successive nights, followed in the morning by
a draught consisting of castor oil, liquor potassae, a little chloro-
form, and a few drops of laudanum. Dr. Head notices that a lacera-
tion of the mucous membrane covering the sphincter ani is some-
times caused by the passage of hard scybalous faeces and by the
forcible expulsive actions of the abdominal and intestinal muscles.

III. On Convulsions in Children. By Samuel Gee, M.D.
— In this paper. Dr. Gee gives a summary account of 102
cases of epileptiform convulsions in children, and he divides
them into three classes according as their causes are local,
general, or uncertain. In twenty-four cases the convulsions were
apparently symptomatic of local disease in or near the cerebrum,
such as tumours, abscesses, disease of the vertebrae, &c. In
73 cases 1 was caused by anaemia, 1 by uraemia, 12 by acute
specific diseases, as scarlet fever, measles. Sec. ; 1 by syphilis, I
by exhaustion from a large ulcer, and one from chronic Bright's
disease, but 56 were unaccounted for, and they are classed
under the head of convulsions depending upon the general con-
dition of the child. Dr. Gee considers that many cases of
essential convulsions (eclampsia) are associated with a constitu-
tion tending to rickets. After giving a brief abstract of the 56
cases. Dr. Gee remarks that hypertrophy" of the brain sometimes
co-exists with rickets ; that sometimes enlargement of the cranial
cavity occurs in rickets, without the brain being enlarged at the
same time ; that in reference to dentition, the backAvardness
of the teeth and the tendency to convulsions are sometimes
concomitants of the ricketty diathesis, and that in several cases
the occurrence of measles did not produce fits, although the
children had been subject to them previously. The cases of
convulsions of uncertain origin were only five in number. The

1868.]

St. Bartholomew's Hospital Reports. 317

treatment adopted inmost of the cases consisted in the adminis-
tration of the bromide of potassium or ammonium (for a child,
for instance, of a year old), in doses of four grains three or four
times a day, and when the fits had ceased, of cod-liver oil and
vinum ferri.

IV. On the Belation of Life to other Forces. By W.
MoRRANT Baker. — In this paper, which is altogether specula-
tive and philosophical, Mr. Baker draws a comparison between
the forces exercised under the influence of life and those which
are displayed by inorganic matter. He shows that the actions
of life consist in a great measure of utilising force, and making
it subservient to special purposes, as when the heat of the sun
under the influence of vegetation is made to assist in the
decomposition of carbonic acid, and the formation of woody
fibre. Vegetation exercises a chemical force in the evolution of
oxygen, and the fixation of carbon, and when vegetable matters
are used, as they constantly are, as the food of animals, the latter
exercise another force in the act of assimilation. Again, it has
been found that certain organic products have already been
prepared artificially by chemical processes, and it is not illogi-
cal or unreasonable to hope that even such substances as gela-
tine and sugar may be formed in a similar manner. But Mr.
Baker also draws distinctions between the powers of life and
those of inorganic matter ; for instance, no chemical process can
form a cell, and no machine of human invention possesses the
power of self-development or of generation. The whole tendency
of Mr. Baker's paper appears to be to show that the forces
excited in living bodies are analogous to other forces, such as
those denominated galvanic, chemical, &c., and that the belief
in the doctrine of the mutual convertibility of all forces, vital
and physical, and their unity and imperishability, is by no
means inconsistent with a belief in the existence of an all-
powerful Creator.

V. An illustration of extensive Cancer, traceable to dispersion
from the primary Tumour, as distinguished from its consti-
tutional reproduction. By Charles H. Moore. — xlfter de-
scribing the different modes in which cancer is disseminated,
Mr. Moore relates the case which forms the subject of his paper,
and in which the communication between the cancer and the
surrounding parts was maintained by the agency of a creamy
liquid, and the continuity of distant tissues with the original
disease was maintained.

The patient was a woman, aged 48, who suffered from a
rapidly-increasing tumour of the left breast, which soon formed
84— XLii. 21

318 Reviews. [Oct.,

an ulcer. There was a cluster of enlarged and moveable glands
in the axilla, and a firm and globular gland was felt above the
clavicle and behind the sterno-mastoid muscle. An operation
was performed with the view of relieving local suffering and
temporarily arresting the growth of the tumour, and the knife
Avas employed in the usual way, care being taken to remove
with the tumour all the thickened integument as well as the
diseased axillary glands. In about two months and a half the
wound was entirely healed, but two small, hard nodules were
perceived below the cicatrix; and in about two months more
six tumours were observable under the skin below the scar.
But Mr. Moore specially draws attention to the fact that above
the scar the integuments were pale, flat, and supple, and the
supra-clavicular gland behind the sterno-mastoid was not larger
than before the operation. The disease again spread ra})idly in
all directions, but the contrast of the appearances above and
below the scar was still very striking, the tumefaction and dis-
coloration being much more marked below than above. Death
ensued in a few months more, and it was then found that the
body was not emaciated, and the muscles were well nourished.
The diseased mass presented a creamy whiteness, and the sur-
face, when cut or squeezed, yielded abundantly a perfectly white
juice resembling cream. The disease was found upon micro-
scopical examination to be cancerous, and the milky or creamy
fluid contained numerous oil-globules. From the examination
of the organs affected with the disease, Mr. Moore infers that
after the operation was performed, and a tough, transverse scar
was established across the left side of the chest, the lymphatic
current was temporarily arrested in its course upwards, but was
conducted downwards into the lower part of the left side of the
thorax, and subsequently to the bronchial glands, diaphragm
and liver, which last, however, presented only one cancerous
nodule. The mesenteric glands were not affected, and hence
the patient was maintained in a state of general good nutrition.
Mr. Moore considers that in this case the disease was nourished
from healthy blood, and that the whole source of the cancerous
impregnation was derived from the left mammary region, whence
alone the oily products overflowed the tissues.

VI. On the Examination of Patients suffering from Deafness.
By Thomas Smith. — In this paper Mr. Thomas Smith, who
disclaims the character of a specialist in diseases of the ear,
describes generally the affections to which that organ is liable,
and the methods by which they are most readily investigated.
He draws a comparison between the eye and the ear to prove
the essential difficulty attendant upon the investigation of dis-

1868.]

Si. Bartholomew's Hospital Reports. 319

eases of the latter as compared with the former, the one organ
presenting a number of transparent structures which are easily
seen, and the other having nearly all its structures concealed in
bony cavities. Mr. Smith describes the instruments necessary
for investigating diseases of the ear, and shows that they need
be only few in number and simple in construction, and he gives
directions as to the inquiries which should be made of the patient
when examining into the history of the disease. The use of an
ordinary watch is available for ascertaining generally the exist-
ence and the degree of deafness ; but in exploring the condition
of the external meatus, a small concave mirror may be used,
together with the simple tubular speculum of Sir W. Wilde.
To ascertain the patency of the Eustachian tube, the patient
should blow air into the tympanum while the surgeon listens,
by means of the otoscope, to the effect produced. The Eusta-
chian catheter is also described by Mr. Smith, and also the mode of
introducing it, which is a matter of some difficulty to be overcome
only by practice upon the dead subject, or on an anatomical
preparation.

VII. On Disease of the Mitral Valve. By J. Andrew, M.D.
— Dr. Andrew commences his paper by relating a case in which
it would appear that a disease of the mitral valve was cured.
The patient was a girl, aged 9, in whom the physical signs and
some of the rational symptoms very clearly indicated mitral
regurgitation, but after treatment for some months the physical
and other signs began to improve, and eventually, but not until
about three years from the date of her first attendance, the
characteristic murmur disappeared, and she became quite well.
The improvement was much greater than in any other that Dr.
Andrew has ever observed, but he has notes of several cases in
which the progress made was so considerable that he hopes the
results in the present case may be equally favorable. In con-
sidering the question of the possibility of recovering from mitral
disease, it is necessary to distinguish between the several forms
of lesion which give rise to regurgitation, for some of these
appear to be remediable ; but of mitral constriction Dr. Andrew
says nothing, believing it to be all but a hopeless affection.
Incompetence, however, depends upon causes which are some-
times removable. In rheumatic fever, for instance, it may
happen that only the surface of the valve is inflamed, and
the murmur may disappear, and no trace of the disease will be
left, but in other cases the substance of the valve is inflamed,
and the murmur is developed more slowly, and the disease is
far more permanent. Supposing that mitral disease is remediable
in certain cases, Dr. Andrew suggests that the curative

320 Reviews. [Oct.,

measures should have for their object to diminish the sum-total
of the blood in the body ; to maintain the nutrition of the heart
and its muscular power, and to diminish the frequency and
energy of the heart's action. The first object is promoted by
prescribing a somewhat restricted diet ; the second by the em-
ployment of some preparation of iron, — preferably the tincture
of the perchloride, — or quinine ; and the third by the avoidance
of all excitement and by the use of digitalis.

VIII. Report on the Cases of Cholera treated in the Wards
of St. Bartholomew's Hospital during the epidemic of 1866.
By William Church, M.B. — The number of cases admitted
into the cholera wards of the hospital in the epidemic of 1866
was 136, being a smaller number than in former epidemics. Mr.
Church arranges in tables the history of the cases admitted,
giving the names, ages, and previous residences of the patients,
together with the nature of the premonitory symptoms, if any
existed, the date of death or of discharge, and other particulars.
The proportion of deaths to admissions was 33'08 per cent.,
being a higher proportion than in the epidemic of 1854, but a
lower one than in that of 1848. Premonitory symptoms, by
which Mr. Church means those which existed at least twelve
hours before the commencement of the algide state, were absent
in 43"1 per cent, of fatal cases, and in %\'Q per cent, of non-
fatal cases. The temperature was noted in thirty-one cases,
twenty-two of which were fatal, and nine recovered. As a result
of his observations, Mr. Church considers that the fall of tem-
perature below 94'5° was an indication that the case was severe,
and the chance of recovery small. The microscopical examina-
tion of the discharges did not lead, apparently, to any very im-
portant results, the chief microscopical characters of the stools
being the presence of large cellular bodies resembling mucous
corpuscles, and a quantity of faintly granular material, with
numerous bodies resembling free nucleoli. The stools were
sometimes of a brickdusty appearance, due in many instances to
the presence of blood-corpuscles ; and this appearance seemed to
be invariably a fatal symptom. The treatment was of the most
varied character, but it was uniformly unsatisfactory. In only
one case, under Mr. Church's care, was the injection of saline
fluid into the veins attempted. The measure was attended,
apparently, with some success ; but the patient died soon after
the injection. In eighteen cases a post-mortem examination
was made, and the appearances observed are arranged in a
tabular form.

IX. Note on Dr. Roberts's method of estimating Diabetic

1868.]

St. Bartholomew' s Hospital Reports. 321

Sugar. By Philip J. Hensley, M.A., M.B, — Dr. Roberts's
rule for estimating the amount of sugar in a specimen of diabetic
urine is to ferment the urine by means of yeast, having first
taken the specific gravity, and then, in twenty-four hours, taking
the specific gravity again, when the fermentation has ceased,
and the scum has subsided. The density after fermentation is
subtracted from the density before fermentation, when the
" density lost" is ascertained, and the number of degrees of
" density lost" indicates as many grains of sugar per fluid
ounce. This method is virtually to estimate the amount of
sugar by determining the weight of carbonic acid lost, instead
of by actually collecting and measuring the carbonic acid, as is
usually done. Mr. Hensley points out that the plan pursued
by Dr. Roberts is open to several objections, and he shows, by
a series of mathematical formulae, the errors which it involves,
but which, we may rem.ark, are not very great, and do not
much invalidate Dr. Roberts's rule, which, as Mr. Hensley
admits, is extremely useful for ordinary purposes.

X. Observations on the Passage of certain Substances into the
Urine in Healthy and Diseased States of the Kidneys. By
Dyce Duckworth, M.D. — Dr. DuclvAvorth, in this paper, em-
bodies a series of experiments conducted by him during the last
two years. The first series of experiments refers to the excretion
of some pigmentary and odorous substances by the healthy
kidney, including the iodide of ethyl, iodide of potassium, bro-
mide of potassium, indigo, aniline, logwood, turmeric, and san-
tonine. It is known that most of these substances can be
detected in the urine when the kidneys are healthy, but in
opposition to assertions to the contrary. Dr. Duckworth shows
that the pigments of indigo and logwood are excreted by the
healthy kidneys. The second series of experiments was made
upon patients suffering from disease of the kidneys, and the
question Avas, to determine whether medicinal and odoriferous
substances passed through the unhealthy as well as the healthy
organs. The general opinion Avas that they did not ; but Dr.
Duckworth shows that this opinion is not altogether supported
by facts. In his examinations he employed chiefly santonine,
iodide of potassium, and turpentine ; and he found that, in a
certain number of cases, where the patients were suflering from
diseased kidneys, the above-mentioned substances were found
in the urine. Santonine, Dr. Duckworth believes, has not been
previously employed in the manner described in his experiments ;
but he observes that it is easily exhibited, is the least unpleasant
of all the substances he has used, and also yields its reaction in
a very marked manner.

322 Reviews. [Oct.,

XI. Ligature of the External Iliac Artery. By Augustin
Prichard. — Although ligature of the external iliac artery is a
rare operation, it happened that the two cases recorded by Mr.
Prichard occurred at the same period in the Bristol Infirmary.
In the first case there was aneurysm in both thighs, and the
femoral artery on the one side and the external iliac on the
other were successively tied, though at an interval of four years.
The first operation, which consisted in tying the femoral artery,
was quite successful, and the recovery was rapid ; but the
second was attended with considerable difiiculty, owing to con-
stitutional and other complications. The aneurysm in this latter
case was immediately below Poupart's ligament, and evidently
extended a little upwards, and the ligature of the external
iliac was effected with some little difficulty, and was followed
by local inflammation and great constitutional disturbance. But
the ligature came away on the twenty-second day, and the
patient seemed to be recovering, when he was seized with a fresh
set of symptoms, partly neuralgic and partly inflammatory, and
the limb was stiff", hard, and painful. Eventually, however, the
man entirely recovered, and resumed his usual employment,
which was that of a butcher. The second case, Avhicli occurred
at the same time as the first, was one of femoral aneurysm, in
which ligature of the external iliac was also performed ; but in
this instance the operation was performed without any difficulty,
and the patient recovered slowly, and without any remarkably
unfavorable complications.

XII. JRemarks on all the Principal Cases of Injury of the
Head admitted into the Hull General Infirmary during the Six
Years from 1858 to 1863. By Charles Jewel Evans. — Mr.
Jewel Evans in this paper arranges in a tabular form the history
of forty cases of injury of the head, placing the simpler cases
first, and afterwards the more serious and the fatal ones : but
no cases of scalp-wound, unless complicated with serious injury,
are admitted. More than half the cases were from falls into the
hold of a vessel, or into a dry dock, and of the whole number
more than half, namely twenty-two, ended fatally. In five
instances the operation of trephining was employed, but the
result was fatal in all but one, and' Mr. Evans agrees in the
opinion now generally entertained that the operation of trephin-
ing is not one from which a hopeful result may be often expected.
In many cases in which the trephine is used the injury is so
serious that no favorable termination can be even hoped for,
and many cases which recover without trephining would, in all
probability, be seriously endangered by the operation. When
j-ecovery takes place after the use of the trephine, it is a great

1868.]

St. Bartholomew's Hospital Reports. 323

question whether the instrument deserves the credit of the cure.
Venesection Avas emplo5'ed in two cases hoth of which were
fatal, and this operation is now comparatively little employed in
injuries of the head, but Mr. Evans thinks that local bleedino-,
especially in mild cases, is sometimes decidedly attended Avitli
benefit. Mr. Evans confirms the general opinion that the
discharge of thin watery fluid from tlie interior of the cranium,
although rare, is pathognomonic of fracture of the base of the
skull. Facial paralysis, on the same side as the injury, is quite
as much pathognomonic of fracture of the base of the skull as
discharge of serous fluid, and is even more pathognomonic of
fracture of the petrous bone, the facial nerve being injured in
its course through that bone. Very little reliance can be placed
upon the state of the pupils in injuries of the head, but the most
common condition is that of dilatation. The respiration, in the
cases where it was noted, was generally slow and laboured, and
the pulse was usually slow.

XIII. On the Value of the Thermometer as an Aid to the
Physician. By \V. Ainslte Holi.is, M.B. — The investigations
which form the groundwork of this paper included an examina-
tion of more than sixty cases of phthisis, and a still larger
number of other cases as diabetes, disease of the heart, aneurysm,
typhoid and typhus fevers, pneumonia, bronchitis, pleuritis,
erysipelas, scarlatina, phlebitis, &c., and Mr. Hollis establishes
the following proposition from his researches, namely, that " all
local disorders, whether organic or functional, have a tendeiicy
to modify the thermometric ranges of the body, either by pro-
ducing local variations of temperature, or by affecting those of
the system at large." He then draws up in two tables the
causes which tend to lower, and those which tend to raise the
temperature of the body. Among the causes leading to dimi-
nished temperature are evacuations of various kinds, as for
instance, diarrhoea, and looseness of the bowels, but when this
diarrhoea is caused by ulceration of the intestines, as in typhoid
fever, the temperature is not diminished, but is raised. Per-
spiration and haemorrhage also tend to diminish the tempera-
ture, and the same effect is produced by blisters and other
counter-irritants. It is stated that the favorable action of
blisters in acute rheumatism may be explained in this view.
Deficient aeration of the blood, from whatever cause, will also
diminish the temperature of the body. On the other hand, the
temperature is raised in many acute and febrile diseases, but
still the height of the thermometer in a case of fever is no
criterion, per se, of the severity of the attack, for the tempera-
ture may be very high in a favorable case, and much lower

324 Reviews. [Oct.,

than that point in a fatal one. The rapid degeneration or
destruction of tissue such as occurs in certain inflammations, and
in tuberculosis, carcinoma, and ulceration, also tends to increase
the temperature. On the whole, Mr. Hollis arrives at the
conclusion that thermometric registrations, although valuable
in themselves, do not supersede or lessen the value of careful
observations of the general symptoms of disease, and that the
real value to be assigned to any given temperature must depend
upon a due consideration of the processes which have caused it,

XIV. Extraordinary anomalous Affection of the Nervous
System in a Boy. By Luther HoldEn. — The subject of this
curious case is a boy, a patient in the hospital, between twelve
and thirteen years old, whose only morbid affection appears to
be a small swelling of the neck about the size of a hen's egg,
situated on the right side of the neck, and who usually seems
to enjoy very good health. But when this swelling is touched,
however slightly, a series of extraordinary phenomena imme-
diately present themselves, the boy becomes deaf, dumb, and
blind, insensible to pain, and tetanic. After remaining in this
state some forty or fifty seconds, he recovers after drawing a
deep sigh. The physiological and pathological nature of this
affection has been investigated hitherto in vain, and all thera-
peutical appliances have been fruitless. A proposition has been
made to remove the tumour, which seems to be of a fatty
nature, but there is a division of opinion as to the probable
result of such a proceeding. Mr. Holden's own opinion is that
its removal would not be attended with any serious results, but
the further history of the case is promised in a future number
of the ' Reports.'

XV. Surgical Cases in the Devon and Exeter Hospital. By
Philip Chilwell Delagarde. — This paper contains the record
of thirty cases taken from the surgical practice of the hospital,
and includes surgical affections of the hand and of the head
and neck, together with several cases of cancer. In a note
on scirrhus and other forms of cancer, Mr. Delagarde ex-
presses his opinion in favour of operating in certain cases of
this disease, as he inclines to the belief that cancer commences
as a local affection and afterwards affects distant parts, in contra-
distinction to the circumstance that the local phenomena of
scrofula and syphilis are manifestations resulting from constitu-
tional taint. Even when little hope of an absolute cure can be
entertained in cancer of the breast, Mr. Delagarde does not
refuse to operate, because such a proceeding alleviates the
symptoms of the disease and does not involve any risk to life
in well-selected cases. The instances in which Mr. Delagarde

1868.]

St. Bartholomew's Hospital Reports. 325

thinks an operation advisable are those of scirrhus and epithe-
lioma, but in encephalo'id cancer there is not much chance of
cure by operation. He prefers the knife to the use of caustic
pastes, and he is unacquainted with the effect of acid injections
either in primary or secondary scirrhus.

XVI. On Tracheotomy in Children ; its Method, its Dangers,
and its Difficulties. By F. Howard Maksh. — In this paper
Mr. Marsh records the conclusions at which he has arrived
chiefly from his experience as House Surgeon at the Hospital
for Sick Children. In the first place, he combats the objec-
tions which have sometimes been made against the operation,
and he concludes that it can be as deliberately performed as any
other surgical proceeding, that the struggles of the patient may
be obviated by chloroform, and that the apprehension of danger-
ous hajraorrhage has been exaggerated. After a brief but
careful description of the structures concerned in the opera-
tions for opening the windpipe, he draws a comparison between
laryngotomy and tracheotomy, declaring his opinion to be in
favour of the latter as being on the whole more efficacious,
although laryngotomy is most easily performed. But laryngo-
tomy affords but little space for the introduction of the tube, it
injures the integrity of the larynx and the vocal apparatus, and
the tube causes great irritation and distress. In tracheotomy,
few structures of any very great importance are involved, the
tube is easily introduced, and the risk of haemorrhage is but
slight. Mr. Marsh then points out the spot most suitable for
the operation, which should not be too low down on the one
hand, where the trachea is very deep seated, nor too high, where
the thyroid gland is placed, and which it is expedient not to
wound. The tube to be employed is then described, and the
different steps of the operation are minutely related, together
with the after-treatment, so far as surgical ministrations are
concerned. Some cases are then recorded in which the opera-
tion was performed, and in some the proceeding was successful ; in
others, where the result was less fortunate, the causes of the
failure are pointed out. The patient may die from the consti-
tutional disease for the relief of which the operation was per-
formed, or from the local effects of the operation itself, and
sometimes in cases which promise well, some accidental circum-
stance produces a fatal result, as where a portion of false mem-
brane becomes entangled in the canula. Ulceration about the
wound, or of the trachea around the canula, is also a more
common result and a more frequent source of danger than is
generally supposed, and Mr. Marsh has notes of nine cases
where this complication occurred.

326 Reviews. [Oct.,

XVII. Case of Anchylosis of the Atlas to the Occipital Bone
and of Dislocation and subsequent Anchylosis of the Atlas and
Axis. By Professor Turner. — The case was taken from a
specimen in the Anatomical Museum of the University of Edin-
burgh, but nothing was knoM'n of the history during life.
From the appearances observed it seemed that the articular
surfaces of the bones had been diseased in the first instance, the
ligaments relaxed and destroyed, and the bones subsequently
displaced and finally anchylosed. The size of the spinal canal
was diminished in the locality where the disease existed, and it
is inferred that the spinal cord must have been considerably
atrophied or much compressed in the antero-posterior direc-
tion.

XVIII. A Discussion of the Mechanical Theories which have
heen advanced to account for the origin of Pulmonary Emphy-
sema. By Philip J. Hensley, M.A., M.B. — Mr. Hensley
first considers three modes of explanation which have been
adopted in accounting for the existence of emphysema. One
offered by Laennec supposed that the lesion was caused by
obstruction of the bronchial tubes, and by the action of the
inspiratory muscles, which, being more powerful than the expi-
ratory, would force in more air than expiration was able to
eliminate, and thus the air would become imprisoned. The
second explanation attributes emphysema to violent efforts in
coughing and other expiratory acts, which are supposed to cause
rupture of the air vesicles. A third view is that pulmonary
emphysema is " a secondary mechanical lesion depending upon
some condition of the respiratory apparatus which leads to
partially diminished bulk of the pulmonary tissue, and conse-
quently disturbs the balance of the air in inspiration." To all
these views Mr. Hensley takes exception, and although he is
not himself prepared to offer any very satisfactory explanation
of the cause of emphysema, he explains some circumstances
which he thinks may give rise to stretching of the lung tissue,
and thus cause dilatation of the vesicles. In almost all cases
emphysema is preceded by frequent attacks of bronchitis,
which disease prevents the free passage of air into the bronchi ;
and Mr. Hensley thinks that if the bronchi leading to some
parts of the lungs are impassably blocked up, the tension in
inspiration will be borne unduly by neighbouring portions, and
thus dilatation of some of the vesicles be established. But he
regards the stretching of the lung tissue only as an accessory
to the lesion, and he believes that there is in the first instance
a degenerative process in the tissues as well as an inflammatory
condition of the bronchial mucous membrane, and that emphy-

1868.] St. Bartholomew's Hospital Reports. 327

sema is caused therefore not only by mechanical, but also by
vital causes.

XIX. Respecting the Treaime?it of Fractures of the Lower
Extremities in the Wards under the care of Mr. Paget. By J.
AsTLEY Bloxam. — Before describing the new forms of apparatus
employed at St. Bartholomew's in the treatment of fractures of
the lower extremities, Mr. Bloxam alludes to the circumstance
that no apparatus is now employed in fractures of the femur
in children and in fractures of the patella. It is found that
splints, bandages, and other such applications, are attended
with great inconvenience in young children, and that the
fractures may be safely treated by rest and the maintenance of
a suitable position of the limb. Fractures of the patella are
also treated without any apparatus, the patient being confined
to bed with the injured limb extended on a level, with sand-
bags placed on each side, and with a cradle to keep off the
weight of the bed-clothes from the limb. In a few days from
the time of the accident, the extensors cease to act, and the
fragments approximate themselves, the union, however, being
usually ligamentous. The description of the apparatus em-
ployed in the treatment of other fractures of the lower extre-
mities is illustrated by diagrams, without the aid of which a
description would be impossible. It should be mentioned,
however, that in fractures of the thigh, the inconveniences of
the long splint are obviated by some novel contrivances, and
that the new apparatus employed in these cases is both useful
and convenient.

XX. Case in which a large Hydatid Cyst was removed from
the Chest, loith ultimate complete recovery. By Reginald
SouTHEY, M.l). — The subject of this interesting case was a
female, aged thirty-one, who suffered from a variety of anomalous
symptoms, somewhat resembling neuralgia and hysteria, from
cough, though without expectoration, pain in the right side of
the chest, and dyspepsia. No benefit followed from the remedial
measures adopted, and change of air seemed to make her worse
than before. The local indications and the physical signs were
very obscure, but at last a marked bulging made its appearance
upon the right side of the spine, extending into the interscapular
region. An exploratory incision was then made by means of a
trocar, and a large quantity of puriform serous fluid was eva-
cuated, and some relief was afforded. But eventually a free
incision was made between the sixth and seventh ribs, and a
soft jelly-like mass protruded which was recognised as part of
an hydatid cyst, which was fortunately entirely removed, its

328 Reviews. [Oct.,

size being about that of a pig's bladder, and it was perfectly
unattached. It appeared to be formed in the sac of the pleura
above the diaphragm, and was Avholly iinconnected with the
liver. The patient was restored to health in less than three
months after the operation, and although she suffered from
occasional pain in the right side, and the lung on that side was
probably permanently altered in structure, she appeared stouter
and better looking, and actually increased in weight more than
a stone.

XXI. Some Cases of Disease of the Brain. By John
Crockett Fish, M.B. — This paper contains a brief history of
five cases of cerebral disease, three being cases of tubercular
meningitis, one of acute meningitis, and one of abscess of the
cerebellum. All the cases were fatal, and in all there was con-
siderable difficulty in the diagnosis, owing to the anomalous
nature of the symptoms. In the last case, where disease of the
cerebellum existed, there was also disease of the petrous portion
of the temporal bone, and it is remarked that the danger in
cases of chronic otorrhcea (which had been the first symptom
in the case), may be staved off" almost indefinitely by attempts
to solicit the return of the discharge, and by other appropriate
means.

XXII. On Senile Scrofula. By James Paget, F.H S. —
Mr. Paget remarks that scrofula is much more common in
advanced life than is generally supposed, and that instances of
the kind are to be found Avith equal frequency in private and
hospital practice. The diagnosis between scrofula and gout in
the old is often difficult, and it must be made by observing the
co-existing constitutional characters, or other marks of the
disease ; and in distinguishing scrofula from cancer in advanced
life, it is to be remembered that the hard cancer is more common
in the old than the young, and that cancer is painful and in-
creases rapidly.

XXIII. The Anatomy of Brain Shocks. Part I. By
George W. Callender. — This paper, which is the first of a
series, contains forty-eight cases of injury or disease of the
brain. The whole series is to include a hundred cases of the
same kind, all fatal, which occurred and were recorded by the
late Dr. Kirkes and by Mr. Callender, during the years 1849-
1859 inclusive. Before describing the series of fatal cases,
Mr. Callender refers to a few instances of concussion or con-
tusion of the brain, which show that various subjects are
aiFected in a very different manner by these accidents, partly

1868.] Structure and Function of the Retina. 339

from the varying nature of the injury, but in some measure by
the constitutional peculiarities of the individual. The fatal
cases are arranged in three distinct groups, the first containing
those which were fatal from pressure on the surface of the brain
or the walls of the ventricles ; the second containing cases
in which portions of the brain were destroyed by disease ; and
the third comprising cases in which there Avas bleeding into
various parts of the substance of the brain.

XXIV. A Case of Traumatic- Anetirysm. By Holmes
CooTE. — In this case there was a wound of the femoral artery
and vein, with effusion of blood into the limb. The case seemed
to be doing well under pressure, but during the treatment the
patient became excited in conversation, and from this and
other causes, profuse haemorrhage occurred, and although the
limb was promptly amputated a fatal result ensued.

The reports conclude with an extract from the " Statistical
Report of the Hospital for the year 1866."

Review IV.

Structure and Function of the Retina.

The microscopic examination of the retina is beset with such
formidable difficulties that even those who are most conversant
with the subject scarcely succeed in mastering all its details, or
in reconciling their own observations with the conflicting state-
ments of others. And since the interest which attaches to
researches of this kind is seldom felt beyond the circle of those
personally engaged in them, it cannot be expected that the
medical practitioner already overtasked by the demands of a
many-sided science should follow very closely the laborious
advance of retinal anatomy.

But looking beyond this drudgery of anatomical detail to the
fair prospect which it offers of a final explanation of the phe-
nomena of retinal vision ; looking also to the extreme interest
and importance of the scientific problems therein involved, we
cannot but regard the numerous contributions recently made to
retinal anatomy with a satisfaction proportionate to their present
and prospective significance ; for whether we measure their
value by the amount of time and pains bestowed on them, or
by their own proper merits, we have eqvial reason to con-

330 Reviews. [Oct.,

gratulate ourselves on the great progress made towards a
satisfactory settlement of the anatomical basis on which the
future physiology of vision may rest.

The retrospect, however, becomes more perplexing, as our
scrutiny of facts must be closer and our breadth of view wider.
Amidst an embarras des richesses arising from the researches of
so many independent observers, a clear insight into our present
position is to be obtained only by free criticism of each dis-
puted point. Meanwhile discoveries multiply, and the reader,
whose point of view is that of a past period of fact and opinion,
and who is dependent on such chance literature as may fall in
his way, finds himself in the midst of a transformation scene,
of which the first masks are all he can recognise. Standing
super antiquas t'ias he is more disposed to remain laudator tem-
poris acti than to join in any forward movement. So much of
fiction has withal intertwined itself with the growth of scientific
fact as to necessitate a careful sifting of the abundant material
now collected. For this, however, leisure and opportunity too
often fail, although the inquiry might otherwise possess sufficient
attraction. We propose, therefore, in the present article, to
attempt a brief summary of the results hitherto achieved, in the
hope of supplying thereby a want which may be felt by many
of our readers.

For the greater part of our knowledge we are indebted to foreign
anatomists, whose persevering efforts attest alike their skill and
patience in microscopic investigation, and their courageous faith
in the ultimate triumph of scalpel and lens over the mysteries of
organic structure. Without disparagement of British anatomy,
we have but to contrast the circumstances which favour the prose-
cution of such studies abroad with the slight inducement held out
to those desirous of pursuing a similar career in England to ac-
count for any seeming indifference or inferiority of research. The
fact, nevertheless, remains that we have to draw largely on Con-
tinental sources for the material of our physiological anatomy,
as may be seen at a glance when we compare our handbooks
and journals with those of Germany. One of the ill conse-
quences of this dependence on foreign labour appears, in the
absence of any continuous effort on our part, to place our know-
ledge of the microscopic anatomy of the retina (and other organs
of sense) on a par with that which we possess of the numerous
organs whose diseased states daily force themselves upon our
observation.

Micrology has, however, won its own undisputed place and
authority in physiological science ; and those who cannot rely
on their own experience must be content, if not to swear to the
words of a master, yet at least to accept the labours of those

1868.] Structure and Function of the Retina. 331

who have devoted themselves to microscopic studies; more
especially since physiological anatomy has become the very
corner-stone of pathology and rational medicine, are we bound
to give the fullest consideration to those new aspects of organic
life and function opened to us by comparative histology. The
larger features of comparative anatomy are now supplemented
by the minutest details which organic matter presents to the
scrutiny of the microscopist armed with magnifying powers
yearly improved and increased, and it would be indeed passing
strange if no practical results should be gathered therefrom.
Again, the study of embryonic development, besides yielding its
interpretative clue to the obscurer facts of general anatomy,
reveals also the genetic relations between the several elements
and tissues, and places in our hands an intellectual pass-key
wherewith to open and explore the secret passages of nature's
labyrinth.

But all this microscopic research demands a practised eye
and hand and a power of interpretation acquired only by expe-
rience. The instrument is efficient only in the hands of an
expert. And herein lies the advantage of the continental system
of academic instruction. Under a master's eye, and encouraged
by the words and example of illustrious teachers, the student,
emulous of fame, seeks to distinguish himself as a candidate for
professorial honours and office, by diligent re-examination of past
discoveries, or by striking out new paths of inquiry. The aca-
demic teaching Avhich made the use of the microscope, needle,
and chemical reagent a second nature, expresses itself in after
life by continued devotion to scientific investigation. The
utterance of an Ehrenberg, " das loissen wird sich im suchen
entfalten*^ (knowledge will unfold itself in the seeking), was
not spoken in waste places.

Nor has such labour, undertaken in the true spirit of science
— that of seeking and finding without bias of preconception or
prejudgment — been in vain. The schools of Germany have
created for us the modern science of histology, built upon an
accumulation of observations which nothing but the zeal of
knowledge could have accomplished ; and histologic studies
have, by imparting to general anatomy precision of detail and
accuracy of method, greatly facilitated our study of the functions
pertaining to differently organized structures. True it is that
anatomical analysis supplies but a portion of the data required
to enable us to penetrate the obscure profound of physiology.
But from whatever other sources additions to our knowledge
may come, a certain correlation between structure and function
must be established before any physiological doctrine founded on
external circumstantial evidence can be unreservedly accepted.

332 Reviews. [Oct.,

On the other hand, it is equally true that the phenomena of
sensation, perception, consciousness, lie outside and beyond the
circle of pure physical science. Notwithstanding that our sen-
sory organs are supplied with special apparatus constructed to
meet the circumstances find conditions of an external world;
notwithstanding that demonstrable physical changes accompany
the proper function of nerve matter, still the essential nature of
that function remains, and perhaps ever will remain, wholly in-
scrutable, a thing " sui generis "

Thus it has happened that the subjective (sensorial) pheno-
mena of vision have been studied separately from their physio-
logical basis, and without reference to the anatomy of the brain
and the eye considered as the organ of sight. A wide chasm
yawns between the physical and metaphysical sides of the
inquiry, the filling-up or bridging over of which demands a
knowledge of things which even the most sanguine investigators
fail to see their way to. In so far as vision depends on certain
arrangements of transparent media possessing special refractive
powers, it is easy to explain on physical principles, and illustrate
with the help of physical appliances, the action of this dioptric
apparatus. But to account for the conversion of material into
psychical impression, to explain the sensation of light or colour,
is another thing. We know not what happens in a nerve when
it perceives blue or red, and if we should ever discover that the
perception was always induced by a certain change in the con-
dition of the nerve, we have not thereby explained what
sensation is.

The psychical phenomena of vision as learnt from our own
perceptions occur in point of time subsequent to the processes
going on in the eye itself. The consciousness of objects in an
external world, and the manifold relations of this consciousness
to other sensorial functions — in brief, all that is understood by
the term " cerebral vision," forms a subject of metaphysical
inquiry. On the other hand, the mode of action of the dioptric
apparatus of the eye forms the subject of physical and mathe-
matical demonstration. We have then a cerebral apparatus
whose function is purely sensorial, and an apparatus of sight in
the front part of the eye whose function is purely physical.
Between these two extreme ends of the complex whole we
find in the retina an intermediate organ Avhich serves as the
connecting link, and combines in itself the material instruments
of physical and psychical action. It would appear in fact to
share the double function of refraction and sensation. lis ana-
tomical elements differentiate as they diverge in opposite direc-
tions, but yet preserve their continuity. If it be asked where
is the proper physiological part of our subject, and what is its

1868. ] Structure and Function of the Retina. 333

basis 1 the answer is implied in the following question — How is
the act of seeing accomplished, and what is the organ of sight ?
In the presumption that this act of seeing- is a retinal function,
and the retina itself the organ of sight, we employ the phrase
*' structure and function of the retina " as defining the subject
and object of our present inquiry.

And since experience teaches us that the function of a part
or organ is intimately bound up with the particular structure of
that part, we have here to inquire what are the anatomical
elements of the retina : in what connection and relation do they
stand to each other separately and as a whole ; and, lastly, what
share is contributed by each element towards the function (if
divisible into parts), and in what manner do they combine to
one common purpose ? An inquiry into the structure and
function of the retina resolves itself thus into two main
branches : — 1. What anatomical substratum exists for our phy-
siological conception of the act of seeing? 2. What is the actual
performance of the retinal structure as declared to us by our
own sensation, or taught us by observation of the phenomena of
vision ?

The remarkable speciality which characterises the structure
of all sensory organs, aifords prima facie evidence of an essential
connection between the particular arrangement and constitution
of elements observed in these organs, and the functions respec-
tively performed by them. The inference is unimpugnable
that the complex organization of the retina is necessary to the
conversion of certain material impulses into corresponding
sensations. And conversely the multiplicity and variety of
sensations which concur to an act of vision,*^, g., the recognition
of so many distinct points, lines, spaces, figures, surfaces, &c,,
or of various light and shade, or of pure and mixed colour;
the combination of each and all with a separate psychical con-
sciousness and intelligence ; the instant and constant inter-
change of light, sight, and thought, lead us equally to the con-
clusion that the material instrument must be both complex and
peculiar. The physiological conception of vision as accom-
plished by material mechanism postulates, at the least, the
following anatomical provisions: — 1. Lines of isolated commu-
nication by which material impressions may travel towards a
central organ. 2. Structural elements capable of being affected
by such material impressions, and of transmitting them in a
new or modified form to a central organ. 3. Intercommunica-
tions between the separate elements themselves, either singly
or in groups. 4. Communications of a second or still higher
order between these combined groups and the central organ.
Finally, where a duplicate apparatus exists (two eyes, two optic

84— XLii. 22

334 Reviews. [Oct.,

tracts, and doubled cerebral ganglia, &c.), communications
between the corresponding parts of each eye, nerve, and brain
mass. A number of additional arrangements are moreover
necessary to the physiological conception of an apparatus ade-;
quate to bring into play the numerous co-ordinated movements'
of the whole body, so as to complete the harmony of visual-
function with the other sensory functions, and with the general
sensation and motion. Such, for example, as 1. Nerve com-
munication between the central organ and the nerve-centres
which direct the motions of the muscles of the eye-ball, and
those of " accommodation." 2. Communications between the
central organ, and the nerve-centres which direct the organs of
hearing, smell, touch, &c. S. Communications of the central
organ with the nerve-centres which control the action of the
limbs. 4. Communications with the centres of common sensa-
tion, and, finally, with the nerve-centres which preside over
involuntary movements related, however remotely, with the
function of vision.

From this brief indication of a complete anatomical basis for
the whole physiology of vision it will be at once obvious that by
far tlie largest portion of the subject is referable to the general
physiology of the brain and nerve-system, which does not
further concern us here. The significance of the retinal
function will be, however, sufficiently marked if the first series
of anatomical postulates should be substantiated as material
facts, as well as physiological assumptions. The fundamental
office of the retina is the reception of material impressions
which are transmitted in modified form to the bi-ain ganglia.
The excitation of the retinal nerves by whatever means effected,
results in the sensation of light. But it is here necessary to
draw a distinction between sensibility to a material impression
and conscious sensation. Thus, the undulations of light passing
through dioptric media reach the columnar bodies of Jacob's
membrane, producing a definite but yet unexplained effect on
their substance. This efiiect is then transmitted from the
columnar stratum to the ganglionic layers of the retina, and
thence to the optic nerve. Now, whatever be the change or
induced condition thus brought about, it may be taken for
granted as one that is essential to the perception of light when
this perception is excited by the impulse of light undulations.
But numerous pathological observations prove that the sensation
of light may be excited through other channels. The excitation
of the retina is therefore neither the perception itself, nor is it
always necessary to this perception. On the other hand the
occurrence of separate and independent sensation of light
caused by stimulation of the optic nerve or the corpora quadri-

1868.]

Structtire and Function of the Retina. 335

gemina does not prove that the rethia is not capable of light
sensations of some kind, or that its function is limited to the
exercise of a more or less specialised " sensibility," As, however,
" conscious sensation " involves a psychical operation, it must be
admitted that the operation of a retinal sense is not likely to
he extended so as to combine single into compound sensations,
or to take cognisa7ice of either. Such acts form more probably
a part of " cerebral vision," though it must be borne in mind
that the retina by its genetic relation to the brain, of which it
was originally an integral part, stands on an equality of endow-
ment in a physiological sense.

Besides the retinal action, which informs us of the existence
of external objects, and which is due to the peculiar excitation
of retinal nerves by light from without, there is an internal
activity of the retina optic nerve and ganglia (corp. quadrig.)
excited by various stimuli (electricity, blood stimulus, pressure,
and irritations of nerve, &c.) which are capable of causing sen-
sations of light, colour, form, &c. These suhjectwe sensations,
whether of retinal or cerebral origin, are interpreted according
to the individual experience or fancy. The shai'e taken by the
retina in this subjective vision forms a branch of inquiry supple-
mentary to that of the principal and ordinary function of this
organ.

Having thus sketched the general outline of a physiological
anatomy of the retina, and indicated its purport and ^mits, we
must now address ourselves to the tedious but necessary labour
of reviewing the history of anatomical discovery, and extracting
from a voluminous literature the facts that seem to be confirmed
by general assent, or that may be accepted provisionally as
being in harmony with that which is known. We require, at
least, to know what are the actual and probable facts and con-
ditions of this organ of sight ; what we may affirm or reject -, and
what surmise, as pointing in the direction of future discovery.
The truth or probability of our facts must be sifted before we
draw conclusions. In the absence of a positive basis, no con-
clusion is better than a false one. Nor will it advance science
to assign arbitrarily this or that function to any given structure
in order to render an hypothesis plausible, or to give undue
force to an argument which may be just in itself.

The pertinence of the foregoing remark will be admitted
when we consider the many errors of fact and interpretation
which are inseparable from the study of such perishable elements
as those of which the retina is composed. The natural bias of
the observer is to suspect that which he has not seen, and to
overestimate that which he has seen. His natural ambition is
to solve each problem that comes before him in a manner agree-

336 Reviews. [Oct.,

able to his own observations and conclusions. But (as is
equally natural) his method of procedure is one-sided, and the end,
seen only in part, is but partially attained. Thus the anatomist
follows to its vanishing point the mechanism of structure. The
physicist watches the equilibrium of forces and the sequence of
changes consequent upon the first disturbance. The physiolo-
gist tests the action and reaction of living organs. The meta-
physician analyses phenomena presumptively beyond the reach
of material actions and influences. Each tasks his utmost powers
and perhaps gains a step here and there, yet finds ample verge
and space for speculation on points which his instruments of
research cannot reach. The struggle is not always progressive,
nor do the several lines of inquiry proceed pari passu. But
on the whole minute anatomy, which has so often fallen behind
the requirements of the physiologists, has in later years gained
most ground, and bids fair to supply such a basis of fact as may
serve for a closer and safer analysis of functional phenomena
than was heretofore possible.

In the history of retinal anatomy it so happens that the
earliest and latest discoveries relate to the same part, namely,
that known formerly as Jacob's membrane ; and the changes of
opinion entertained concerning its structure and function are
not a little curious. As each successive examination revealed
new and unexpected facts, the attention of anatomists concen-
trated itself more and more upon this marvellous structure.
The interest first excited by the discovery of a direct connection
between the optic nerve-fibres and this columnar stratum has
been further enhanced by the proof adduced (many years later) of
its physiological significance as the probable percipient portion of
the retinal apparatus. Quite recently an hypothesis has been
revived by the discovery of facts which yield presumptive
evidence in its favour ; namely, that the rods and cones perform
a catoptric function, in arresting and inflecting the undulations
of light by virtue of a peculiar molecular arrangement, and high
refractive power of the substance of which these elements are
composed. Such a catoptric function had been formerly assigned
to the columnar stratum on physical grounds by Briicke,
but the hypothesis was rejected by those who first propounded
the notion that both rods and cones were either actual nerve
papillse or modified nerve ends, and consequently endowed
solely with the properties of nerve matter. New observations
respecting the nature of the organic substance of which these
cones and rods are composed have again brought into prominence
the hypothesis of Briicke. Schultze has in his endeavours to
explain the function of the columnar stratum laid great stress
on the physical character and special morphology of the rods

1868.] Structure and Function of the Retina. 337

and cones, and brought fresh evidence in support of the theory
of Briicke, modified, however, so as to include the theory of
nerve action. To this much vexed question we shall recur
when treating of the physiology of vision, mention having been
here made of it for the purpose chiefly of explaining the frequent
allusion to anatomical points bearing on the discussion, which
will be found in our historical notice.

Fifty years ago the retina was supposed to consist of a " me-
dullary expansion" of the optic nerve, supported on its inner
surface by a " vascular" coat, which again rested against and
was adherent to the " hyaloid " membrane. This *' vascular
coat" was demonstrated by macerating and scraping away the
layer of" medullary" fibres, and obviously corresponds with the
capillary network accompanying the ganglionic layer of nerve-
cells supported by the connective tissue of the memhrana limitans
interna.

Exclusive of these two layers, says Jacob Q Cycl. Anat. and
Phys.,' article " Eye"),

" I find that the retina is covered, in its external surface, by a
delicate transparent membrane, united to it by cellular substance
and vessels."

After describing his method of demonstration he further
says —

" That it is not the nervous . layer (medullary expansion) which I
detach is proved first by the impossibility of separating that part of
the retina so as to present the appearance I mention ; and secondly,
because I leave the retina uninjured and presenting the appearance
described by anatomists, especially the yellow spot of Sommering,
which is never seen to advantage until this membrane is re-
moved. (!)...

" Besides being connected to the retina I find that the membrane
is also attached to the choroid coat apparently by fine cellular tissue
and vessels, but its connection with the retina being stronger it
generally remains attached to that membrane, though sometimes
small portions are pulled ofi" with the choroid coat. . . .

" The appearance of this part I find to vary in difierent classes of
animals and in man according to age and circumstance. In sheep,
ox, horse, and mammalia generally it presents the same character as
in man, but it is not so much tinged by the choroid pigment, and
adheres more firmly to the retina. In the bird it presents a rich
yellow brown tint, and when raised the blue retina shows beneath.
In fishes the structure is peculiar and curious. It has been already
described as the 'medullary layer' of the retina by Haller and
Cuvier, but I think incorrectly, as it does not present any of the
characters of nervous structure, and the retina is found perfect
beneath it."

The foregoing extracts from Jacob's communication to the

338 Reviews. [Oct.,

* Phil. Trans./ 1819, fairly represent what the author knew and
what he did not know respecting the structure to which his
name was given in honour of the discovery.

Dalrymple, led astray in his account of the " Tunica Jacobi"
by the current doctrines respecting serous membranes, described
it as a double layer. Jacobs, however, denies this :

" If" (says he in his article " Eye," ' Cycl. Anat. and Phys.') " the
retina be merely in contact with the vitreous humour and choroid,
we argue from analogy that a cavity lined by serous membrane exists
both on its external and internal surface ; but this is not the fact.
In the eye a distinction of parts was necessary, but to accomplish
this a serous membrane was not required, a single membrane with
the interposition of cellular substance answers here."

And in another place —

" My observations lead me to conclude that wherever the different
parts of the eye are in contact they are connected to each other hy
cellular substance, and consequently by vessels," &c. &c.

The chief interest in these extracts lies, firstly, in this — that
they show how theoretical notions interrupted the observation
of facts, and, secondly, how the idea of a connective tissue grew
out of the discussion.

In the introduction to Mackenzie's 'Treatise on the Eye' (2nd
edit., 1835) a representation is given by W. Jones of the " tunica
Jacobi" as seen under the microscope, which leaves not the
slightest doubt of his having had the columnar stratum under
observation.

The yellow spot of Sommering received about this time much
attention. The following is the anatomist's account of it :

" In the very centre of the retina is found an actual deficiency of
the ' medullary layer,' or a real hole perfectly round with a defined
margin. The transparent vitreous humour and black pigment are
so clearly seen through this hole that there can be no doubt that it
is a real aperture. Surrounding this ''foramen centrale ' the re-
markable yellow colour is so disposed that it appears much deeper
towards the margin, and totally disappears at the distance of a line."

Jacobs concluded from his examinalion of the yellow spot
that no " foramen" existed, but that a fold of retinal substance
normally existed at this spot. He erroneously states that the
yellow spot was aj»ro/ec^/ow of retinal substance inwards towards
the vitreous humour. Whilst examining the internal surface
of a fresh retina under strong sunlight illumination, he satisfied
himself of the prominence of the fold by holding a needle oppo-
site to it, and observing that the shadow deviated from the
straight line, when passing over the situation of the fold. Had
the "fovea centralis" not been distorted by this fold, Jacobs'
ingenious observation would have demonstrated a depression

1868.]

Structure and Function of the Retina. 339

instead of a prominence. Sommering correctly interpreted
this fold as an accidental puckering. With respect to the ante-
rior termination of the retina, opinions varied ; some anatomists
asserting that it extended to the lens, and even hehind it ;
others that the " vascular layer" only extended to the margin
of the lens, whilst others again believed that this vascular layer
lined its posterior surface. Jacobs fixes correctly the limit of
the " nervous layer" at the " era serrata,''^ and admitting the
appearance of a continuation of the vascular layer (memhr.
limitans) as far as the lens, concludes finally against the exist-
ence of a pars ciliaris retince.

The next series of observations was made by German anato-
mists. In 1834 Gottsche demonstrated the filamentous structure
of the " nervous expansion," previously held by all anatomists
to be " medullary." Behind this he found a " compact layer"
(the granule layers of modern authors) from the external surface
of which ■ ' staff-like bodies" were seen projecting which pre-
sented an appearance like a thatched roof (figures representing
this are to be found in many modern works, e. g., ' Carpenter's
Human Phys.,' 1854). Gottsche macerated and scraped off this
retinal structure in order to demonstrate what appeared to him
of greater import, namely, the nervous expansion of fibrils.

In 1835, Huschke, simultaneously with Treviranus, noticed
the staff-like bodies, and Treviranus, after long examination,
came to the following conclusions respecting the relations which
the layers of the retina bore to each other: 1. The optic nerve-
fibres change in some part of their course from the meridional
to the radial direction.

" After the optic nerve has penetrated through the sclerotica and
chorioidea its cylinders (nerves) spread out singly, or in bundles, on
the outer (!) surface of the retina in all directions. Each individual
cylinder or each bundle consisting of several cylinders at a certain
part of its course, bends inwards towards the inner surface of the
retina. Immediately after this it passes through openings in a
vascular network which springs from the central vein of the optic
nerve. Before it arrives at the inner surface of the retina it pene-
trates through a second vascular network formed by the twigs of the
central artery of the optic nerve. Having passed the latter it is
received by a sheathlike continuation of the vascular layer, and
covered by this it terminates behind the vitreous body in the form of
a papilla."

Allowing for the mistake by which the position of the optic
nerve-fibres is represented as outside instead of inside the retinal
layer in which they are supposed to terminate as nerve
^' papillae," Treviranus seems to have had a distinct notion of a
radial set of nerve-fibres. And if the " papillte" described by

340 Reviews. \ Oct.,

him were really the cones of the columnar layer, his assertion
of a direct connection between the optic nerve-fibres and these
cones (or rods), though then unproved, must be accepted as an
anticipation of later discoveries. The comments of Job. Miiller,
in his ^ Jahresbericht,' 1837, shows how the statement of Trevi-
ranus was understood by his contemporaries. Miiller says —

" The termination of each separate fibre of the nerve layer, in a
Btaff-like body, seems still a postulate rather than an ascertained
fact."

And he adds —

*' If every nerve extremity correspond to a fibre of the optic nerve
the thickness of the retina ought to diminish progressively from the
point of entrance of the optic nerve to the border of the ciliary liga-
ment independently of the varying thickness of the coats of the
retina."

And, again, after discussing the thickness of the nerve-fibres
and the relative fineness and number of elements of the colum-
nar stratum, he remarks that —

" It is not easy to understand how so many fibres as are necessary
to furnish the stafi'-like bodies can be compressed into the narrow
compass of the optic nerve."

These acute remarks of J. Miiller bear out the assertion that
the physiological significance of Treviranus's discovery was fully
understood, and point to two important facts not made out till
a much later date, namely, 1, the regular thinning off" of the
optic nerve expansion towards the ora serrata ; and, 2, the
greater number of the radial nerve-fibres as compared with that
of the meridianally disposed optic jibres.

In 1836, Langenbeck described the retina as consisting of a
cortical (external granule) layer ; a filamentous (nerve) layer ;
and a vascular layer. He observed, also, that the granule layer
was at the yellow spot circumscribed by a sharpe edge (in con-
sequence of the separation of the optic nerve-fibres). Besides
this, he notices that the granule layer ceased at the ora serrata,
and that apars ciliaris retince lined the posterior surface of the
corpus ciliare terminating at the junction of the ciliary processes
with the urea.

In 1837, Valentin (* Repertorium,' vol. ii), in his account of
the retinal structures, demonstrated the following noteworthy
points : — 1. The primitive fibres of the optic nerve do not simply
run alongside each other, but interweave in a plexiform manner,
leaving elongated fusiform spaces or meshes, in which " over-
laying globules" were seen. These overlaying globules (Bele-

1868.] Structure and Function, of the Retina. 341

gungskugeln) were the ganglionic 7ier de-cells discovered, or
mentioned, for the first time, by Valentin, who first, also, men-
tions the plexiform arrangement of optic fibres. 2. The
granule layer he describes as consisting of a mass of granules
lying close together, but no connecting fibres were seen. 3.
Valentin lays due stress on the absence of retinal layers at the
entrance of the optic nerve, in consequence of which he remarks
that " this point being still pure optic nerve (only with numer-
ous "overlaying granules" — ganglionic nerve cells) is merely
a light conductor, not an organ impressible hy light.

Michaelis (1837) describes four retinal layers : 1, external
serous layer (tunica Jacobi) ; 2, a granule layer ; 3, a nerve and
vessel layer ; 4, an internal serous layer. In the first layer he
recognises the cone and rod structure, and notices the red and
yellow-coloured globules found in the bird's retina. The first
accurate description of the bending of the optic nerve-fibres
round the " yellow spot " is given by Michaelis. They are
arranged, he says —

" In a peculiar manner roimd this spot, for whilst in other s4||p-
tions the nerves radiate in straight lines, around the macula luiea
they are arranged in the form of arches, of which one part meet in
the ^foramen centrales the next in succession curve in regular arcs
on each side of it towards a line which stretches outwards from the
macula lutea towards the peripheral portion of the retinal expansion."

The thin transparent spot, which has obtained the name of
foramen centrale, is elongated. Further, he observes that at this
macula luten the granule layer is very thin in the centre, but
increases in thickness towards its circumference. The ^^ fora-
men " is formed by a single layer of little globules — in fact,
Michaelis believed the foramen to be simply a " fovea," as it
is now called. He also found that the nerve-fibres which run
to the " yellow spot" ended on its surface. The internal
" serous" membrane of Michaelis (membrana limitans interna)
is described by him as containing many globules furnished with
fine threads, which he took for nerve-fibres, but which Kolliker
considers to have been threads of the radiary system of fibres
(connective tissue) running to the tnemhr. Urn. ext., and mis-
taken for nerve-cells and their prolongations.

In Joh. Muller's classical work on physiology (1840) the
chapters on " sight " are occupied with physical and meta-
physical expositions of the general phenomena of vision.
Nothing is added in his account of the human retina to the
researches of the authors quoted. J. Muller's own observations
on the constructive details of the retina relate chiefly to the
eyes of invertebrata. What may be termed the first period of

34:i Reviews. [Oct.,

retinal anatomy closes at this date, and the observations of the
next ten years form a middle epoch.

In 'Miiller's Archiv,' 1839, Henle argues in favour of the
theory of Treviranus; and in liis ' Allg. Anat.' the whole
previous history is clearly and succinctly given. A close study
of the columnar stratum led him afterwards to the discovery of
threadlike prolongations from the inner ends of the rods, which
he likened to nerve-fibres. He then also describes the various
changes which they undergo during maceration and decompo-
sition. In the rods of the retina in reptiles and fishes he notices
a striation of their substance. Michaelis had already shown
that the columnar stratum lay external to the nerve layer; and
in 1840 Bidder and Hannover demonstrated this fact in all
vertebrata. The latter discovered several new facts — the exist-
ence of double or twin cones {co7ii getnini) ; also of coloured
globules in the retina of amphibia and birds. In respect to the
cones he distinguished a fiask-shaped body surmounted by -a
tapering rod-shaped outer portion, which showed a cross
striation of its substance, and a disposition to break across in
the lines of striation. This observation is of prior date to
Henle's notice of the same fact. Hannover asserts that the
cones are solid, and denies the nerve character attributed to
their substance. The prolongations from their inner ends he
mistakes for filamentary attachments to the choroid pigment
membrane, and this confounding of the inner with the outer
end of the rods and cones led him into the error of asserting
that the columnar stratum was intimately adherent to the
choroid, but simply in contact with the " true retina.'' He
therefore viewed it not as nerve structure, but as a reflecting
surface, whose function was to throw back the light penetrating
the globe of the eye on the transparent nerve-cells and fibres
through which it had passed. This opinion he maintained
controversially in later essays (' Recherches,' &c., 1844, and
'das Auge,' 1852).

Briicke, 1844 (Miiller's ' Arch.'), describes the cones as
thickened rods, and assigned to them a catoptric function, the
object of which was to arrest and isolate the lines of light pro-
jected on the retina by the dioptric apparatus in front, and to
reflect them back on the nerve-cells and fibres, producing
thereby single impressions of light intensified by this mode of
reflection (as from mirrors). To understand Briicke's theory
■we must refer to the constructive detail of the invertebrate eye.
In the " compound eye " of the invertebrate the separation of
rays of light entering it is efiected by means of numerous small
corneal facets, with lenses behind them, to each of which is
apportioned a separate bundle of nerve-fibres, which run straight-

1868.]

Structure artd Function of the Retina. 343

forward to the front of the eye, ending immediately behind the
cornea. In the vertebrate type the light passes in lines, de-
termined by the dioptric apparatus in front, through the globe
of the eye and transparent retina, till it falls on the closely
packed rods and cones of the tunica Jacobi. These have their
long axes directed radially to the centre of the eye, and the
light reflected by them is thrown in isolated lines upon the
nerve-fibrils (or prolongations of their inner ends), whose
direction is also radial, until they meet the nerve-cells of the
ganglionic layer. In the invertebrate compound eye the nerves
run forwards in a cone-like expansion, filling the globe of
the eye; whilst in the vertebrate eye the optic expansion is
spread out on the inside of a hollow sphere, and the nerve-
fibrils turn backwards through the thickness of the retina upon
the outer layer of cones and rods. Instead of a multitude of
separate images, produced by the corneal structure of the in-
vertebrate compound eye, a more perfect camera picture of
external objects is formed in the columnar stratum, which
Briicke looked upon as a close-set series of small mirrors,
formed by the ends of the rods and cones which efiect the same
isolation of points in the picture that is accomplished by the
corneal facets of the invertebrate eye, and the reflection in the
radial direction brings back the picture upon the separate fibres
of the optic nerve. Thus the columnar stratum at the back of
the retina in vertebrate eyes performs a function comparable with
that of the corneal structure at the front of the invertebrate
eye. A more perfect camera picture is first produced, and then
the " mosaic " of cones and rods enables this picture to be
recognised in detail. In the latter scheme vision is effected by
a backward view on the concave of the tunica Jacohi ; in the
invertebrate plan vision is directly forwards on the convex
cornea.

We noAV continue our historical sketch. In 1845, Pacini
described the retina as consisting of five layers, thus counted in
order from Avithout inwards : 1, T. Jacobi ; 2, layer of nucle-
ated granules ; 3, grey nerve layer with fibres ; 4, ganglionic
layer ; 5, optic expansion. The cones of Jacob's membrane he
describes as single and double (coni gemini of Hannover), some
being furnished with an outer narrow rod- like portion. The
inner ends of both cones and rods enclose a granule with nucleus
in it with a thread-like prolongation. Pacini contends for the
true nerve character of the whole. The granule layer he
figures in one thick, undivided mass made up of numerous rows
of granules containing nuclei, and giving off fine threads of
communication. He also gives the true position of the gan-
glionic layer and saw nerve prolongations from these ganglia.

344 Reviews, [Oct.,

which he conjectured to be continuous with the optic nerve-
fibres. A fine granular mass (" fibre grigie") lying immediately
behind the ganglionic layer is correctly described by him as con-
sisting of a minute network of delicate fibres in a finely granular
matrix.

Bowman (" Lectures," 1846, ' Med. Gazette,' and ' Todd and
Bowman's Phys. Anat.') describes the following layers of the
retina, counting from within outwards. 1. Fibrous grey
layer —

" Apparently consisting of the tubular fibres of the optic nerve
deprived of their white medullary substance that is being no longer
tubular and white but solid and grey, and united more or less into
a membrane. The bundles of fibres anastomose in a close plexiform
manner, and finally constitute a thin sheet becoming thinner and
less fibrous as we trace it forwards."

This fibrous layer is united to the hyaloid membrane by a layer
of nucleated cells, almost transparent, and difficult of discovery
onthat account (fig. 117, ^ Phys. Anat.'). 2. Outside the fibrous
layer follows a vesicular grey layer (the fibre gris and ganglionic
layer of Pacini), resembling the grey substance of the brain.
In this layer is distributed the network of capillaries (the
vascular layer of older authors). Bowman describes ("Lectures,"
1846) pale nerve-threads similar to those of the cerebral nerve-
ganglia which proceed from the cells of the ganglionic layer,
but were not traced to the optic nerve-fibres. 3. Next outside
to this ganglionic layer the granule layer is described and
figured as divisible into two separate layers. The granules he
compares with nuclei of cells. 4. The tunica Jacobi is de-
scribed as consisting of club-shaped rods, whose outer ends "are
seen to be formed by a sudden bending back of the stem like a
crook." Cones, as well as rods, are distinguished by Bowman,
and the layer " forms a connecting medium between the retina
and choroidal epithelium." The " yellow spot " is stated to be
formed by a projection of the retina towards the vitreous humour
with a minute aperture at its summit (see a7ite, T. Jacobi).
The expansion of optic fibres cannot be traced over the yellow
spot, but sweeps in an arch round it —

"Nucleated cells occupy the elongated meshes of the fibrous
plexus, until at length the fibres disappear and the closely set cells
seem to cover the whole surface of the spot. The gradual subsidence
of the fibres in the intestines of the cells we have distinctly seen."

The colouring matter of the yellow spot is not deposited in
grains of pigment, but is diffused through the tissue. Bowman

1868.] Structure and Function of the Retina. 345

concludes his account with the observation that the use of the
yellow spot is unknown C Phys. Anat.')

Hassall (' Micr. Anat.,' 1849) gives a description which is, in
many points, erroneous and retrograde. The T. Jacobi is a
single stratum of cells, whose thickened ends lie against the
choroidal epithelium, and their ends towards the granule
layer :

" Although these cells adhere together with sufficient firmness to
constitute a distinct membrane, it would appear that they possess a
certain power of movement (!) upon each other, for it is only on
such a supposition that we can explain satisfactorily the fibrous
appearance which the membrane frequently presents when viewed
in extensoy

Hassall's figure, instead of demonstrating this, simply shows
the decomposed state of the rods, long before explained by
Henle as a result of maceration. Hassall maintains that the
T. Jacobi is " certainly not a nervous structure." Among the
facettce of retinal anatomy may be placed his observation that
each cell of the tunica Jacobi " has not an inexact resemblance
to a human spermatozoon ! than which it is, however, less con-
siderable in size." In his account of the granule layer he
follows Bowman. The ganglionic layer (hitherto overlooked !
says Hassall) is an exceedingly thin and delicate structure,
consisting of " caudate ganglionic globules," and hardly to be
considered a distinct stratum. Immediately outside the fibrous
layer Hassall describes " a vesicular layer :" the cells composing
it are several times larger than the nuclei of the granular layer.
His figure delineates "clear transparent globules without
nuclei," but no other anatomist has found such globules in this
part of the retina. The fibrous grey layer (optic nerve expan-
sion) " is made up of grey gelatinous fibres without any tubular
sheath." A vascular layer is supposed by him to exist in the
inner surface of this nerve layer, an error into which Pacini
also fell.

In 1850 Corti (Miiller's ' Archiv.') traced the course of the
offsets from the cells of the ganglionic layer, and found them to
be continuous with the optic nerve-fibres. His observations
were made on many mammalia. In the retina of the elephant
he found the best examples, and figures the communications
between the ganglionic cells themselves, as well as Avith the
optic nerve-fibres (' Zeitschr. f. Wiss. Zool.,^ vol. v.)

In 1852 Henle ('Zeitschr. f. Rat. Med.') confirms with
Dittrich, Gerlach, Herz, KoUiker, and Virchow, the fact that
the " yellow spot " is visible immediately after death, but that
no fold of the retina exists at that spot. The transparency of

346 Reviews. [Oct.,

the retina allows the parts behind to be seen through, especially
at this part. A surface view of the T. Jacobi shows a mass of
clearly defined but very small circles (end view of the rods)
with somewhat larger circles interspersed (cones). The pro-
portion of rods to cones varies at different parts of the retina.
In the middle of the yellow spot co7tes alone are seen closely
packed together. At the edges of the spot a single circle of
rods surrounds the centrally placed cone ; towards the equator
oculi a double or triple circle of rods is grouped round each cone.
The somewhat larger circle which represents the greatest width
or thickness of the cone contains a small circle Avithin it, which
indicates the smaller rod-like outer half. Sometimes instead of
this circle the rod itself, looking like a small nail (" Stiftchen")
within the outer circle, indicates its accidental breaking off or
curve, so as to be seen in oblique position. The action of
solution of iodine on I'ods and cones is different, the substance
of the rod becoming stained while that of the cone does not.
The colouring matter natural to the yellow spot is diffused.
Granule and ganglionic layers were seen, but no fibres of com-
municatiori. A transparent, tough gelatinous cement unites
the whole in one firm mass. The rods appeared to project into
the pigment layer of the choroid.

We now come to a turning-point in the history of retinal
anatomy. Hitherto the presence and alternation of the concen-
trically disposed layers of the retina had received almost un-
divided attention. Although several observers had noticed
fibres which were sxipposed to run from one element to another,
and had surmised a direct continuity of the columnar stratum
with the optic nerve-fibres which, however, was not yet proved,
nothing approaching to a correct statement of their true rela-
tions had been put forward, though many new details had been
ascertained during the years 1840-51, which may be called the
middle period of retinal anatomy. The third and last period
commences with Heinrich Miiller's researches, since which the
anatomy of the retina has made continuous progress on the new
basis afforded by H. Miiller's discovery of the radial system of
fibres. In 1851 H. Miiller described this system of fibres, which,
in contradistinction to the '^ meridional " course of the fibres of
the optic nerve expansion, was named '^ radial " by their dis-
coverer (' Zeitsch. f. Wiss. Zool.'). These fibres he found to
extend from the inner ends of the rods and cones to the outer
granule layer, then forming a solid mass between the outer and
inner granule layer and finally penetrating the ganglionic layer,
to be inserted on the outer surface of the internal limiting
membrane. The existence of a constant and distinct anatomical
continuity between the outer and inner layers of the retina by

1868.] Structure and Function of the Retina. 347

means of this radial system was the first result of H. Miiller's
investigations ; and the same anatomical disposition was proved
for all classes of vertebrate animals but man. The inquiry was
soon afterwards taken up by KoUiker, with whom H. Miiller
then conjointly carried on his researches on the human retina.
In his microscopic anatomy (1854), Kolliker gives the further
results of their joint examination, and of his own studies and
opinions respecting the nature and function of the several parts.
Kolliker re-discovered, or rather confirmed, most of the facts
already mentioned, added a number of carefully observed facts,
and based on the whole a new physiology of vision.

The anatomical peculiarities of the cones and rods receive
much attention and elucidation. The cones are described,
much as Hannover had described them, as consisting of a flask-
shaped inner ])ortion and a rod-like outer portion, the two being
separated by a fine cross-line. But the statement of Hannover
that the cones are solid bodies is refuted, Kolliker afl[irming
them to be long tubular nucleated cells, the outer prolongations
of which formed the tapering cone-rods resting against the
choroid pigment layer, and the inner prolongation (the nucleus
placed at the inner end of the cone) being continuous with
Miiller's " radial fibre.^' The whole structure he declares to be
a modification of ordinary nerve matter. He confirms Henle's
statement that cones alojie exist at the " yellow spot/' and that
this spot is bare of nerve-fibre layer. He agrees with Miiller in
representing the cones of the '^ yellow spot " as longer and
narrower than elsewhere. The rods also he describes as having
a fine nucleus towards their inner ends, and an extremely fine
nerve thread proceeding from this end. The cone fibres he
distinguishes as being much thicker than the rod-fibres, but
considers rods as well as cones to be modified nerve-ceWs, and
fibres. The fibres of Muller proceeding from these elements he
at first believed to run to the outer and inner layers of grannies
respectively, but this first description of their destination he
afterwards recalled.

Two layers of granules with an interspace filled by the fibres
of Miiller running from without inwards are described by
Kolliker. The granules are recognised as small cells filled with
a large nucleus, and interpreted to be bipolar ganglia. These
granule cells with their communicating fibres are likened by
Miiller to " currants on their stalk." The intei'-granule space
is entirely occupied by the fibres of Miiller running in close
pariillel lines in a finely granular cement. The ganglionic layer
of Kolliker includes the grey substance of Pacini, with its
minute plexus of delicate fibres (see Ecker, plate xix, fig. 2),
and the large multipolar cells described by Bowman, and Corti,

348 Reviews. [Oct.,

and others. Kolliker succeeded in demonstrating the fibre
connections between the ganglia themselves, and between the
ganglia and optic nerve-fibres. Through this ganglionic layer
the system of radial fibres is seen to penetrate in bundles col-
lected together at close intervals, and finally attaching them-
selves by a broadened triangular foot, or pencil of fibres, to the
outer surface of a membrane described for the first time accu-
rately as an integral and independent layer on the inside of the
retina, the membrana limitans interna (Ecker, pi. xix, fig. 7).
Many important particulars of measurements and details of the
several layers and elements are given, for which we must refer
to the various papers by Kolliker (' Wui-zburg Transactions ').
The optic nerve at its entrance is composed of ordinary bundles
of nerve-fibres with enclosing sheaths or neurilemma. In its
passage through the sclerotic the fibres are still tubes having
dark outlines and filled with white nerve substance. But im-
mediately after they appear as yellow-grey strongly refractive
fibres, consisting no longer of ordinary medulla ; they have no
nuclei on their outside, are markedly varicose, and devoid of
any axial fibre. The expansion of fibres is thick at the com-
mencement, where the fibres overlie each other forty to sixty
deep, but rapidly diminishes in thickness as it spreads out,
becomes very thin round the ** yellow spot," and ends with a
single intercepted layer towards the ora serrata. The anasto-
mosis of the fibres in bundles, with interspaces filled out by the
deeper seated ganglionic cells and the termination of fibres in
these cells, is demonstrated. The arching of the fibres round
the " yellow spot," as described by Pacini, is confirmed. A few
nerve-fibres round its margin seem to drop into the depressed
surface and, as surmised by Remak, are traced to the ganglia of
the "yellow spot." Kolliker extends this conclusion to the
whole retinal surface, affirming that each single optic nerve-
fibre runs to its ganglion or perhaps several fibres to one
ganglion.

Shortly after Miiller's discovery of a radial system of fibres,
doubts were entertained as to its right interpretation. Some
histologists maintained that the whole system was to be con-
sidered as a framework of fine connective-tissue fibres, for the
support of the delicate elements of the several layers. Miiller
himself came, after repeated examinp,tion, to the following con-
clusions: — 1. The fibres proceeding from the inner ends of the
rods and cones, and ending in the granules of the outer layer,
are unquestionably nerve-fibres ; 2. The fibres passing in
bundles through the ganglionic layer, and inserted into the
memb. lim. interna, are not the same as those which have been
traced from the nerve-cells to the optic expansion : on the

1868.] Structure and Function of the Retina. 349

contrary, their connection with the raembr. lim. interna indi-
cates their histological character as conneclJtive-tissue fibres.
From the position of this inner system the hypothesis of their
being concerned in the perception of light is of itself disproved ;
whilst the fact of the connection of the optic nerve-fibres with
the ganglionic cells receives repeated confirmation. 3. The
distribution of the inner radiary system varies in different parts
of the retina ; through the thick mass of optic fibres at the back
of the eye the radial fibres pass in strongly defined bundles or
pillars, Avhich run direct to the membr. lim. interna, and are
inserted by distinct but delicate filaments on its outer surfiice ;
but it is just at this part of the retina that the nerve-cells are
few in number. At the equator oculi the inner radial fibres are
also strongly developed, while the nerve-cells are at this part
relatively less numerous than at and around the yellow spot.
At the yellow spot, when the nerve-cells are found in mass, the
inner radial fibres are entirely wanting, and this again corre-
sponds with the fact that at the " yellow spot " there are no
optic fibres, and therefore no support for them required ; the
membr. lim. interna lying here close against the ganglionic
cells. Towards the front of the retina the radial fibres are
present in much greater proportion than the ganglionic and
granule cells ; and here the connection of the radial fibres with
the membr. lim. interna is most distinct and least liable to be
confused with ganglionic offsets to the optic nerve expansion.
Thus, throughout the retina the disproportion between the
number of inner radial fibres and the nerve-cells of the gan-
glionic layer goes to prove that these fibres are not nerves but
connective-tissue framework. But Miiller maintained rightly
that all radial' fibres are not to be confounded together, and
that the outer set (running from the inner ends of the cones and
rods to the outer granule layer) are different in character as in
distribution.

Other details given by H. Miiller deserve notice, as they bear
upon the investigations of later anatomists. Of the rods, he
says that they extend through the whole depth of the columnar
stratum, and appear divided into an outer and inner half by a
cross line in the middle, at which point they readily break into
two portions, each half reacting differently to chemical agents.
At its inner end the rod contains a nucleus, and then suddenly
tapers into a fine thread which runs to the granule layer ending
in one of the granules. The cones are also separable into two
halves — an outer tapering rodlike part (Henle's ' Stiftchen '),
which reaches to the choroid pigment ; and an inner flask-shaped
part, which occupies the inner half of the depth of the columnar
stratum. The two halves arc defined by a cross line, as is the

84— xrii. 23

350 Reviews. [Oct.,

case with the rods. The inner half (the conical part) contains
at its inner end (that is, just at the boundary line between the
columnar stratum and the outer granule layer) a nucleated
granule, and then tapers into a thread considerably thicker than
the rod thread. This cone thread ends with a triangular button
or triangular-shaped enlargement at the inner border of the
granule layer. These threads, given off by the conea and rodsy
are the radial werwe-fibres.

With respect to the granule layers, Miiller observes that their
mass (thickness) varies, not only in different animals, but also
in the different parts of the same retina (see * Ecker. Icones.
Phys.,' table 19). Thus at the " yellow spot," the inner granule
layer is thick, the outer thin, and the inter-granule space occupied
by radial fibres is deeper in proportion as the outer grainile layer
thins off. Towards the equator oculi the outer granule layer
increases in thickness, and the inner is relatively thin, whilst
the inter-granular space for radial fibres likewise diminishes.
Both granule layers run thin as they spread towards the ora
serrata, and almost disappear at the ora itself, and the inter-
granular space regularly decreases as the thickness of the
granular layer diminishes.

The ganglionic layer also varies in mass at different parts of
the retina. Reduced to a single layer of cells at the entrance
of the optic nerve, where the nerve-fibre mass is thickest, it
becomes a deep aggregation of cells at the " yellow spot,"
which grows less and less as the layer spreads over the equator
oculi, and from thence forwards through the ora where the cells
no longer form a continuous layer.

The figures and text of Kolliker's 'Micr. Anat.' (figs. 404-5-6-
7 and 411) sufficiently indicate the uncertainty then prevailing
(1853) respecting the mode of connection of the outer layer of
radial fibres (namely, the prolonged ends of the rods and cones)
with the inner system of fibres whose bundles are seen running
from the inner border of the granule layer through the stratum
of optic nerve-fibres to the outer surface of the membr. lim.
interna. In fact, Kolliker draws a scheme of communication
which does not really exist in the form delineated by him in his
' Microscopic Anatomy.' In discussing the question of the
nature of the inner radial fibres, he endeavours to show that
these fibres are allied morphologically and chemically with the
substance of Avhich the tissue of the vitreous body is composed,
rather than with that of ordinary connective tissue. The
objection that the membr. limitans in which the fibres terminate
is obviously not a nerve structure, he disposes of by affirming
that the connection is one only of contact, not of intermixture
of tissue. The conically expanded ends, ranged close together.

1868.]

Structure and Function of the Retina. 351

or crossing each other as they join the Hmiting membrane, give
rise, he adds, to an appearance of a clear border between the
layer of optic fibres and the membrane, which is produced by
the swelling of the delicate fibres into a gelatinous mass ; and
this liability to swell by imbibition of water has led to an
erroneous conclusion that a layer of transparent vesicles exists
here, which in section shows a row of clear globules. This
appearance he figured in the first edition of his ' Handbuch.'
Bowman describes the same as an epithelial layer. It is possible
that the papillae of Treviranus may in reality have been these
altered conical ends of the radial fibres. Michaelis (see ante)
<lescribed the membr. limitans as a " serous " layer. According
to KoUiker, the substance of this membrane, which is exceed-
ingly thin and delicate, differs chemically and morphologically
from that of the radial fibres attached to it ; these latter, as
already mentioned, he likens with the tissue of the vitreous
humour, the membrane with the hyaloid coat. Yet he noticed
in the fibres and the membrane nuclei, a circumstance which
favours the opinion that the tissue is of the kind known as
connective.

Some anatomists have compared the membrane, with its
attached fibres, to that which lines the ventricles of the brain,
being genetically identical ; and in the foital brain this lining
basement-membrane of the ventricles shows the same kind of
delicate fibrous tissue passing from its under surface in contact
with the cerebral substance, and penetrating its mass. Henle
calls the membrane " hyaloidea limitans," on account of its
being so often found inseparable from the hyaloid membrane.
Schultze objects that they are genetically distinct, the membrana
limitans belonging to the retinal system, the hyaloid to the
vitreous body. This anatomist also contends (against KoUiker)
for the intimate connection of the radial fibres with the limitans,
and considers both to be integral parts of the connective tissue
of the retina.

Nunneley's account of the retina, 1858, is extremely imper-
fect. He separates the layer of rods from that of the cones,
making the first external to the latter. The granule layer is not
divided into two, and the intergranular fibre layer receives no
notice. Neither is there any account of the radiary system of
connective-tissue fibres, or of the rod and cone threads. The
cells of the " nucleated vesicular layer" are spoken of as having
no communicating fibres with the granule layers or with the optic
nerve layer. The optic nerve pierces a single narrow aperture of
the choroid. Its fibres, of different lengths, terminate as they
pass forward by being lost or continuated into the true retinal
elements ; the granules being the connecting medium between

352 Reviews. [Oct.,

the nerve-fibres and the rods. A "vascular layer" is needlessly
retained, being, in fact, no layer. A layer of hyaloidal cells is
described (see Kolliker's explanation). The account of the
yellow spot is confined to the question of a " foramen," which
he correctly decides as abnormal ; the yellow colouring matter he
attributes to " minute choroidal globules," and not to any colour-
ing matter diffused in the T. Jacobi, The rods of this T. Jacobi
he correctly describes as continuous on the outer surface. But,
on tlie whole, " inclines to regard this much debated spot as a
vertigiform remains of the spot where a large blood-vessel has
passed through the retina in the development of the eye ! and
carried with it some of the choroidal colouring matter." No
wonder that he says *' it is very difficult to offer any satisfactory
opinion of the use of this peculiar spot."

The details given of the several retinal elements are some-
what contradictory. He notices, however, a fine transverse line
dividing the cones of fishes into an outer rod-like and an inner
bulbous portion.

So many researches by different observers have followed the
first piiblication of Kolliker and Miiller's discoveries that it is
impossible in any article like the present to give separate
abstracts of them. Besides that the repetition of similar obser-
vations is as unnecessary as it would be tedious. We refer to
our bibliography of a list of the more important researches, and
some of the results will be found incorporated in the hasty
abstract with which we must conclude.

We give here the enumeration of retinal elements as counted by
Kolliker (see Ecker's ' Icones Phys.,' pi. xix) in 1853 ; and also
the tabular arrangement devised by Ilenle (' Handbuche'). By
a comparison of the two, the corrections and additions made
during the last fifteen years may be gathered at a glance. We
confine our explanatory remarks to the points of difference
observed in the two schemes.

Kolliker and Muller. HenU.

1. Layer of rods and cones. fl. Rods and cones.

2. Outer grannie layer. ^ " Mosaic layers " J 2. External limiting meni-

3. Intergranule layer. ' I brane.

4. Inner granule layer. \j^. Granule layer,

5. Fine molecular layer. 2. Fibre layer. 4. Outer fibre layer.

6. Nerve-cell layer (gan- " ["5. External granular layer.

glionic). 6. „ ganglion layer.

7. Optic nerve expansion. 3. Nerve layers. < 7. Internal granule layer.

8. Ends of radial fibres in- 8. „ ganglion layer.

serted into. L.^- Optic nerve expansion.

9. Membi-ana limitans. 4. Limiting membrane. 10. Limitans hyaloidea.

On comparing these tables we see that the earlier one is a sim-
ple enumeration of layers, whilst the second is a classification

1868.]

Structure and Function of the Retina. 353

of elements based on physiological distinctions. The physiolo-
gical argument we must defer to a future opportunity, and con-
tent ourselves at present with stating the facts which determined
Henle in his arrangement.

The " mosaic layers " Henle separates from the rest because
firstly, the retina naturally separates into two portions, the outer
of which includes all that belong to the " mosaic" structure;
secondly, because the blood-vessels of the retina are confined to
the " nerve layers" of the inner portion, and are wholly absent
in the " mosaic layers;" thirdly, because Henle denies that the
continuity of the cones and rods with undoubted nerve struc-
tures is as yet absolutely demonstrated, although he does not
exclude them from the series of nerve formations by the use of
the term '* mosaic layer." And, similarly, the " granule layer"
(No. 3), counted as belonging to the mosaic layers is separated
from the " nerve layers, firstly, because Henle considers the
granules of this layer differ in substance as well as position from
the granules of the nerve layers. He finds them to be striated
as though made up of molecules possessing different refractive
power, and showing other differences which distinguish them
from all other known nerve-cells, whilst he allows the ganglionic
character to the granules of the inner layer.

" The " outer fibre layer" of Henle is thus named on account
of its position and unmistakeable character : denominatio Jit a
potiori. Schultze (de ret. struct.) declared this fibrous layer to
be composed of connective tissue, and held also the rods and
cones from which they spring to be modified connective tissue.
But in his later writings he emphatically expresses his convic-
tion that the rods and cones with their thread-like prolongations
are nerve structures, and the granules in the middle course of
these threads to be bipolar ganglia. Henle agrees that the outer
fibre layer is composed of nerve fibres. This " outer fibre layer"
constituted by the thread-like prolongations of the granules
(outer granule layer of Miiller and Kolliker) obtains, according
to Schultze, its distinctive character when the granules are few
in number, and is, in short, the inner half of the outer granule
layer devoid of granules.

The " nerve-layers" of Henle include several of the layers
of KoUiker's table differently arranged. The name " inter-
granule layer" Henle omits, having substituted for it his " outer
iibre layer" and " external granular layer." In comparing the
two tables layer for layer we find that KoUiker's first (rod and
cone stratum) receives as an addition or new layer, a mpinhrana
Jimitans externa, and that KoUiker's second layer (outer granule
layer) is Henle's third layer. KoUiker's third layer Henle
divides into two (outer fibre layer and external granular layer

354 Reviews. [Oct.,

4 and 5). The fourth layer of Kolliker corresponds with
Henle's !$ixth. His fifth, sixth, and seventh with Henle's
seventh, eighth, and ninth. The eighth and ninth of Kolliker
make up Henle's tenth. We proceed to explain the reason of
these changes.

The difficulty first experienced in interpreting the true sig-
nificance of the radial systems of fibres has been resolved by
repeated examination of them. It is now believed that a
complete framework of connective tissue exists for the support
of the delicate nerve-fibres and cell elements of the different
retinal layers. A line drawn through the stratum of rods and
cones just above the slight swelling at their inner ends which
indicates the position of the " outer granule layer," marks the
external limit of this connective-tissue framework, and this
boundary line (H. Muller distinguished it by the name " rod
and cone granule line ") represents what is called the external
limiting membrane. It is not a membrane (Schultze), but
simply the outer surface of the coimective-tissue mass, pierced
with openings for the passage of the rods and cones through it.
This surface, if the rods and cones could be removed would
appear as a sieve-like expansion, but the rods and cones in
passing through it fill up the openings. Immediately under-
neath it are the rod- and cone-granules (or cell nuclei). The
name limitans externa is accepted by anatomists as indicating
the exact outer boundary of the connective-tissue framework, as
the inner boundary has long been recognised by the name
" limitans interna." The latter is a true limiting membrane, as
it is not pierced by any retinal element, and in fact completes
the retina on its inner face. Henle's granule layer (No. 3)
(Kolliker's outer granule layer. No. 2) is formed by the
mass of granules which Kolliker, Miiller, Schultz, and others,
hold to be bipolar ganglia (striated granules of Henle). Schultze
contends that they are imbedded in a sponge-like mass of con-
nective tissue, whose outer limit is the membrana 1. externa, and
which is continuous with the connective-tissue fibres that
accompany the rest of the retinal elements until they reach the
limitans interna. This connective tissue is at one place finely
reticulate, at another brought into a large meshed network, at
a third gathered into bundles of fibres supporting or isolating
the nerve-fibres and cells, according to the disposition of the
several layers. But the radial disposition predominates, and
thus attracted Miiller's attention. As we have seen, Miiller
found both the rod- and cone-threads which he considered nerve
fibres, and the inner system of radial fibres whose difference of
])osition and histological character he recognised. Kolliker and
Miiller failed to prove the continuity between these two systems

1868.1 Structure and Function of the Retina. 355

of fibres, because, as later researches have shown, they are not
continuous in the sense supposed by these authors at the time
of their first publication.

In the inter-granular layer of Kolliker the intermixture of
connective-tissue fibres with rod- and cone-threads is, according
to Schultze, so intimate that neither can be isolated readily or
for more than very short distances. In the following inner
granule layer of Kolliker the granules (also bipolar or multi-
polar cells) form the chief mass, but is supported, says Schultze,
by a radial areolar tissue in which connective-tissue nuclei may
be seen. In the fine molecular layer of Kolliker (Henle's
seventh) si minute plexus of exceedingly delicate fibres, both of
nerve- and connective tissue (Pacini's grey layer), gives its
distinctive character. In the ganglionic layer the large nerve-
cells are retained in position by the sponge-like areolar tissue
(Schultze; see also figures in 'Phil. Trans.,' vol. cli. May,
1866, section of fovea centralis by Hulke), which encloses the
cells in partitions. Finally, the optic nerve fibre-layer is sup-
ported by the relatively massive system of connective-tissue
fibres, whose bundles have been already frequently mentioned
as inserted into the internal limiting membrane.

It is worthy of notice that blood-capillaries spread through
all the inner nerve-layers of the human retina, penetrating
outwards as far as the intergranular layer. These capillaries
are supported by the connective tissue. He (1865) fancied
that he had detected perivascular lymph canals accompanying
the blood-vessels, such as he has found and described in the
grey cerebral substance. In some mammals only a few capil-
laries are found, chiefly in the neighbourhood of the entrance
of the optic nerve. In birds, reptiles, amphibia, and fishes, no
blood-vessels capable of being injected have been found. In
the human retina the capillaries are abundant.

Course of the radial nerte-fihres. — The course of the rod- and
cone-fibres has never been followed in unbroken continuity to
the ganglionic layer. Schultze explains this by afiirming that
the radial fibres enter into a plexiform anastomosis in the inter-
granular layer, and also in the grey molecular layer, changing
at each place their radial into horizontal direction. The ends
of the rods taper into exceedingly fine threads, which run to
one of the outer granules, and thence from its opposite pole to
the inner border of the outer granule layer, ending there, to all
appearance, in a small knob. The ends of the cones likewise
taper into cone-threads, which are much thicker than the rod-
threads. Schultze and others believe this thick cone-thread to
be a strand containing two or more nerve-threads. At the
inner border of the granide layer these cone- threads end appa-

356 Reviews. [Oct.,

rently like the rod- threads in an expanded button-shaped knob.
Henle observed two fibres given oif, one from each corner of
this knob. These fibres turned off in opposite directions, and
ran horizontally in his outer fibre layer. Hasse, a third fibre
proceeding from the under side of the knob. Schultze, a great
number of fine fibres all given off from the inner side or base of
the knob. These observations are supposed to afford an ana-
tomical basis for the theory of colour perception first propounded
by Young and carried out by Helmholtz.

The now horizontal course of the rod- and cone-threads, and
their anastomosis with each other, precludes any further isola-
tion so as to follow their continuous course. A narrow band
running concentric with the granule layers is thus formed
(Henle's layer 5). On the hypothesis that the cone- and rod-
threads transmit separate single impressions of light (effected in
the substance of the cones and rods), this first plexus of hori-
zontal fibres offers an anatomical basis for the possible combi-
nation or grouping of single impressions. On the inner side of
this band spring the fibres, which again take a radial course to
the granules (nerve ganglia) of the inner layer (Kolliker 4,
Henle 6). Through the granule layer the direction of the fibres
is radial. Next on the inner border of these nerve-granules the
fibres again form a minute plexus, where the continuity is a
second time lost in consequence of the horizontal direction and
constant anastomosis of the fibres, and the intermixture of con-
nective-tissue fibres. From the border of this plexus (Kolliker
5, Henle 7), which is contiguous with the large nerve-cells of
the ganglionic layer (Kolliker 7, Henle 8), fibres are readily-
traced till they join the nerve-cells. Most authors agree in
describing these as devoid of any cell-membrane, and in every
respect similar to the ganglia of brain substance. Ofisets from
them, joining the optic nerve-fibres as well as connecting the
cells together laterally, may be considered equivalent to the
axial cylinders of ordinary tubular nerves.

We must here conclude our summary of the retinal structure,
which is, from want of space, incomplete in many details.
Sufficient, however, has been said to give some general idea of
the complicated relations of the several elements. Before we
can enter into an analysis of the function of these elements ;
before we can apply our anatomical facts to the physiology of
vision, a number of observations respecting the intimate structure
and material condition of the cones and rods have still to be
collected. We are at present, so to speak, but at the beginning
of the end. On a future occasion we hope to lay before our
readers many points of interest already made out, especially
regarding the comparative anatomy of the columnar stratum.

1868.]

Structure and Function of the Retina. 357

Recent investigations offer a prospect of great promise, and
there is every reason to believe that retinal anatomy will ere
long disclose to us a safe anatomical basis for the explanation of
many questions relating to the physiology of vision, for the
solution of which there have hitherto been no satisfactory data.
Meanwhile we cannot but oifer our meed of praise to the many
distinguished anatomists who have carried us thus far on our
way. In the wide range of microscopic anatomy no subject
ojffers more formidable difficulties than the examination of the
retinal sti'uctures, and none has been met with greater deter-
mination and ingenuity of research.

Jacob's ' Cyclop. Anafc. and Phys.,' article " Eye."

Gottsche, 'Pfars Mitth.,' 1836.

Huschke, 'V. Ammon's Zeitschr.,' vol. iv, 1835 ; 'Lehre v. d. Sinnesorgan,' 1844.

Langenbeck, ' De ret. Obs.,' 1836.

Treviranus, ' Ueb. d. innern Bau d. Netzh.,' 1835-7.

Valentin, ' Repertoriuin,' &c., vol. ii, 1836-7.

Job. Miiller, ' Report in Arcbiv,' 1837.

Micbaelis, in ' Muller's Arcbiv,' 1837 ; and in ' Nova Acta,' &c., 1842.

Remak, in ' Miiller's Arcbiv,' 1 839.

Bidder, Ibid., 1839.

Burovv, Ibid., 1840.

Hannover, in ' Muller's Arcbiv,' 1840 — 3 ; ' Recb. Micr.,' &c., 1844 ; ' Zeitscbr.

f. Wiss. Zool.,' vol. V ; and ' Bidrag,' &c., 1850.
Brucke, ' Muller's Arcbiv,' 1844 ; and ' Anat. Bescbr. d. m. aug.,' 1847.
Pacini, ' Nuovi Annali delle Se. Nat.,' 1845.

Bowman, ' Lectures in Med. Gaz.,' 1846 ; and ' Pbys. Anat.,' 1849.
Hassall, ' Mic. Anat.,' 1849.
Gray, ' Pbil. Trans.,' 1850.

Corti, in ' Muller's Arcbiv,' 1850 j and ' Zeitscbr. f. Wiss. Zool.,' vol. v.
Hein. Muller, 'Zeitscbr. f. Wiss. Zool.,' 1851 and 1857; ' Verbandl. d.

Wurzb. Med. Ges.,' 1852-3-5; 'Arcbiv f. Opbtb.,' ii, iii, iv, 1856;

' Wurzb. natur wiss. Zeitscbr.,' 1861-2.
Kolliker, 'Verbandl. d. Wurzb. Ges.,' 1852; ' Comptes Rendus/ 1853;

'Micr, Anatom.,' 1854; 'Handbook,' eacb edition; and in ' Ecken

Icones Pbys.,' edit. 2, table 19, witb text ; ' Untersuch. ueber die Entw.

d. Wirbeltb.'
Henle, ' AUg. Anat. ;' 'Zeitscbr. f. wis. Zool.,' N. f., vol. ii ; 'Nacbr. v. d.

Kon. Ges. d. Wiss. Gottingen,' 1861—64; 'Handbucb d. Syst. Anat. d.

Menscb.,' 1866.
Job. Miiller, ' Report in Arcbiv,' 1853.
Bergman, ' Zeitscbr. f. Rat. Med.,' 1857.
Nunneley, ' On tbe Organ of Vision,' 1858.
Ritter, ' Arcbiv f. Opbtb.,' 1859, 1861, and ' Die Struct, der Ret.,' 1864 ;

' Grafe's Arcbiv,' 1865.
Manz, ' Zeitscbr. f. Rat. Med.,' 1860.
Brown, ' Vienersitzungsbericbt,' 1860.

Krause, ' Gottingen Nacbr.,' 1861 ; and ' Zeitscbr. f. Rat. Med.,' 1861—1863.
Scbultze, ' De Ret. Struct. Pen.,' 1859 ; ' Arcbiv f. Anat. and Pbys.,' 1861 ;

'Arcbiv f. Microsc. Anat.,' 1866; ' Gottingen Nacbr.,' 1864; 'Arcbiv f.

Microsc. Anat.,' 1867, pp. 215, 404, and 371 ; ' Ueber der gelb. Flecke,'

1866.
Scbien, ' Zeitscbr. f. Rat. Med.,' 1863.
Aubert, ' Phys. der Netzh.,' 1864.
Babucbin, ' Wurzb. Natur. Hist. Zeitscbr.,' 1863-4.

358 Reviews. [Oct.,

Welcker, ' Zeitschr. f. Rat. Med.,' 1863.
Hensen, ' Virchow's Archiv,' vol. 35.

Hulke, 'LondoQ Opth. Hosp. Reports,' 1862; 'Phil. Trans.,' 1866.
Steinlin, ' Schultz's Archiv,' 1868.

Leydig, 'Lehrb. d. Histol.,' 1857 ; 'Archiv f. Mic. Anat.,' 1861 j ' Beitrage,'
&c., 1852 J ' Untersuch. iib. Fische u. Reptil.'

Review V.

1, Spiritual Wives. By William H. Dixon. In two volumes,
8vo. London, 1868. Pp. 675.

S. Grace abounding to the Chief of Sinners ; or^ a brief relation
of the exceeding mercy of God in Christy to his poor servant ^
John Bunyan. London, 1666.

We are not admirers of Mr. Dixon's style of dressing his
goods for market, of expanding into two handsome volumes,
decorated with all that costly bravery which will require a great
sale, and entails heavy advertising, four cases of the epidemic
development of a certain mental diseased state. But we must
allow that his flowing and brilliant periods render the reading
easy, and the highly coloured descriptions carry us onwards,
like the thrilling lithographs in travellers' tales, so that we
arrive at the end incredibly quicker than we had expected from
the size and weight of the book. Also we thus gain an abun-
dance of detail, interesting to the morbid anatomist of the mind,,
and perhaps not without value to him whose office is the endea-
vour to cure and prevent its diseases. It is with a view to the
last-named end that we have studied the strange confessions and
exposures here embodied, and have joined to them an auto-
biography, which we found it a wholesome exercise to re-read
after them, for the purpose of purging our contempt and renew-
ing our hopes for human nature. The recent publication
placed first in the heading of this article records the victory of
the disease ; the other work, the victory of the patient. This
more fortunate event is, we believe, by far the most common ;
but it does not so often come before the public, as the sufferers are
only too glad to wipe away the memory of that which seems
shameful, and even to their medical confidants are reticent of
their hazy recollections. The conjunction of pleasure in telling
the truth, vivid power of word painting, and clear language,
such as we find in Bunyan, is unique.

The morbid condition of which we speak consists essentially

1868.]

Spiritual Wives. 359

in taking the idiopathic suggestions of the patient's own mind
for the external stimulus of a separate intelligence.

"As I was in the midst of a game of cat," writes Bunyan, "and
having struck it one blow from the hole, just as I was about to strike
it the second time, a voice did suddenly dart from heaven into my
soul, which said, ' Wilt thou leave thy sins and go to heaven, or
have thy sins and go to hell ?' At this I was put to an exceeding
maze," &c.^

Again, at a later period of his life, he tells us, —

" I was much followed by this scripture : ' Simon, Simon, behold
Satan hath desired to have you ;' and sometimes it would sound so
loud within me, that once, above all the rest, I turned my head over
my shoulder, thinking verily that some man had behind me called
me; being at a great distance, methought he called so loud." ^

In Mr. Dixon's book an adventure of one Miss Mary Lincoln
records the same feeling, —

" During the afternoon she heard the voice of God warning her to
flee — escape for her life, for the judgments of God awaited the place.
Her voice changed, and she was filled with power. She waited in
Little Rest (a small village in Brimfield) until evening, when another
dear sister felt drawn to follow her — Flavilla Howard. .
She felt that the clothes she had with her and those she had on were
a burden. She laid them all aside. They then escaped to the west
mountain," &c. ^

This inexplicable terror, this hearing of voices unheard by
the world, is exceedingly contagious ; as it is worded by the
last writer, others are " drawn to follow " by sympathy ; and
times and circumstances concurring, there ensues what is tech-
nically called " a revival," sometimes limited to small infected
districts, sometimes widespread enough to be historical.

Why does not this oftener take place ? It is very usual for
patients to complain to us of voices and warnings and threaten-
ings ; why are they not irresistibly driven to obey and to com-
municate their feelings ? Simply because they question them,
bring them to the test of common opinion, exercise free will
upon them, and so regain the use of reason. If the sugges-
tions are in accordance with reason they may be obeyed, if not
they are cast out and forgotten with all speed. These wise per-
sons are in fact their own keepers and mad-doctors. Whereas
the foolish by an initial yielding find their will weaker day by
day, till at last recovery by their own efforts, however wished
for, becomes impossible.

Compare the conduct of the two persons whose cases we have

1 • Grace Abounding,' § 22. 2 jbia., § 93.

* ' Maria Brown's ' Letter to John H. Noyes,' Uiscon. ii, 38.

360 Reviews. [Oct.,

quoted. The impression ou the senses of Miss Lincoln does
not appear to have been very vivid, or she would have repeated
the sentence as she heard it ; yet she sets off and defies decency
without a pause. Definite words are burnt in upon the nerves
of John Bunyan, yet after a short argument Avith himself he
goes on with his game of cat ; and the warning which he really
allows to have a practical influence is reasonable enough, namely,
the rebuke he received from an old woman for profane swearing,
a month after the notable game of cat. Again, the " Simon,
Simon," which came rattling in his ears so distinctly that he
looked back to see if somebody was not calling out behind him,
he thinks afterwards was designed to stir him up to prayer and
watchfulness ; but he never thought of screaming it out to
others like a ranter, or shaping his actions in accordance with
it : indeed, he is struck Avith the fact that Simon was not his
name, and set himself to " muse and wonder, what should be
the reason of this Scripture " — there was his safeguard, he at
once brought his reason to bear. Nor was his ear the only sense
affected ; at another place he mentions having felt something
pulling at his clothes when alone in prayer. Constantly assailed
in this way, living the life of an enthusiast, an excited preacher
and writer and martyr, in excited times, he yet preserves his
sanity to the end. On the other hand the well-educated lady first
mentioned yields at once to the lightest force, becomes con-
tagious, infects others, and is soon the centre of a band of
ecstatics. We are not surprised to find them next giving way
to the instinctive promptings of the reproductive organs; and
the singing of " Woe, woe, to Babylon " was followed by what
Noyes (one of their temporary prophets) calls " a bold self-
sacrifice for the purpose of killing shame and defying public
opinion." This consisted in nocturnal visits to the bedrooms
of their male leaders, for the purpose of spiritual bundling.

It is doubtless singular, as Mr. Dixon points out, that in such
various countries as Germany, America, and England, epidemic
disturbances of the established relation between the sexes should
have originated always in religious revivals. But we think the
explanation lies close at hand for the psychologist. The aim of
these revivals is to inject, by the agency of sympathy, certain
active panics into the mind. The dogmas inculcated are mostly
true and harmless in themselves, in fact, mere platitudes. The
danger consists in teaching the patients to obey instantly and
without question ; to obey the emotion excited in their own
souls, which they are led to consider the voice of God. To that
they surrender their volition. But when will it cease to be
the voice of God ? Who is to draw the line at which thoughts
that arise in the man are to be examined and questioned

1868.]

Spiritual Wives. 361

again ? It is so pleasant to feel safe under the infallible guid-
ance of an omnipotent spirit within, that we are not surprised at
those affected being loath to suspect the re-assertion of their
rights by the animal and intellectual propensities. The man
''has God in him ! the man is God !" Archdeacon Ebel allows
his more intimate followers to look upon him as a secret mani-
festation of the Deity, Schonherr is the Holy Ghost, Prince is
"The Beloved," the Rev. Abram C. Smith claims to be in-
spired when he invades the once happy home of the Cragins
and makes Mary Cragin his concubine before the weeping eyes
of her overawed husband.

We must pause a moment to notice the exceeding pathos of
the last-quoted episode, described very much in the words of
the actors of the tragedy. The wills of a loving couple are
slowly and inextricably inwound with the coils of spiritual
influence. They never cease to love one another, as human
creatures ought to love ; but with the husband^s sad consent,
the poor woman is unwillingly yielded to the arms of the repre-
sentative of the divine. The only thing in literature like it is
Homer's picture of the heralds, in the strength of their sacred
office, leading off the lingering Briseis from Achilles' tent —

'H ^' aEKOWff' o-na roicri yvvj) kuv k. t. X.

while her master sits down and weeps with his gaze fixed
on the dark-blue horizon of the ^gean. The situation is too
harrowing for the poet to dwell on, as we here find when it is
acted in real life.

But it is only because we are not furnished Avith the details
that we feel less in other instances the horrible slow torture to
the affections which the preachers of spiritual matrimony do not
scruple to inflict by wholesale. With one exception (a plump
beauty in middle life) Mr. Dixon describes all the female inmates
of the Agapemone as having a look of ill health, in spite of the
favorable external physical circumstances under which they are
placed.. The unnatural degradation of the mind has reacted on
the bodily aspect.

What is meant by spiritual matrimony ? Some readers may
exclaim — " Is not all this mere hypocrisy and lust, or vanity,
taking advantage of weak intellects for its selfish gratification ?"
It is impossible to think so in regard to the persons whose
biographies are related by Mr. Dixon. Archdeacon Ebel was
from his youth up occupied wholly with religion ; Mr. Prince,
at Lampeter, as one of the " Praying brethren,'' was a daily
living protest against the prevalent worldliness of the place ;
Noyes, Smith, Worden, and all the rest whose names come before
us, were characterised by zeal, perseverance, and power in the

362 Reviews. [Oct.,

service of God ; their daily walk was convincing to their neigh-
bours that they held a holier faith, and lived better lives, than
common men. Neither will it do to set the matter aside as
" mere insanity," and so end it. Often would the relations of
Ebelians, Free-lovers, Princeites, have been glad to demonstrate
insanity sufficient for a certificate, but cannot do it. No doubt
it is a morbid condition of mind, or we should have no excuse
for reviewing it in this periodical, and it also sometimes ends in
insanity (as in the case of Miss Lincoln), but even then it is a
cause, rather than an effect, of that condition which the law is
able to recognise as incapacitating a person for self-guidance.
The confession of M. L. Worden marks its position in psychical
nosology. He says of the leaders of the movement,

" They believed in salvation from sin ; that whosoever is born of
God does not sin and cannot sin, and has no disposition to sin
. . . they believed they were led by the Spirit. They rejoiced
in deliverance from what they called Babylonish captivity, or the
legality of the churches, and no doubt this sentiment finally affected
their feelings and practice in various ways, and especially was applied
to domestic and social relations."

Then in nauseously pious, and tediously exculpatory lan-
guage, the narrator goes on to tell how the marriage tie was
discarded, and temporary comminglings of male and female souls
indulged, till " the relation became so far carnal as to lay just
foundations for scandal." It is clear that the aberration dates
from the moment when the voice within is held to be the voice
of God, and ex vi termini deserving of immediate obedience.
We are quite ready to believe that when the Rev. Mr. Prince
entered the room to perform the blasphemous rite by which he
selected poor Miss Paterson as his concubine, with his own law-
ful wife standing by as an assistant, he did not know what he
was going to do. Sister Ellen, who was also present, assured
Mr. Dixon that from close (shall we say "jealous" ?) observation
she was certain of the fact:^ and to all these people the mere
entrance of some notion into their heads is sufficient, and indeed
the only, evidence of its truth. When once a man has deter-
mined that the infection of nature has been expelled from hi&
body, all the rest logically follows. The restraints of the higher
life being thrown off, the degenerate man reverts into the pro-
miscuous intercourse of the inferior animals, and joins a herd of
'* Free-lovers." The reason w^hy revivalism leads to adultery and
fornication more than to other sins is simply the universal pos-
session of generative instincts.

Mark how shrewdly John Bunyan scents out the old Adam
' ' Spiritual Wives,' vol. ii, chap, xxxiii.

1868.]

Spiritual Wives. 363

lurking still, probably unconsciously, in the proud, spiritually
led prophet. He is speaking aboTit those salutations to which
Mr. Dixon applies the German student's term of " Seraphim
kisses." " Some indeed," says he, " have urged the holy kiss ;
but then I have asked why they made baulks, why then did
they salute the most handsome, and let the ill-favoured go?"
By such habitual questioning of the spirit and bringing it
under the yoke of reason, " God's poor servant, John Bunyan,"
pestered Avith voices, haunted with horrible despairs, twitched
by the devil while praying, terrified with visions, surrounded
with persecuted enthusiasts when out of prison, and when
in companioned by his own morbid thoughts, not only kept
himself sane enough for all the needful purposes of life, but
turned his sorrows into an everlasting treasury of charming
allegory for all ages and nations. And herein lies the moral
we would draw : let those who confide to us their delusions be
taught that they can and ought to restrain themselves by their
own free will ; that the free will grows by exercise ; and that
if they judiciously exert it, no one need ever know anything
about the morbid conditions of their minds till they publish an
autobiography.

It is remarkable what an effect a single lesson of this kind
will have sometimes. We once went to live for a few months
with a lunatic of no great compass of mind, and rather spoiled
by an idle dilettante life, but still with the feelings of a man of
honour. He was haunted with the conviction that all meat
brought to table was human flesh, and had other equally
nauseous impressions regarding most articles of food. The first
day at dinner he exhibited his delusions, and we then told him
positively that he could restrain himself, if he liked, from such
disgusting thoughts, and that a repetition of them would lead
to a breach of our engagement, and that therefore such repetition
would be not the conduct of a gentleman. During three months'
companionship there was not only no display to us of the special
delusions, but all others much abated.

If every one Avill act thus as his own keeper from the first,
lunatic asylums will be needed in much fewer numbers ; let a
man once yield to a morbid impression, say he cannot help it,
or place his will under the dominion of another's, and the most
serious step of all has been taken in the direction of a madhouse.

364t Reviews. [Oct.,

Review VI.

1. Epidemic Meningitis, or Cerebro-spinal Meningitis. By Alfred

Stille, M.D., Professor of the Theory and Practice of
Medicine, University of Pennsylvania, &c. Philadelphia,
1867.

2. Eighth Heport of the Medical Officer of the Privy Council^

1865. London, 1866.

3. A Biennial Retrospect of Medicine and Surgery for V&oh-^.

(New Sydenham Society, 1867.)

4. Report of the Proceedings of the Medical Society of the King
and Queen's College of Physicians of Ireland. (In * Medical
Press and Circular,' 1867.)

5. Klinische Beohachtungen uher Meningitis Cerehro-spinalis epi-

demica. Von Prof. Ziemssen und Friedrich Hess, in
Erlangen.
Clinical Observations on Epidemic Cerebro-spinal Meningitis.
By Professors Ziemssetst and Friedrich Hess, of Erlangen .
From the ' Deutscher Archiv fiir Klinische Medicin,' 1866.
Bd. I, pp. 72 et seq., and pp. 346 et seq. (' German Arcliives
of Clinical Medicine.')

6. Four Cases of Cerebro-spinal Meningitis in Shorncliffe Camp.

'Medical Times and Gazette,' April 4th, 1868.

7. A System of Medicine. Edited by J . Russell Reynolds,

M.D., &c. London, 1868. Art. Epidemic Cerebro-spinal
Meningitis. By J. N. Radcliffe, M.D.

8. Zur Pathologic der Epidemischen Meningitis. Von Dr. Klebs,
in Berlin. ' Virchow's Archiv,' 1865. Band XXXIV, pp. 327
et seq.

On the Pathology of Epidemic Menitigitis. By Dr. Klebs, of
Berlin.

9. Publications of the Massachusetts Medical Society. Vol. II,
No. 1. Spotted Fever, or Cerebro-spinal Meningitis in the
State of Massachusetts. Report, &c. Boston, 1867,

10. Proceedings of the Pathological Society of London. Vol.
XVIII. 1867.

11. A Report upon Epidemic Cerebro-spinal Fever. By Ed. W.
Collins, M.D., &c. ' Dublin Quarterly Journal of Medical

Science,' August, 1868.

Dr. Stille speaks of epidemic meningitis as having ravaged
the United States for the last ten or eleven years, and as now

1868.] Recent Works on Cerebrospinal Meningitis. 365

appearing to approacli the end of its career (1867). One hun-
dred and twenty cases were treated in the Philadelphia Hospital
in the first quarter of that year. He regards the disease as
distinct from typhus fever, and as presenting " a surprising
variety of morhid phenomenon by virtue of its double character
as a blood disease, and an inflammation of the cerebro-spinal
membranes."

He considers that morbid anatomy has of late enabled us (o
distinguish the disease from forms of fever, with which in the
last and in previous centuries it was confounded. It was not
recognised as a distinct affection until the beginning of the
present century.

Unconnected with animal or other putrefaction. Dr. Stille
says it is pandemic, and uninfluenced by any *' miasmatic,
cryptogamic, or analogous agent." Nor is it due " to a special
poison like cholera, small-pox, or measles.

" Its outbreaks have occurred almost simultaneously in regions as
widely separated as Europe is from America, and annually it has
made a mid-vpinter attack upon towns and rural districts, the salu-
brious and unhealthy alike, completing the cycle of its progress in a
period varying between ten and fifteen years. Three such periods,
at least, have occurred during the present century. The first of
eleven years began in 1805, and terminated in 1816 ; the second, of
thirteen years, occurred between 1837 and 1850"; and the third
extends from 1856 to the present time, and has already lasted for
eleven years, during which the disease has been almost constantly
present in Europe, but absent during four years from the United
States."

Yieusseux described epidemic meningitis in 1805 as a disease
new to himself and his colleagues ; a petechial eruption and en-
gorgement of the brain marked the course of this " malignant
non-contagious fever." Mathey in one of the fatal cases found
a gelatinous exudation on the convex surface of the brain, and
a yellow puriform matter upon its posterior aspect, upon the
optic commissure, the inferior surface of the cerebellum, and
the medulla oblongata. Prussia, Holland, Rhenish Germany,
Bavaria, or the east of France, had the disease prevalent each
year from 1805 until 1816.

It prevailed in America from 1806 to 1816. In 1822 it
appeared in France, in 1823 in Connecticut, in 1828 in Ohio.
tSunderland, in Englatad,was visited in 1830, and Naples in 1833.

From 183T to 1850 it visited France, Italy, Algeria, Gibraltar,
England, Ireland, Denmark. America was again visited from
1842 until 1850. Between 1850 and 1854 we did not hear of
the disease ; in the latter year, however, it broke out violently
in Sweden, where it continued till 1860. Sporadic cases now

84— xLii. 24

366 Reviews. [Oct.,

occmred in Britain, and it again appeared in several parts of
the United States.

Holland was attacked in 1860, Portugal in 1861, and Ger-
many in 1863 ; in the latter country it was severely felt also
in 1864 and 1865.

It occurred in Dublin also in 1865, and also in the United
States from 1861 up to the commencement of 1867. To this
account by Dr. Stille we regret to add that the disorder has
now^ (January, 1868) reappeared in Dublin.

Tlie author dwells upon the great diversity in signs, both
during life and after death ; referrible, as he considers, to the
double nature of the disease, namely, one of the blood and of
the nervous system.

Meningitis, sometimes sudden, at other times gradual in its
development, presents generally the former character in the
earlier period of its prevalence.

Chilliness, prostration, vomiting, and headache, are com-
monly the earliest symptoms, and may continue from an hour
or tAvo to several days. In general, the longer these symptoms
continue the milder will be the attacks.

Feverishness and pains in the back and limbs occur, and as
the case advances, the symptoms already named become alarui-
ingly severe either with or without the occurrence of a heavy
chill. The pain in the head becomes excruciating, the face
livid or pale and sunken, and extreme restlessness comes on.
The pulse is as often slow as frequent, and the skin little if at
all warmer than natural.

The pains, which at first were " vague," are now concentrated,
and seem to dart in every direction from the spine, which is
also, especially at its upper part, the seat of severe aching; and,
in many cases, its muscles become more or less rigidly con-
tracted, so that the head is drawn backwards, or the whole
trunk is arched as in tetanus. Trismus is not uncommon, and
clonic spasms frequently affect the extremities ; even general
convulsions are occasionally observed. Wandering and halluci-
nations, delirium, violent maniacal ravings, incoherent niutter-
ings, and stertorous coma, may often be present in greater or
less severity. The pulse now increases in frequency, sometimes
becoming extremely rapid ; the skin, althougli it grows warmer,
does not acquire the temperature of idiopathic fevers, nor sustain
it as equally as in them. Eruptions often are observed. In
some epidemics only herpes labialis is seen ; in others, the state
of the skin may resemble roseola, measles, or the mulberry rash
of ty])hus, or, from the first, it consists of petechia;, vibices, or

' Happily, however, the disease did not exceed the sporadic form this year in
Ireland. August, 1868. — Revieweb.

1868.] Recent Works on Cerebrospinal Meningitis. 367

extensive ecchymoses. The tongue generally is like that of
typhoid fever ; at first moist, then coated with " mucus," then
red and shining, or hrown and fuliginous.

The appetite fails, thirst is not often urgent. One or two
liquid stools at first are generally followed by constipation,
although in very grave and protracted cases diarrhoea may even
become colliquative.

A soporose condition, with muscular relaxation, debility, and
tremulousness, with paralysis of the sphincters and of other
muscles generally, but by no means always, attends the fatal
issue of the attack ; rigid opisthotonos may be present. When
recovery occurs, the cases have seldom if ever been so grave as
depicted above, " especially the typhoidal symptoms."

If the nervous symptoms have been very serious, and life
spared, the return to health is long delayed, oi', it may be, is
never perfectly attained.

Dr. Stille w^ith much reason speaks of the almost endless
variety in the symptoms of this Protean disorder.

Our space does not permit of our giving the detailed obser-
vations of Dr. Stille, upon the several signs and symptoms
noticed in various parts of the world, by the numerous authors
whom he quotes, as well as those made in the cases that came
under his own notice. He treats of those affecting the nervous
system imder the headings of — " Headache," — which presents
great variety in those cases which are not at once smitten down
with '^ lightning speed" (meningite foudroyante). It is variously
described as " acute," ''violent," "heavy pain," "distress amount-
ing to torture, particulaidy through the temples," *' lancinating,"
" crushing," " boring," " as if nails were forced into the brain,"
resembling rather what is caused in inflammation by tubercu-
lous or other deposits or by wounds, than the pain of typhoid or
typhus.

Vertigo, — this symptom, with anxiety at the stomach, quick
and irregular pulse, nausea, and even fainting, was commonly
observed early in the disorder.

Debility, " great, surprising, and sudden," " a death-like
sinking sensation in the epigastrium," " syncope," — these symp-
toms exceeded both in uniformity of occurrence and in degree,
anything of the kind met with in typhus or typhoid fevers.

Delirium sometimes ushers in an attack of the disease, and
although not constantly present in severe degree, it not unfre-
quently occurs in greater or less severity in most outbreaks of
meningitis.

Coma, almost always present in fatal cases, most usually
occurs in a marked degree only towards the closing scene.

Complete loss of memory, especially as regarded the circum-

368 Reviews. [Oct.,

stances attending the commencement of their illness, very fre-
quently occurred.

The facies, or expression of countenance in this disease, is
also peculiar; the suffering, whether paroxysmal or persistent,
being represented by the features. As the case advances, the
expression becomes " fixed and stupid," differing, however, from
that of a drunken person in the absence of turgidity or purplish-
ness, as well as from the dark swollen and flushed face of
typhus, or the languid expression and the circumscribed flush
on the cheek of typhoid fever. The face is generally pale and
sunken from the beginning ; in not a fcAV cases it bears resem-
blance to that seen in cholera.

Hyperesthesia of the skin is a frequent symptom ; it may,
however, as Dr. Stille observes, be sometimes confounded with
reflex irritation. It is often folloAved by cutaneous numbness
or insensibility.

Pain in the spine and limbs like the last-mentioned symptom
is referrible, as Niemeyer considers, to pressure upon the roots
of the spinal nerves by exudation matter.

The severity and rapidity of these pains which are described
as pricking, stinging, benumbing, often causing blindness,
faintings, sickness at the stomach, precordial distress, partial
loss of motion in one or both limbs on one side, with great
prostration of strength, have been fully noticed in the records
of the disease from all countries where it has been observed. It
may occur in any stage of the disease and vary in duration,
being sometimes limited to its early period, in other cases con-
tinuing throughout the whole course of the disease, and even
after convalescence. The author puts confidence in cupping
the nape of the neck and along the cervical vertebrae in
sthenic cases, and in the use of dry cups followed by vesica-
tion in cases accompanied by debility for the relief of the
neuralgic pains. The latter appear generally to be aggravated
by pressure.

Tetanoid phenomena are even more characteristic of epidemic
meningitis than pain of the spine and limbs; but this symptom
may be absent as well as the petechial spots. In some cases
the sterno-masto'id muscles of one or both sides may only be
affected, in others the muscles of the neck more generally, and
in some those of the abdomen as well as of the neck, jaws, and
superior extremities may be firmly and rigidly contracted.
Cases have been recorded by Stokes, Kendall, and others in
which the head was drawn back to an extreme degree. So vari-
able have been the symptoms of this disorder that, both in
America and in Europe, thoughtful and able physicians have
been divided as to the real nature of the disease, some regarding

1868,] Recejit Works on Cerebro- spinal Meningitis. 369

it with Dr. Stokes as a disease of the blood of an essential
nature, many others as cerebro-spinal meningitis. A reason for
this latter opinion, which the writer of this review, in common
with Dr. Stille, holds, is the fact that during the prevalence of
the disease many cases of fever assume to a greater or less
extent the tetanoid or other cerehro-spinal character. Opistho-
tonos of the muscles of the neck attended cases that were
ushered in by furious delirium as recorded by Love (1847).

Dr. Parks found in the records of 261 eases in Massachusetts
that " severe opisthotonos existed in 107, slight in 80, and in
* nearly all' of 26 cases ; so that the symptom was absent in only
48, or in less than one fifth of the whole ninnber."

Tremors and twitchings of tendons are much less frequent
than in typhus, observes Dr. Stille ; we have observed in 1867
in Ireland tossing of the arms occurring in a child of seven
years of age in the advanced stage of a fatal case.

Clonic spasms or convulsions have been frequently observed,
especially in children. One half of the body has been con-
vulsed while the other half was paralysed.

Paralysis, or loss of muscular power in different degrees, and
more frequently still, abnormal muscular contraction has often
been met with in the limbs, and as observed by Jackson, para-
lysis of the muscles of deglutition. This latter symptom was
seen by us in at least one case, and lately we had under our
care a lad, of eleven years, with muscular contractions of both
legs at the knees ; this case has dilated pupil and ptosis of the
left eye, and vomiting of greenish matter often in the morning as
well as convulsions at night.^

Dr. Stille is disposed to refer the prostration which has
obtained for this affection the name of " sinking typhus," to the
effects of the congestion, effusion, or exudation upon the origin
of the pneumo-gastric nerve, which associates the actions of the
lungs, the heart, and the stomach.

Symptoms furnished hy the Organs of the Semises. — The Eyes.
— Differing from the dark or dusky, almost purplish colour of
the eye in typhus, and the rather striated redness of the con-
junctiva in typhoid fever, the eye in tneningitis generally pre-
sents a reddish or pinkish colour without distinct vessels being
to be seen; sometimes conjunctivitis, with profuse^ purulent
discharge is present. Double and triple vision was noticed by
North, Banks, Armstrong, Gilkrest, and Jenks. Banks,
Burden Sanderson, and many others observed strabismus ; we
have observed this sign in meningitis and also in a case of fever

' After an illness of upwards of three months this hoy died, having become
attenuated to the last degree. No autopsy was allowed.
'^ Gordon.

370 Reviews. [Oct.,

which relapsed into meningitis; in some epidemics it is not
a common symptom.

Blindness was often observed in America as the earliest devia-
tion from health. In some cases sight returned in a few hours,
in others in a few days ; and although restoration of sight was
the rule, permanent loss of sight by amaurosis occurred in one
case reported by Jenks ; cataract, injected cornea, soft and
shrunken globe were also seen in America. Cases of rapid
destruction have been observed.

Purulent ophthalmia, softening of the cornea, hypopion,
opacity of the vitreous humour, and synechia posterior have
been met with. The affections of the eyes have been^ attributed
to inflammation of the neurilemma of the trunks of the nerves
which supply the eyes.

Some writers attribute ulceration of the cornea to its exposure
in consequence of paralysis of the orbicularis.

The pupil varies much in shape and size in meningitis ; sud-
den contractions and alternate dilatations, permanent dilata-
tion, one pupil contracted and the other dilated, contraction,
photophobia, and spasmodic movements of the ball of the eye
have all been witnessed in the disease.

Loss of hearing in some cases, and of the sense of smell in
others, and instances of purulent discharges from the ears and
nose have been met with.

Though the physiognomy varies from that indicating maniacal
fury to that of profound stupor, yet as Dr. Stille observes, " its
average condition does not indicateeither excitement or coma, or
even a greater degree of dulness. The patient moves his eyes
more briskly than in the two forms of fever several times
referred to, and winks their lids in a manner quite unknown in
those affections."

Sympto?ns presented hy the Digestive Organs. — The general
state of the tongue was " moist, whitish in the centre and at
the tips and edges." The appearance was not constant, being
in some cases dry, and more or less brown. A " bloodless
appearance" was regarded by some as indicative of approaching
death.

Nausea and vomiting have been observed as characteristic
of the disease, evidently traceable to the cerebral lesions.

The appearance of the matters vomited has generally been
bluish or greenish, though in some cases it was whitish and
viscid. Faintness, or coldness, or a deadly feeling has been
experienced in the stomach by many of the sick, indicating,
as Stille observes, the cerebral origin of the symptoms.

Constipation appears rather to attend the disease than diarrhoea,
^ Niemeyer.

1868.] Recent Works on Cerebrospinal Men'mgitis. 371

though the latter has been occasionally seen ; in many persons
the bowels continued to act regularly.

ContraiT to what is seen in typhus and typhoid fevers, the
appetite in meningitis very early returns, and even becomes
craving almost as soon as the " painful stage of the disease is
passed." This more especially is the case Avith children. Thirst
is not characteristic of epidemic meningitis, at least " cool and
acid " drinks were very rarely grateful ; if a desire was evinced
for liquids it was for such as were " warm and aromatic," as
they relieved the depression so constantly felt at the stomach.
This was not always the case, howevei", as Stille observes that
at Philadelphia, recently, the patients were " clamorous for
fluids." A form of sore throat resembling cynanche maligna —
minus the SAvelling of the tonsils — was seen in some of the
American epidemics. Hale observed that sometimes the gums
and fauces were swelled and inflamed, and that there was
accompanying partial salivation. Only one European observer —
Levy, Stille thinks, noted a similar condition ; the latter writer
speaks of a thin pearl-coloured or whitish band upon the gums,
which in one case invaded the fauces.

Aphthae have been seen. Swelling of the cervical parotid
and sub-maxillary glands were met with, and not infrequently
in fatal cases. To impaired nniscular power, and in some to
blunted perception in the nervous centres, as well as in other
cases to the use of fly-blisters, may be attributed the occur-
rence of retention, of incontinence of urine, and in other cases
of dysury.

The chemical characters of the urine also varied in one case,
albumen, granular casts, and pus-cells were found, together or
singly, in the former case without urea, in others phosphates
with diminution of the chlorides occurred.

Pain and swellings, often of a purple colour, of the joints,
not unlike gout, pointed to the predominance of the bloocl
element in some cases. " Synovitis," " inflammatory effusions
in the joints," and effusion without redness, were observed by
different physicians in Europe and America.

Respiration was generally difficult, in some cases sighing^
laboured and interrupted (Tourdes). Burden Sanderson
mentions cases in which " its embarrassment was marked by a
slow laboured inspiration, followed by a quick inspiration and
a long pause." Serous effusion in the air-tubes causing
gurgling rhonchi often preceded death. Pneumonia pretty
often occurred. The suspirious and interrupted respiration
resembled that seen in tubercular meningitis. It is most often
seen in cases presenting tetanic symptoms, paralysis, and other
evidences of central cerebral compression.

372 Reviews. [Oct.,

The state of the pulse varied much in the records of menin-
gitis compiled from very many American, British, French, and
other authors, and in the cases observed by Stille himself, and
corroborates the observations made by Ziemssen and ITess,
recorded in another portion of this review. Diminished force
and volume, and a tone so much impaired that slight causes
produce extreme variations in its rate and rhythm are, there-
fore, the characteristic qualities of the pulse in this disease,
and those by Avhich it is distinguished from the fevers to which
it bears a superficial resemblance.

The state of the skin varied greatly from dryness, usually in
the earlier stages, to " profuse sweats," which latter were apt
to continue if once excited.

As to temperature great variety was observed, although fre-
quently below the normal standard it not uncommonly rose,
especially in fatal cases, as the disease advanced. Thus Wun-
derlick noted 107°, 108°, and 110° respectively in three cases at
the point of death. These observations extend to cases recorded
in several parts of the world, by many physicians, agreeing
with what we have seen, and what we have had occasion to
note from other observers. As Dr. Stille observes, this irre-
gularity of temperature serves to distinguish epidemic menin-
gitis from typhoid and typhus fever. Eruptions of the skin
did not by any means invariably occur, according to the obser-
vations collated by Dr. Stille ; however they were present suffi-
ciently often in the various American epidemics to give the
name of spotted fever to the disease, and in Europe, though
not occurring as frequently as do the characteristic eruptions of
typhus, still our experience and reading lead us to agree with
Ziemssen and Hess in regarding the disease as very rich in
cutaneous affections.

Petechife, though noticed as occurring rarely by some, were
considered by the two last-named authors, as the most frequent
form of cutaneous affection.

The authors quoted by Stille mention the following as occur-
ring in the disease : — efflorescences, carbuncles, pustules, buboes,
bright red eruptions, some like measles and some like erysi-
pelas, miliary eruptions, nettle-rash, rash like scarlatina, bullae,
herpes labiales, ecchymoses, roseolous and erythematous affec-
tions.

The disease in Ireland in 1846 has not been described as
presenting cutaneous affections, but the epidemic of 1866-7
presented a considerable variety, viz., herpes, urticaria, bullse,
petechiae, and large spots resembling purpura hsemorrhagica ;
large mortifying portions of integument and subjacent soft parts
also occurred in some cases.

1868.] Recent Works on Cerebro- spinal Meningitis. 373

The fatal end appeared in some cases to depend upon asphyxia
from pressure of the serous effusion upon the medulla oblongata
and spinal cord ; coma, gradual asthenia, convulsions, pai-alysis,
and in other cases delirium were varieties presented by the
closing scene of this remarkable malady. Some individuals
gradually recovered, a few lingered for months, reduced to
skin and bone, others recovered with impaired vision or hear-
ing; such is the tenour of the records of the recent Irish
epidemic.

Extreme variety in duration of epidemic meningitis has
characterised the disease in all countries. Tourdes well
observed that it is " distinguished by the slowness of its
cure, and the rapidity of its fatal issue," and Hirsch as-
serts that " its duration is between a few hours and several
months."

The return to health is generally slow, irregular and un-
certain, rapid and extreme prostration and emaciation which
attend the attack being followed by tardy and irregular conva-
lescence, as described by Fish and Gallup in America, and
Tourdes and Gillkerst, among European authors. Hale and
others, however, record several cases that were followed by
rapid convalescence. " Still the general statement continues to
be true " (as Stille observes), " as it is expressed by Hirsch,
'convalescence is irregular and protracted; in spite of good
food and regular digestion, emaciation and debility are some-
times of long duration.' "

" Persistent headache, neuralgia, convulsions, stiffness of the
neck, or pain in moving it, morbid sensibility of some portions
of the skin, palpitation of the heart, dyspepsia, &c., embarrass
the return to health." " It is highly probable," as Gallup
remarks, " that the internal membranous inflammation is
always present more or less."

Deafness more or less perfect ; impaired vision ; paralysis of
one or more limbs, and general impairment of muscular power ;
loss of memory and even insanity are consequences of the dis-
ease, deafness or dulness of hearing and affections of the eyes
being more frequent than paralysis, and far more common than
the affections of the mind.

" Apathy or apparent stupor" is, however, far from un-
common, and continues for a considerable period in some cases,
resulting, if the cases recover, in deafness not infrequently.
Sanderson, Gordon, Mayne, and others, have mentioned this
condition. Recurrence of the initial symptoms (Sanderson)
frequently occur. Hale, Gallup, Parks, Jackson, also state that
relapses are very far from being uncommon. Stille observes
that the earlier authors considered '' cure" common in relapsed

374 Reviews. [Oct.,

cases, but that tlie more recent writers do not coincide in this
observation.

The mortality varies much : thus, Hirsch found it, in the
greater number of epidemics of meningitis between 1838 and
1865, to vary from 75 per cent, to 20 per cent. Stille found
that it varied from about 6 per cent, in Massachusetts to but
35 per cent, in the Philadelphia Hospital. And in ten epi-
demics occurring in various places between 1838 and 1848, the
last-named author states the rate to have been 70 per cent., and
in the decade 1855 to 1865 it was but 30 per cent.

Nieraeyer found the mortality in the Baden epidemic to be
30 per cent., whereas in West Prussia it was probably not much
less on the whole than 50 per cent.^

Murchison advocates the idea that the cerebro-spinal epidemic
of Germany was but a variety of typhus.'^ Stille regards this
as a serious error, especially in respect of the treatment of each
disorder.

Stokes, Banks, McDowell, Gordon, and other able Irish phy-
sicians consider the epidemic as quite different from typhus.
H. Kennedy records what we have ourselves also seen, namely,
cerebro-spinal meningitis complicating typhus and typhoid
fevers, and he advocates local bleeding and mercury. M'Dowell
in 1846, Burns and others in America also observed the ten-
dency to spinal irritation in ordinary fever cases, and in persons
in health, when cerebro-spinal disease was epidemic.

Dr. Banks regards the epidemic as it appeared in Ireland as
appearing in two forms, one bearing all the characters of a
blood disease, but not presenting the cerebro-spinal symptoms ,
in the second, on the other hand, were found all the symptoms
and post-mortem appearances of cerebro-spinal meningitis.^

Dr. Stokes spoke of the occurrence of two forms of essential
disease in Dublin in 1866, the first being that which he pro-
posed to call malignant purpuric fever, and which preceded the
other, namely, the cholera. He pointed out the great rapidity
of some, especially of the early cases of the former disease,
which became much less frequent during the pressure of the
cholera, to reappear again on the subsidence of the latter dis-
ease. Dr. Stokes observed from the fact of the occurrence of
these two diseases, almost at the same time it was hard to avoid
the conclusion that some relation existed* between them. Be-

1 ' Biennial Retrospect, New Sydenham Society,' 1867.

2 ' Lancet,' April, 1865, and ' Sydenham Society's Retrospect,' 1865-6.

^ Report of the Medical Society, College of Physicians of Ireland, *Med.
Press and Circular,' June 19, 1867.

* The apparent relationship between cholera and meningitis epidemica was
alluded to in the articles " Cholera Authorities" in this ' Review.'

1868.] liecent Works on Cerebro- spinal Meningltu. 375

tween the epidemic under consideration and typhus, existed the
following difference, the great rapidity of the course of the
former, the eruption, its mode of appearance, character, and
duration, the frequency of cerebral and spinal lesions. Again,
the temperature was generally low in the purpuric cases. Some
very rare cases have undoubtedly been recorded in which a tem-
perature of 107° and even 110°Fahr. was attained: these latter
observations have been made since Dr. Stokes recorded his
experience as above related.

Another point to which Dr. Stokes alluded, was the idea held
by some that an affinity existed between the epidemic and
measles, owing to the great prevalence of the latter in a very
fatal form at the same time as the former. " All these facts
would strongly bear out the vicAV that this disease was a blood-
poisoning, and that the cerebro-spinal affection was a secondary
disease in this form of fever."

Dr. Stokes remarked that in a few cases there were grounds
for supposing it to be contagious. It is worthy of remark that
an outbreak of purpuric measles occurred also in 1867, in an
epidemic form at Sydney,^ Ncav South Wales, and it Avas con-
sidered by Mr. Carroll to bear considerable analogy to the epi-
demic as it was observed in Dublin. The cases were frequently
ushered in by convulsions, and nearly every fatal case was ter-
minated by them.

Arnes and Hirsch have observed the intermittent type of the
epidemic in malarial districts, but Stille says it is by no means
confined to such localities.

Authors have made several classifications of the forms of
meningitis as seen in different epidemics. The abortive form
seen as a complication of ordinary fever has been already men-
tioned as observed by H. Kennedy. M'Dowell, Sargent, Stille,
Gaune, Burns, and Kempf, have all mentioned the liability of
persons resident in affected localities to headache, neuralgic
pains in the nape of the neck, and in various parts of the body.
Wunderlich classifies the disease according to its degrees of
severity ; other authors mention the congestive and inflamma-
tory, the malignant and mild forms of the disease.

Stille observes that " according to its type and duration there
never fail to be found some of those changes in the membranes
or in the substance of the great nervous centres, which denote
the existence of inflammation. Congestion of the blood-vessels
and exudation of serum, fibrin, or pus, beneath the meninges,
and different degrees of alteration in the nervous pulp attest the
nature of the process." He continues to say that Ave are not
always to expect to meet Avith positive changes post-mortem,
1 ' Medical Press and Circular,' 15th April, 1868.

376 Reviews. [Oct.,

owing to death at an early stage of the inflammatory process,
or to a constitutional element, a niorhid condition of the blood,
which underlies all the phenomena of the disease, and modifies
more or less its features.

While Biirdon Sanderson states that post-mortem rigidity
did not affect any of the muscles which had been contracted
during life, Gordon thus speaks of a girl of fifteen that died of
the disease after a week's illness :

" The body, after death, presented a very frightful appearance.
It was still prominently arched forward ; it was of a dusky blue
colour, and with a copious eruption of black spots of various sizes
from that of a small pea to a crown piece ; some small and circular
others large and irregular in form. One or two of those near the
knee had taken on a gangrenous action, and appeared to have been
rapidly spreading ; several of the smaller spots were effusions into
the layers of the skin — very prominent, hard, black, and circum-
scribed, like the minute spots of apoplexy of the lung. There were,
moreover, various patches of hepatic eruption on different parts of
the body, and several bullae containing dark-coloured serum. In
this case the brain and spinal cord presented all the appearances of
intense purulent arachnites. The blood in all the cavities was very
fluid and dark-coloured. The lungs were ' intensely congested.' " ^

This author points out the absence, in his experience, of the
almost paralytic condition of severe cerebro-spinal cases in the
debility of malignant measles, which has often co-existed epi-
demically with cerebro-spinal meningitis ; he also says,

" Although there may be many spots of petechise, there are never
found those ecchymoses from decomposed blood in the substance of
the true skin which are so characteristic of the epidemic ; and while
the rubeolar eruption is dark-coloured in the extreme, it retains its
characteristic of being an elevated eruption, and affecting more or
less the crescentic form."

We must observe that the eruption of epidemic meningitis is
in some cases raised. Gordon well observes the difference be-
tween the coryza of measles and the pulmonary affections of
the epidemic, those of the latter being oedema of the lungs or
diffuse pulmonary apoplexy, and these combined with a more
or less emphysematous condition of the anterior portions. The
last writer also speaks of the necessity of distinguishing between
meningitis and hysteria, and of the occurrence of albuminous
urine in the epidemic disease. For ourselves, we do not regard
cerebro-spinal meningitis as being likely to be confounded with
hysteria.

The purplish spots on the anterior surfaces, the congestion of
1 ' Proceedings of the Pathological Society of Dublin.' 1866-67.

1868.] Recent Works on Cereb7'o- spinal Meningitis. S77

the eyes, &c., disappear or grow paler after death, ■while (Stille)
states that large patches of a livid colour, or a uniform discolora-
tion of the same hue may sometimes be observed along the
posterior parts of the neck, back, nates, and thighs.

Klebs states that to atrophy of the muscles and connective
tissue is due the rapid emaciation of protracted cases.

American authors generally mention considerable congestion
existing in the cerebral veins and arteries, in meningeal cases.
The same has been observed also in the earlier stages by Euro^
pean Avriters. The transparency of the arachnoid becomes im-
])aired if the cases pass the congestive stage, and the pia mater
often is found adherent to the brain.

The " arachnoid cavity and ventricles" often contain serum
which is sometimes of a red colour. The microscope showed
pus-globules in the serum. Occasionally (Tourdes) the arach-
noid cavity was dry or marked by flakes of pus.

The ventricles often contained serum, which assumed a milky
hue in some cases from exuded fibrine.

Stille quotes many writers to show the inflammatory nature
of meningitis, where the disease had lasted long enough to form
flbro-purulent, pus-like, semi-purulent deposits in the coverings
of the brain and spinal cord.

The stages of congestion and of exudation are exhibited in
the post-mortem examinations of fatal cases. In malignant
cases death occurs before time has sufficed for the full develoj)-
ment of inflammatory lesions; in those of longer course may be
found, first of all, turbid serum, then a more or less pasty and
fibrinous deposit Avith some admixture of pus, and, finally, in
cases of long duration, the exudation becomes tougher, more
adherent, and shrivelled.

As we find deviation from the state of health evident from
the post-mortem appearances of the meninges in proportion to
the duration of the case, so are the results of the disease upon
the substance of the brain and spinal cord.

Softening of the spinal cord appears less frequent than that
of the brain, but the former does not very infrequently occur.
Partial and superficial softening of the cervical portion is
repeatedly seen.

Examination of the blood drawn from those affected with epi-
demic meningitis bears evidence of the^ inflammatory nature of
the disease. Some observed firm fibrinous clots in the heart,
but " perhaps (Stille) the greater number of observers have
reported it to be dark and liquid." " A shrivelled or crenated
appearance of the edges of the blood-discs, and an irregular

1 These observations of Dr. Stille's are qualified by comparison with those of
others — Dr. Klebs, for example.

378 Reviews. [Oct.,

distribution of these bodies in the fiekl of the microscope,
instead of the ordinary arrangement in rouleaux or piles," was
noted by many.

Evidence is thus afforded to show that inflammatory^ action
exists in the early stage of the disease, and that in a large
number of fatal cases disorganisation of the blood is one of the
conditions producing death. But in many other cases death is
evidently caused by agencies independent of such a change, and
results from direct interference with the functions of the nervous
centres which are necessary to life. Stille does not regard
morbid changes in the lungs, heart, stomach, intestines, liver,
kidneys, and spleen, in fatal cases, as properly belonging to the
pathological history of the disease. We think it well, however,
to call attention to the state of the lungs, spleen, and heart, as
worthy of being always noted when a post-mortem examination
of a fatal case of epidemic meningitis is procurable, and as
affording characteristic lesions generally in the disease ; indeed,
it would be well to note the condition of all the organs as far as
possible in this peculiar malady.

Pus has in some cases been found in the joints.

The cause of deafness Klebs has traced, in some cases, to
suppuration of the internal ear ; in others it was probably owing
to alteration in the structure of the brain or medulla oblongata.

Stille regards the disorder as pandemic in the temperate zone,
as more prevalent in winter than in summer, and as visiting all
localities, whether rural or urban, preferring the former rather
than the latter. Youth and early manhood, rather than age,
suffer by the disorder.

Debilitating agencies, as over-fatigue, fear, grief, nursing,
abuse of stimuli, wet, cold, and previous illness, as measles, in-
fluenza, chincough, and fever, as has been noted in Ireland,
predispose or even excite this disease.

Some in America have thought war had a bearing on the
matter also. On this latter point, however, evidence is rather
against its correctness. Stille argues, too, that as London,
Liverpool, and New York have escaped the disease in an epi-
demic form, very little importance can attach to the influence of
dirt and over- crowding.

We purpose reverting to this subject in connection with the
consideration of the writings of other authors ; another point to
which we also hope to refer again is the question of the con-
tagiousness or non-contagiousness of the affection. The author
whose work we now more especially have under consideration
thinks the great preponderance of testimony is in favour of the

1 This again might deceive those who have not witnessed the disease, and lead
to severe antiphlogistic treatment. See, however, p. 380 for Dr. Stille's treatment.

1868.] Recent Works on Cerebrospinal Meningitis. 379

latter idea; however, when speaking of the writings of Boudin,
he says it only shows " the existence of some local cause
capable of determining the development of the disease in all wlio
came within its influence ; a cause susceptible of being trans-
ported by healthy men, or by their camp equipage, from one
place where the disease existed to another where it had not pre-
viously occurred. The views of Boudin have failed to satisfy
and convince all judges who have examined them. They fail
most Avhere most they need strength, in the proof that the dis-
ease is ever communicated from man to man ; and without that
proof there is no evidence of contagion," &c.

It appears to us that Stille allows his own opinion to sway
him, when he says that " a cause susceptible of being trans-
ported by healthy men, or by their camp equipage," &c., is not
contagion.

Varying extremely in the mortality of different epidemics,
meningitis is, for the most part, of greater gravity in winter
than in spring, and in childhood and advanced life than in those
between those periods.

When the attack comes on with great suddenness and severity
the prognosis is unfavorable, especially if coma appears early.

Though the danger is greatest in the first few days of the
illness, and the prognosis becomes more favorable as the case
advances, fatal relapse may occur, even in the convalescent
stage.

Of unfavorable symptoms we may enumerate the following :
— delirium, and, still more so, persistent coma; unconcern about
the patient's own self; a slow and compressible pulse ; lively
jactitation, rigid retraction of the head, spasms of other than the
spinal muscles, general convulsions, extensive hypersesthesia,
dilatation and insensibility of the pupil, retention or incontinence
of urine, and all cerebral paralyses (Mannkopf). To these Stille
adds — deep coma, paralysis of the muscles of deglutition, and a
rapid change of the pupil from a dilated to a contracted con-
dition. Coolness of the surface is very significant of danger,
especially when the skin grows purplish by the diffusion of
blood beneath it, or even by venous stasis. Petechiae are less
unfavorable than the last-named symptom, and light-coloured
eruptions, incidental to the disease, are rather favorable than
otherwise. Rapidly developed, dark-coloured discoloration or
eruption, profuse sweats, with coma, bullae, and gangrenous
spots, bronchial obstruction, Avith serum or mucus, pneumonia,
and pericarditis, are all signs of danger. A dry, shrivelled, or
fissured pale tongue, a fuliginous condition of the mouth, ob-
stinate vomiting and diarrhoea, and persistent albuminuria, fornr
also grounds for a most unfavorable prognosis. Whereas, mild-

380 Reviews. [Oct.,

ness of symptoms, slight loss of strength^ moderate pain and
stiffness, absence of petechise or vibices, a desire for*food, and
power to assimilate it, are, it need hardly be said, favorable
indications.

Prognosis is, however, very uncertain, owing to the possibility
of a sudden accession of nervous symptoms, even when the hour
of danger seems to have passed away; and, on the other hand,
])atients have recovered after all hope seemed to have passed
away.

Acute pain in the head, neck, spine, and limbs, faintness,
vomiting, stiffness, or spasm of the cervical or spinal muscles,
hypersesthesia of the skin, delirium alternating with intelligence,
and merging afterwards into dulness or coma, occasionally con-
vulsive spasms, paralysis of the face or of one side of the body,
constitute the symptoms more especially indicative of inflamma-
tion of the cerel)ro-spinal meninges. The epidemic prevalence
of the disease, the cutaneous eruptions, ccchymoses, debility,
redness of the eyes, foulness of the mouth and tongue, and more
or less of other typhoid conditions, are among the evidences
afforded by epidemic meningitis that it partakes of the nature
of a blood poison. To these must be added its great mortality
to complete the diagnosis.

Stille gives a tabular summary, in parallel columns, of the
diagnosis between epidemic meningitis and typhus. Most of
the points enumerated have been already quoted by us.

He thus concludes a chapter on the nature of epidemic
meningitis : — " The inflammatory element and the septic ele-
ment are both necessary to constitute the disease ; either may
be in excess and overshadow the other. According to the rela-
tive predominance of one or the other, the disease assumes more
of a typhoid or more of an inflammatory type ; and it is this
diversity in its physiognomy which has led to such opposite
doctrines in regard to its nature and its nosological affinities."

The treatment has varied with the epidemic, as when re-
garded as " sinking typhus " it was actively stimulating and
tonic, if it assumed an inflammatory type, antiphlogistic.

Many highly intelligent practitioners used opium largely on
account of the severe pain, and the spasmodic phenomena.

Our modern experience would not warrant our returning to
the use of tartar emetic as used by Vieusseux and mentioned by
Stille, nor can we for a moment suppose that any one would
now advocate purgatives. As to depletion, if only local, Stille
thinks it may be practised in some sthenic cases. I3ut in young
persons, especially in children, he states, the least abstraction
of blood may be followed by dangerous exhaustion. He has
seen cupping the nape of the neck, and along the cervical

1868.] Recent JVorks on Cerebrospinal Meningitis. 381

vertebrae of essential service. If scarifying cupping is contra-
indicated dry cups give much relief and aid the effects of
vesication.

Cold to the head and spine has long been used in America as
well as in Europe with effect in the forming stage of the disease
and while the ])ain in the head is most intense : in many cases,
hovvevei', benefit from its use has not followed. Confidence has
generally been placed, especially in America, in the use of
blisters applied to the vertex, and upper part of the spine in
some cases. It must, however, be borne in mind that Tourdes
and some other authors quite disapprove of their use. Warmth
to the surface was the practice formerly in America, and is now
advocated by Gordon. Nutritious diet, liot aromatic infusions,
claret, port, madeira, or even brandy, and other stimulants
have been generally regarded in America in former epidemics
as essentials in the treatment. Recent experience, however,
has led to the rule that alcohol, as Dr. Stille says, should not
be included in " the ordinary and systematic treatment of epi-
demic meningitis, but as a cordial to be held in reserve against
those signs of failure in the power of the nervous system, which
call for its administration in diseases of whatever name. In
this, as in so many other respects, epidemic meningitis presents
a striking contrast to typhus fever."

Though in America the evidence is not unanimous, still enough
remains to justify the use of opium in epidemic meningitis in free
and often repeated doses. Stille says that sixty years ago it
was freely used in the epidemic of 1808, and he quotes several
authors to show that even in coma, large doses of opium pro*
duced the best effects. The tolerance of the drug he states to
be remarkable — the doses he himself used were a grain of opium
every hour, in very severe, and every two hours, in moderately
severe cases. Under this treatment " the pain and spasm sub-
sided, the skin grew warmer and the pulse fuller, and the entire
condition of the patient more hopeful." The early stage of the
attack, however, seemed that in which greatest benefit from the
opium arose. Quinine is not considered efficient by Stille in
epidemic meningitis. Mercury has been used by practitioners
in the various epidemics with but very doubtful benefit.

Arsenite of potassa, iodide of potassium,^ belladonna, and
erjiot are other remedies mentioned in Stille's work. He re-
connnends nutritious diet and great care that no exertion, such
as assuming the erect or even the sitting posture be made
before convalescence is fully established, pointing out tiie
danger from tlie singular debility characteristic of the disease,

' Bromide of potassium lias been much recommended by Trajer. — ' Me;iici\J
Times and Gazette,' 1867.

84 — XLii. 25

382 Reviews. [Oct.,

expressed in the title typhus syncopalis, which was conferred
upon it.

To the rapid extension of epidemic cerehro-spinal meningitis
over a great part of Germany, as well as to its peculiar and
varied symptoms, the frequent malignity and rapidity of its
course, so often inexplicable by post-mortem appearances, the
insufficiency of atmospheric data, the conflict of opinions as to
its most suitable treatment may be attributed the interest taken
by German physicians in the inquiry into its nature, pathology,
and treatment.

Having traversed much of Western and Northern Europe, as
well as North America, cerehro-spinal meningitis visited
Northern Germany in 1863. In the succeeding year the
disease was first recognised in Southern Germany, at Erlangen,
by Professors Ziemssen and Hess. They record forty-three
cases, with twenty post-mortem examinations.

As to the etiology of the disease, telluric conditions appeared
to be entirely without influence upon the spread of the affection.

The effect of atmospheric influences appeared to be very
limited. In general, however, most patients were placed under
unfavourable hygienic conditions, only five belonging to the
wealthy classes.

The epidemic afforded no grounds for assuming the existence
of contagion. This statement differs, as our readers may re-
member, from the observations of Boudin, and from some parti-
culars recorded in Britain and Ireland where contagion could
not be excluded from consideration.

With respect to age the disease was most frequent and most
severe in childhood ; at that age, too, it proved most frequently
fatal.

From 1 to 16 years, 24 were attacked.
„ 17 „ 65 „ 18

42

of the former 16 died, and of the latter 6 died. The sexes
were tolerably equally affected — of the above 22 were males
and 20 females.

As to the previous condition of the patients the majority
were in good health, and only three had been exposed to any
directly injurious influences.

The existence of a premonitory stage could only be traced in
five instances.

Headache, languor, nausea, loss of appetite, and flying pains,
constituted the precursors of the attacks, and were usually fol-
lowed by a completely free interval, which lasted for several
hours, during which the patients felt perfectly well and con-

1868,] Recent Works on Cerebrospinal Meningitis. 383

tinned apparently so nntil the ontbreak of the disease, which
was always sudden.

The initial symptoms were rigors, intense headache, vomit-
ing ; not infrequently from the commencement loss of conscious-
ness, coma or delirium, convulsions, rigidity of the back of the
neck. When the attack issued in hydrocephalus, the return or
increase of the headache with vomiting constituted the most
important symptom. Even in the slighter attacks the restless-
ness of the patients was characteristic. Except in the hydro-
cephalic cases convulsions were not observed. Of spinal
symptoms contraction of the deep muscles of the neck was the
most constant, and it was entirely absent only in six cases.

Retraction of the head was for the most part so considerable
that the occiput stood at a right angle to the thoracic vertebrae,
and swallowing was rendered extremely difficult.

The contraction of the neck occurred on the first day of the
illness, only in five instances; in all other cases it first appeared
between the second and fifth days.

General hyperesthesia, for the most part confined to the
trunk and lower extremities, was met with in sixteen cases.

The pulse was liable to great and sudden changes, and the
course of the temperature was irregular.

The hearing was affected ii: eight cases, and the eyes were in
some instances implicated, but not severely. Bronchitic, atelec-
tatic, and broncho-pneumonic conditions in the lower lobes of
the lungs and their dependence on the spinal rigidity were
frequently noted. The frequency of respiration was, in general,
not essentially altered ; in particular the striking arhythmia of
respiration, characteristic of tubercular basilar meningitis was,
in accordance with Niemeyer's experience, not observed. Cuta-
neous affections were frequent, especially facial herpes. Ery-
thema, roseola, urticaria, sudamiiia, and petechise, the latter
being relatively the most frequent, were observed. They were
usually symmetrical on both sides of the body.

" The frequency of the occurrence of exanthemata, but especially
their frequently symmetrical arrangement in a severe afFectiou of the
central nervous system, might contribute to confirm the assumption
of a direct dependence of these eruptions on irritations of the
cutaneous nerves of nutrition, a dependence which, as is well known,
Daniellsen and others endeavoured to establish for herpes zoster, as
Von Baerensprung has recently done for herpes in general, so far as
it does not depend upon fungus formation."

The digestive organs on the whole suffered but little.
The duration of the 42 cases varied between 12 houi-s and
30 weeks.

384 Reviews. [Oct.

53*o per cent, of the cases terminated fatally; 4 of the 22
deaths being due to clironic hydrocephalus. Three cases ended
in imperfect recovery, viz., 1 in chronic hydrocephalus, I in
complete deafness, and 1 in hardness of hearing; the other IT
recovered completely.

Among the post-mortem appearances, almost all the cases
presented exudation accumulated beneath the cerebral arach-
noid; in eleven it was purely purulent or gelatino-puruleiit, in
five, it was only slightly turbid serous fluid ; in two, purulent
and turbid gelatinous exudation alternated in different places.
In one case the dilatation of the central canal of the spinal
cord, and the filling of the same with pure pus was very remark-
able. The authors never observed any injurious effect to attend
the even frequent employment of morphia ; on the contrary, its
effect was so remarkably palliative that it appeared to them to
be, with the application of cold to the head and spine, the most
indispensable agent in the treatment of meningitis.

Dr. Klebs, of Berlin, records twenty-six post mortem exami-
nations of acute primary meningitis, seven of the patients having
been military, and nineteen civilians. In the first two cases of
the latter the brain alone was examined, in all the rest the
spinal cord was also examined. The pia mater is the exclusive
seat, according to Klebs, of purulent meningitis, he corroborates
Mayne's researches in Ireland in 1817 as to the general exemp-
tion of the arachnoid from pus ; he has constantly found the
greatest accumulations of pus in the cerebral membranes at the
base of the brain and in the sub-arachnoid spaces situated
between the infundibulum and the pons, along each side of the
latter to the under surface of the cerebrum, and with very vari-
able intensity into the fossse Sylvii.

The vertex, over the fissures, around the larger venous trunks,
and thence more or less on the lateral surface of the cerebrum,
are frequently the seats of ])urulent collections. The microscope,
however, frequently reveals more or less extensive cell forma-
tion, where the eye can only detect o))acity or dulness of the
pia mater ; so that in all cases the affection is much more widely
spread than one would be inclined to assume from the distribu-
tion of the purulent collections.

The anterior surface of the spinal cord often exhibits only
microscopically perce])tible clianges ; while even considerable
deposits of pus may occupy the dorsal surface of the pia mater.
The greatest deposits of pus are found in the lower cervical
j)ortion and in the lumbar part of the cord, being so placed as
Klebs considers by gravitation, so far as obstacles in the struc-
ture of the parts permit. To the same influences is due, as it
iippears to us, the position of the purulent deposits so often

1868.] Recent Works on Cerebrospinal Meningitis. 385

found at the base of the brain and at the occiput along the
sinuses, &c. ; other agents affecting the site, in which pus is
found, are the different mobility of tlie several parts of the
column, and the so-called spontaneous motion of the corpuscles,
demonstrated by Von Recklinghausen. In the sjnnal cord the
dura mater is rather more often affected, being also found ad-
herent to the pia mater on the dorsal surface in the lower
cervical, and upper dorsal portions of the canal.

Dr. Fischer has lately striven to show that the composition
of arachnoid pus approaches, that of the secretion in catarrhal
processes, in the great amount of rnncus present.

Purulent substances are rare in the ventricles of the brain.
In the great majority of cases there is a slight increase of the
fluid of the ventricles, whicli in that case is usually slightly
tin-bid, but without containing pus corpuscles. Sometimes we
meet also with fine fibrinous coagula, deposited especially upon
the lateral plexuses, but likewise without admixture of pus
corpuscles.^

Changes of a double nature occur in the cerebral and spinal
medullary substanc* in meningitis, namely, extensive softenings
and purulent encephalitis.

(Edema and suppuration co-existing, especially if the fluid con-
tents of the medullary sheath are increased, loosen the connection
of the nervous elements by the consequent distention, especially
in those directions in Avhich the most numerous blood-vessels
run. Thus, the extensive motor disturbances, Avhich are ob-
served with slight amount of pus in the arachnoideal spaces
are explained ; while on the other hand cases occur, in which
immense purulent accumulations are met with, without very
considerable motor or sensory lesions having existed. Oedema
is, however, regularly present in a high degree in those cases
where the greatest purulent masses lie in the arachnoideal
spaces.

*' But that the coutact of the pus does uot, as might be supposed,
produce a maceration of the adjoining parts, is evident from the
fact that at the base of the brain, where precisely the greatest puru-
lent masses usually lie, such softenings do not occur.

" Moreover, at least in recent cases, the pus mixed with a large
quantity of mucus is not a substance specially adapted to produce
such maceration.

" I have left it for many days in contact with cerebral substance,
without the latter being more softened or broken up, than in the

' Dr. Klebs " reserves the expression pia mater for the entire membrane in-
vesting the whole cerebral and spinal medulla, within which the meshy arachnoid
is very sharply distinguished from the sheath (tunica propria), composed of denser
and tiner fibres, which, as well as on the testicles and kidneys, presents a su])er-
ficial expansion of the interstitial connective tissue."

386 Reviews. [Oct.,

other parts which were not in contact with pus. The case is of
course different with the ventricular surfaces, which have long been
exposed to the action of the fluid dropsical contents of the ventricles.
These are reduced by softening to the well-known white pappy sub-
stance."

A second kind of softening occurs not unfrequently, around
small extravasations of not movable blood- points, in the white
substance of the brain ; this softening usually forms only a
slender softened zone around the blood-point which was not, in
the cases examined by Dr. Klebs, of embolic origin.

If diffuse encephalitis be looked upon as embolic, this change
must be reckoned rather among the complications of the process
giving rise to the epidemic meningitis.

Forget, of Strasbourg, alludes to implication of the heart;
articular affections are more common. Dr. Klebs, however,
only found moderate increase of thickness in the synovia in a
case where the knee-joint was said to have been extremely
painful.

On the other hand, Corbin gives four cases of purulent affec-
tion, von Jacquenin gives two, and Ziemssen and Zenker
another similar case.

Klebs regards Boudin's views as to the likeness between
epidemic meningitis and puerperal fever in the tendency to form
pus, as drawn by Boudin, as exact only in reference to the
septicsemic precursors in the puerperal process.

Pathological changes of the other organs. — External Skin. — ■
Petechise or roseola-like exanthem. In many cases which ran
a rapidly fatal course I found small bluish spots, scarcely as large
as the head of a pin, appearing as extravasations of blood in the
upper layer of the corium, and mostly in the vicinity of the
duct of sudoriparous gland.

As to the blood, the French have found it rich in fibrin, and
have consequently referred the disease to the phlegmasiae.

Forget has found a thick crust on blood taken from the arm,
and from his experience advocates bleeding. Maillot^ likewise
found increase of the fibrin, especially in the further course of
the disease, but has also perseveringly bled, though he makes
the remark that the first bleedings often did not improve the
pulse, and that the patients who recovered had lost less blood
than those who died.

The author remarks that when we consider how rapidly, even
during venesection, the quantity of fibrin increases, all the state-
ments, such as the above, that have been made possess but little
value.

In the dead body we find the blood in very different states ;
• ' Gaz. de Piii-is,' 1848. ' Hop. Milit. d'lustruction de Lille.'

1868.] Recent Works on Cerebrospinal Meningitis. 387

but in the great majority of cases thai proved rapidly fatal, it
has been found fluid, or containing only a few soft fibrinous
coagula. The colour of the blood in the vessels vras very dark ;
both conditions met with, also, in other so-called infectious
diseases, especially in typhus and spotted fever.

The large abdominal glands and muscular system Dr. Klebs
states show highly important pathological changes. The spleen
was generally rather small, very flabby, the pulp dark-greyish
red, the follicles in one case small and few, in another numerous
and enlarged ; only in some very recent cases was there a con-
siderable recent splenic tumour.

The changes of the kidneys and liver are much more uniform.
These organs are seldom enlarged ; and when they are so, the
enlargement appears to be of older date. The kidneys present
a very characteristic condition : more flaccid than usual, capsule
easily separable, surface smooth, of a grey or greyish-red colour.
On section, the medullary portion is usually found very full of
blood, and the cortical portion presents an alternating sangui-
neous and turbid greyish-red condition.

In many, even very recent cases, the cortex is pale, greyish,
yellow and opaque. The convoluted tubes contain often a very
large quantity of fine fat granules, rendering them dark to
transmitted, and white and shining to reflected, light. The
same change exists in the thicker variety of loops, while the
straight canals and finer loops remain free or often contain
fibrinous cylinders and fibrinous scales.

In cases of longer standing there is, also, usually well-marked
papillary catarrh. The more minute changes in the liver are
analogous ; here, also, aflecting the secretory elements, which
consist in granular, albuminous, or fatty turbidity.

The macroscopical changes in the liver are like those seen in
abdominal typhus : — The liver is scarcely, if at all enlarged, very
flaccid, its section being always of a dirty greyish-yellow, or
greyish-brown colour, dry as if " boiled." These changes, from
which that of the kidneys is distinguished by an alternating,
usually moderate amount of albumen in the urine, is attended
with an extremely extensive and early affection of the voluntary
muscles, an affection the results of which are seen most plainly
in convalescence.

In recent cases we find granular depositions in the muscular
fibres distinguished from those in other toxsemic diseases — such
as typhus and phosphorus poisoning — by the greater fineness of
the fatty molecules, the fibres appearing to be sprinkled or filled
with an extremely fine dust. The change of colour is, in this
case, also less characteristic. Thus, while in the greater degrees
of phosphorus poisoning the muscles acquire a dirty greyish-red

388 Reviews. [Oct.,

pale appearance, in CO poisoning a cherry red, in abdominal
typhus a dry dark violet-red aspect, in meningitis epidemica
they are mostly rather dry, flaccid, brownish-red. With this
change is combined enormous emaciation of the muscular tissue.

Similar changes are found in the heart, but on the whole
slight fatty infiltration ; the heart is usually flabby, its substance
is of a rather greyish-red colour.

The lungs are generally not much altered ; in more recent
cases they are usually highly hypersemic. The lymphatic system
is not much affected, its glands are usually somewhat reddened,
but are otherwise normal; the swelling of the solitary glands of
the intestine is too slight and too inconstant to possess a special
importance.

The lesions of the organs of sight and vision stated to occur
in this disease appear to be rather sequelae developed only in
protracted cases without fatal result, and they therefore do not
often come under the cognizance of the pathological anatomist.

The Position of the Epidemic Meningitis in the Pathological
System. — The earlier writers, who had aii opportunity of observ-
ing the disease in the commencement of the present century,
brought it into close relationship with typhus (" tifo tetanico-
apoplettico" of the Italians, Hildebrand's cerebral typhus).
This is owing to the undue extension of the terms " typhus
fever," " status typhosus," &c, Griesinger speaks most de-
cidedly against the identification of the cerebral typhus of earlier
writers with epidemic meningitis. The author looks upon the
phenomena of the latter disease as " passive lesions of nutri-
tion." In conclusion he gives a brief resume of the cases of
meningitis noted in the records of the Pathological Institute
since the beginning of 1861. This exhibits a great increase of
the disease in the years 1864 and 1865. The following table
presents a clear view of the course of the two epidemics in these
years. The cases are those of acute primary meningitis, proved
by dissection to have been such. In the month of —

1864. 1865.

Military .12 2 11 7

Civil .. (1) (1) 1 2 ... 1 1 3 3 3 1 (1) 1 19

It will be seen that the epidemic began in the coldest season
of the year, and extended with diminishing intensity into the
summer.

" The first case in the year 1864 from the civil population
died on the same day, as the first from the military did, on 13th

] 868.] Recent Works on. the Diseases of Childre?i. 389

February; from that time the disease lasted in both divisions of
the population until May and June respectively. With the
year 1865 an epidemic begins affecting, as it seems, exclusively
the civil population. It would be very desirable if the results
thus obtained were verified by the publication of as many cases
as possible observed in this place. Nevertheless, this result is
probably essentially reliable, that the disease has confined itself
to the first five or six months of the year. This agrees with
Boudin's statements, who in a report including 17!2 cases,
reckons 1 09 in the first half of the year and sixty-three in the
second. The maximum fall in the months of January (26),
February (29), and December (20), and the minimum in
August (3). It cannot be denied, therefore, that the coldest
seasons of the year are specially disposed to produce the disease.
Two elements may come under consideration with respect to
this point ; the local effect of cold and the condensation of a
portion of the population in confined spaces. Comparison with
the years 1861 to 1863 shows that in those years, too, isolated
cases of quite analogous nature occur; thus, in 1861, cases 1
and 3 ; in ] 862, case 3 ; in 1863, cases 1 and 2 (?) may belong
to this disease. It is very remarkable that in these sporadic
cases also distinct indications are met with, in the reports of
dissections, of the presence of parenchymatous organic diseases,
and this circumstance may still further confirm the identity of
the cases in question with the epidemic affections of the last
two years."

{To be continued.)

IvEVIEW VII.

1. Diseases of Children: a Clinical Treatise based on Lectures

delivered at the Hospital for Sick Children, London. By
Thomas Hillier, M.D., &c. London, 1868. Pp. 402.

2. A Practical Treatise on the Diseases of Children. By D.

F. CoNDiE, M.D. Philadelphia, 1868. Pp. 783.

3. The Surgical Treatment of the Diseases of Infancy and

Childhood. By T. Holmes, M.A., Surgeon to the Hospital
for Sick Children, &c. London, 1868. Pp. 648.

4. Logons Cliniques sur les Maladies Chirurgicales des Enfans.

Professees par M. J. Giraldes, Chirurgien de I'Hopital des
Enfans malades, &c. ler — 3euie fascicules. Paris, 1868.
Clinical Lectures on the Surgical Diseases of Children. J^y
Dr. J. Giraldes, Surgeon to the Hospital for Sick Children.
1st — 3rd parts. Paris, 1868.

390 Reviews. [Oct.,

Of the four works whose titles we have just enumerated two
deal with the medicine, and two with the surgery, of early life.
They represent almost entirely the state of science with regard
to the most important of all our specialities, and we should be
wanting, therefore, in our duty to our readers if we did not
give some account of them.

Dr. Hillier's hook is so good in one way as to be disappoint-
ing in another. By modifying It'ctun s delivered at the Hospital
for Sick Children, he has produced what he rightly describes
as " a series of short monographs," which testify to so much
careful observation and study as to give us serious grounds for
complaining that he has not published the results of his ex-
perience with regard to many other infantile diseases of import-
ance. Thus, gastric, intestinal, hepatic, and renal affections are
not noticed, scrofula is only incidentally referred to, and syphilis
dismissed in a dozen lines. We trust that Dr. Hillier has only
postponed these subjects for a second edition of this valuable
work, in which case room might be, perhaps, made for them by
curtailing the articles on pleurisy, pneumonia, and scarlatina,
which, although not too long for the importance of those
diseases, are out of proportion to the size of the work. Where
all is instruction, it is difficult to select anything for special
praise ; but, to our minds, the articles on tuberculosis, pj semia
and otorrhcea, and acute and chronic hydrocephalus, are the
most interesting. In his account of diphtheria he argues
strongly — against those who (as Sir Wm. Jenner and Mr. Squire)
would distinguish between croup and diphtheria. One very
commendable feature of the volume is the formulary for pre-
scriptions ; another is the large number of illustrative cases, of
which many are very valuable.

Dr. Condie's book is, in many respects, the most striking
contrast to Dr. Hillier's. The English author avoids, even
more than most clinical lecturers, quotations from other authors,
and seems to rely almost exclusively on his own experience,
while Dr. Condie is profuse in his references to others, and
keeps his own judgment and experience too much in the back-
ground. Were his subject philosophy, and not medicine, we
should say that he is a syncretist, and not an eclectic — that is to
say, he collects and registers various, and often conflicting,
opinions, without any effort to conciliate or systematise them.
This tendency is most notable in those points where the pro-
gress of science has led to the abandoning of opinions which
were formerly held. Thus, we believe that the accounts of
lung-collapse and gastro-malacia would be unintelligible to any
one who has not studied those questions, simply because con-
tradictory statements, introduced into successive editions of the

1868.] Recent Works on the Diseases of Children. 391

work, have been allowed to remain in juxtaposition without
sufficient explanation. The articles on diphtheria and croup,
again, are very confused, from the same defect. The descrip-
tion of '* remittent fever " as a disease of the digestive organs,
and the omission of all reference to the true nature of the
epiphytic skin diseases, are also, no doubt, due to the incomplete
preparation of the later editions of this Avork, which is the
more unfortunate because it contains a great amount of useful
matter. The whole of the first part (containing the general
pathology, semeiology, &c., of children's diseases, is remarkably
superior to the rest of the work ; the description of infantile
cholera, which is much more frequent in the United States than
in Eui'ope,^ is interesting, both as to pathology and treatment.
The disease is attributed to the action of hot, moist, and impure
air, primarily upon the skin, and secondarily upon the mucous
surface of the alimentary canal, which is already predisposed to
disease by dentition ; the chief means of treatment is, therefore,
to supply abundance of pure and cool air.

Epidemic cerebro-spinal meningitis has, in some American
epidemics, been observed almost exclusively in children under
tifteen years of age. Many American physicians still seem to
rely upon the action of mercury in this disease, while others
have found decided benefit from the administration of large
doses of quinine.

The reader will meet with some expressions here and there
in this book which will remind him that the author is not an
Englishman, of which, perhaps, " illy," for the adverbial use
of " ill," is the most curious ; but the style is, on the whole,
more flowing and easy than that of most American books we
have read.

It is a pleasure to us to turn to a work of which we can speak
in terms of unqualified praise. Mr. Holmes's ' Surgical Treat-
ment of the Diseases of Infancy and Childhood ' is a book quite
Jiors ligne, and one which the student and the experienced
practitioner may alike study with pleasure and profit. It com-
bines all the good qualities which should be found in such a
work, being the fruit of considerable book-study, as well as of
an extensive practice, clearly and elegantly stated ; and (what
is no little matter) with everything done, in the way of excel-
lent plates and engravings, and judicious typographical arrange-
ments, to facilitate its perusal.

Our best course will be to give an analysis of the more
important parts of the work, as it may be taken to represent
the present state of infantile surgery.

It is divided into two parts, the first treating of malforma-
1 Dr. Condic is wrong in supposing it to be unknown here.

392 Reviews. [Oct.,

tions, the second of injuries and surgical diseases. Some of
the malformations (hermaphroditism, joined twins, tracheal
fistula, &c.) are too rare to have any practical interest, althoiigh
even the description of these contains cases of importance which
have occurred in the author's own experience ; but others are
among the most important surgical affections of childhood.

We are glad to see that ]\Ir. Holmes gives prominence to tlie
fact that all dangerous operative procedures for niDvus sliould
be avoided, since the disease is, when left unchecked, seldom or
never fatal. He condemns excision by the knife in all dangerous
positions, and thinks it should always be confined to hospital
practice. He recommends the use of setons (which he generally
dips in solution of perchloride of iron) for large nsevi, subcuta-
neous ligature for smaller ones, and repeated applications of
strong nitric acid to those which are merely superficial. Liga-
ture of the carotid, or even of the vessels at the base of the
tumour, is condemned as dangerous, and uncertain in its results ;
vaccination is only available in such cases as may be much
better treated by nitric acid ; and injection of the perchloride of
iron, though it has the advantages of being very effectual, and
leaving hardly any visible trace of its action, has in several
instances proved fatal, by coagulating the blood in a large vein.
If employed at all, only two or three drops should be injected
into different parts of the tumour at each sitting. The purely
palliative treatment, by pressure or cold, is tedious and trouble-
some, and offers no security against a return of the disease.

In harelip Mr. Holmes always uses pins, and not the suture.
He leaves the pins in for only forty-eight hours, so that no mark
of them remains, and he has never yet had a case in which the
wound gave Avay after their removal.

The operations of staphyloraphy and uranoplasty are recom-
mended to be performed, in otherwise healthy children, before
they have acquired the habit of speaking in the peculiar way
characteristic of cleft palate, say at about three years of age. It
would formerly have been very difficult to operate on sucli
young patients, but the use of the gag invented by Mr. T.
Smith, which holds the mouth open to the widest extent, has
made it much easier. The operation will, however, always be
a troublesome and tedious one (Billroth estimates its duration
at about three quarters of an hour), and union is, perhaps on
the whole, less likely to occur in infancy than later in life.

In case of imperforate rectum we are advised to wait for a
day, if the symptoms are not urgent, so as to allow the lower
part of the bowels to become distended. If there be then no
positive evidence of the presence of the rectum, it is probably
better only to make a puncture Avith a grooved needle or explor-

1868.] Recent Works on the Diseases of Children. 393

iii^- trocar, and, if no inecouium is found, to proceed at once to
colotoiny. If any further search in the perinaMiui is to be made
it shouhl be a careful dissection, aided by tlie presence of a staff,
kept strictly in the middle line, in either the bladder or vagina,
according to the sex. If the colon has to be opened, Littre's
operation should be preferred to Amussat's ; and this because
in infants the colon usually has a long mesocolon (so that it
could not be opened from behind without wounding the peri-
toneum), and presents at once in the wound in the groin. M.
Rochard is quoted to prove that colotomy has been successful
in ten cases, and in three of these at least the artificial anus
did not prevent the patient from leading an active and easy life.
In those cases where an imperforate rectum opens into the
vagina there is little danger to life; but when the natural
passage is restored the vaginal fistula does not, as a matter of
course, close. Recto-vesical fistula, in the male infant, is more
serious, as the urethra is choked by the accumulation of solid
faeces ; such cases require, therefore, earlier operation than the
last variety ; generally, if the intestine opens into the urethra,
it will be accessible from the perinaeum, but if into the bladder,
colotomy will be necessary.

The general remarks on operations in childhood, which are
prefixed to the account of the surgical injuries and diseases of
infancy, will be read with great interest. Mr. Holmes is, on
the whole, of opinion that operations are less dangerous in
children than in adults, inferring this, partly from some
statistics (which he published in vol. i of the ' St. George's
Hospital Keports'), partly from the a priori considerations that
the healthy state of the viscera, and the ease with which long
confinement or pain can be endured, more than counterbalance
the more transitory effects of violent pain or haemorrhage, which
are more serious in the infant than in the adult.

A very minute account is given of the operations for opening
the windpipe, which are so frequently necessary in children,
and several points of detail brought into notice, which, although
we have not space to mention them here, should be read by
those who are likely to liave to perform them. Mr. Holmes
has established, we think, tbat Mr. Marsh's objections to the
performance of laryngotomy (in vol. iii of the ' St. Bartholo-
mew's Hospital Keports') are not valid, and that in very early
life it would be extremely unwise ever to operate below the
thyroid isthmus; even in older children tracheotomy should
only be performed when a larger opening (for the extraction of
foreign bodies) is required than can be made above. In case
there is reason to suppose the existence of some polypus or other
tumour in the larynx, he recommends that, after laryngotomy.

394 Reviews. [Oct.,

the thyroid cartilage shouhl be divided through its whole length,
so as to expose the interior of the organ, cai'e being taken to
avoid the vocal cords. Although this does not appear to be so
dangerous an operation as one might have supposed, we cannot
say that the results, as he gives them, of his cases are sufficiently
encouraging to lead to its general adoption.

We hope that Mr. Holmes is mistaken in fearing that, be-
cause he dissents from the ordinarily accepted views of the
nature of " struma," he will be regarded as ill-informed on
the subject. We quite agree with him that the way in which
low inflammations and diseases of very different kinds are
"lumped together" betokens an unscientific habit of mind,
and leads to errors in prognosis and treatment. He follows
Sir William Jenner in discarding altogether the word " struma,"
and in distinguishing sharply between tuberculosis and scro-
fula, two diathetic states which, so far from requiring the
common term struma for connecting them, need to be kept
carefully apart. But he also brings into prominence a point
which has been too much neglected, viz. that many of the
cases known as " scrofulous " are only examples of local disease
which, by long continuance, have pi'oduced general disorder.
These are constantly confused with the totally opposite state in
which local disease is produced by a pre-existing diathesis, and
a careless diagnosis (for which the words " scrofulous " and
*' strumous " are an excuse) leads to serious mistakes in treat-
ment.

We cannot do more than refer briefly to the excellent article
on rickets. Mr. Holmes tells us that the experience of the
Children's Hospital is that phosphate or superphosphate of
lime is of no real use in this disease ; with regard to its sur-
gical treatment, he is decidedly in favour of applying splints to
prevent deformity. With all deference to his authority, we should
be inclined to add Ur. Hillier's qualification — that the splints
will only be of use when the general disease has been cured,
and merely the local softness of bone remains.

The account of periostitis will be read with particular interest,
as the disease has only been accurately known within the last
ten years, and this is probably the best description of it in the
English language. In cases of this kind, where the disease has
gone so far as to separate the bone from its surroundings, and
periosteal abscess has resulted, the author strongly advocates
subperiosteal resection of the diseased bone, even before new
bone has formed. He claims two advantages for the operation
over the expectant plan of treatment — the one, that it removes
a constant cause of dangerous irritation ; the other, that the
operation is more easily performed, and is more rapidly re-

1868.] Receyrt Works on the Diseases of Children. 395

covered from, before than after the formation of a large seques-
trum, and it is fair to admit that his detailed cases bear out his
statement. The principal objection is the great probability of
shortening of the limb.

On the other hand, Mr. Holmes is decidedly in favour of not
removing bone w^hich caries has destroyed, but of trying perfect
local rest, with or without the application of a strong liniment
of mineral acid, as recommended by Mr. Pollock.

The chapter on joint diseases is remarkably practical; the
author rightly attaches little importance to the distinctions
usually established by systematic writers between affections of
the bones, cartilages, tendons, ligaments, and synovial mem-
branes, but confines himself particularly to questions of progno-
sis and treatment. Abscess, the almost invariable result of
joint disease in children, should generally be freely opened,
and, supposing any further operative measures to be required,
the smaller joints may be excised; but if the knee, hip, or
shoulder be affected, amputation will generally be required.

Mr. Holmes applies to the consideration of chronic joint
diseases the general principles which he lays down under the
head of struma. He is of opinion that the majority of what
are called "strumous joints" are merely instances in which
long-continued local disease has produced constitutional mis-
chief, basing his opinion on the ordinary course of such cases,
Avhich, in their origin, progress, tendency to spcmtaneous cure,
and usually complete recovery after excision or amputation,
resemble local rather than diathetic diseases. The pathological
appearances, too, are rather those of simple chronic inflamma-
tion than of any peculiar morbid action.

The whole question is analogous to that raised by some
modern German and French physicians — whether pulmonary
phthisis is, in many instances, not a simple chronic pneumonia ;
but it is more easily soluble, and much more immediately
practical, for, if chronic joint disease is essentially constitu-
tional, operations ought only to be performed when urgently
called for ; while if it is local, it may generally be advisable to
perform them, if only for the sake of preventing the local
disease affecting the general health.

Of all the operations for diseased joints, Mr. Holmes is best
entitled to speak with authority about excision of the hip, which
he has performed more frequently than any other surgeon. He
has preserved notes of nineteen cases, in all of which he
followed the rule of not operating as long as there was any
reasonable chance of natural recovery. To abridge his statistics,
we may say that three of the nineteen made complete recoveries,
three have useful limbs, but with sinuses, one case was doubtful.

396 Reviews. [Oct.,

and two were very little benefited. Seven died from the direct
results of the operation, one of whom was in a dying state when
it was performed, and five of pyaemia, which seems then to have
been prevalent at the Children's Hospital. The remaining
three cases died some time after the observation ; one from
independent disease, the other two from long-continued sup-
puration.

These, as Mr. Holmes very fairly allows, are not satisfactory
results ; but, considering the ordinarily long duration of the
disease, and the hopelessness of a natural cure in poor chihhen
once the bones have become carious, they imply that the opera-
tion will often be advisable merely to save life, while the limb
is far more mobile after a successful excision than after spon-
taneous cure.

With regard to the vexed question of excision of the knee,
our author is of opinion that it is a more severe operation than
amputation, being both more immediately dangerous to life and
requiring a longer time for convalescence. It is, therefore, only
to be recommended in the most favorable cases, in which it
has over amputation the great advantages of leaving a useful
limb instead of a stump.

We have dwelt so long on this subject that we have no
space to give an account of the important suggestions made by
our author for tlie various operations in disease of the tarsal
joints, but "we regret this the less that we hope Avhat we have
already said will induce every practical surgeon to study the
book for himself. We would especially call attention to the
chapters on infantile prolapsus, hernia, and stone. The highest
praise we can give them is that they are fully equal in merit to
tlie rest of the volume.

Mr. Holmes is unable to find room in his volume for dis-
eases of the eye ; if any special account of these is desired,
probably none can be found better than that given by M.
Giraldes, in the lectures which stand last upon our list. As
these are still unfinished, it would be unfair to say more in
the way of criticism than that they are, ])erliaps, too clinical.
Being the exact reproduction of the lecturer's words, the con-
tinuity necessary in a book is constantly broken by digressions
to cases of a totally different kind, under treatment at the same
time. Besides diseases of the eye, hydrocephalus, harelip,
hydatid cysts of the liver, ovarian and myeloid tumours, are
the principal subjects treated of, and all of them in a way that
is thoroughly practical and interesting. When finished, these
lectures will probably form a complete course of infantile
surgery, worthy of tlie successor of Guersant, and of the
unrivalled means of observation at M. Giraldes' disposal.

1868.] Recent American Works on Surgery. 397

Review YIII.

1 . A Manual of the Principles of Surgery, based on Pathology,
for Students. By William Canniff, Licentiate of the

Medical Board of Upper Canada ; M.D, of the University of
New York; M.R.C.S. England, &c. Philadelphia, 1866.
Pp. 402.

2. Conservative Surgery, as exhibited in remedying some of the
Mechanical Causes that operate injuriously both in Health
and Disease. By Henry G. Davis, M.D., Member of the
American Medical Association, &c. New York, 1867.
Pp. 315.

3. A Practical Treatise on Surgical Apparatus, Appliances,

and Elementary Operations. By Philip S. Wales, M.D.,
Surgeon U.S.N. With 642 Illustrations. Philadelphia,
186T. Pp. 685.

4. Plastics : a new Classification and a Brief Exposition of

Plastic Surgery. By David Prince, M.D. Philadelphia,
1868. Pp. 93.

The books which we have grouped together in this article are
all of American origin, and they well illustrate the eminently
practical character of the American mind. They deal with a
variety of subjects in surgery, as it is at present practised, and
supply us with some valuable suggestions ; but they hardly
touch upon any questions of theory. Our American brethren
have singular advantages for the pursuit of medical and surgical
inquiries. They have a country so vast that it presents the
most different climatic and hygienic conditions ; they are brought
in contact with a variety of races ; and the recent war has sup-
plied them with an amount of experience and with a mass of
statistics which can hardly fail to prove of service to science.
And it must be admitted that the American surgeons have made
a good use of their opportunities, for they have given us some
valuable additions to the practice of surgery, and have helped to
advance this department of knowledge in a notable degi'ee.

In reading these books one can hardly fail to be struck — and
not a little flattered — by the frequent references which are made
to our professional literature, and the weight and authority
which are allowed to the opinions of English surgeons.

Thus, if we turn to the first, ' The Principles of Surgery,
based on Pathology,' we must admit that the author is cer-

84— XLii. 26

398 Reviews. [Oct.,

tainly very candid, for in his preface he gives a list of German
and English works which he has " freely consulted ;" and as we
read through his pages we see that he has not over stated the
use that he has made of them. We find scattered throughout
his whole work long quotations from Paget's ' Lectures on Sur-
gical Pathology,' Virchow's * Cellular Pathology,' and Holmes's
' System of Surgery,' hesides many shorter passages extracted
from other authors. Moreover, the whole of his illustrations
are taken from Mr. Paget's Lectures ; so that we are thus fur-
nished, with a very good skeleton for a work upon ' Surgery,
hased on Pathology.' It needs only that the extracts from
standard authors should be carefully selected, and that the
woodcuts should be used with judgment, in order to make a
trustworthy ' Manual of the Principles of Surgery.' And this
much praise we may certainly accord to our author. If there is
nothing original in his work, and if his quotations appear to us
to be taken with rather too free a hand from the writings of
others, at any rate he deserves the credit of having pieced them
together so as to form a useful and readable book.

The writer is a Canadian, and, as he tells us in his preface,
his grandfathers and his father were pioneers in the wilderness
of Canada, so that he himself did not enjoy the advantages of
early literary training. It is only fair that we should bear this
in mind, for the volume before us certainly reflects credit upon
the energy and industry of the author. He appears to have
received his medical education partly in this country and partly
in the United States ; and he has evidently made a good use of
the extensive opportunities for observation which he has had
both in Europe and America. He has served as a military
surgeon with British troops and with the United States army;
and perhaps the most interesting part of his book — the only
part indeed which has any novelty about it — consists of his
experiences during the recent civil war in America. The
chapters upon gunshot wounds are those that we have read with
the greatest pleasure, because they are almost the only ones
which have an air of freshness. In most of the others we are
sensible that we are perusing what we have read elsewhere, and
the occurrence of the well-known illustrations from Mr. Paget's
Lectures helps to confirm the fact.

On the question, How far an alien race fan flourish in a
country to which they do not originally .belong, our author
makes the following remarks. They are intended to supply an
answer to the theory that colonising races will inevitably die
out, unless they are constantly recruited by fresh emigrants
from the mother country. Upon this subject Mr. Canniff''s
opinion may be allowed to have weight, for he has himself been

1868.]

Recent American Works on Surgery. 399

brought up among the descendants of English and French
emigrants in Canada, and he has subsequently had opportunities
of comparing the colonists with the European races from which
they have sprung.

" The French of Lower Canada, even under many adverse circum-
stances, have fully retained tbeir ancient bodily vigour, and caa
compare favorably with the present inhabitants of old France, while
their number has increased ; yet their ancestors, many of them,
emigrated to New France 200 years ago ; and, since the colony
became a part of Britain, no ' replenishment' has been received from
the old stock. Turning to Upper Canada, we find a fact no less im-
portant, and quite as antagonistic to the theory that native Ameri-
cans are doomed to die out. In consequence of the American
revolutionary war, some 25,000 or 30,000 united empire loyalists
were forced or induced to seek a home in the Canadian wilderness.
Many of these were descendants of those who had first peopled
New Holland along the banks of the Hudson. A large number of
these limited empire loyalists settled along the St. Lawrence and
the Bay of Quinte. In the main, indeed, almost altogether, until
very recently, these old settlers have intermarried. Now and then
an emigrant might settle among them, but it was an exception. The
great grandchildren of those American pioneers now live on the
old homestead, and are found scattered over the whole province ;
and although I have no positive data upon which to base my asser-
tion ; yet, from careful observation, I have no hesitation in declaring
that in physical development, in slight mortality among the children,
in length of life, in powers of endurance, not to say in bravery and
patriotism, they cannot be excelled by any class of emigrants." —
P. 141.

The next extract that we shall offer to our readers is intended
to show the value of veratrum viride as a vascular sedative and
antiphlogistic. The American evidence in favour of this drug
seems to indicate that it deserves a more extensive trial than it
has yet had in this country. The tendency of medical practice
of late years has been so much opposed to anything like active
antiphlogistic treatment, that we have perhaps failed to give the
veratrum viride a fair trial. However this may be, here is our
author's testimony in its favour, and very strong testimony
it is.

" Veratrum viride is a medicine which does not enjoy the long
established reputation which belongs to antimony ; but it success-
fully rivals that drug as a powerful antiphlogistic I have

found it particularly useful in inflammation of the lungs. Two
cases of such, which were also most interesting in a surgical point of
view, I will particularly refer to. These were cases under my im-
mediate care in Lincoln Hospital, at Washington. Both came in
at the same time, direct from the battle-field. The first one which

400 Reviews. [Oct.,

engaged luj attention was unable to lie down, but had to sit leaning
forward considerably. His efforts to breathe were most urgent.
He could barely tell me that he was wounded in the chest — that the
ball had passed through his body. I hastily looked at the wound
in front, which was the place of entrance ; it was between the
fifth and sixth ribs, on right side of and very near to the sternum.
I not only considered his case hopeless, but thought he could not
live an hour. I ordered him a draught of compound spirits of ether,
which was shortly repeated. In half an hour he went to sleep, his
head resting forward on a chair, made somewhat comfortable for the
head. He slept for two hours or more. During the sleep and on
waking he could breathe a little more easily. I examined the wound
posteriorly, and found that the ball had passed almost directly
backwards, and had made its escape. It was now some thirty hours
since the reception of the wound. The action of the heart was
laboured, and there was some fever ; the skin was hot and dry. I
put him on veratrum viride, to be given often, in small drop doses.
I had every reason to believe, from the symptoms, which I cannot
here fully describe, that the ball had passed through the lung. It
was several days before the patient could lie down. Symptoms of
pneumonia presented themselves, but were kept under control, and
finally the patient became convalescent.

" The other patient was also wounded with a ball, which had
struck the right clavicle at about its middle, and, shattering the
bone, had buried itself in the part. In this case, also, there were
well-marked signs of the lung being wounded. At first the distress
was not great, the dyspnoea but little ; in two days, however, it was
very great. He was ordered the veratrum viride every three hours.
I found it unnecessary to give anything else. In a few days the
symptoms of inflammation subsided. Because of the important
structures immediately beneath the clavicle, the ball was but slightly
searched for. When the patient passed from under my care, his
condition was most promising. The wound remained open, from
which was a little purulent discharge, which might have been due
to the necrosed state of a part of the clavicle. Now, both of these
men were young and full of healthy blood ; but neither general nor
local bleeding was deemed necessary. The inflammation was suc-
cessfully treated solely by the veratrum viride." — P. 87.

We have already said that some of the best chapters in the
volume before us are those which relate to gunshot wounds, and
that some of the most interesting passages are Mr. CannifTs
experiences during the late conflict in the United States. In
speaking of the strange course which a bullet will sometimes
take, he says —

" One case which I saw after the battle of Chancellorsville will
serve to illustrate the extraordinary direction the ball may take. A
private of one of the New Jersey regiments had been wounded in
the right arm, while in the act of putting a cartridge into his musket.

1868.] Recent American Works on Surgery. 401

The ball had completely cut off his forefinger, then passed directly
through the body of the hand, and again entering the back of the
arm, about two inches above the wrist, had ploughed a furrow for a
few inches, and then entering into the deeper part of the arm, had
finally made its exit and escape a little above the external condyle
of the humerus."— P. 229.

Here is another case of a somewhat similar kind, which illus-
trates not only the curious couise that a ball will sometimes
take, but also the necessity of looking for it in the most unlikely
places.

"Sergeant C — had been wounded in the leg, I think, while
advancing at the double quick. The ball had entered the front of
and a little below the knee. It was a fortnight afterwards when he
came under my care. In the mean time the wound had been
repeatedly probed in the efforts to find the ball, but without success.
Believing from the character of the wound that the ball had taken a
downward course, I proceeded to carefully examine the leg on every
side. Coming to the ankle, and while pressing the finger inward
beneath the tendo-Achillis, near its attachment, he complained of
soreness, and at the same time I could distinctly feel a hard sub-
stance. The patient, assured that this must be the ball, submitted
at once to the use of the knife, and a large Minie ball was extracted
through the wound. It had not caused, so far, any inflammation.
The ball was slightly battered from striking the bone. Of course
the patient was delighted as well as surprised. Now, here is a case
illustrative of the usefulness of trying, by external examination, to
find a ball, when the probe fails to reach it through the wound.
The ball was not only more than a foot from the place of entrance,
but it was also at the opposite side of the limb." — P. 23 i.

In the chapter upon the diseases of the joints, our author
relates a very interesting case in which he excised the ankle.
This is an operation Avhich is so seldom attended with a really
satisfactory result, that one is glad to hear of an example in
which, at the end of the year, the patient could run upstairs
three steps at a stride. This certainly sounds a very successful
case, and we congratulate Mr. Canniff upon it. The subject
was well chosen to begin with, the experiment was cautiously
and carefully made, and the result appears to have been most
encouraging. It may be that an increased experience will show
that the operation of excision of the ankle, like excision of the
wrist, has been somewhat hastily condemned ; and that in well
selected and suitable cases the surgeon should consider whether
he could not perform it with advantage. Many operations have
suffered more from their friends than from their foes ; and this
is particularly true of the excisions. It is because the advocates
of excision of the knee have pushed their practice to an extreme

403 Reviews. [Oct.,

length, and have operated on suitable and unsuitable cases alike,
that so many doubts have been entertained regarding the value
of this mode of practice. But if the cases had been more care-
fully selected, we believe the verdict of the profession would
long ago have been given in favour of the operation. And the
same may be said of excision of the wrist. Within the last few
years cases have been brought forward showing the value of the
operation, and it now bids fair to take its place among the estab-
lished proceedings of surgery. Perhaps the same thing may be
found to be the case with the operation here discussed. Excision
of the ankle, after having been hastily tried and hastily laid
aside, may at length assert its proper value and come to be
recognised as an important means of dealing with those diseases
of the ankle which are so common in this country.

There are some idioms and expressions in this volume which
fall rather harshly upon an English ear ; but we are not disposed
to criticise them severely, because there can be no doubt that
our language has received useful additions from the other side
of the Atlantic, and it may be that words, which displease us
when they are first heard, may hereafter be found well suited to
the requirements of this busy age in which we live.

The book appears to have been passed through the press
without the revision of the author, and in several places it bears
evident marks of a want of finish. It seems to have been
hastily written and hastily printed, to meet a supposed want,
which might have been better supplied by one of the existing
text-books, either American or English. Mr. Canniff would
have done well to have waited until he had a larger experience
of his own to draw upon, and until he had leisure to give his
work the careful revision which it ought to have had.

The book which stands second upon our list is of a different
kind from that which we have just noticed. It is called ' Con-
servative Surgery,' but this title is somewhat misleading — at
any rate to a person who is imbued with English ideas. In
this country the term "conservative surgery" is generally ap-
plied to those partial operations, such as resections and exci-
sions, whereby we are enabled to avoid the necessity of
amputations. But the volume before us does not deal with
" conservative surgery" in this sense. Indeed, it does not treat
of any operations whatever. Truly conservative it undoubtedly
is, and that in the best sense of the word ; but it aims at pre-
serving parts, not by limited operations, but by mechanical
appliances which shall make operations unnecessary. If it were
called " The Application of Mechanism to the Treatment of
various forms of Disease," it would give the reader a clearer
idea of ils contents than the present title does.

1868.]

Recent American Works on Surgery, 403

It would appear that Dr. Davis Avas convei-sant with surgical
mechanism before he began the study of the medical profession ;
and it is evident that he has approached the subject from a
mechanician's point of view. It seems to us that he is inclined
to lay too much stress upon mere mechanism, and to think that
it is capable of accomplishing more than experience warrants us
in believing.

The mechanical principle which he has applied to the treat-
ment of various injuries and diseases, is that of continued elastic
extension. This is his hobhy — if we may be allowed the expres-
sion— and he claims to have been the first to introduce this
method to the notice of the profession. It is a principle which
is now very generally used in dealing with contracted joints and
other cases, and if we owe it to Dr. Davis we have reason to be
grateful to him for his suggestion. But we doubt very much
whether it is capable of effecting all that he supposes. Thus,
he applies the principle very ingeniously to transverse fractures
of the patella, and then he says —

" This plan so effectually overcomes the contraction of the muscles,
and leaves the patella so free to be kept in apposition, that we can
but think the vast majority of fractures of this bone will unite by
bone. It is certain they will not fail to do so from want of co-
aptation of parts."

We are afraid this opinion — which, by the way, is almost
entirely unsupported by cases — is rather too sanguine, and that
Dr. Davis's plan of treating these fractures, like many others
that have been proposed for the same purpose, will fail in
securing bony union.

In speaking of dislocations our author is still more confident
of the good results which may be produced by the method he
advocates.

" At the present time [he says] by means of the principle we
have promulgated, that a ligament or other soft tissue can be elon-
gated to any desirable extent by the use of continued elastic exten-
sion, we have it within our power to reduce almost any dislocation,
without reference to the length of time it has been luxated ; and it
can be done, not only without pain or suffering, but without the
slightest danger to life, and with almost a certainty of a perfect
restoration of the joint to all its functions."

This may be so. It is not wholly impossible ; but such a state-
ment ought to be supported by well selected cases before the
profession is asked to adopt it and act upon it.

In cases of congenital dislocation Dr. Davis has used the
same method, and, as he assures us, with the most satisfactory

40^! Reviews. [Oct.,

results. He relates two cases, one of a girl aged six years, the
other of a girl aged fourteen, in both of which he effected what
he considered a perfect restoration of the parts to their natural
situation and function ; but we trust he will pardon us if we say
that it requires more evidence than he adduces to convince us
that it is desirable to attempt to reduce a congenital dislocation
of the hip in a girl fourteen years of age, or that lost parts can
be restored in the way that he supposes. Still we shall be glad
if the publication of the volume before us should induce sur-
geons to give continued elastic extension a fuller trial, and to
apply it to some cases for which it has hitherto been thought
hardly suitable.

In dealing with cases of club-foot Dr. Davis applies his
method of treatment in a manner similar to that which has been
employed by Mr. Barwell in this country — that is to say, he
supplies the place of the paralysed and atrophied muscles by
Indian-rubber cords, which draw the foot into its proper position.
Dr. Davis claims to have been the first to make use of this
method, and he complains that in this point, as well as in others,'
his " discoveries" have not had justice done to them. It may
be so ; but he should have taken care to make his principles of
treatment known when he first began to use them. There was
no need to wait until he had tried them for thirty years. The
gist of the present volume might have been given in a pamphlet.
The accounts of the pathology and symptoms of various diseases,
which he has introduced, and which he has drawn out to weari-
some length, might have been omitted with advantage. This
much might have been taken for granted, or very briefly recapi-
tulated ; and then the principles of continued elastic extension
might have been explained and enforced by cases. But, instead
of this, Dr. Davis has adopted a very different course. He has
evidently been desirous of Avriting a hook ; and as his methods
of treatment might have been explained in twenty pages, and as
he appears to have but few cases to support them with, he has
filled up the space with a tedious account of the symptoms and
pathology of some of the diseases that he has treated — a subject
with which it might be supposed that his readers were already
sufficiently acquainted. Indeed, all through the book, as we
read we are constantly desiring to have cases quoted in support
of the opinions which are expressed. Strong statements are
made — statements which it appears to us must be very much
exaggerated — and yet they are left to stand alone. Thus in a
long chapter in which the author discusses phthisis and its
treatment by regulated movements calculated to expand the
chest, not a single case is related. Dr. Davis is very sanguine
of the benefit which will arise from his method. He says.

1868.]

Recent American Works on Surgery. 405

" When the treatment of phthisis we here propose commences
with the disease, and is pursued uninterruptedly, we have every
reason to expect that every case will recover." And, again,
" The views advanced- in this chapter have been accumulating
for thirty years, and the application of the principles has never

failed of producing results more or less favorable" These are
strong statements ; and yet Dr. Davis expects us to receive them
without the evidence of a single detailed case.

This may serve as an example — and a notable example it is —
of the faults that we have to find with the volume before us.
That continued elastic extension and regulated muscular move-
ments are excellent modes of treatment in some cases we do
not doubt for a moment, and we are glad to give Dr. Davis the
credit of having applied them to various parts of the body with
considerable ingenuity. But he appears to us to have ridden
his hobby to death; for his statements are so strong that he
can hardly expect his professional brethren to receive them,
except upon much better evidence than any he brings forward.

^ The third book on our list is a treatise on ' Minor Surgery
and Bandaging,' wherein the chapters upon bandaging and
surgical apparatus are drawn out to great length. Indeed it
appears to us that the whole work might have been abbreviated
with the utmost advantage. What is wanted in such a book
is not a catalogue of all the bandages and splints that have
ever been devised, but a judicious account of those appliances
which are in most frequent use at the present day, and whose
value has been proved by long experience. If Mr. Wales had kept
this object steadily in view he would have produced a smaller, but
a much more useful book. As it is, the volume before us contains
a great deal that is obsolete, and would have been far better
omitted. Moreover, our author would have done a gi'eater service
to the profession, and particularly to medical students, if he
had adopted fewer old-fashioned terms and old-fashioned illus-
trations, and given an account of the bandages and splints that
he is in the habit of using in his own practice. The tendency
of the present day in medical and surgical practice is towards
simplicity. Hence it happens that many appliances which
suited the views of our forefathers have been allowed by us to
fall into disuse. We are inclined to think them unnecessarily
heating and irksome to the patient, and so we have laid them
aside. Sometimes we find that a single turn of a roller, or a
strip of adhesive plaster will take the place of a complicated
bandage. Sometimes a simple light wooden splint may be
made to serve the purpose of a heavy and cumbrous one. Our
object in each case is to carry out the indications for treatment
as simply as possible, and with the least amount of restraint or

406

Reviews. [Oct.,

inconvenience to the patient. But this is not what Mr. "Wales
aims at teaching. He has collected together a numher of
bandages and splints, and these he has explained at length,
notwithstanding that some of them are never used at the present
day. And not only has our author drawn out his book to great
length by introducing obsolete appliances, but he has adopted
the obsolete names for them as well. Whoever speaks now of
a " Bis-oculo-occipital triangle," or a " Compound dorso-bis-
axillary cravat " ? When Mr. Wales addresses himself to his
patients or his assistants does he use such terms as these?
Surely not ; and yet his book is full of them, as any one may see
by a glance at the table of contents. In works upon bandaging
which were published tliirty years ago — such, for example, as
*' Cutler's Practical Guide," — this pedantic phraseology is em-
ployed. It may have been in common use among surgeons at
that time, but it is a dead language now. No one uses it. No
one understands it. Moreover, it is a barbarous and obscure lan-
guage, which has no merit of its own to make one regret the
loss of it. What, then, is the advantage of employing it? What
good purpose can be served by perpetuating it ? W^e can see
none. It only makes a simple subject complicated, and repels
men from the study of what is a very necessary branch of sur-
gical practice. Some few old-fashioned terms are still current
among us. Thus, some still speak of a capeline bandage and a
spica ; but even these terms are rapidly falling into disuse.
We have observed with pleasure that the books which have
recently been published upon this subject in this country are
almost entirely free from such pedantry.

Not only has Mr. Wales adopted an antiquated phraseology,
but he has also introduced a number of old-fashioned illustra-
tions. These he appears to have culled from a variety of
sources, and almost all of them we recognise as old friends.
Very few appear to be new ; and some he has adopted so care-
lessly that he has not even taken the trouble to explain the
letters of reference upon them ! Indeed the whole work has a
strong air of book-making about it. It seems as if our author
has been seized with the cacoethes scribendi, and had determined
to write upon minor surgery and bandaging. With this view
he has brought together, from different sources, as much mate-
rial and as many woodcuts as possible, and these he has digested
into the present volume. But we are afraid he has overshot
the mark, and frustrated his own purpose. A book upon minor
surgery ought to be concise and clieap, suited to the wants of
students and junior practitioners; and the best advice we can
give Mr. Wales is to simplify and shorten his work if he wishes
to adapt it to the wants of the present day.

1868.]

Recent American Works on Surgery. 407

Mr. Prince's modest volume is a reprint of a " Report made
to the Illinois State Medical Society, in 1867," and the author
has done good service by publishing it in a separate form.
Plastic surgery is a subject which has attracted a great deal of
attention of late years, especially since the inti-oduction of anaes-
thetics ; and the variety of reparative operations is very nume-
rous— indeed, one is hardly aware how numerous such proceed-
ings are until one sees them all collected and brought together
as they are in the volume before us. There is scarcely any part
of the body which may not be the seat of a plastic operation —
for example, to release the cicatrix following a burn — and the
nature of the operation which has to be practised must vary of
course with the position and extent of the injury. But there
are some situations in which operations of this kind are much
more important and much more interesting than others. Thus,
plastic operations about the face for the restoration of the nose,
the eyelids or the lips have occupied the attention of some of
the greatest surgeons. Again, those painful and distressing
cases of extroversion of the bladder, which are occasionally met
with, have taxed the ingenuity of surgeons to the utmost : but
now, if we may judge by reported cases, it seems as if we had
it in our power to relieve them materially, and to make the
condition of the unhappy sufferers much more tolerable. A full
account of the operations which have been undertaken for the
relief of these different malformations and injuries will be found
in Mr. Prince's work, and any surgeon who has cases under his
care which may require plastic operations, and who is debating
what course he ought to pursue, and what method he ought to
adopt, cannot do better than refer to this monograph. He will
find under each head a variety of operations described and
figured, and he will be able to make his choice among them.

Mr. Prince begins by giving a brief account of the various
modes of arresting hsemorrhage and dressing wounds, and the
influence of each upon cicatrization. This is a matter which
has lately occupied a great deal of attention among surgeons,
and has a direct bearing upon plastic operations, in which im-
mediate union is of the utmost importance. This forms a very
appropriate introduction to the subject of the report, and some
of the most interesting passages it contains are those in which
the author speaks of the experiments he has made with anti-
septic lotions and the success that has attended the use of
them.

Mr. Prince then takes the different plastic operations in
detail and discusses them at some length, giving us the results
of his own experience as well as the opinions of others. His
special object has been to reduce the various kinds of plastic

408 Reviews. [Oct.,

operations to a system, and to classify them, so that henceforth
they may be described with greater accuracy than has hitherto
been possible ; and we will only add that if his classification
should be found to meet the wants of surgeons, so as to come
into general use, he will have done good service by giving pre-
cision and clearness to an important department of our art.

1868.] 409

PART SECOND.

Art. I. — A Manual of the Pathology and Treatment of Ulcers
and Cutaneous Diseases of the Lower Limbs. By John
Kent Spender, Surgeon to the Mineral Water Hospital,
and to the Eastern Dispensary, Bath. London, 1868. Pp.
89.

This short and simple treatise on a subject eminently suited
to the position and opportunities of its author will well repay
the time necessary to peruse it, and to master its details. The
doctrines which Mr. Spender desires to teach are not very
recondite, perhaps it may be said not very novel ; but every
day's experience will teach any one Avho chooses to open his
eyes that they are very free from being generally acted upon.
They are shortly summed up in the following extract from Mr.
Spender's preface, which we give with the more pleasure as
illustrating the literary honesty and the engaging candour and
modesty with which the work is written.

" Filial piety and literary justice dictate that my earliest acknow-
ledgments should be made to a work written and published by my
father in 1835, entitled ' The Pathology and Treatment of Ulcers of
the Leg.' This work is, in part, the basis of the book which I now
offer to the profession ; and the portions which I have specially made
use of and endorsed are two in number.

" Firstly, the argument that ulceration of the leg does not come
from a natural imperfection in the limb, but from a fault or weak-
ness to which its vascular structures are liable. This argument was
originally developed with singular logical force and perspicuity. I
have not attempted to add to the completeness of the exposition,
but I have rewritten the language in which it is conveyed. Secondly,
the proposal to treat the ulceration by imitating the natural process
of healiag by scabbing, which can be done by using a particular form
of ointment ; and I have attempted to explain and illustrate this
proposal by reference to the surgical pathology of our own day."

The connection of the great majority of ulcers with a varicose
condition of the veins, the means of best relieving this condition

410 Bibliographical Record. [Oct.,

by judicious support given by bandages applied secundum artem,
the imitation of the natural process of union under a scab by a
peculiar form of ointment, in which Mr. Spender has found
reason to place peculiar reliance — such are the main topics
which the reader will find dwelt on in this volume. The
pathology of ulcers is plainly and well stated, not so fully as in
some formal treatises, but perhaps sufficiently for ordinary
practice, special prominence being given to the great prevalence
of the varicose variety. In treating of this condition, Mr.
Spender calls attention to a circumstance which has often
attracted our attention, and which has been noticed by Mr.
Hilton, but to which less weight is usually given than it
deserves — we mean the pigmentary degeneration which so
often occurs in the skin of elderly persons, a little above the
inner ankle. On this subject the following extract may be
worth our readers' notice (p. 15).

" But there is a nerve-element in the case which must not be dis-
paraged or ignored. The pigmentary discoloration spoken of by
Mr. Hilton represents a neurose derangement, leading, not to an
exaltation of nutrition but to a degradation of it. It is a local
index of diminished pnysiological force. It is a sign of loss and
waste in a circumscribed area of tissue, denoting early embarrassment
and distress in the blood-changes ; the cuticular epithelium is fed
with a lower quality of haematine, and textural metamorphosis is less
free. And this deviation from a normal state arises very much from
a want of power in the vaso-motor nerves of the part affected ; more
or less they cease to preside over its nutrition, and they are engaged
in the same troubles which cause the stasis in the blood-vessels.

" The form and extent of this patch of tegumentary pigment are
worth attention. Most often it is, I think, seen as an ovoid mark
extending from the inner malleolus at its lower edge, and having its
long axis in a perpendicular direction three or four inches up the
inside of the leg. Not unfrequently the pigmentary stain extends
on the back of the leg in the line of the ' tendo Achillis,' and to a
higher extent than on the inside. Now and then it surrounds the
whole of the leg below the calf as a broad band of pale tint, and only
very little darker than the neighbouring skin. As a rule, the smaller
the patch the darker it is. It is seldom seen before middle life ; and
though usually a sign and note of varicose veins, it is sometimes
present without any superficial varix being visible.

" Moreover, this cuticular pigment has its practical interest. If at
all intense, it leads to the suspicion of varicose veins, and ought to
induce us to search for them. At the very least, it betrays a low
organisation of the skin-structure ; very often there is a shedding of
white, dry, thick scales, which may even conceal a partial ulceration
of the cutis, further masked, perhaps, by overhanging borders of
hardened connective tissue. We are obliged to predict a tardy cure
of any varicose ulcer which is comphcated with this condition."

1868.] Spender on Ulcers. 411

The plan -which Mr. Spender advises for ordinary ulcers is
very careful bandaging from the toes upwards, with a "domette"
flannel bandage, and forming an artificial crust over the ulcer,
with the following dressinsj :

" An ointment containing a very large quantity of prepared chalk
forms the best artificial crust. The earthy matter must be in a
much greater proportion than enters into any ointment in the
'Pharmacopoeia,' consisting of about three pounds of chalk to two
pounds of lard. The best way of preparing this application is not
by rubbing tlie chalk down with the lard ; but, having previously
reduced the chalk to a very fine powder, melt the lard in any con-
venient vessel over a slow fire, and then add gradually the chalk to
the liquefied lard. This should be stirred and thoroughly mixed
until nearly cold, and it is then ready for use. A much more homo-
geneous compound is thus obtained than could possibly be procured
by simple admixture or trituration ; the materials are more intimately
blended together."

Rest in bed Mr. Spender is inclined to regard as generally
superfluous, and therefore deleterious, and as far as ordinary
cases go, we are prepared to agree with him, and greatly
deprecate that absurd addition to the specialistic hospitals
which was started a few years ago in the form of a hospital for
ulcers. Still there can be no doubt of the rapidity with which
the healing process proceeds in some cases on confinement to
bed ; but we cannot here spare the space to point out the ap-
propriate cases.

If such details appear to our readers unnecessary, or too
universally known to be worth writing, we beg to assure them
that it is not so. A very moderate experience of hospital or
dispensary practice is sufficient to teach any one that an un-
known amount of sufiering, loss of activity, and consequent loss
of the means of livelihood is caused to our poorer patients, in
large towns especially (but in the country, perhaps, even more
in proportion to the smaller number effected), by the fact that
almost all such cases are either shovelled off" on the pupil or
assistant, or are treated in the most cursory manner, and usually
by telling the patient to apply water-dressing. The trifling
expenditure of time and money required for the application of a
proper bandage, and proper permanent dressings to the ulcer is
grudged, and the consequence is, that an easily curable disease
is allowed to persist for an indefinite length of time. To tell a
poor ignorant man to apply water-dressing is a mere absurdity.
The least attention to the case would show the surgeon that the
ulcer is for about five sixths of the twenty-four hours covered
and irritated by a dry, dirty piece of rag. To allow a man to
go about without a bandage is equally negligent, since, if the

413 Bibliographical Record. [Oct.,

surgeon would look at the leg he would see that after an hour or
two all the parts around the ulcer are thickened and turgid with
congestion. To remedy this state of gross neglect it is not
necessary to found more private hospitals, but merely to treat
these somewhat troublesome cases with a little more care and
more humanity — to give, in fact, to the ailments of the poor a
similar attention as to those of the rich. Mr. Spender's method
seems to us an excellent one ; but the great essentials — cleanli-
ness, equability of temperature and moisture, and constant
equable support — may, no doubt, be attained by means of different
methods. . The great merit of his book is that it recalls the
attention of the profession to a subject, humble, perhaps, but
very important, and one which is too much neglected in favour
of more brilliant and alluring themes. We wish the volume
every success.

Art. II. — Lectures on Injlammation : heitig the first Course
delivered before the College of Physicians of Philadelphia
under the bequest of Dr. Mutter. By John H. Packard,
M.D., Secretary to the College of Physicians, &c. Phila-
delphia. Pp. 276.

We are happy to learn from the author's preface, that our
transatlantic brethren are following the example which has long
been given in this country in the founding of lectureships,
designed by the individuals to whom we are indebted for them,
to elicit information, and more especially to incite inquiry on
special subjects, — lectureships, which amongst us have been
found so eminently useful ; for instance, those of the Royal
Society, of the Royal College of Physicians and the Royal
College of Surgeons, — and that they will prove equally prolific
of good in the United States who can have any doubt, seeing
the wonderful progress its people have made in all things
requiring the exercise of mind ?

The College of Physicians of Philadelphia has, we think,
been peculiarly happy in the choice it has made of the gentle-
man to inaugurate the undertaking, and Dr. Packard not less
so in the subject which he has selected to begin with. These
lectures, comprising a history of inflammation, are, in our
opinion, highly creditable to their author, and to the American
medical school, which has already done so much for medical
science : we can strongly recommend them, as affording a good
example of inquiry in accordance with the best modes of
scientific research. One of their peculiarities — we should say,

1868.^ Packard's Lectures on Inflammation. 413

excellences — is, that their author never confounds facts with
conjectures, and is always ready to acknowledge what is obscure
as obscure, and what is inexplicable as inexplicable.

The doctrines advocated by him are those of the advanced
English and German schools: and no authors are more fre-
quently q\ioted by him with approval than Mr. Paget and Pro-
fessor Virchow. We need hardly observe that they are founded
on the cellular theory.

These lectures are sixteen in number ; that they should be so
many will surprise no one who considers the importance of the
subject, and how much inflammation is connected with the
majority of the diseases to which the organism is liable.
Following an orderly method. Dr. Packard has succeeded in
giving a comprehensive account of all that relates to his great
subject. He holds inflammation to be a disease (never a
healthy process) and "always and everywhere the same thing,"
a morbid change in the nutrition of the affected part, taking its
origin from irritation, beginning with excess, and ending with
diminution of supply, and that all its phenomena are either
those which go to make up the process of nutrition, or are the
results of such modifications. Further, he offers the conjecture
— off^ering it for consideration — that its seat is in every instance
the connective tissue, which, is distributed everywhere through
the body, forming as it were the seat of the soft skeleton, supple-
mentary to the bony one. This conjecture is supported by
him by many facts, and some ingenious reasoning.

We had some intention to give an analysis of the work, but
reflecting how often the subject matter has been noticed in our
periodical, especially in those numbers in which the lectures of
Professors Paget and Virchow were reviewed, it has seemed to us
rather unnecessary. AVe shall limit ourselves to a few par-
ticular passages ; and these, not so much for the information
they afford, as for the logical and strict method which they
display.

True to the cell-theory, the author holds that the cell is
equally the agent of healthy life and function, and " the true
theatre of whatever morbid change may take place."

In considering the influences to which the physical organiza-
tion of man is subject, mechanical, chemical, vital, he observes
that, so far as mind affects the body, it is through the incom-
prehensible connection between it and the nervous system;
adding, as to expression somewhat obscurely : " Our observations
begin outside of this, which we cannot attempt to explain :"
and that the brain " the physical exponent of the mind," as
regards the agencies affecting it, is analogous to other organs,
all that we know about it being, that if unduly stimulated, if it

84— xLii. 27

414 Bibliographical Record. [Oct.,

have an undue amount of work, inflammation of it may ensue,
just as it might ensue in the liver or kidney, and as in skin the
result will be a certain morbid change in nutrition.

Adverting to the unmistakable evidence of inflammation,
such as is afibrded by the effusion of lymph, ulceration, sup-
puration, he remarks that, singularly enough, the phenomena
by which it is first made known, viz., redness, heat, swelling,
pain, alteration in function, are only non-essentials by them-
selves, pain being often met with where no structural lesion
is discoverable, whilst any of the other phenomena may be due
to causes purely physiological. When discussing the question
of the heat of an inflamed part and its cause, he maintains, and
we think with good reason, that it never exceeds in degree that
of the central organs, heat being communicated from the blood;
in other words, that no heat is generated in the process of
inflammation, or if any, of inappreciable amount, the great
source of animal heat being oxidation, and that chiefly displayed
by the production of carbonic acid. In confirmation, he states
that in sloughing there is an apparent exceptional rise of tem-
perature, insisting, however, that it is merely apparent, inasmuch
as sloughing is essentially an oxidating process, adding the
practical truth, that if a wound be cleaned and a dressing used
not yielding oxygen and excluding air, the gangrene will be
arrested. This, we may mention, well accords with the fact of
the strong attraction of lymph for oxygen, and of the rise of
temperature out of the body resulting from their union amount-
ing, as we have witnessed, to many degrees, when the mass
of fibrin exposed was considerable.

He offers some just remarks on the utter passiveness of the
tissue elements, these being subject to as inevitable laws as
those governing chemical changes, or the phenomena of gravi-
tation ; and he takes occasion to point out how delusively ex-
pressions are applied to their passive changes, denoting, as it
were, feeling and intelligence.

Whilst commending highly the excellent work of Mr. Hilton
on the influence of rest in the treatment of surgical diseases,
he introduces a passage from it for comment, in which the
term " assisting nature " is freely used, and as he thinks
misused. We quote the passage with the comments, inas-
much as the higher the standing of the individual, the greater
is the danger in the way of force of example. Mr. Hilton's
words are — "In fact, nearly all our best-considered operations
are done for the purpose of making it possible to keep the
structure at rest, or freeing nature from the disturbing cause
which was exhausting her power, or making her repeated
attempts at repair unavailing. The operation does not cure ; it

1868.] Packard's Lectures on Inflammation. 415

only makes recovery possible, where, without the aid of the hand
or head of the surgeon, nature would have ceased her compe-
tition with the results of the injury, or succumbed to the
exhausting influence of unmitigated disease. In aneurysm, I
think I am not in error when I say, that aneurysm is cured by
rest, and not by the surgeon — the surgeon takes care to stop
the blood, or to moderate its flow ; nature herself actually cures
the disease by rest."
Dr. Packard says —

" I feel constrained, correct as I believe the bearing of these
statements to be, to enter a protest against this idea of a gigantic
female doctor, to facilitate whose treatment is the sole function of
human skill and experience. Nature has no power, and does not
even exist in the sense implied in such expressions. Their incor-
rectness would be of less consequence, if it were not that they are
apt to lose the figurative meaning to which they are alone entitled,
and being literally interpreted, to colour professional thoughts."
. . . . " The true function of the physician or surgeon is then to
assist in carrying out, in the body, of the laws governing matter in
general, and organised matter in particular."

This comment is followed by another in the same strain on
the vis medicatrix naturce. It shall be our last quotation :

" Much has been said in medical writings about the vis medicatrix
naturcB, and about the natural tendency of parts to return to health.
This idea of nature has been very much misapprehended and misused.
It really means no more than the system of laws under which the
atoms of which all material things are composed act and react upon
one another. And as I have before urged, these laws are the same,
or at least in perfect harmony for organised and inorganic matter.
Only, in the organised beings, we have a new condition superadded,
and if I may so speak, a new code also. It is much the same as
when a body of men organise themselves for any purpose. They
adopt certain rules and regulations, differing perhaps from the laws
of the community in which they live, because their aim is a special
one, but not clashing with these laws."

After what we have already said of these lectures, we will
merely add, that throughout they bear marks of careful inquiry
and original thought. Works thus written, in so philosophical
a spirit, are rare : when they do appear, they cannot, we think,
be too highly prized, as tending to form a scientific taste and
check the tendency to a loose, illogical, and popular style of
thinking and writing, of which we have too many instances
in our own medical literature.

416 Bibliographical Record. [Oct.,

Art. III. — Prahtiske Bemcerkninger am Behandlingen af
Klumpfod. Meddelte i Philiatrien af Prof. A. G. Drach-
MAMN. (Sserskilt Aftryk af Ugeskrift for Lseger, 3 E,., v,
Nr. 28 og 29, 1868). Kjobenhavn. 1868.

Practical Remarks on the Treatment of Club Foot. Commu-
nicated in the Philiatria, by Prof. A. G. Drachm ann (Re-
printed from the Ugeskrift for Lseger, 3rd series, vol. v,
Nos. 28 and 29, 1868). Copenhagen, 1868, 8vo, pp. 27.
Illustrated.

In the above pamphlet the author gives a concise and clear
description of the deformity of which he treats, laying especial
stress upon the points of distinction between the congenital
affection and that which arises at a later period ; a distinction
of considerable importance " as the congenital variety is scarcely
ever accompanied with paralysis or atrophy of the muscles con-
cerned from birth, while that which has arisen at a later period
is almost invariably referable to the results of the so-called
infantile paralyses, which attack the child in the first years of
life."

The properly active mechanical forces which in this deformity
are in play, and produce the increased extension, adduction,
and rotation of the foot, are the muscles of the calf, and the
tibiales posticus et anticus. The more passive forces are the
difierent ligaments connecting the several bones of the foot,
and in some cases, especially those of long standing, the aponeu-
rosis plantaris. The author's

"Experience led him gradually to deviate from the English mode
of operation, and to confine himself to division of the tendo Achillis
alone, except in cases where the other tendons mentioned, after
tenotomy of the tendo Achillis and in the course of the mechanical
treatment, evidently prevented the reduction of the deformity, under
which circumstance it became necessary to divide them at a later
period. This is the method which I have adopted during the last
decennium, and which has afforded me as good results as that I
formerly employed." — P. 11.

The author remarks upon the frequency of the occurrence of
the deformity in England, 1780 cases having been under treat-
ment in the course of ten years in the Orthopajdic Hospital in
London. He enters into the details of the operative and me-
chanical treatment adopted by himself, to which he attributes
the following, among other special advantages :

*' 1 . That it is the simplest, and requires only a very plain and
easily procurable apparatus.

1868.] Trideau on Diphtheria. 417

" 2. That tenotomy is confined to the tendons which are evidently
in fault, and do not yield to the mechanical treatment ; and
" 3. That it is completely painless."

Art. IV. — Nouveau Traitement de VAngine Couenneuse du
Croup et des autres localisations de la Diphtheric par la
Baume de Cophapu et le poivre Cuhebe. Par M. H. Tri-
deau. D'Andonille (Mayenne).

A new Mode of Treatment of Plastic Croupy Angina and of
other Modifications of Diphtheria hy Balsam of Copaiba and
Cuhebs. By M. H. Trideau. Paris and London. Pp.

The new method described in this pamphlet of treating
diphtheria, a disease of late years so formidable and fatal,
appears to be of a very promising kind ; should its success be
confirmed by extended and varied experience, great will be the
boon conferred, and great will be our indebtedness to the
author who has introduced it.

We learn from M. Trideau that he was first led to give atten-
tion to the disease in question at a time that it raged with
unusual severity, indeed to such an alarming degree as to incite
the inhabitants of the districts, with the hope of arresting ity
to undertake pilgrimages to a particular chapel, an event never
before witnessed in the memory of man.

M. Trideau reflecting on the nature of the malady, as afiect-
ing the constitution generally, and keeping in mind the ineffi-
cacy and bad eftects of local treatment, was induced, reasoning
from analogy — that which he traced between diphtheria and
general catarrhal affections, especially of the adynamic and
gangrenous varieties — to make trial of balsams, medicines of
acknowledged efficacy in catarrhal ailments, they alone, as he
holds, having the property of drying up the sources of mucous
secretions.

He first made trial of styrax with copaiba, but finding the
former so often adulterated, he substituted for it cubebs — a
medicine more readily taken, rapidly absorbed and diffused
and followed by no bad effects, but, on the contrary, by an
improved appetite and digestion.

Of the results obtained, he speaks with the most perfect con-
fidence, stating that after the experience of many years, and
the treatment of more than 300 cases, he has been almost in-
variably successful ; at least, when he had to contend with the
malady in its first or second stage ; and further, that the con-
valescence has been of short duration. He qualifies, however.

418 Bibliographical Record. [Oct.,

his statements, by insisting on the necessity of distinguishing
between simple croup (le croup d'emblee), and croup the con-
sequence of pseudo-membranous angina, — the latter so often
baffling any remedial means.

His special mode of treatment, as described by him (we
almost literally translate it) is the following :

For adults half a table-spoonful of the syrup of copaiba every
second hour, followed by a gramme (about fifteen grains) of
freshly powdered cubebs in a table-spoonful of syrup, also every
two hours, but in the intervals of the administration of the
copaiba.

For infants the dose should be one half of the preceding ;
or six grammes of cubebs in the twenty-four hours in a tea-
spoonful of copaiba every two hours.

In some cases the cubebs may be given to the amount of
twenty-four grammes a day to adults and of twelve to infants.

After twenty-four hours, it usually happens that the copaiba
is no longer tolerated. Then it should be suspended. It should
be discontinued also if the strength of the patients be much
reduced, or should there arise a repugnance towards it. One,
two, or three drops of laudanum are recommended to be added
to the syrup, as likely to make it tolerated.

Commonly the malady yields to the treatment in three or
four days. Nevertheless, it is sometimes prolonged to the
seventh. Then, under the continued use of the balsam, the
following symptoms not unfrequently occur : — a sensation of
diffused itching, an increase of the angina, and of febrile ex-
citements, with an eruption simulating that of scarlatina, some-
times discrete, sometimes confluent and resembling urticaria.
This eruption never co-exists with false membranes. These
infallibly cease when it shows itself, if they have not disap-
peared before the treatment has been so much prolonged. The
ecthyma is most frequent when the cubebs and copaiba are
administered together.

As parts of the general treatment alimentation should never
be neglected, and tlie use of coffee is recommended as favouring
the recovery of strength. Moderate exercise should be taken ;
indeed, it is considered essential by the author, and that the
patients should not be confined to bed except when the eruption
has appeared, or there has been an entire prostration of strength.
M. Trideau forewarns the not unfrequent occurrence of profound
and prolonged sleep as the effect of the medication, it having
been often observed by him in instances in which no laudanum
has been administered ; it should, he says, create no alarm.

Relative to the rationale of the treatment, he is judiciously
brief, not forgetting that in therapeutics our best guide, the

]868.]

Tynoall's Lectures on Sound. 419

only reliable one, is careful experience. The hypothesis which
he advocates in accounting for the effects of the balsams
is that of substitution. He thus reasons : The scarlatini-
form eruption described which often occurs on the seventh or
eighth day of the treatment is the infallible correlation of
the disappearance of the false membranes. This phenomena, so
remarkable, readily intelligible by those who comprehend the
physiological and pathological affinities which unite the mucous
and cutaneous tissue, demonstrates the modus operandi of the
balsamic treatment. In brief, it is evident that the whole of
the recovery is under the influence of the medicines, as it was
before under that of the malady : on the other hand, that the
cure is accomplished by the way of a general substitution ;
adding, emphatically : Now this substitution can result only
from the antagonism between a morbid exanthema and the
medicinal exanthema. Consequently, it is specially requisite
to produce the latter. The treatment is illustrated by twenty-
six cases. In conclusion, the author refers to Dr. Garreau,
Chief Sui-geon of the Hospital of Lowal, in confirmation of
the efficacy of the treatment in question.

In a subjoined note he calls attention to a remarkable pecu-
liarity, that though the exanthema ordinarily only occur after a
prolonged treatment, yet it occasionally appears sooner, after
three or four days ; nevertheless, whether the treatment be re-
stricted to the shorter period, or the doses be equally prolonged,
it is on the seventh or eighth day that the eruption is always
produced.

Art. V. — Sound : A Course of Eight Lectures delivered at the
Royal Lnstitution of Great Britain. By John Tyndall,
LL.D., F.R.S.

These eight lectures on Sound, intended to interest not only
those who possess special scientific culture, but all intelligent
persons, have already attained popularity, and are likely to be
widely read and respected by medical men of a physiological
turn. The author informs us that he has made much use of
Helmholtz^s work, ' Die Lehre von den Tonempfindungen,' that
he has been assisted, in going through the press and otherwise,
by English and German friends, and that "one celebrated German
friend" had read through all the proof sheets. Thus when it is
also borne in mind that the subject is a pet one of so able a man
as Dr. Tyndall, it will be perceived that this book must carry
with it an unusual weight of authority. Besides, it abounds

420 Bibliographical Record. [Oct.,

with excellent woodcuts, and its style is charming. It will,
none doubt less than ourselves, be justly treasured not only as a
pleasant, but a safe guide in acoustics.

On the other hand, we regard any statement made in a book
so diligently supervised and polished, should it be inaccurate,
as particularly detrimental to the spread of correct knowledge,
and we therefore think it imperative on us as physiologists to
venture to demur to a few statements that fairly fall within our
province. At page 75 we read : —

"Dr. "Wollaston was expert in closing the Eustachian tube, and
leaving the space behind the tympanic membrane occupied by either
compressed or rarefied air. He was thus able to cause his deafness
to continue for any required time without any effort on his part,
always, however, abolishing it by the act of swallowing. A sudden
concussion may produce deafness by forcing air either into or out of
the drum of the ear. In the summer of 1858 I was on the Fee Alp,
in Switzerland, where, jumping from a cliff on to what I supposed to
be a deep snowdrift, 1 came into rude collision with a rock, which
the snow barely covered. The sound of the wind, the rush of the
glacier torrents, and all the other noises which a sunny day awakes
upon the mountains, instantly ceased. I could hardly hear the
sound of my guide's voice. This deafness continued for half-an-hour,
at the end of which time a suitable act opened the Eustachian tube,
and restored, with the quickness of magic, the innumerable murmurs
which filled the air around me."

We would ask for a reconsideration of this account. The
author has just described the Eustachian tube as keeping itself
closed, and only opened by means of muscles in the act of swal-
lowing ; but Wollaston never suspected but that it is naturally
patent, and that it can only be closed artificially by the swelling
of its wall on the diminution of the air-pressure usually there pre-
sent; to him, unless Dr. Tyndall, which we cannot think, had
some other source of information than Wollaston's paper in the
* Philosophical Transactions,' the experiment of retaining com-
pressed air in the drum was unknown. It was only this ignorance
of the fact that the tube, when passive, is shut, that led Wollaston
to imagine that his powers of exhausting the air in the drums
(causing the tubes to more completely collapse) by a forced in-
spiration with shut nose and mouth excelled those of other
people. There is no reason to suppose that he could perform
any particular feat in this way. Indeed, Dr. Tyndall's own
tubes seem to be at least as well able ,to keep closed with un-
equal aerial pressure in the fauces and tympana, for they are
related to have so remained for half an hour. But we own to
be at a loss to understand his adventure. He expresses no
opinion whether the concussion had increased or diminished the

1868.]

Tyndall's Lectures on Sound. 421

quantity of air in his drums. It must have been easy to have
observed which event had happened, and yet it seems that it
was only inferred from the effects that one or other had occurred.
As the concussion operated perpendicularly to the paths of the
two tubes, it would not directly tend to knock air either into or
out of the drums; and certainly we cannot suppose that one
drum was partially emptied and the other over-filled, — what
happened to one happened to both. There would be, perhaps,
on the sudden arrest of motion through the feet a tendency to
send the air in the lungs towards the bottom, and withdraw
some from the throat, and thus from the drums. But then the
nostrils, if not the mouth, would supply a current of air, and
swallowing would not take place at the instant of collision to
open the Eustachian tubes — tubes too minute, when fully open,
to permit an instantaneous escape of much air. In short, it is
inconceivable that the quantity of air in the drums could be
affected by an accident having far less tendency to lessen the
air in the fauces than an ordinary act of inspiration ; and an act
of swallowing would have been sure to have quickly restored
the aerial equilibrium, could such a thing have been. There is
a mistake, we are convinced, somewhere, a lapse of memory, the
shock on the nerves in scenes too exciting for careful observa-
tion, or transient confusion in the sensorium. The remarks are
given by Dr. Tyndall in support of WoUaston's view, that a tense
membrana tympani is unfitted for hearing low sounds, though
it is fitted for hearing high ones as well or better than a slack
membrane. However, our author seems to have been deaf to
all the mountain sounds, various as they were, some of which
may be presumed to be of high tone, and thus gives only a dubious
support to WoUaston. We cavil at these statements because the
correctness of WoUaston's observations as to the effect of a tense
membrane upon the hearing of acute sounds has been disputed,
and with sufficient force to render it desirable to have his ex-
periments repeated by dispassionate observers.

Besides, WoUaston's observation of the different ranges of
tones that are audible to different individuals, and which, he
thought, indicated the different degrees of tension of their tym-
panic membranes, is now being used to support a theory that
(p. 324) there is a lute of 3000 strings in the human ear that is
adapted to the hearing of at least so many tones. In individuals
the scope of this organ is supposed to differ, and to more pro-
perly account for W^ollaston's observation. There is no impossi-
bility, or even improbability, in this idea ; but we always advise
caution in deciding by the aid of such comparisons. The ear is a
complex organ, and many of its parts may, if altered, produce
similar results as to audition, and those who make such com-

422 Bibliographical Record. FOct.^

parisons as to individual endowments ought to be very watchful
against sources of error. \Ye remember well the sensational
announcement, made, some years ago, by a then Scotch professor,
of the great proportion of mankind who were hopelessly affected
with colour-blindness, and of the urgent necessity there was for
ceasing to use coloured lights for railway signals ; insomuch that
the public was terrified : and yet we have known other persons
deeply interested in eye-disease through long years of inquiry
unable to meet with a single case of marked colour-blindness.

Art. VI. — Observations on the Nature and Treatment of Polypus
of the Ear. By Edward H. Clarke, M.D., Sec.

This pamphlet of Dr. Clarke's is a study of aural polypi
chiefly as they presented themselves in a few cases treated by
the author. The cases are fully related with an eye to pathology
and treatment, and the morbid structures are illustrated by
microscopic drawings which are well engraved. It is deduced
that polypi may be divided into two varieties, the fibro-plastic
and epithelial. The former rarely spring from the tympanum,
and rather from the outer than inner half of the meatus, but
may be attached to the membrana tympani itself. They grow
from the fibrovis tissues of the ear, are globular or pyriform, and
covered by a kind of pavement epithelium. The latter group
grow from the epithelial tissues of the ear, consist of epithelial
elements, and are highly vascular. These may be found in any
part of the meatus, or may spring from the mucous membrane of
the drum. In all of both groups of cases, he infers that otorrhoea
preceded the polypus ; and he thinks the growths are due to
something of the nature of inflammation. In the majority
the membrana tympani was perforated to a greater or less
degree, or at all events diseased. Both kinds may be success-
fully extracted, and by persevering after-treatment with caustics
and astringents, their return may be obviated. In one instance
an epithelial polypus which filled the meatus, obstinately reap-
peared even after a second removal. At length a swelling
showed itself in the mastoid process, on which being opened,
a copious discharge of pus resulted, and w^ater injected into
the meatus flowed out through the mastoid process. A polypus
was seen in the cavity of the drum, which was injected with
perchloride of iron, when the growth shrivelled up, and dropped
out of the ear two days after, never to reappear. — A very in-
structive case. The essay is practical and philosophical.

1868.] SouTHAM on Spontaneous Fracture of Calculi. 423

Art. VII. — Three cases of Spontaneous Fracture of Urinary
Calculi in the Bladder. By George Southam, Surgeon to
the Manchester Royal Infirmary. Pp. 4.

In this pamphlet, Mr. Southam calls attention to a singular
circumstance, which is sometimes, though rarely, noticed in
vesical calculus, viz., that the stone Avill spontaneously separate
into fragments. After relating three cases of this occurrence,
two under his own care and one in Mr. Luke's practice, he
contrasts vs^ith them the history of a case in which there were
numerous calculi, which seemed to have been ground against
each other during violent exertion, and so to have become par-
tially disintegrated. He then goes on to say :

" In each of the cases I have brought forward, there being clear
evidence that there was but one calculus, we must look for other
causes of the fractures. Not only were they single, but, at the time
of the fracture, two of them were composed almost entirely of lithic
acid and oxalate of lime — materials not likely to be affected by any
degree of force which might be applied to them in the movements of
the body or from the action of the muscles of the bladder. As the
calculus in Mr. Luke's case was composed chiefly of triple phosphate,
the lithotrite may possibly have contributed to its fracture, although
there is no evidence to that effect ; but in the other two, though
each patient had been sounded before he came under my care, the
stone had not been detected. Nor could any injury have led to
their fracture from my examination, for their structure was too com-
pact to be affected by the sound ; and, moreover, their surfaces
plainly show they must have been broken some weeks at least
before I discovered them. The cause of their fracture must, there-
fore, be sought in the calculi themselves. It may probably have
taken place through the generation of some gaseous agent, from
chemical changes in their earthy constituents ; or through the
decomposition of the animal mucus of which their cementing
material is formed, and which exists in various quantities in different
calculi. This view seems to be confirmed by the appearance some-
times, though rarely observed in calculi where the fracture is limited
to the internal layers, of which there are two excellent specimens in
the Dupuytren Museum at Paris, the separated portion of one
appearing to have become again cemented together, and encrusted
with a subsequent deposit."

The circumstance is curious and interesting, though some-
what remote from ordinary practice, and Mr. Southam's short
paper is therefore well worth perusal.

424 Bibliographical Record. [Oct.,

Akt. VIIT. — NederlandscJi Archief voor Genees- en Natuur-
kunde, onder Medewerking van P. Q. Brondgeest, M.
Imans, a. p. van Mansvelt en H. Snellen, uitgegeven
door F. C. DoNDERS en W. Koster. Deel III. 3^ Aflevering.
Utrecht. W. F. Dannenfelser, 1868.

Dutch Archives of Medical and Natural Science. Edited by
F. C. Bonders and W. Koster, with the assistance of
P. Q. Brondgeest, M. Imans, A. P. van Mansvelt and
H. Snellen. Vol. III. Part 3.

The present number of the above excellent journal, from the
former issues of which we have often drawn largely in the pages
of this ' Review,' contains many important articles, the first of
which, on the terminations of the gustatory nerves in the tongue
of the frog, by Dr. Engelmann, has been noticed in our July
number.

W. Koster contributes a paper on the * Exudation of the
Colourless Blood-cells through the Walls of Vessels, and the
Morbid Processes resulting therefrom.'

The discovery of this phenomenon, so important in its relation
to the study of morbid changes of nutrition, is due to Cohnheim
of Berlin,^ who has already pointed out its significance with
reference to suppuration in general. Hr. Koster adds some
observations and investigations, illustrating its influence on the
estimation of some other morbid processes, and of suppuration in
the liver.

The fact observed by Cohnheim is briefly this :

" By a simple and easily repeated experiment with the mesentery
of a frog, we can satisfy ourselves that in the commencement of an
inflammatory process, while the red blood-cells are still carried along
with great rapidity through the axis of the vessel, the colourless
blood-cells remain firmly adherent to the inner surface of the
smallest veins and capillary vessels. We speedily see, particularly
in the minute veins, the colourless blood- cells penetrate into and
soon through the wall, and gradually pass further into the intervening
tissue. At the same time they now and then, like anioebse, alter
their form, acquire one or more pointed outrunners, in a word dis-
tinctly manifest their contractility."

The fact then stands thus : that without rupture of the
vascular walls, on irritation of a part of the body, the colourless
blood-cells push their way outwards in great quantity through

' See his essay " On Inflammation and Suppuration," (Ueber Entzundung
und Eiterung) in ' Virchow's Archiv,' Bd. xl, p. 1.

1868.] Dutch Archives of Medical Science, ^c. 425

the vessels. The important conclusion naturally thence directly
deduced by Cohnheim was :

" The pus occurring after inflammation is, so far as relates to the
cells contained in it, if not entirely, certainly for the greater part,
the product of the colourless blood-cells.

" This proposition at once throws an unexpected light upon some
pathological facts: the analogy between pus-cells and colourless
blood-cells, the impossibility of distinguishing the two in the blood,
respecting which so much has been written, the morphological agree-
ment between a recent exudation (in pneumonia or pleuritis, for
example) and the product of purulent softening of the same, on
microscopical examination, &c.

" Cohnheim's discovery, moreover, gives an unexpected blow to
the generally received theory of inflammation, according to which
the newly-formed cells in inflammation, and subsequently the pus-
cells, are the product of a proliferation of the connective-tissue cor-
puscles, or in general, of the constituents of tissue."

The author illustrates the above condition in a case of highly
developed leukhsemia occurring in a man aged twenty-five. He
shows that when the blood is overloaded with colourless cells,
formed in the spleen and lymphatic glands, these cells pass out-
wards in great number through the vascular walls. He also
adduces an instance of the " emigration" of colourless cells in a
case of abdominal typhus in a girl of sixteen, in which he con-
siders. " that the so-called ' leukhsemic new formations' must be
regarded as products of the exudation of the colourless blood-
cells." In the third section of his paper he adduces as an illus-
tration a short description of the so-called "hydrops lymphaticus"
of Virchow. His statements respecting the formation of pus in
the liver of the rabbit he briefly sums up as follows :

" 1. In the first two days there is swelling of the morphal con-
stituents produced by fluid, coagulated or otherwise, with con-
siderable modification of the circulation and nutrition, but without
the occurrence as yet of fresh morphal constituents.

" 2. On the third and fourth days, in the interlobular connective
tissue around the divided vessels, we see densely compressed cells,
sometimes lying on one another like an epithelium, resembling
colourless blood-corpuscles; there is also distension of the intercellular
passages and diff'usion of the recent small cells therein.

" 3. Through further development of this process and retro-
gressive change of the hepatic cells, softening and formation of matter
arise. Around such " purulent foci" we then find especially a large
quantity of connective tissue, in which again are many small round
(pus) cells. Through the further progress of this process, and
increase and condensation of the surrounding connective tissue,
arises evidently the peculiar, sometimes tolerably thick membrane,

426 Bibliographical Record. [Oct.,

' tlie membrana pyogenetica of early writers,' often found around
hepatic abscesses and other purulent cavities in man.

" The course of things in this increase of connective tissue, which
around suppurating spots, or in a chronically inflamed part, even
without suppuration, is so well known, lies still as a difficult problem
before us, for the solution of which our knowledge of the normal
formation of connective tissue likewise must be more accurate. At
the same time the question directly arises of the signification of the
colourless blood-cells, and the part played by the already existing
connective tissue, whose protoplasmatic constituents undoubtedly
increase in extent. The increase of connective tissue, although in a
stricter sense deprived of its hypothetical importance with respect to
inflammation and suppuration, continues certainly of great import-
ance for the ' new formation' to which the inflammation may give
rise. Thus, through Cohnheim's theory of pyogenesis, a much more
defined boundary would exist between what Virchow called nutritive
and formative morbid processes than can as yet be demonstrated.

" If we should soon succeed in obtaining a more positive and
distinct explanation of the origin of the change of the circulation of
the blood, as a starting point for inflammation, a great light will
undoubtedly be shed by the facts discovered in late years upon a
process of which we may in general assert what Cruveilhier said of
phlebitis in particular — ' qu'elle domine toute la pathologie.' "

Professor Bonders contributes a long and very elaborate
paper, based upon numerous experiments, upon the " Innervation
of the Heart, in connexion with that of the Respiratory Move-
ments." It would be impossible to attempt, in the present
article, even an abstract of this essay : we must content our-
selves with quoting the author's own summary of his results,
which is as follows :

"The conclusion is this, that the object with which the above
investigation was originally undertaken — the explanation of the
connexion between the respiratory movements and the duration of
the cardiac periods — has been in no part obtained ; but that, however,
among others, two unexpected facts have been discovered, which are
not without importance for the nerve-mechanism of respiration and
of the circulation of the blood :

"1. In dyspnoea a strongly increasing stimulation of the retarding
nerves of the heart is associated with each inspiration.

"2. In the course of the nervus vagus run centripetally acting
nerve-fibres, which depress the activity of the central organ of the
retarding nerves of the heart."

Of the next paper, ' On the Seat of Irritation in the Muscular
Fibre on the Closing and Opening of a constant Galvanic Cur-
rent,' by Th. W. Engelmann, assistant in the Physiological
Laboratory at Utrecht, a translation, in eztensd, appeared in the

1868.] Dutch Archives of Medical Science, &^c, 427

' Journal of Anatomy and Physiology for May, 1868, p. 435.'
The question was, whether in the muscular fihre the irritation
takes place on closing of the current only at the negative pole,
on opening only at the positive. On this point von Bezold and
Aeby came to different conclusions. The author commu-
nicates an experiment " which in a simple manner solves the
question."

" The sartorius muscle of a frog was cleanly prepared, cut off, and
suspended by means of a clamp at the upper end. If we now place
a few millimetres beneath the clamp, one electrode on the right, and
the second on the left sharp edge of the muscle, the free end of the
muscle is drawn to the side of the cathode on closing the current,
and to the side of the anode on opening it, because in the former
case only those fibres of the muscle on the side in contact with the
cathode contract, while in the latter case only those on the side in
contact with the anode are thrown into action."

A paper by N. J. A. C. Sternberg, Med. Cand., is based upon
the observation lately made, independently of each other, by
Cohnheim and Recklinghausen with Hoffmann, that cells from
the lymphatic vessels find their way into the irritated cornea.
Professor Bonders thought it important to ascertain whether the
pus-cells in syndesmitis mucipara are likewise derived directly
from the vessels, which, a priori, seemed to him not impro-
bable. He also wished to investigate the remarkable influence
of nitrate of silver, which usually rapidly produces an ordinary
syndesmitis mucipara with increase of mucus ; and, when applied
to healthy connective tissue, is followed by temporary production
of muco-purulent matter.

The action of the nitrate of silver was investigated first on the
vessels of the mesentery of the frog, in solutions of various
strengths. All produced dilatation of the vessels, lasting only
some moments, and followed by strong contraction. After some
hours, the latter again gave place to dilatation. The changes
affected chiefly the arteries. As an immediate result of the con-
traction, the exudation of the blood-corpuscles was diminished,
if not entirely prevented.

A second point investigated was the origin of the mucus-
globules in inflammation of the conjunctiva. On touching the
membrana nictitans of the frog with nitrate of silver in sub-
stance, numerous pus-cells were found collected, a couple of
hours later, between the cornea and the membrana nictitans.
The latter, cut off and brought under the microscope, exhibited
a mass of colourless blood-corpuscles with some red ones, scat-
tered in the tissue, but especially along the vessels. Here and
there the blood -corpuscles were seen also situated between the
epithelial cells.

428 Bibliographical Record. [Oct.,

On dropping into the eye of a rabbit one part of nitrate of
silver in 480 of water, many colourless corpuscles were usually
found, after the lapse of half an hour, in the plica conjunctiva?.
On trying whether, without previous irritation, such corpuscles
occur on the conjunctiva, a positive result was obtained : in the
rabbit, and particularly in man, they are not entirely absent,
and it is therefore not improbable, that in the normal condition
also colourless blood-corpuscles penetrate to this mucous
membrane.

The journal contains two or three other important commu-
nications, which our limited space will not allow us to notice at
present.

Art. IX. — Statistique MMicale des Hopitaux de Paris. Tome I.

Pp. 196. Tome II. Pp. 408.
Medical Statistics of the Paris Hospitals, Volumes I and II.

Paris, 1867.

These two large handsome volumes, in imperial quarto,
recently issued from the ' Administration Generale de I'Assist-
ance Publique,' ,are to be the first of a series of annual returns
of the combined tabulated statistics of all the hospitals in the
French metropolis. The idea of such a work is a happy one,
and reflects the highest credit on the enlightenment, as well as
on the energetic zeal of M. Husson, the director-general of this
important department of the public service. As early as the end
of last century, the then Prefect of Paris, Count Frochot, pointed
out in a remarkable report the valuable results which might be
expected from a yearly record of the administration of the nine-
teen hospitals of the city, and clearly indicated how such a
scheme would in course of time conduce to important hygienic
discoveries directly affecting the welfare of the sick, and leading
to the prevention of much disease and death. But neither
medical men nor the public at that time appreciated the signi-
ficance and value of statistical researches -, and although, under
the direction of the " Conseil General des Hopitaux," much was
done during the following sixty years to improve the condition
and organisation of the Parisian hospitals, and to introduce a
better registration and more accurate records of the cases ad-
mitted into them for the purposes of medical instruction, no real
attempt was made to bring together the experience of the
different hospitals until the appointment, in 1860, of M. Husson
to the post which he so ably fills. When he found that nearly
100,000 sick, of both sexes and of all ages, pass every year
through the various hospitals and hospices of Paris, he felt con-

1868.]

Statistics of Parisian Hospitals. 429

vinced tliat the registers, if kept on one uniform plan, of such a
vast experience of disease, could not but aiFord most important
data for the general elucidation of curative medicine and surgery,
as well as for the special comparison of different hospitals, one
with each other, with the view of determining various sanitary-
problems relating to hospitals much mooted in the present day.i
He thereupon sought the co-operation and advice of the medical
staff of these institutions, for the purpose of organising a general
system of registration and classification of all the cases received
into them, so as to give unity to the work he had in view. In
1862, he published his 'Etude sur les Hopitaux,' wherein,
after reviewing their past history, he pointed out the improve-
ments required in their management and arrangements, and
suggested the great advantages that might be derived from an
annual record of the associated results of their united expe-
rience. In the same year, a report was issued of the examination
which Dr. Blondel and M. Ser had made of the leading hos-
pitals in London, with the view of comparing their condition
and economy with those of the French hospitals, and of obtaining
hints for carrying out the statistical records of the sick admitted
into them. The two volumes now published are for the years
1861 and 1862. It is of course impossible to give the reader an
adequate idea of the mass of tabulated statistics here presented
to his notice ; he must examine the work for himself; and this
Ave strongly recommend all hospital physicians and surgeons to
do, as it must be obvious, that if the scheme initiated by
M. Husson in respect of the hospitals of Paris be a good one, it
ought unquestionably, as he anticipates, to be extended to those
of London and other European capital cities.

As a specimen of the information to be derived from these
volumes, we have selected the data given respecting the number
and results of amputations of the thigh and leg in the two years
recorded, and also of the accouchements during the same period.

In 1861, the number of amputations of the thigh in the Paris
hospitals were 42, of Avhich 20 were for injuries, and 22 for
disease of the limb. The total deaths amounted to 35, or in the
proportion of 83'3 per cent. Six of the pathological cases reco-
vered, but one only of the traumatic cases was saved. The fatal

' It would seem from the following observation of M. Husson, that unfavor-
able rumours have been current respecting the far-famed Lariboisiere hospital.
" C'est pour avoir meconnu I'influence qu'exereent sur la mortalite d'un hopital
la composition de son personnel des malades et les habitudes de la population qui
I'alimente, qu'on a ose dire, avee una legerete qui n'a pas ete assez blamee, que
I'hopital Lariboisiere, place dans les conditions notoires de salubrite, aussi bien au
point de vue de sa position topographique que de son installation, etait un hopital
insalubre." Future returns will show how necessary it is, in estimating the
death-rates in different hospitals, to have due regard to the gravity of the cases
treated therein.

84— XIII. 28

430 Bibliographical Record. [Oct.,

issue is ascribed to purulent infection in 6 cases, to i)lilebitis in 2,
and to secondary haemorrhage in 1.

Of 14 amputations of the leg, 10 of which were for injuries,
all were fatal with the exception of one of the pathological
cases. Purulent infection and gangrene are assigned as the most
frequent cause of the fatal termination.

In 1862, there were 40 amputations of the thigh, 11 for
injury and 29 for diseases. Of the former 7 were fatal, and 14
of the latter. The death-rate for the whole number was nearly
55 per cent. ; a marked improvement upon the former year.

Out of 15 amputations of the leg, 8 of which were for injuries,
there were only 5 recoveries, viz. 2 among the traumatic, and
3 among the pathological cases.

With such disastrous results of operative surgery in Paris
before us, it is certainly high time that some comparison be made
with the results in other large cities.

The total number of " deliveries " in hospitals, in 1861, was
7309. Of these 5796 occurred in single, and 1513 in married,
women.

The deaths amounted to 695, or at the rate of between 9 and
10 per cent. Of the total deaths, 550 were due to what are
designated " puerperal affections," and 145 to " diseases which
have preceded or followed delivery, and were foreign to the
puerperal state." In the latter category are enumerated 9 from
typhoid fever, 12 from purulent infection, 16 from gangrenous ery-
sipelas, 16 from smallpox and scarlatina, 20 from pulmonic affec-
tions, 17 from phthisis, 6 from metrorrhagia, and 5 from phlebitis.

In 1862, the number of deliveries was 7027, of which 5683
were in single, and 1344 were in married women. The deaths
amounted to 490, or in the proportion of very nearly 7 in the
100. Of these, 399 were caused by "puerperal affections,"
and 91 by non-puerperal. The deaths from typhoid fever were 4,
from purulent infection 2, from arthritis and abscess 4, from
erysipelas 7, from eclampsia 12, from metrorrhagia 12, and 1
from each of the following causes, viz. " suites de couches,"
rupture of the uterus, and application of the forceps, which
surely belong to the category of " puerperal affections."

These few data suffice to suggest anything but a favorable
opinion of the existing condition and arrangements of the
lying-in wards in Parisian hospitals.

Art. X. — The First Step in Chemistry. By R. Galloway.
Fourth edition. London. 1868. Pp. xxiv, 477.

This new edition of an old and favorite introduction to the

1868.] Galloway's Chemistry. 431

theory and practice of chemistry scarcely requires any fresh
commendation of its merits. The experiments described are
interesting as well as instructive; they are selected with judg-
ment and explained with clearness, while the ways in which
they are to be performed are given with adequate detail.

We are not quite sure as to the propriety of the alteration
made in the fourth edition. One fourth of the whole book is
now occupied by a long chapter on a non-chemical subject —
electricity ; and in this, so far as we see, the most important
new discoveries and new fundamental laws of the science, such
as the correlation of forces, electrical and others, are unnoticed.
Part II is, however, a perfectly new addition to the book. It
contains a brief account, in sixty pages, of a new notation and
nomenclature. But either the whole book should have been
constructed in harmony Avith the new notation, or the old and
new views should have been contrasted and compared through-
out. Mr. Galloway " recommends those who really wish to
study the science to learn the old notation and nomenclature
first, because they must at one time or another make themselves
acquainted with it, as all the past literature of the science is
written on the old system, and for the beginner it has some
advantages over the new." But really have we any right to
teach the old errors because they are supposed to be more easily
learned than the new truths? We demur to Mr. Galloway's
reasoning and his pi-actice on several grounds. The new notation
is more valuable as an educational instrument, because it is,
without doubt, more logical, more consistent in its parts,
explains phenomena better, sticks closer to facts, and explains
them more systematically than the old. We maintain, too, that
it is wrong to say that the atomic weight of oxygen is eight
when we are sure that it is sixteen, and when we should not
dream of committing the exactly parallel error of assigning,
instead of 14, the number 4"66 to nitrogen. While, therefore,
acknowledging the not inconsiderable merit of Mr. Galloway's
digest of the new views we think they ought to have taken a
less subordinate place in his treatise, and have been credited
with a larger measure of usefulness and authority.

Our author, indeed, is not always exact enough in carrying
out the principles of the new notation. He refers to, but does
not use, molecular formulae, though we possess almost con-
vincing proofs that the atoms of most elements cannot exist
alone. Our author also employs the word atom or its deriva-
tives in two perfectly distinct senses. For in order to describe
the value of an element as compared with hydrogen — that is to
say, the number of chlorine atoms with which it can combine,
or of hydrogen atoms which it can replace — the word atomicity,

432 Bibliographical Record. [Oct.,

already otherwise used, is inappropriate, and the older word
equivalent confusing. A word such as vinculance, expressing
with the addition of various prefixes, the number of bonds in an
atom, would prove very convenient, and be at the same time
precise in meaning.

Here we take leave of this new edition of a popular and useful
book, commending our suggestions to its author's notice.

Art. XI. — A Monograph on the Structure and Development of
the Shoulder -Girdle and Sternum in the Vertebrata. By
W. Kitchen Parker, F.R.S., F.Z.S. 1868. Issued by
the Ray Society to the Subscribers for the year 1867.

We have much pleasure in calling the attention of our
readers to the exceedingly valuable work on the shoulder-girdle
which has been presented by the Ray Society to their sub-
scribers for the year 1867. It is one that will constitute an
era in the progress of philosophical anatomy. It has required
for its production infinite pains and consummate knowledge.
It is a questioning of nature of the closest kind ; and it will, we
are sure, gain for its author, whose time is still occupied in the
harassing cares of a general practice in the metropolis, a
European reputation. It is, indeed, a matter of deep regret,
and a reproach to our time and nation, that one of our finest
and purest intellects should be compelled to descend to duties
capable of being performed by any ordinary mortal, and to
waste, for very maintenance, his energies, time, and thought,
on subjects that are of necessity uncongenial to him. A mind
so choicely gifted — and we are using, as those who know him
know, no terms of hyperbole — should be treasured with the
utmost care, should be encouraged in his progress, assisted in
his difficulties, and have his labour lightened in every possible
way. Such men appear but rarely.

That Mr. Parker should have produced the works he has
done, the numerous admirable essays on the Foraminifera, the
philosophical treatises on the Tinamous, on the Ostriches, and
on the Boatbill, is only an evidence of his unconquerable enei-gy,
and of the way in which an earnest mind can strive against and
overcome difficulties.

The nature of the treatise before us is such that it is scarcely
possible to analyse or compress it ; and we can only recommend
all who take interest in such subjects to study the work for
themselves. We may remark, however, in regard to its scope,
that, beginning with the simplest examples of the vertebrate
type, he fully describes the shoulder-girdle from its first appear-

1868.] Parker on the Shoulder- Girdle and Sternum. 433

ance in the rays and sturgeon, the lepiclosiren, the pipe and
globe fishes, and the sticklebacks, to the mullet, pike, cod,
salmon, and herring. To these succeed the Amphibia, in-
cluding most of the known forms from the urodelous proteus
and menobranchus, to the anourous frogs and toads. Then
follow the reptiles, birds, and mammals. Under the head of
reptiles, nineteen species are described at length, and allusions
made to many others. The section devoted to birds and mam-
mals contains full accounts of almost all the typical varieties.
The many difficulties that surround this investigation are, per-
haps, best shown by the frequency with which Mr. Parker finds
himself compelled to dissent from views previously held, and
the numerous corrections he has been able to make in the names
applied to various bones by preceding anatomists, not even ex-
cepting such observers as Rathke, Owen, and Huxley. His
own determinations have been made from frequent dissections
of the various species in the earliest stages of their development ;
and it is curious to notice the freaks that nature plays in
dividing and multiplying what was at first single, or in uniting
and combining what was formerly manifold. The reason,
indeed, is not always obvious ; and Mr. Parker wisely refrains
from any reference to the teleological meaning of the parts,
partly because, as he says himself in his concluding remarks,
structural fitness is self-evident in most cases ; partly because
teleological explanation is a mere impertinence in a morpholo-
gical work — a biassing hindrance — " a pretty golden ball that
diverts the racer from his course ; and partly also because mor-
phological science is more perfectible than teleological," the
latter being often of very difficult, and even in some cases of im-
possible attainment ; whilst morphology only requires materials
and patience to enable us to acquire a very clear conception of
the step-by-step stages of anatomical structure."

The variations in the structure of the shoulder-girdle found
amongst the higher vertebrate birds and mammals are shown by
Mr. Parker not to result from the adoption of new structures,
nor by leaving out the old, but by segmetitation, arrest, and
metamorphosis. The raw material is taken up again from those
larval and pupal types — the fishes, amphibians, and reptiles ;
but the primordial masses are cloven, selected, and brought into
new and closer relation, so that their original reptilian and
icthyic conditions have to be sought for in their earlier and
rapidly changing states.

Here, as elsewhere, we are astonished at the singular fixity
of type that exists in the general features of the organisation,
whilst the individual parts appear to undergo endless modifica-
tions in detail. Mr. Parker has observed that the ostrich and

434 Bibliographical Record. [Oct.,

monotremes present, in their arrested simple condition, nume-
rous reptilian characters ; but not the less may most unmistake-
able Lacertian characters be noticed also in the noblest aerial
types. . . , .

Mr. Parker makes some interesting observations on the
various modes in w^hich ossification takes place in the animal
series, and the names he has suggested and employed are so
simple and intelligible that we do not doubt they will come into
general use, and supersede those at present employed. Thus
the ossification which occurs in the intercellular substance of
hyaline cartilage, and of which examples may be seen in the
epiphyses of the long bones of mammalia, and in the sternum
of lizards and birds he terms " endostosis •" and of this there
are three varieties — central, superficial, and sub-central. The
epiphyses of mammalia just mentioned are good examples of
central endostosis, in which the ossification commences at the
centre of the hyaline mass, and radiates outwards. The second
form, superficial endostosis, occurs constantly in the rays and
skates. The third, or subcentral, where the ossifying centre
encloses and is itself enclosed by cartilage, occurs in many of
the feebly ossified parts of the lizards, and in the sternum of
most birds.

A second mode of ossification is that in which bony matter is
deposited in the almost structureless inner layer of the perios-
teum, and in immediate contact with the outermost cartilage
cells, as in the shafts of long bones generally. This mode,
formerly called intra-membranous ossification, Mr. Parker terms
** ectostosis."

Lastly, to such bony formations as appear primarily in the
skin, in the subcutaneous fibrous mesh, or in the aponeurotic
tracts, he applies the term " parostosis." Such parosteal tracts
in the higher classes are apt to graft themselves upon primary
cartilage, and thus to become practically the ectosteal plate of
such cartilage, as in the clavicle of man and the furculura and
basi-cranial splints of birds.

We may here remark in passing, that the furculum of birds
is no longer to be regarded as merely composed of the coalesced
clavicles, but consists first of a central angular portion formed
by the so-called episternals (Mr. Parker's interclavicular bone),
and of the elements of the compound clavicle of the mammal ;
that is, of segmented fragments of the shoulder-girdle, which
combine at a very early period with the true (reptilian)
clavicle.

For the benefit of our readers, who are probably for the most
part more interested in human than in comparative anatomy,
we will just add the morphological relations of the several parts

1868,] Parker on the Shoulder-Girdle and Sternum. 435

of the shoulder-girdle in man. Beginning with the scapula, the
thin epiphysial ossification running along the vertebral border is
the suprascapular bone well shown as segmented from the
scapula in the ray and sturgeon, and large, but not quite
segmented off from the scapula proper in the frogs.

The Avhole of the infraspinous fossa represents the scapula
proper, seen forming the greater portion of the scapula of the
bird, but best differentiated as a distinct bone in the iguana and
turtle.

The acromion process, with the whole of the spinous process,
constitutes the meso-scapula, which is seen partly segmented
from the body of the scapula in the pangolins, but is well shown
also in the iguana.

The neck of the bone and the articular facet forming the
glenoid region has a separate internal ossification in the frog
and toad.

The coraco'id process forms a large separate bone in the
ovipara and in monotremes, of which only the part corresponding
to the head is developed in the human subject, which speedily
coalesces with the other elements forming the scapula.

The portion of bone around the coracoid notch, with the fore
part of the supra-spinous fossa, is the prse-scapula. It is well
seen as a distinct bar, above the glenoid cavity in certain lizards,
and exists as a separate cartilage even in the cat.

The clavicle, in a human foetus, 2 in. 4 lines long, with
its two fibro-cartilages, is thus described by Mr. Parker :

" The clavicle was stout and sigmoid ; it had drumstick-shaped ends
formed of hyaline cartilage. These are the remnants of a rod
primarily developed, quite independently of the clavicles (and as is
best seen in the frogs and toads behind and within them). The
meso-scapular segment (or outer extremity of the clavicle) is attached
by fibrous tissue to the acromion, and a synovial cavity has com-
menced at this part. At the other end (inner extremity of the
clavicle), the cartilage has been cleft into two segments, the outer
one, the prse-coraco'id, has become hyaline cartilage, and is in close
contact with the bony clavicle, whilst the inner or distal piece has
become fibro-cartilage."

This inner portion corresponds to the well-developed omo-
sternum of frogs, often erroneously called episternum, as though
it Avere equivalent to the episternum of lizards.

The praecoracoid is also well developed in frogs. The clavicle
of man, regarded from a purely osteological point of view, may
be stated to be a parosteal bar grafting itself on a delicate rod
of cartilage.

The sternum of man is primarily double, with right and left
portions, each moiety being segmented from the primarily undi-

436 Bibliographical Record. [Oct.,

vided sternal extremities of the ribs, which with the sternum
form at first a common cartilaginous mass or rib plate.

The monograph is enriched with thirty plates on stone, con-
taining no less than 508 separate drawings, all made from
Mr. Parker's own original dissections and drawings. They are
most clearly represented, the nature of the tissue being easily
distinguished by the colouring and the markings in the litho-
graph, dots, striaj, &c. All credit is due to the Council of the
Ray Society for publishing so valuable a work at so cheap
a rate ; but it ought to be stated that the Royal Society
granted a hundred pounds towards the expenses of the plates.

Art. XII — On the Immediate Treatment of Stricture of the
Urethra hy the Employment of the " Stricture Dilator. ^^ By
Barnard Holt, &c. Third Edition. London, 1868.
Pp. 136.

The method of treating obstinate stricture by forcible dilata-
tion is one which has long engaged the attention of surgeons,
and various apparatus have been devised for carrying it out, of
which those which go by the names of Wakley, Maisonneuve,
and Holt, are most widely known. Mr. Holt introduced his
plan to the profession in London in the year 1861. It must
have been well received, since he has now to publish a third
edition of his treatise, and Mr. Holt's own experience of it must
be allowed to be sufficient, since he tells us he has operated in
670 cases ! There is one rather remarkable circumstance con-
nected with this work of Mr. Holt, which, though it is not
perhaps essential to the formation of a surgical judgment on the
plan of treatment, yet surely deserves more distinct mention
than Mr. Holt has thought proper, as far as we can see, to give
it — we mean the originality of the proposal. Mr. Holt certainly
in his first edition, denominated his instrument "A new
stricture-dilator ;" and he applies the same term to it still, on
p. 4 of the present edition. But it was soon stated by Sir
H. Thompson^ and others, that this instrument bore a great
resemblamce to one introduced into practice by Perreve in the
year 1847 ; and Mr. B. Wills Richardson, of Dublin, has repro-
duced Perreve's figures side by side with Mr. Holt's, in order to
show that the "new stricture dilator" could really be made from
Perreve's drawings ; that, in fact, Mr. Holt's proposal is an
entire plagiarism, down to its minutest details. Mr. Holt
attempted to show that there was some essential difference
1 Holmes's ' System of Surgery,' iv, 398.

1868.]

Holt on the Stricture Dilator. 437

between his dilator and Perreve's ; but the only effect of this
■was to provoke his assailant to prove, beyond all possibility of
doubt, that this was not so, and that any instrument maker
could have made the one from the drawings of the other. Still
Mr. Holt continues to consider himself as the inventor of the
method, and all that we can find on the subject of his own
originality in this edition is the following rather curious para-
graph (p. 127).

" In conclusion, I may add, that in advocating the treatment of
stricture by rupture, I claim simply that credit which attaches to the
publication of a series of interesting cases (examples of many others)
which have been subjected to this novel treatment. That the prin-
ciple upon which the instrument is constructed is as old as the hills,
and that the power of the wedge has been known as long as the
simplest rules of mechanics have been taught, I freely admit, but I
have yet to learn that that principle has been heretofore applied to
the treatment of stricture of the urethra in the manner detailed
above, and with such highly satisfactory results."

This is hardly an answer to the charge that Mr. Holt know-
ingly adopted all the details of Perreve's invention and passed
them off on the public as his own, without mentioning Perreve's
name in any of his three editions. The plain fact is, that if
Mr. Holt was acquainted with Perreve's book before writing his
own, he ought to have acknowledged his obligation to the
French surgeon ; if, on the contrary, so remarkable a coincidence
of invention took place without any previous knowledge on his
part of his predecessor's labours, Mr. Holt ought in justice to
his own character to have distinctly asserted it.

We gladly leave this personal question, which however touches
too nearly the cliaracter of English surgery to be altogether
passed over. Apart from the originality of the proposal what is
its merit ? Mr. Holt has contributed an abundance of successfu .
cases in detail in this volume. He has operated on the enor-
mous number of 670 cases, and the operations have all been
successful except two, the details of which are given. The
experience also of other surgeons has abundantly shown that
the operation is very often most successful, and affords an
amount of relief in a period of time, and with an immunity from
risk, which no other operation can promise. Besides, further
experience has shown, that the stricture is not (in many cases at
any rate) really ruptured, but only dilated, and therefore there
is no risk of extravasation of urine, or of septic poisoning from
the pangs of inflamed urine over a raw surface. The following
observations (pp. 96 — 98) are of much interest :

" Since the above was written, a very interesting essay, for the

438 Bibliographical Record. [Oct.,

Fellowship of tlie Eoyal College of Surgeons by examination, * On
Organic Stricture of the Urethra, and its Treatment by Holt's
Method,' has been published by Dr. Millar, of Edinburgh, in which
he records the post-mortem appearances of the urethra of a patient
upon whom he operated nineteen days prior to his death, occasioned
by obstruction of the bowels ; and after detailing the appearance of
the intestine, he says : ' The bladder and urethra were removed. In
so doing, an abscess, probably connected with Cowper's glands, and
lying close upon the membranous portion of the urethra, was opened
into. The bladder was hypertrophied, and the mucous membrane
thickened, as is usual in cases of long-standing stricture. The
urethra, on heing cut open, was without a trace of rupture or cicatrix
{vide plate). The membranous portion was attenuated, owing to the
abscess formerly mentioned. A preparation was made of the bladder
and urethra, which I had the honour of showing before the Medical
and Chirurgical Society in December last.' And another very remark-
able case was about the same time recorded by Dr. M'Donnell, of
Dublin, in his paper ' On the Treatment of Stricture by the Stricture
Dilator,' of a patient who died from cholera, and in whom the imme-
diate operation had been performed fifteen days prior to his death.
Dr. M'Donnell removed the bladder and urethra, and they were
examined carefully by Dr. Cruise, Mr. William Stokes, and himself,
soon after removal. The appearance, however, at that time was not
materially different from what the members had now an opportunity
of seeing. A No. 9 catheter could readily be passed along the
urethra. Except for the hypertrophied condition of the muscular
coat of the bladder, and the dilated state of the portion of the
urethra behind where the stricture had been, there teas no other sign
of the disease having existed.

"Dr. Millar has also referred to three cases, published in my
' Opinions and Statistics on the Immediate Treatment,' where the
parts were examined shortly after death, and where the mucous
membrane was found to be entire, and arguing upon these facts, and
the examination of numerous preparations, he infers that in most
cases the mucous membrane is not torn at all, but that the deposit
of lymph in the submucous tissue around the canal is alone
ruptured*^

Thus it appears that the lesion is much less and the operation
is much safer than was at first supposed. The question remains,
is the treatment desirable ? We have Mr. Holt's assurance that
he has operated on 670 cases — 420 since the publication of his
second edition. This would seem to show that he has operated on
every case of stricture which has come into his hands. If so, can
this be good practice ? Our own experience of Mr. Holt's
operation is very restricted, since we have always confined ope-
rative treatment to cases presenting some peculiarity ; but we
have observed occasionally very severe and apparently cicatricial
recontraction when the stricture has been neglected (as patients

1868.] Sandahl on Compressed Air-baths. 439

will do in spite of every warning), after forcible dilatation ; and
we confess to considerable incredulity as to the applicability of
Dr. M'Donnell's and Dr. Millar's explanation to the severer
forms of stricture and to traumatic strictures above all others.
In these tougher cases we have little doubt that rupture is
actually produced. In all cases there is certainly some danger
of it, if there is any real obstruction present ; and experience
has shown that death or alarming symptoms sometimes, though
rarely, follow the operation. We have no hesitation, therefore,
in expressing a strong opinion that the operation performed in
this indiscriminate fashion is a mistake. Used with judgment,
and on properly selected cases, we believe it to be one of very
great value ; and we hold that Mr. Holt, by introducing it to
the notice of the profession in England, has done us a real
service, and is deserving of the highest credit if he is really
original in the matter.

Art. XIII. — 1. Berdttelse afgifven till Kgl. Sundhets-KoUegium
am den Medikopneumatiska Anstaltens verksamhet i Stock-
holm under dren 1863 och 1864. Af Dr. Oscab. Theodor
Sandahl. Stockholm, P. A. Norstedt och Soner. 1865.
8vo, pp. 56.

Report presented to the Boyal College of Health on the Opera-
tion of the Medico-pneumatic Institution in Stockholm during
the Years 1863 and 1864. By Dr. Oscar Th. Sandahl.
Stockholm, P. A. Norstedt and Sons.

2. Nyare under sokningar och iakttagelser rorande de fysiologiska

och terapeutiska verkningarne af had ifortdtad luft. Medde-
ladeaf\yx. Oskar Th. Sandahl (Aftryck iir 'Hygiea').
Stockholm. 1865. 8vo, pp. 35.
Jtecent Investigations and Observations respecting the Physiolo-
gical and Therapeutical effects of Bathing in Condensed
Air. Communicated by Dr. Oscar Th. Sandahl (reprinted
from the ' Hygiea '). Stockholm. 1865.

3. Des Bains d'Air Comprime : court Apergu de leurs Effets

Physiologiques et Therapeutiques ; precede dhme description
de r etahlissement medico-pneumatique de Stockholm. Par
OsKAR Th. Sandahl, Docteur en Medecine et en Chirurgie,
Professor Agreg^ a I'Ecole de Medecine de Stockholm.
Stockholm. 1867. Pp. 60, with two plates.

440 Bibliographical Record. [Oct.,

Baths of Compressed Air : a short Sketch of their Physiological
and Therapeutical Effects ; preceded by a Description of
the Medico-pneumatic Establishment at Stockholm. By
Oscar Th. Sandahl, Doctor in Medicine and Surgery,
Joint Professor in the School of Medicine, Stockholm.

In the above list we have arranged the three works of Dr.
Sandahl, now brought before us, in chronological order ; but as
the third is a translation of the second, with the advantage of
revision by the author, after two years' additional experience,
we shall, in the present notice, in the first instance, place
before our readers a summary of its contents, concluding with
such remarks as may be suggested to us by the facts recorded
in the report of the Medico-Pneumatic Institution in Stockholm,
which stands at the head of our list.

x\ccording to the author, it is about thirty years since baths
of compressed air were first employed in a rational manner. It
is to M. Emile Tabarie, of Montpellier, that we are indebted
for the first trial of this new remedy. Since that time their
employment has spread widely. Medico-pneumatic institutions
have been established at Montpellier, Lyons, and Nice ; Stock-
holm, Gothenburg, and XJpsala ; Helsingfors ; Copenhagen ;
Berlin, Doboeran, Dresden, Leipsic, Hanover, Nassau, Ems,
Johannisberg, Wiesbaden, Frankfort-on-the-Maine, Stutgardt,
Reichenhall, Vienna ; in London ; and at Petersburgh. The
bibliography of the subject, of which a full catalogue is given by
Dr. Sandahl, is already tolerably extensive.

The establishment in Stockholm was opened on the 10th
October, 1860, and on the 1st April, 1866, it Avas found neces-
sary, in consequence of the increase in the number of patients,
to transfer it to a more roomy locality. It now consists of a
large hall for the receivers, and of five chambers (two for the
inhalation of pulverised medicaments, two little waiting rooms
for patients, and one in which the mechanist of the establish-
ment lives), with antechamber, all situated on the ground
floor, and communicating with the underground chamber, in
which the steam-engine and the pump for compressing the
atmospheric air work.

The duration of the sittings is from one to two hours. The
increase of pressure is usually from one quarter to one half
atmosphere. A library is provided for those who wish to read
during the sittings.

H]\Q physiological effects of compressed air are said to be as
follow :

I. Effects on respiration. — 1. The force of the respiratory
muscles is increased. 2. The vital capacity of the lungs is

1868.]

Sandahl on Compressed Air-baths. 441

augmented. 3. The respiration becomes slower in compressed
than in ordinary air. 4. There is a change in the rhythm
of the respiratory act, expiration becoming relatively longer.
The experiments of Vivenot on himself and two other persons,
with those of Dr. G. Lange, exhibit an average increase in the
amount of carbonic acid exhaled in compressed over that exhaled
in ordinary air of 22'26 q. p. per cent. Professor Panum, of
Copenhagen, in his * Physiological Investigations' (' Fysiolog.
Undersogelser '), concludes that in compressed air, " during
tranquil and natural respiration, in a certain lapse of time, a
greater quantity of carbonic acid is expelled, and that doubtless
a greater quantity of oxygen is absorbed, than during tranquil
and natural respiration in the same space of time and under the
ordinary pressure."

Panum, however, considers these changes in the chemistry of
respiration to be only transitory, and lasting no longer than the
bath of compressed air. Our author, on the contrary, believes
that " the improvement produced is an effect of the oxidation of
the blood, dependent on a quantitative change in the chemistry
of respiration — a change which is maintained by the increase of
the pulmonary capacity induced by the baths of compressed air,
and prolonged after the cessation of the treatment."

II. Action of compressed air on the circulation of the blood. —
The usual effect is a retardation of the pulsations of the heart
and arteries. The mean of this diminution, in a large number
of observations, was 9'.24 beats per minute; the maximum
was 26.

III. Action on animal heat. — Under the influence of the
diminished evaporation and increased oxidation produced by
the compression of the air the heat of the body is naturally in-
creased during the bath, though at the end it becomes lower
than before the commencement of the bath.

IV. Action of compressed air on the muscular strength. —
The latter, as has already been experienced subjectively by
workers in diving-bells, is increased in baths of compressed air.
This increase is attributed to the augmented absorption, both by
the lungs and skin, of oxygen during the bath. Is it not
possible that there may be a source of fallacy in some of the
experiments referred to, and that when it is stated that J. Lange
" found that a weight which, under the ordinary pressure of the
air, could be raised with the extended arm only for some
seconds and with the greatest effort, was, under an augmented
pressui-e of the air, raised more easily, and could be increased
in proportion as the degree of pressure of the air rose," some-

412 Bibliographical Record. [Oct.,

thing may be due to the increased support given to the weight
by an additional " quarter or half atmosphere " ?

Under the head of " Action of compressed air on the trans-
formation of substances in the organism," it is stated that — 1st,
the activity of the digestive organs is increased ; 2nd, that
compressed air renders resorption more active ; 3rd, that under
the influence of compressed air a change, both quantitative and
qualitative, takes place in the urine, the total amount excreted
being augmented, with an increase in the urea, accompanied
either with an augmented excretion of sulphates or with a
diminution of phosphates.

The list of diseases, deduced in part from the report above
referred to, in which the therapeutical influence of compressed
air is said to have been experienced, is sufficiently extensive ;
it includes general lesions of nutrition — anaemia, chlorosis,
and scrofula; acute catarrhs of the mucous membrane of
the nose, pharynx, larynx, and lungs; chronic catarrhs
of the same; pulmonary emphysema and asthma; pulmonary
tuberculosis ; hooping-cough ; certain organic affections of the
heart; afi^ections of the auditory apparatus. Under the
eighth and last head we are informed that " compressed
air exercises, in certain cases, a salutary action on the
genital organs of the female." Our space does not permit us
to enter into a critical examination of the statements made in
reference to so long a catalogue. We would point out only the
apparent contradiction between the idea of treating pulmonary
consumption by the inhalation of compressed air and the views
of Dr. Miihry, as set forth in our review of his work on climate,
to be found in our twenty-third volume, page 62, where he is
quoted as stating that " phthisis diminishes decidedly in elevated
situations, in consequence of the great rarefaction of the air."
It is there argued that this exemption is due to increased ex-
pansion of the lung, caused by such rarefaction. Perhaps the
same effect may be produced by the opposite condition of in-
creased atmospheric pressure. We have endeavoured, as fully
as the brief space at our disposal enabled us to do, to put our
readers in possession of the physiological and therapeutical
effects attributed to the mode of treatment we have been con-
sidering; we must, however, in conclusion, confess our scepti-
cism as to the efficacy of a system from which its advocates
promise so much.

1868.] Barwell on Spinal Curvature. 443

Art. XIV. — The Causes and Treatment of Lateral Curvature
of the Spine. By Richard Barwei.l, F.R.C.S., Surgeon
to, and Lecturer on Anatomy at, the Charing Cross Hospital.
London. 1868. Pp. 179.

"VVe have read Mr. Barwell's book with much interest. His
views are original and independent, and he has worked them out
carefully and conscientiously. We have therefore the gratifica-
tion which arises from hearing an ingenious theory well sup-
ported by arguments and facts. And when we reflect that this
theory goes to explain a very frequent and distressing malady,
our interest is heightened ; for we can hardly help hoping that,
when the causes of lateral curvature are better understood, a
simpler and more efficient treatment will speedily be devised.
That the present method of treating curvature by means of steel
stays and supports is far from satisfactory is a matter Avhich we
take for granted. Such appliances are complicated and expen-
sive ; they are irksome if not actually painful to wear ; and
the benefit which results from their use is often very doubtful.
Such being the case, it will be a substantial advance in surgery
if a simpler, cheaper, and more efficient mode of treatment can
be suggested. And if Mr. Barwell's estimate of his own method
is not over-sanguine ; if it is found to bear the test of time and
trial, then we may reasonably hope that the treatment of lateral
curvatures will henceforth be more satisfactory to all parties
concerned than it has hitherto been.

Mr. Barwell begins by discussing the causation of lateral cur-
vature, and he points out that any satisfactory theory must
account for these three peculiarities of the disease, viz., that it
affects almost exclusively the female sex ; that the curvature
almost always occurs on the right side ; and that the vertebrae
are twisted upon their own axis. He then proceeds to set
forth his own views. We might do him an injustice if
we attempted to epitomise them in a brief notice such as
this. We must therefore refer our readers to the book itself.
Suffice it to say here that our author considers that the serratus
magnus muscle is the chief agent in producing dorsal curvature,
and that the muscle of the right side is excited to excessive
action sometimes by the greater weight which is thrown upon
the right shoulder, sometimes by the greater capacity of the
right lung. If this is so, we have a reasonable explanation of
the three conditions with Avhich we set out. The serratus
magnus, using the ribs as levers, rotates the bodies of the ver-
tebras. The right arm is naturally heavier than the left and is
frequently called upon to do more work, so that the serratus of

4M Bibliographical Record. [Oct.,

the right side is more used and more developed than its fellow.
Hence the curvature is generally towards the right. But the
serratus is also a very important muscle of respiration and
wherever the breathing is chiefly thoracic it is called into active
operation. Now, in women the respiration is notably much
more thoracic than it is in men ; and hence arises the greater
frequency of lateral curvature in females than in males. This
is a very brief and imperfect outline of Mr. Barwell's theory.
Those who are interested in the subject, and who wish to see
how well it is worked out, must refer to the volume before us.

One cannot help hoping that Mr. Barwell's views may be
found correct and that they may be confirmed by the experience
of the profession at large, for the treatment which he founds
upon them is so extremely simple. If simplicity is the test of
perfection, then the treatment of lateral curvature has made a
considerable advance under our author's guidance. But it re-
mains to be seen whether the bandages of twilled cloth with
elastic tension, the sloping seats, the postures, and the calis-
thenic exercises which he recommends are really so eflicacious
as he supposes. If it is so, the days of the costly and compli-
cated steel supports are numbered, and the change will add not
a little to the comfort of the patient, and to the credit of surgery.

We must not conclude without bestowing our tribute of
praise upon the way in which this book is illustrated. In a
former work by the same author which it was our duty to
notice, we ventured to say that a few good woodcuts would
have been better than a number of indifferent photographs, and
we are glad to see that Mr. Barwell has acted upon our sug-
gestion. Nothing can be better in their way than the illustra-
tions in the present volume.

Art. XV. — Hoarseness, Loss of Voice, and Stridulous Breath-
ing in relation to Nerco-miiscular Affections of the Larynx.
By MoRELL Mackenzie, M.D., &c. Second Edition,
enlarged and revised. London, 1868. Pp. 74.

Dr. M. Mackenzie is a well-known assiduous worker in the
investigation of the nature and treatment of thi'oat-diseases, and
the author of an excellent treatise on the laryngoscope, favor-
ably noticed in this ' Review' about a year ago. The use of
galvanism, and a convenient instrument for applying it, were
described very briefly in that work, the reader being referred to
a special pamphlet, previously published, on hoarseness and loss
of voice. The small book now before us is a new edition of that
pamphlet, conveying the results of five subsequent years' expe-
rience. It is also a reprint, with emendations, of an article pub-

1868.] M. Mackenzie on Hoarseness. 445

lished by the author in the third volume of the * London Hospital
Reports.' We welcome its appearance in a separate form as a
valuable contribution to our knowledge of laryngeal disorders.

The practice to which Dr. Mackenzie has especially devoted
himself has been productive, like most special branches of prac-
tice, each in its own department, in the recognition of several
additional morbid conditions of the larynx of which we have
hitherto lived in happy ignorance. And truly a certain measure
of bliss attaches to ignorance of many refinements of modern
pathology ; for the self-satisfaction and complacency of the un-
informed practitioner are thereby not marred or minished, and
the even tenor of his way can be pursued unruffled by cares
about the minutiae and hair-splitting which special pathologists
are so greatly concerned with. To those whose pride it is to style
themselves practical men, we fear Dr. Mackenzie's subdivisions
of laryngeal disorders will not prove acceptable additions to
knowledge. Leaving out of the question all structural changes
in the larynx, the author distinguishes nervous affections as
connected with the motor or with the sensory system. The
former group are again placed under two heads, according as
there is paralysis or spasm of the vocal cords, and the following
varieties of paralysis are enumerated : — Bilateral and unilateral
paralysis of the adductors ; bilateral and unilateral paralysis of
the abductors ; paralysis of the tensors and paralysis of the
laxors ; — the two last forms being also either unilateral or
bilateral. Moreover, "some of these paralyses may co-exist
together, and indeed are often found associated," and therefore
an ingenious terminologist might manufacture as many different
further kinds of laryngeal paralysis as there happen to be com-
binations, with corresponding additions to our nosological list.

Dr. Mackenzie has, however, compassionately stopped short
of this complete terminology, and contented himself with
treating in detail the varieties of paralysis above enumerated.
Though we doubt whether the busy physician will stay in each
case of aphonia or hoarseness to ascertain with certainty whether
it is the adductors or the abductors, or the tensors, or, otherwise,
the laxors of this or of that side, or of both sides, that may be
deficient in power, it must be allowed that a certain advantage
accrues in the more distinct conception of disease, from such
minute pathological discrimination as is here attempted.

Spasm of the laryngeal apparatus occupies a much less space
with its consideration than paralysis. Only spasm of the
adductors and of the tensors is alluded to. And, lastly, the
diseases of the sensory system — hypersesthesia and anaesthesia,
are discussed in a single page. An appendix on atrophy of the
vocal cords concludes the treatise.

84— xLii. 29

446 Bibliographical Record. [Oct.,

A good collection of cases, — some few of which are illustrated
hy wood engravings, — adds to the practical value of the book,
and no medical man will fail to cull useful information
respecting treatment from its pages. The direct application of
electricity to the vocal cords is a remedy the author declares
almost always successful in paralysis of the adductors, — the
most common nervous disorder of the larynx, and also in lost
power of the tensors. The instrument for applying electricity
was an invention of Dr. Mackenzie's. It was formerly called a
" laryngeal galvanizer ," but the inventor now prefers to term
it a " laryngeal electrode." It is an ingenious instrument ; but
it needs a practised or well-skilled hand to introduce one of its
poles within the glottis so as to come into contact with the
vocal cords.

Art. XVI. — Rodent Cancer, with Photographic and other Illus-
trations of its Nature and Treatment. By Charles H. Moore,
F.R.C.S., &c. London, 1867. Fcp. 8vo, pp. 128.

Clinical Illustrations of various Forms of Cancer and of other
Diseases likely to be mistaken for them, with especial refer-
ence to the Surgical Treatment. By Oliver Pemberton.
London, 1867. 4to, pp. 128.

The author of the first-named treatise enjoys particular oppor-
tunities, as Surgeon to the Middlesex Hospital, for the observa-
tion of the nature and treatment of cancerous diseases, and has
already given proof of his good use of those opportunities by his
previously published book on ' The Antecedents of Cancer.' In
the present work he has undertaken to set forth the grounds
for considering rodent facial ulcerations to have a close alliance
with cancer, and to illustrate their fitness for adequate surgical
operations and the large success that may be looked for from
such operations. The definition, pathology, diagnosis, course,
and general principles of treatment, are well conveyed in the
first fifty-eight pages of the volume, the remainder of the book
being occupied with the detailed history of fourteen cases of rodent
cancer which justify the hopeful views of treatment expressed by
the author. The first two cases are illustrated by five excellent
photographs from life, and Cases III, V, and VI, by engravings.

Mr. Moore regards rodent cancer as a local textural ailment,
which progressively advances upon and involves the adjoining
healthy structures, producing induration ; ulceration following
thereon from the centre of the diseased mass. " Did the disease
only spread in the skin by growth, it would form a broad tough
plate, resembling keloid; but it is a keloid with all the central

1868.] Moore and Pemberton on Cancer. 44!7

part of the flat plat ulcerated out. If it spread without a pre-
ceding solid growth, it would be rightly called an ulcer." The
disease penetrates from the integument and involves all the sub-
jacent structures, and after piercing the cranial bones may grow
into the very substance of the brain, but is, at the same time,
almost invariably concentrated into one mass by its continuity of
growth. Unlike the solid substance of scirrhus, that of rodent
cancer has no contractility, hence the absence of pitting and
cupping, and the preservation of the contour and position of the
as yet undestroyed integument. In this absence of contractility
epithelial cancer agrees with it, and a similarity prevails between
the microscopical constituents of the two cancerous lesions.

Rodent cancer is a disease of the decline of life, and as a rule
makes its appearance in previously healthy persons. " It is not
usual to find any disease of the subordinate glands in connexion"
with it. The diseases from which it requires to be distinguished
are lupus, syphilis, and epithelial cancer. To the last named
it bears the closest resemblance, particularly in the early stage of
epithelial cancer of the face. The particulars of diagnosis are
well stated in a few pages, and deserve careful study, as does also
the discussion concerning the nature of rodent cancer and the
characteristics of cancerous disease. The conclusion drawn is
that rodent cancer is one of the lowest forms of cancerous disease,
possessing a lower vital energy than others. It possesses every
local quality of cancer, being uninterruptedly continuous in its
growth, but is, at the same time, so meagre a growth, " that it
has no superfluous material for circulation in the blood to dis-
tant parts, and very little for the lymphatics and textures
nearest to it."

In the matter of treatment, Mr. Moore's opinion is that '^ con-
stitutional alteratives " are of little or no value. The essential
part of the disease is not the ulcer, but the solid subjacent tissue,
and it is this which must be destroyed. This end may be obtained
by caustics, and the form preferred by the writer is the chloride
of zinc. Ordinary mild superficial applications are of no use.
The treatment by caustics is applicable only where the disease
is of small extent ; when extended to the size of a half-crown
or crown-piece, excision is required ; and both this proceeding
and also caustics may be needed again and again, owing to the
tendency of the malady to recur.

The foregoing remarks embrace many of the leading conclu-
sions arrived at by Mr. Moore ; but every practitioner called
upon to deal with rodent cancer should not fail to make himself
fully acquainted with the author's teacliing, and to study also
the cases placed upon record.

Mr. Pemberton's work is of a much more extended character.

418 Biographical Record. [Oct.,

It undertakes to illustrate the several forms of cancer and of
diseases apt to be mistaken for it. This it does by pathological
description, by recorded examples of disease, and by pictorial
illustrations ; the last named constitute a leading and valuable
feature of the volume, for, besides many woodcuts intercalated
vrith the text, there are tw^elve large lithographed plates more
especially illustrative of cancer in bone. As the author puts it
himself, the work "is simply a record of a very considerable
number of the cases of malignant disease that have fallen under
my own observation during the labours of many years, preceded
by a brief account of the symptoms " presented, " and accom-
panied by such clinical comments as my experience has suggested.
I have, consequently, omitted all reference to the writings of
others and all controversial matters."

Mr. Oliver Pemberton has long been a well-known provincial
surgeon attached to the large general hospital of Birmingham ;
but his reputation will for the future be greatly raised by this
monument of his industry, and of his careful observation
and excellent pathological knowledge. The work essentially
addresses itself to practical surgeons, and constitutes for them,
by its numerous cases and ample and truthful illustrations, a
most valuable book of reference and a guide in forming an esti-
mate of the nature, progress, and prognosis of cancer under all
its best-known aspects.

The species of cancerous disease recognised are scirrhous and
an acute variety of this hard cancer; medullary or encephalo'id,
having three varieties — the firm, the melanotic, and the cystic ;
osteoid, fibrous, colloid, and epithelial, the last named pre-
senting a melanotic variety. Rodent ulcer is introduced at the
end of the treatise, but is not regarded as a true cancerous
affection.

The species of cancer actually illustrated are scirrhous, ence-
phalo'id, melanotic, and epithelial, each species being dealt
with according to the region attacked — as, for instance, ence-
phalo'id of the cranium, of the nose, of the jaw, breast, &c.
The opening chapter is dedicated to the diagnosis of malignant
from benign growths, and this object is well attained by a series
of contrasts drawn between the two. This disquisition is followed,
in the second chapter, by a descriptive account of the physical and
microscopical characters of the several recognised species of can-
cer. The author thereupon proceeds to clinically illustrate
** the symptoms, progress, diagnosis and treatment of the chief
scirrhous growths, as they commonly fall under the notice of the
surgeon," by a reference to cases that have occurred under his
own observation. The same course is pursued with the other
species of cancer above enumerated.

1868.]

Greaves on Factory Certificates. 449

The preceding observations will suiRce to convey a notion of
the plan of the work ; of the value of the matter it contains the
highest opinion may justly be pronounced, but a further com-
mendation is incumbent upon us for the manner in which the
book is got up. The volume is certainly an edition de luxe^
produced in quarto, with unusually good paper, wide margin,
and very clear, large type, as though the author desired it to
fall into the hands of those who would wish to preserve it in
their libraries in company with the productions of our great
surgeons of by-gone days, who wrote for posterity, and not for
practice, and whose ambition it was to diligently observe and to
record the teachings of experience, and not, as nowadays, merely
to produce ephemeral compendiums of the observations and
doctrines of the time.

Art. XVII. — Hints to Certifying Surgeons under the Factory
Acts. By George Greaves, Consulting Surgeon, Charlton
Union Hospital ; formerly Lecturer on Medical Jurispru-
dence, Manchester Royal School of Medicine ; Certifying
Surgeon, «&c. London, Knight and Co. Pp. 23.

This pamphlet is intended for the guidance of medical men
who have to examine children and young persons according to
the requirements of the Factory Acts. As these acts have lately
been extended to a variety of occupations besides those for
which they were originally framed, it is probable that many
surgeons throughout the country will be called upon to certify
who have hitherto had no special experience in determining the
age of children from their physical development, or in testing
their fitness for certain kinds of work. It is to supply these
men with a few hints and rules for their direction that Mr.
Greaves has written the pamphlet before us. His own expe-
rience seems to have been large, and to have extended over a
number of years, and accordingly he is entitled to speak with
weight and authority. The brochure that he has produced is
excellent as far as it goes ; but we could have wished that it
had gone somewhat further. The information it contains is
thoroughly practical, and it is conveyed in clear and precise
terms ; but the subject is one which might well have been ex-
tended beyond the limits of a pamphlet. If the author had
entered more fully into it — if he had discussed in detail some of
the difficulties which most frequently present themselves in ex-
amining children — and if he had given us the benefit of his
experience upon such cases he would have conferred a still
greater boon upon certifying surgeons.

450 [Oct.,

PART THIRD,
©riflinal OTommunications.

Art. I.

On the Range of Temperature in Typhus and Enteric Fevers.
By J. W. Miller, M.D. Edin., Physician to the Dundee
Boyal Infirmary.

In the following remarks are given the results of thermo-
metric observations of the range of temperature in some cases of
typhus and enteric fever. A few of the cases occurred in private
practice, the others in hospital.

In order to render more manifest the variations of tempera-
ture and pulse, I have had recourse to diagrams. In these the
thick line indicates the temperature, and the faint line the
pulse. The degree of temperature and rate of pulse indicated
by the horizontal lines are so set down as to bring as nearly as
possible within the same space the highest and lowest tempe-
rature and pulse likely to be observed. A pulse of 72 and a
temperature of 98° Fahr. are taken as conveniently and very
nearly representing the standard of health ; this being indicated
more prominently by the thicker horizontal line.^ The spaces
between the vertical lines represent the days of the illness in all
those cases whose date of commencement could be ascertained
with any approach to correctness ; in those cases in which this
was not known, they represent merely the current date. By
a glance at such a diagram, a very good general idea of the case
represented is at once obtained, much more readily than by a
perusal of columns of figures and dates ; and not unfrequently
the case may be so diagnosed without any further knowledge of
its symptoms. In a few instances a third line was added, to
show the rate of respiration co-existing with the rate of pulse
and degree of temperature, but this created an appearance of
confusion, and it is preferable when the noting of the rate of
respiration is thought desirable to do so by figures.

' In children this should be a little higher, especially for the pulse.

1868.]

Mill I! 11 on Temperature in Fever. 451

These observations have been made by placing the thermo-
meter in the axilla for four or five minutes or longer. There are
two observations daily, one about noon, and the other about
eight in the evening.^ Of course, this can, after all, only give
an approximation to the actual range of temperature, for it
seems evident that the temperature is almost constantly varying,
and it can only be by an occasional chance that the observa-
tion happens to be made while this is at its maximum or mini-
mum point. To obtain the real range of temperature would
require observations so frequent as to be equally out of the
question both for patient and observer.

With regard to the application of the thermometer to the
investigation of the disease, although it has become more gene-
ral of late, it may be still considered by some as an unnecessary
refinement, and it may be thought that the temperature of the
skin can be estimated with quite sufficient accuracy for practical
purposes by the mere application of the hand of the observer.
That this idea is erroneous may easily be proved by any one
who will take the trouble to test the point by first applying the
hand and forming his opinion as to the heat of the skin, and
then observing the result as given by the thermometer. Not
unfrequently the heat of the skin, as estimated by the hand,
may seem to be not above what is healthy, while the tempera-
ture is in reality, as the thermometer in the axilla will show,
several degrees above the normal standard.

It will be seen by a very cursory examination of these dia-
grams, that although on taking a general view of the tempera-
ture and of the rate of pulse over a series of days, they rise and
fall very much together, yet this correlation is by no means
uniform ; a high temperature being very frequently found along
with a slow pulse, and a low temperature with a quick pulse,
the pulse also frequently rising in rapidity while the tempera-
ture falls, and falling while the temperature rises.

In Professor Aitken's work on the ' Science and Practice of

Medicine,' he says that as a general rule the correlation of

temperature and pulse may be given as follows :

Temperature 98° corresponds with a pulse of 60
99° „ „ „ 70

100°

> » >

80

101°

» » >

90

102°

> »> >

100

103°

> j» »

110

104°

> »» >

120

105°

130

106°

» >» >

140

^ In some of the cases which occurred in private practice, the morning observa-
tion was at an earlier hour, and to the diagrams of these cases a note to that effect
is appended.

452

Original Communications.

[Oct,

That is, that for every rise of temperature by one degree, there
is an increased frequency of pulse by ten beats per minute.
He states, however, that this correlation is not constant, and
that it is far from being so is shown by the following table, in
which is noted the number of occasions on which each degree
of temperature was observed in thirty cases of typhus of eighteen
years of age and upwards, with the average pulse, and also the
maximum and minimum pulse, which on different occasions
were found Avith each degree of temperature :

Table showing correlation of Temperature and Pulse in thirty
cases of Typhus, of eighteen years of age and upioards.

Temperature.

Number of
observations.

Average pu]se.

Highest and lowest
pulse.

— 96°

5

82

64— 96

96-1°— 97°

39

78

60—112

97-1°— 98°

77

77

50—120

98-1°— 99°

70

94

60—150

99-1°— 100°

60

99

72—164

100-1°— 101°

61

104

72—144

101-1°— 102°

86

106

84^144

102-1°— 103°

140

114

84—156

103-1°— 104°

173

115

84—144

104-1°— 105°

55

120

96—158

105-1°— 106°

1

96

The average pulse here rises, though very unequally, with
each degree of temperature from 77 with 98°, to 120 with 105°.
The range of pulse, however^ corresponding with any one tem-
perature is very wide, from 50 to 120, for example, with 98°,
and from 84 to 156 with 103°. In some cases the disparity
between the height of the temperature and the frequency of the
pulse is very remarkable, and continues for several days, some-
times throughout the whole case. More particularly does this
occur in enteric fever, in some cases of which disease the pulse
may be throughout very slightlyj if at all, above the natural
frequency, while the temperature remains at a high standard.
The occurrence of a rapid pulse with a low temperature need
not cause surprise, the former being so easily accelerated in
weak or nervous patients, even by the slight excitement conse-
quent on the visit of the medical attendant ; but the absence
of excitement of the circulatory system while the high tempera-
ture shows the existence of much pyrexia is more difficult of
explanation.

This table also brings out what was the most common tempe-
rature in these thirty cases of typhus. Putting aside the
observations below 98°, and forty-six of those between 98° and

1868.] Miller on Temperature in Fever. 453

99°, as mostly occurring after the commencement of convales-
cence, we have 600 observations, of Avhich 369 were above 102° ;
considerably the most frequent temperature was from 103* 1° to
104°, this occiu-ring 173 times. A higher temperature than
105° seems to be rare ; it was only once observed among these
thirty cases, and among seventeen other cases of typhus of ages
below eighteen, it was observed only five times, twice in the
case of a girl aged thirteen, twice in that of a male aged seven-
teen, and once in that of a girl aged fifteen ; on these five
occasions the pulse was twice 108, twice 120, and once 132.

In studying the range of temperature in typhus fever (and
in other diseases likewise) one of the first points to arrest the
attention is that neither in its rise tOAvards the acme of the fever
nor in its subsequent fall is it regularly progressive. It rises
one day, falls a little the next, rises again the next to a point
higher than it had previously attained, and so on, until the
defervescence has commenced, when it descends in a similarly
interrupted manner until it has reached or fallen below the
normal standard. The same description applies to the accele-
ration and diminution of the frequency of the pulse before and
after the turn of the fever. The evening temperature is most
commonly higher than that of the morning, but to this there are
very numerous exceptions. The difference between the morn-
ing and evening observations is sometimes very considerable ;
for example, in Diag. Ill, on the 8th day, it is 2° ; in Diag.
VI, on the 7th day, it is 2*7°, and on the 11th day, 2-6°; in
Diag. IX, on the 7th day 2°, and on the 9th day 3-8°, besides
other instances. It is, however, the exception in typhus for
the difference to be much above one degree during the period
between the 3rd or 4th day and the 10th or llth ; and in this
relation of the morning temperature to that of the evening is to
be found one point of distinction between the range of tempera-
ture of typhus fever and that of enteric. In those cases in
which, during the height of the fever, the evening observation
was below that of the morning of the same day, the difference
was sometimes as much as from 1*7° to 2*4° (see Diag. Ill, 6th
and 8th days ; Diag. VII, 7th day ; Diag. X, 9th day ; and
Diag. XVI, 8th day). About the beginning of the deferves-
cence and during its progress, the difference between the morn-
ing and evening temperature is most likely to be considerable ;
and in some cases there may be one or two great fluctuations,
but there is not in typhus the prolonged period of oscillating tem-
perature which occurs towards the close of a case of enteric fever.

In typhus fever the day of illness on which the highest
temperature occurs is much more uncertain than might have
been expected. Twenty-seven cases were regularly observed

454 Original Communicaiions. [Oct.,

morning and evening from not later than the fourth day, and
in these, the day on which the highest temperature occurred
was as follows :

In 4 cases, maximum temperature occurred on 3rd day.

I. 8 „ „ „ 4tli „

» 3 „ „ „ 5th „

.. 3 „ „ „ 6th „

»> 2 „ „ „ 7th „

„ Lease „ „ 8th „

M 1 » » „ 9th „

„ 2 cases „ „ 10th „

.. 3 „ „ „ 11th „

27

The early days of the fever would, therefore, seem to be com-
monly the period of most intense pyrexia, for we see that in twenty
out of these twenty-seven cases the highest temperature occurred
during the first week, and in twelve of these twenty on the
third or fourth day. The difference, however, between the
maximum temperature and what occurs up to the commence-
ment of decided defervescence is in some of these cases but
trifling in amount. As a general rule, it may be considered
that the temperature rises very rapidly during the first two or
three days of the case to a point which it rarely much exceeds.
In the majority of cases, also, the rise seems to be much more
sudden than the defervescence generally is, although it is not so
easy to demonstrate this, the patients very rarely coming under
observation until the third or fourth day, and seldom even so
early as this. Three of these cases, however (Diags. I, XVII,
and XX), came under observation, the last on the first day of
illness, the other two on the second, and they are in accordance
with this opinion.

Very commonly, though not constantly, there is a remission
of the temperature during the second half of the first or first
half of the second week, this abatement continuing sometimes
one day, sometimes several days, after which the temperature
again rises before the defervescence begins (see Diags. II, V,
VI, VII, IX, XI, XII, Sec). In only four of the twenty-seven
cases referred to above, it will be observed, did the highest
temperature occur on seventh, eighth, or ninth day.

The day of maximum temperature does not seem at all to
correspond with the day of most frequent pulse, being some-
times earlier in the case, sometimes later, by far most frequently
the former. This is what might be expected, the mere rapidity
of pulse being not so much dependent on the intensity of the
febrile condition shown by the elevation of temperature as on
the increasing efiects of the poison on the whole economy, effects

1868.]

Miller on Temperature in Fever. 455

which in the worst cases rapidly bring down the temperature,
while they accelerate the pulse.

The highest temperature observed in each of these twenty-
seven cases respectively was as follows :

In 1 case the maxinmm temperature was 102*°

» 1 „ ,. „ 102-5°

,, 1 „ ,, » 102-8°

„ 1 „ „ » 103-8° •

„ 4 cases „ „ 104-°

„ 3 „ „ „ 104-2°

„ 1 case „ „ 104-4°

„ 2 cases „ „ 104-5°

» 2 „ „ „ 104-6°

» 3 „ „ „ 104-7°

„ 5 „ „ „ 104-8°

„ 1 case „ „ 105-1° •

„ 2 cases „ „ 105*2°

27

The highest temperature shown in these diagrams occurs in
the case of a lad aged seventeen (Diag. X). The case did
not come under observation till the fifth day, so that it is not
included in the two preceding tables. On the evening of the
seventh day, the temperature was 105'8°, the pulse being at the
same time of so moderate a frequency as 108. The case was a
pretty severe one, but notwithstanding this very high tempera-
ture, there was nothing specially alarming in the symptoms.
In only four of the twenty-seven cases did the temperature fail
to attain an elevation of 104°.^

With regard to the defervescence, the rule among the cases
which I have observed has been that it is gradual. A sudden
defervescence, occupying from twenty-four to thirty-six hours,
and fully deserving to be denominated a crisis, has been quite an
exception. The defervescence in Diags. Ill and XII approach
most nearly to this character, and that in Uiag. I would have
been a fair example of crisis, but for the elevation of temperature
on the 17th day ; so also would have been that in Diag. XI, but
for a similar elevation of temperature on the 13th day. In the great
majority of the cases the defervescence has occupied several

^ The results of these observations are in some respects at variance with what
is stated in Prof. Aitken's work ' On the Science and Practice of Medicine.' For
example, it is said that "both in mild and in severe cases the temperature always
rises above 104-7°, and it frequently reaches 106° Fahr. or more," It is also said
(page 44) that a temperature below 103-3° Fahr., without any external cause,
between the middle of the first and the middle of the second week, in a person
under eighteen years of age, is conclusive against the case being one of typhus.
In the cases shown in diagrams I, III, IX, and X, and more markedly in XII
and XIII, cases in which there could be no doubt about the diagnosis, the
temperature was found below this point between the fourth and tenth day.

456 Original Communications. [Oct.,

days, and, as I have akeady stated, it is not regularly progres-
sive. In one case (Diag. VII) it is very gradual and steady
however, beginning on the 9th day, and terminating on the
13th, thus occupying four or five days. By reference to the
diagrams, the character of the defervescence in each case will be
readily seen ; and any detailed description is unnecessary. In
most of the cases the pulse during the defervescence pretty
closely corresponds with the temperature in its fall towards the
natural standard, particularly so in Diags. I, II, IV, VI, and
XII. Occasionally there occurs what might be described as an
unsuccessful attempt at a crisis, some days before the deferves-
cence really commences, the temperature falling as much as
three degrees or more, but rising again the same evening or
next day to its former elevation. There is an example of this
on the ninth day of the case shown in Diag. IX.

A most important point as a distinctive characteristic of the
range of temperature in typhus, particularly as an element of
diagnosis between that fever and enteric, is the period of the case
at which the normal temperature is permanently regained. In
some of the earlier cases observed, the notes of the temperature
were discontinued too soon after it had become normal ; for not
very unfrequently after having been normal it again rises even
several degrees, and does not again fall to the healthy standard till
some days later ; and this may occur independently of any com-
plication. In the following statement, therefore, with reference
to the date of termination of the fever, only those cases are
included in which the temperature continued to be noted for at
least two days after it had become normal, with the result of
showing that it continued at or below this standard. Cases are
also excluded in which there occurred any complication so seri-
ous that it might be expected materially to affect the range of
temperature. The suitable cases then are fifty-three in number.
Their respective ages are as follows :

1 case ...... 5 years of age.

27 cases 10 to 19

38 „ 20 „ 29

4 „ 30 „ 39

3 „ 40, 46 and 53 „

Of these fifty-three cases, the fever ended —

In 1 case on the 9th day.
„ 1 „ „ 10th „

„ 5 cases „ 11th „
„ 2 „ „ 12th „

„ 10 „ „ 13th „

„ 6 ,, ,, 14th ,,

In 9 cases on the 15th day.

„ 5 „ „ 16th „

„ 5 „ „ 17th „

„ 6 „ „ 18th „

„ 2 „ „ 20th „

,, 1 case „ 21st „

1868.]

Miller on Temperature in Fever. 4^7

The diversity shown here as to the period of restoration of
normal temperature is very great, from the ninth to the twenty-
first day. Notwithstanding this diversity, however, the period
at which the abnormal temperature ends will go far in the great
generality of cases to establish the diagnosis between typhus
and enteric fever. We find only three of these fifty- three cases
protracted beyond the eighteenth day. The day on which the
largest number of cases terminated was the thirteenth, but no
particular day possessed any marked pre-eminence in this
respect.

After the commencement of convalescence, the temperature very
generally falls for a few days or longer below normal, being fre-
quently 97°, not unfrequently 96°, and sometimes even lower. In
the case of a man aged fifty-seven, it fell as low as 94 8°. A tem-
perature so low will probably only be found to accompany, as it
did in this case, a state of great danger to life; the grave nature
of the case being manifest, however, without the aid of the
thermometer. Under a liberal administration of whisky this
patient gradually improved and finally I'ecovered. The tempe-
rature rose very gradually, and five days after being at the low
point mentioned was 97*8°.

An elevation of temperature about or after the commence-
ment of convalescence is said to be frequently the first indica-
tion of the occurrence of some internal local inflammation. In
one such case an elevation of temperature during and after the
fourth week was found to accompany a pleurisy with effusion,
which ultimately ended in death. The daily use of the ther-
mometer may occasionally be useful in thus drawing attention
to a complication which might otherwise have escaped notice ;
and any considerable elevation of temperature, when not to be
expected in the ordinary course of the case, or still more when
the temperature has already begun the descent towards the
normal standard, should at once call for a careful examination
of the patient, in search of some cause for the occurrence. The
existence of some complication, either engrafted on the fever, as
a pneumonia, or of old standing, as phthisis, will occasionally
very much alter the range of temperature, and this must be
borne in mind in cases where a doubt as to the diagnosis might
so arise. Pleurisy may occur, however, without affecting the
temperature ; it supervened in one case of typhus after the
convalescence had begun, the temperature nevertheless remain-
ing natural ; and I may mention in passing two other cases of
pleurisy unconnected with typhus, in which the temperature was
noted and found normal. One was a case of phthisis ; there
was severe pain in the chest catching the breath, loud friction
murmur, and the pulse was 120 ; the other was a case of simple

458 Original Communications. [Oct.,

pleurisy in a man about seventy years of age, in whose case the
pulse, like the temperature, was normal.

Seven of the cases shown in these diagrams terminated in
death.

In the case of A. M. (Diag. XV), the highest temperature
was 104"5°, on the fifth day. There was nothing in the range
of temperature to create any alarm, except perhaps that while
it was falling, the pulse was rising. There was much delirium,
iloccitatio, muscular tremors, feeble dicrotic pulse, and albu-
minous urine with tube-casts. Death occurred on the ninth day.

In the case of P. D — (Biag. XVI), which was fatal on the
twelfth day, the highest temperature was 103'6° on the eighth
day. In this case, also, there occurred a falling temperature
with a rising pulse. The cardiac sounds and the pulse were
very weak, and there was coldness of the extremities and
hiccup.

The case of W. D— (Diag.XVII) proved fatal on the twelfth
day. So early as the sixth day the urine was found to be
decidedly albuminous, contained abundant tube-casts, and was
scanty in amount; and next day it was still more deficient.
Notwithstanding these very unfavorable circumstances, the
patient's aspect and other symptoms continued good till the
tenth day. The highest temperature noted was 104'3° on the
third day. There Avas nothing in the range of temperature to
cause anxiety, except perhaps the fall on the sixth day, while
the pulse rose, and this fall could scarcely be looked upon with
suspicion, it being the period of the case when an abatement in
the temperature was to be expected, and the pulse was by no
means very rapid, being only 118.

In the case of M, L — (Diag. XVIII) the highest temperature
was 102° on the third day. The temperature range was cer-
tainly very abnormally low, but the dangerous nature of the
case was obvious without the aid of tlie thermometer.

The case of J. G — (Diag. XX) terminated in death on the
sixteenth day. The highest temperature was 104*5° on the
eleventh day. The only unfavorable symptom in the range of
temperature was the fall on the fourteenth day while the pulse
continued to vary between 132 and 144.

The case of J. A — (Diag. XXI) proved fatal on the
eighteenth day. The highest temperature was 104" 1° on the
thirteenth day. While there was nothing abnormal in the range
of temperature, the increasing frequency of the pulse up to the
extreme rapidity of 166, and the severity of the other symptoms
sufficiently declared the gravity of the case.

In the case of R. L — (Diag. XXII), there occurred a very
abnormally low temperature with an extreme rapidity of pulse,

1868.]

Miller o'a Temjjerature in Fever. 459

but liere too the danger was obvious without the use of the
therniometer.

The results of these observations do not lead me to lay much
importance on the use of the thermometer as an aid to the pro-
gnosis of a case of typhus. Bad cases may present nothing
extraordinary in the temperature range from beginning to end.
On the other hand, in several of these cases there occurred a
very high temperature early in the fever, notwithstanding which
the cases did not prove in any way serious. For example, in
Diag. I, the temperature was 104*9° on the 3rd day ; in Diag.

II, 104-8° on the 6th day, and 105° on the 9th; in Diag.

III, 105° on the 5th and 6th days, and 104-8° on the 8th ;
in Diag. IV, 104-9° on the 5th day ; in Diag. VI, 105° on the
7th day ; in Diag. IX, 105-2° on the 3rd day ; and in diag. X,
105-8° on the 7th day.

There is one circumstance which when it occurs to a consider-
able extent must be looked on suspiciously, that is a falling tem-
perature with a rising pulse. An exceedingly high temperature,
again, 106° or upwards, indicates a dangerous height of pyrexia,
and an exceedingly low temperature at any period of the fever
may be considered a symptom of failing power, but in either
case, in order to form a correct judgment, the collateral symp-
toms must be considered, and particularly the pulse and cardiac
sounds. Indeed, if any one symptom is more than another
capable, when considered by itself, of conveying an idea of the
amount of danger present, it is the state of the pulse, not merely
as to its frequency, but also its strength, volume, and rhythm.
The intensity of the febrile condition will be of course much
most certainly estimated by means of the thermometer, but the
danger to the patient is by no means constantly in proportion to
the severity of the pyrexia. In a patient of excitable tempera-
ment, the typhus poison having been received into the system
may light up a violent febrile state, but the various emunctory
organs being in a healthy condition, and rapidly carrying off
the morbid matter, there may be no danger to life during the
whole course of the malady. In another patient, on the other
hand, the feebleness of his constitution or the malignancy of
the poison may be such that he is prostrated from the first onset
of the disease, and his condition may be one of absence of much
febrile reaction throughout. The temperature in such a case
may present nothing out of the ordinary course, but a bad pro-
gnosis will in all probability be correctly formed from the state
of the pulse and the general symptoms.

While holding this opinion as to the value of thermometric
observation for purposes of prognosis, and therefore that the
use of this instrument in the great majority of cases of typhus

460 Original Communications. [Oct.,

is not of much practical service, I believe that every now and
again a case will occur in which from absence of the charac-
teristic eruption, for example, the diagnosis will be obscure, and
that in such a case, with a rare exception, the employment of
the thermometer will be of the greatest importance as an aid
towards the formation of a correct judgment. Such an excep-
tion however may occur. For instance, had the specific rash
been wanting in the cases of M. H — (Diag. XIII) and H. C —
(Diag. XIV), in Avhich cases the temperature was never observed
higher than 102"8°, and in which it became normal so early as
the ninth day in the one, and the tenth or eleventh in tlie
other, the diagnosis of typhus could scarcely have been ven-
tured upon. The rash was quite unmistakeable however, and
could leave no doubt as to the real nature of the fever ; and
notwithstanding such cases must be very rare, their occurrence
should render us very cautious how Ave lay down absolute laws
founded upon observations however numerous.

Having referred so frequently to the cases shown in the
diagrams, I will not allude to them further than to direct atten-
tion to Diag. VIII, as an instance of the occurrence of typhus
almost immediately on recovery from enteric fever.

The range of temperature and its relation to the pulse in
enteric fever, present several characteristics which differ very
decidedly from what is observed in typhus ; and these points of
difference are such as to be frequently of the greatest service in
contributing towards a correct diagnosis. The point in which
they differ most conspicuously, perhaps, is the duration of the
abnormal range of temperature ; for while in the great majority
of cases of typhus this has terminated by the middle of the
third week, and in many cases considerably sooner ; it is rare
that it terminates in enteric fever before the fourth week, and it
is not unfrequently protracted into the fifth, or even the sixth
week. While referring to the duration of the fever, I would
remark that it is frequently very difficult in enteric fever to fix the
precise date of its commencement, the patient in many instances
having felt his symptoms come on so gradually that he finds it
impossible to say on what day they began. The onset of the
fever seems to be more gradual than that of typhus, and the
temperature during the earlier days is said to be less elevated
than in that fever. This observation, however, would be of
little value for diagnosis, for we have seen that in some cases
of the latter fever the temperature is exceedingly moderate.

The evening temperature in enteric fever is almost constantly
higher than that of the morning of the same day ; there are
occasional exceptions to this rule, but they occur much more

1868.]

Miller on Temperature in Fever

461

seldom than in typhus. The difTerence also between the
morning and evening observations is greater. This holds good
during the whole course of the fever, but it becomes very
remarkable in the great majority of cases during a period which
immediately precedes the settling down of the temperature to
the standard of health. At this stage of the case, generally
about the end of the third week, but varying of course accord-
ing to the total duration, there occurs a series of oscillations
between low temperatures in the morning and high tempera-
tures in the evening, in which the difference may amount to
five, six, or even seven degrees. This alternation may continue
from a fcAV days to a week or more, and when it is well marked
may be considered as conclusively diagnostic of enteric fever.

Another peculiarity not unfrequently met with in enteric
fever is the co-existence throughout the case of a slow pulse,
occasionally very slightly if at all above its normal frequency,
with the high fever temperature ; this being sometimes 103° or
higher, while the pulse is only 72 or even less.

The following Table shows the correlation of Temperature and
Pulse in twelve cases of Enteric Fever, their respective ages
being 14, 17, 17, 18, 21, 22, 22, 22, 25, 36, 37, and 44.

Temperature.

Number of
observations.

Average pulse.

Higliest and
lowest pulse.

96-1°— 97°

18

78

48—120

97-1°— 98°

68

86

48—144

98-1°— 99°

83

91

48—132

99-1°— 100°

60

94

60—132

1001°— 101°

58

97

54—132

101-1°— 102°

94

102

60—144

102-1°— 103°

137

105

72—132

103-1°— 104°

95

110

72—136

104-1°— 105°

23

112

84—144

105-1°— 106°

2

90—120

Though the number of observations is rather small, the table
is interesting so far as it goes By comparing it with that
referring to typhus (p. 452; it will be observed that the average
pulse with each degree of temperature, at least in its higher
range, is somewhat lower, and the minimum pulse considerably
so. The degree of temperature most frequently observed is also
lower.

Having premised these few remarks as to the chief points of
difference between the ranges of temperature in typhus and enteric
fever, I will now direct attention, without going into the details
of the cases, to the principal features which they present.

84— XLii. 30

46«i Original Communications, [Oct.,

The case of G. B— , male, set. 17 (Diag. XXIII), though
somewhat short, was a very characteristic one of the enteric
range of temperature. With two exceptions (tenth and eleventh
days) the evening temperature was higher than the morning, and
the difference between the two was considerable. The highest
temperature observed was 103"8° (eighth and ninth day). The
oscillation of temperature at the beginning of the third week
was Avell marked. The case was a mild one, and terminated
on the nineteenth day. The subsidence of the temperature
proved that the rapid pulse which continued was not due to
prolongation of the fever.

In the case of A. S — , male, aet. 22 (Diag. XXIV), the highest
temperature observed was 103"7°, on the tenth day. Through-
out there was no exception to the evening temperature being
higher than that of the morning. The normal range of tem-
perature was regained on the twenty-third day. The pulse
was very slightly accelerated, being mostly about 84, and only
once as high as 96. The notes cease on Nov. 1st, and the case
is especially interesting from the patient taking ill of typhus on
Nov. 12th, a few days after having left the hospital. This
attack of typhus was also mild (see Diag. VIII), and taken
along with this, furnishes a very good contrast of the ranges of
temperature peculiar to typhus and enteric fever.

The case of M. P — , female, get. 25 (Diag. XXV) was one of
considerable severity. Notwithstanding this, it is an instance
of the almost entire absence of one of the most prominent symp-
toms of enteric fever, the diarrhoea, which occuri-ed on only one
day, the fifteenth, the patient requiring several times castor oil
and enemata to procure an evacuation. The evening tempera-
ture was, with a very few exceptions, higher than that of the
morning. The oscillation of temperature towards the end of the
case was not very well marked, continuing only over two days,
but it occurred to a greater extent during the third week. At
this period the case seemed to be tending towards convalescence,
but on the eighteenth day a severe exacerbation occurred, and
convalescence did not commence till the thirty-fourth day,
making the total duration of the case five weeks. The highest
temperature observed was 105°, and occurred on the twenty-
second day.

The case of J. C — , female, set. 18 (Diag. XXVI), was chiefly
remarkable for the great oscillations of temperature throughout,
at least from the period of its coming under observation. The
highest temperature was 104'2° on the evenings of the tenth and
fifteenth days. Convalescence commenced on the thirty-first
day. With one exception the evening temperature was above
that of the morninsr.

1868.] Miller on Temperature in Fevers. 46S

The next case, J. L — , male, set. 36 (Diag. XXVII), was
another of those characterised by a peculiarly low pulse. On
Sept. 20th (the day of illness on admission could not be ascer-
tained) the temperature was 1036°, and with this exalted tem-
perature the pulse was only 72. The highest temperature,
104°, occurred on the morning of the day of admission. The
alternation of high and low temperatures was particularly well
marked, and without exception the temperature was higher in
the evening than the morning. Although the precise date of
commencement was doubtful, yet from the specific eruption
being present on admission, we cannot be far wrong in assum-
ing at least eight days as the previous duration of the illness,
which would put the beginning of steady convalescence (Oct.
4th) at the twenty-eighth day.

In the case of M. R— , female, set. 18 (Diag. XXVIII), the
date of commencement was also doubtful ; but the day of
admission was probably at least the eighth. The highest
temperature, 105*7°, occurred on the evening of the ninth (?)
day. Up till April 26th (twenty-fourth (?) day), which was
probably about the termination of the fever, the evening tem-
perature was invariably above that of the morning. When the
notes ceased the temperature continued above that of health,
its elevation being probably due to tuberculosis.

In the case of J. B — , male, set. 21 (Diag. XXIX), there was
less variation between the morning and evening temperatures
than in most of the others, and the evening temperature was
not so constantly above that of the morning. The highest
temperature noted was 104'5° on the evening of the fourteenth
day. The last stage of the fever was somewhat protracted, and
convalescence was not steady until the thirtieth day.

The following case, that of C. D — , male, set. 23 (Diag.
XXX), was also a long one. With three exceptions, the even-
ing temperature was higher than that of the morning. The
highest temperature observed was 103*6°, on the evenings of
the twentieth and the thirty-second day. Steady convalescence
did not commence till the thirty-ninth day.

The case of T. S — , female, set. 22 (Diag. XXXI), was a
somewhat peculiar one. Considering its duration, it more
resembled typhus than enteric fever. The oscillation of tem-
perature occurred most unusually early, between the tenth and
fifteenth days, and the normal range of temperature was
regained so soon as the seventeenth day. The general symp-
toms however, namely, the diarrhoea, the characteristic erup-
tion, the ilio-csecal tenderness, and gurgling on pressure, were
such as to make the diagnosis quite clear. NotAvithstanding
the short duration, the case was by no means a mild one, and

461 Original Communications. [Oct.,

the general symptoms as well as the temperature in its earlier
stages were such as would have led to the expectation of a pro-
tracted illness. The highest temperature noted, 104'7°, occurred
on the evenings of the sixth, tenth, and fourteenth days ; and
the evening temperatures are with a few exceptions higher than
the morning.

The last case to which I will direct attention (Diag. XXXII)
was an example of the co-existence of typhus and enteric fever.
The character of what little appearance there was on the
skin when the case came under observation, the diarrhoea during
the latter half of the second week, the ilio-csecal tenderness,
the late appearance of the typhus rash, the unmistakeahle
appearance of that rash, and, lastly, the advanced period of the
case before the temperature had regained its normal standard,
all in my opinion go to establish this diagnosis. It is confirmed
by the range of temperature, which is rather irregular ; it was
frequently lower in the evening than in the morning, and had
not become steadily normal by the twenty-fifth day.

My impression Is that the principal value of the thermometer
is, in enteric fever as in typhus, diagnostic, and that for prognosis
our reliance must be in a careful consideration of all the
symptoms presented by the case; among these of course the
temperature will have a place, but not, I believe, the pre-
eminence which is by some observers ascribed to it.

In conclusion, the leading diagnostic points between the
range of temperature of typhus and that of enteric fever, may
be briefly stated as follows :

Typhus Fever. Enteric Fever.

The duration of elevated temperature The duration of elevated temperature

is very rarely beyond eighteen days; is very rarely less than twenty-one days;

it is generally shorter by several days, it is generally longer, and may be pro-

and may be even so short as nine days. tractedto thirty-five days or even more.

The evening temperature is frequently The evening temperature is almost

lower than that of the morning. constantly higher than that of the

morning.

The difference between the morning The difference between the morning

and evening temperature, during the and evening temperature is generally,

height of the fever, or from about the throughout the case, greater than in

third to the tenth or eleventh day, is typhus, and towards the end of the

comparatively seldom above one degree, fever there occurs the very character-

and although about the period of defer- istic oscillation of temperature, during

vescence the difference is sometimes which the difl'eronce is frequently five,

much greater, the oscillation is not six, or even seven degrees, and which

continued over more than one or two may continue from a few days to a

days. week or more.

A high temperature is, as a rule, ac- A high temperature is frequently

companied by a high pulse. accompanied by a pulse but slightly

accelerated, and occasionally by a pulse
slower than normal.

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1868. J Lindsay on the Toot Plant. 465

I take this opportunity of expressing my thanks to Drs.
Anderson and White for the trouble they have taken in observ-
ing and noting the cases.^

Art. II.

On the Properties and Products of the Toot Plant of New
Zealand? By W. Lauder Lindsay, M.D., F.R.S. Ediu.,
Honorary Fellow of the Philosophical Institute of Canter-
bury, New Zealand, &c.

All the New Zealand species (4) of Coriaria appear to be
more or less poisonous, the seeds and leaves especially being
apparently the chief seats of the poisonous principle. The most
usual poisonous form of the Toot plant — at all events in the
eastern districts of Otago, which I visited in 1861 — is the
species that I have elsewhere described as C. Tutu,^ the C.
ruscifolia of authors. Dr. Hector, however, informs me * that
in Otago C. thymifolia is considered the most poisonous of all
the New Zealand Coriarice. C. arborea^ appears also to possess
in abundance the poisonous alkaloid of the genus, as it occurs
in New Zealand.

From the descriptions given me in 1861-2 of the action of the
poison on man and animals [illustrations of which action I have
supplied in my former Memoir in this ' Review'] , I came to the
conclusion that the said poison is of the nature of an alkaloid,^
allied to, if not identical with, the active poisonous principle of
the European C. myrtifolia, viz., CoriamyrtineJ If the poison of
the New Zealand Coriaria should yet prove so different from
Coriamyrtine as to deserve separate nomenclature, I venture to
propose for it the name Tutuine as appropriate, and under this
name I will subsequently speak of it provisionally in this paper.

Desirous of extracting or isolating this poisonous alkaloid, in

1 This paper was read before the Dundee Medical Society, 8th January, 1868.

" Supplementary to a memoir " On the Toot Plant and Poison of New Zealand,"
in this 'Review' for July, 1865, p. 153. Additional details relating to the
botanical characters of the "Toot Plant" and its allies may be found in the
author's * Contributions to New Zealand Botany,' London and Edinburgh, 1868,
genus Coriaria, p. 83 ; and in his memoir " On the Toot Poison of New Zealand,"
' Proceedings of Sec. D, British Association,' 1862.

3 ♦ Contributions to New Zealand Botany,' p. 84.
• " Letter of October, 1865.

* ' Contributions to New Zealand Botany,' p. 84.

^ Referring to this opinion, Dr. Hector wrote me (October, 1865) as to the
"supposed alkaloid, of the existence of which I have no doubt."

' Vide former paper in this ' Review,' pp. 162, 175.

466 Original Communications. i Oct.,

order to render it the subject of physiologico-pathological
experiment on the lower animals, and so to determine the cha-
racter of its toxicological, and perhaps also therapeutic^ action, I
not only brought home considerable quantities of the dried
plant, which were placed in the hands of a competent ana-
lytical chemist,^ but I sowed under glass in the spring of 1863
Toot seed collected in Otago of the seasons 1861 and 1862. None
of these seeds, however, came up ; whether because of their age,
or because they were not previously steeped in warm water, as
was successfully done subsequently in the case of ^' Goal seeds
{Sophoratetraptera Pdt.),"^ I have insuflScient data for deter-
mining. Unfortunately all my efforts, and those of Professor
Murray Thomson, failed in their main object — the elimination
in a separate form of the Tutuine.

The government analyst of Otago, however, Mr. Skey, appears
to have been more successful, with the greatly superior local
advantages at his command. ^ He professes to have succeeded
in extracting the " true alkaloid,^' which is supposed to be the
source of the poisonous action of Toot. He failed to separate
it by any of the recognised '' standard processes" for the ex-
traction of poisonous organic alkaloids ; and succeeded only by
means of a new process, wherein dry sulphate of soda was the
prime agent of elimination. He obtained the Tutuine, how-
ever, in too small quantity to be available for experiment on
its chemical composition or its physiological or toxic action. He
found it in the leaf in as large quantity as in the ripe fruit. It
is described as a very bitter principle, having "a pure bitter
taste of great persistency^' when dissolved in water. These
experiments of Skey's are, however, far from being complete
or satisfactory, though they will prove serviceable in paving the
way for others of a more exhaustive kind.

In Otago, Tutuine is supposed to be analogous in its action to
strychnine : '' it has been used in epilepsy with supposed suc-
cess" (Buchanan) . In truth, however, nothing can yet be said
to have been determined regarding its physiological or thera-
peutic action. It has yet to be proved whether it will be
serviceable in medicine at all. My friend Dr. Irvine, of Nelson,
says that Belladonna is the antidote of the Toot poison, but there
is no sufficient evidence that this has been established as 2^ fact.
There are anomalies in the toxic or pathological action of Toot,
which, however, are not singular, but find parallels in the action
of Amanita muscaria L., and certain other neurotic poisons ;
anomalies that have not yet been made the subject of proper

' Tide former paper in this * Review,' pp. 175-6.

* Vide author's ' Contributions to New Zealand Botany,' p. 73.

' ' Jurors' Reports of the New Zealand Exhibition of 1865,' p. 428.

1868.] Lindsay on the Toot Plant. 467

study by the lights of modern chemistry, physiology, and
pathology.

The Toot plant continues to be, in all parts of New Zealand,
the fertile source of accidents, fatal to man, as well as, on an
enormous scale, to cattle. Fortunately, in the neighbourhood
of the larger towns, which are surrounded by cultivation. Toot
has now been more or less cleared away; and the accidents
referred to are, therefore, becoming in and around these centres
of cultivation more and more rare. This is especially true of
the older towns, such as Nelson. But in and around the so-
called '' mushroom" towns, or " canvas " towns, that are con-
stantly springing up in new and wild districts, following the
successive gold-finds and gold-fields, the case is very diflFerent.
Every now and then I still find recorded in the public prints
the details of some coroner^s inquest — generally relating to the
death of a child, arising from eating some part of the plant.
The jury generally requests the coroner " to bring under the
notice of the proper authorities the very dangerous properties of
the plant, with the hope that steps would be taken for its total
eradication," which is indeed the only complete or certain
means of preventing such accidents. The following newspaper
account of one of such poisonings illustrates, sufficiently for
present purposes, the general circumstances of such accidents.
" An inquest was held at Cambridge [Waikato district, Auck-
land province] on the body of a little girl about

four years and a half old It appears that the child, while

playing with some other children, picked up a piece of " Tvtu"
plant, which she ate of and ofi^ered some to her sister, who was
a year older. The latter providentially did not partake of it,
but her younger sister soon became ill, and was seized with
violent convulsions ; and, after lingering for about ten hours,
died after much suffering. Dr. Sam presided at the inquest;
and one of the witnesses who gave evidence was a Maori woman,
who, having seen the symptoms displayed by the child, said she
had eaten Tutu, and administered salt, which is invariably used
by the natives, and with good effect if given in time."i The
death of an adult, a gold digger at Hokitika, in two hours,
from eating Tutu berries, is also recorded in the 'Lyttelton
Times' [of Dec. 14th, 1865].

In the earlier days of settlement the so-called berries weJfe
made to yield a juice and a wine to the natives and colonists ;2
but the use of both seems to have been nearly entirely given up
in consequence of the unenviable notoriety the Toot plant has
acquired as a ^fatal poison. Dr. Geo. Bennett, of Sydney,

' 'Southern Cross,' Auckland, New Zealand, October 28, 1865. - '
'^ Vide also former paper in this ' Review,' pp. 161-2.

468 Original Communications. [Oct.,

relates that the Auckland natives were careful to strain the juice
of the berries, so as to separate the poisonous seeds. They soaked
their baked fern-root^ in this juice, or they drank the latter by
itself.2 The Bay of Islands Missionaries also "make an

agreeable wine which tastes like that made from

elderberries/^^

Siramonds says/ "The New Zealanders used to prepare a
Seaweed jelly called ' Tutu;' but, like many other articles formerly
employed by the natives, either as food or delicacies, it is now
seldom or never seen. The preparation was, I am informed by
Mr. Chas. Ilursthouse, chiefly confined to the natives along the
northern shores of Cook's Straits." My friend, Mr. Simmonds,
here evidently confounds two quite distinct substances, and he
is not the first compiler that has done so, viz., the Jelly of a Sea-
weed, of the nature of " Carrageen,^' and the juice of the berries
of the " Tutu" [species of Coriaria~\ . I have elsewhere shown
that New Zealand contains at least one marine alga capable of
yielding a jelly of the "Carrageen" class ;5 and in my former
paper in this 'Review' T referred to the association of the
juice of the Toot berry with seaweed jelly as a delicacy of the
blancmange order.^ Dr. Thomson says,'^ "Almost all the sea-
weeds were occasionally eaten'' by the natives ; but this must
have been after the manner of our " Dulse." In another part of
his work on New Zealand, he remarks, " Several .... seaweeds
are edible ; one of the latter, with the juice of Tutu berries, is con-
verted into a jelly. "^ I am somewhat at a loss to determine
what amount of credence to give to some of Dr. Thomson's
assertions as to the food of the natives; for in the same place^ he
mentions lichens as edible, a fact whereof I have elsewhere found
no record.^*^

All the New Zealand Coriarice appear to abound more or less,
and in every part of the plant, in Tannic acid, or in some of the
allies of this acid — some, perhaps new, astringent acid, belong-

1 Vide paper by author on "Otago Ferns," * Trans. Botanical Society of Edin-
burgh,' vol. ix, p. 40.

'^ DiefFenbach (' Travels in New Zealand,' vol. ii, p. 50) says that the Maoris
drink the juice MMfermented ; a statement which contradicts that made in my
former paper in this ' Review,' p. 161.

3 ' Wanderings in Australia and New Zealand.'

■• 'Waste Products and Undeveloped Substances,' p. 216.

^ Vide paper by author on " New Zealand Carrageen," ' Trans. Botanical Society
of Edinburgh,' vol. ix, p. 137.

6 Pp. 161-2.

7 ' Story of New Zealand,' vol. i, p. 19.

8 Ibid., p. 155. The juice obviously, however, only imparts flavour, taste, and
colour ; it does not assist in the formation or " setting" of the jelly.

9 Ibid., p. 155. " Several Mosses, Fungi, Lichens, and Seaweeds are edible."
lo I wrote to Dr. Thomson on this subject in 1862, but never received a reply.

I have failed also in other quarters in eliciting information on this point.

1868,1 Lindsay on the Toot Plant. 469

ing to the tannic series. Astringent principles abound equally in
C. arborea, the ''Tree Toot," and in the more familiar herbaceous
Toot [C. tutu). Hence the economic properties of the former pro-
mise to be the same virtually as those of the latter. In the New-
Zealand Exhibition of 1865 (Nos. 724-5 of ' Catalogue 0
specimens of Tannate of Quinine were shown, the tannic acid
whereof was prepared from the indigenous '' Toot/' Astringent
principles seem to pervade the genus Coriaria wherever distri-
buted. The root of the European form C. myrtifolia is largely
used for tanning purposes in Russia; and there is every reason
for supposing that some at least of the New Zealand species
may be applied to similar purposes.

Skey has made the Tannin of the Toot plant of Otago the sub-
ject of careful experiment. Amonghis results are the following:^ —

Tannin abounds in the following parts of the plant : — Leaf,
root, calyx, seed, flower-stalk, old wood and its pith. The parts
of the plant richest in tannin are, in the order of their richness, —

1. Young leaves = maximum, from 030 to 208 percent.;
average, 135 per cent.

2. Old shoots.

3. Root.

4. Old wood.

The per centage is much higher in the dried than in the fresh
state, varying from 2*14 to 8*32 (average 4*45) in the former.
There is no perceptible loss of tannin by drying the plant at
130° to 150°, whence it is inferred that the small branches could
be dried and stacked like oak -bark without losing any of their
tanning properties. So abundantly does Toot contain material
available for tanning, and so common is the plant in many, if
not most, parts of the colony, that it is strongly recommended to
the notice of the local tanner as a competitor to, or substitute
for, the materials currently in use. In reference, however, to
any future applications of Toot-products in the arts or in medi-
cine, it must be borne in mind what I have had occasion to
point out in reference also to the indigenous Flax (species of
Phormium),^ that future permanent market supplies must depend
on the cultivation of the plant, inasmuch as the wild plant is
rapidly hastening to its inevitable doom — scarcity or extinction
— in that " struggle for existence'' that long ago began with the
hardier immigrant weeds of Europe.

Skey's experiments leave many points yet undetermined in
the natural history both of the poisonous and astringent princi-
ples of the New Zealand Toot plant, and inter alia :

1 ' Jurors' Reports of New Zealand Exhibition of 1865,' p. 427.
' " On the Obstacles to the Utilisation of the New Zealand Flax " {Phorm'mm
tenax). ' Seemann's Journal of Botany,' vol. v, 1867, p. 342.

470 Original Communications. [Oct.,

I. Tuiuine.

A. What are its precise nature, its chemical composition,

and chemical or physical properties ?

B. What is its mode of action on the human and animal

system^ — physiologically, pathologically, or thera-
peutically ?

C. Can it, and under what circumstances, be applied in

medicine ?

D. What is its appropriate antidote in man and animals ?

E. What treatment is indicated as likely to be most service-

able under different classes of circumstances [man
or animals, genus or species, age and sex, &c.], if no
specific antidote exists?

II. Tannin.

F. On what precise modification of tannic acid, or on

what ultimate principle, does the astringency of Toot
depend ?

G. To what extent can such principle or principles be ren-

dered available in the arts or in medicine ?

III. Tutuine and Tannin.

H. In what species or varieties — in what parts of the
plant, and at what period of growth — are they in great-
est quantity and of finest quality ?
I. To what extent are they modified in quantity or quality

by the cultivation of the plant ?
J. What is the simplest and easiest mode of extraction —
having regard to the quantity and quality of the
product ?

In my former paper^ in this Review, I stated that Toot, while
poisonous to certain animals, is innocuous to certain others ; and
1 showed that the same may be said of several other of the most
deadly vegetable poisons with which man is acquainted. In
works of travel I not unfrequently meet with instances similar
to those I have already narrated ; and I believe, indeed,
they might be largely multiplied. The subject is one of such
importance in connection with physiologico-pathological ex-
periment on the lower animals^ — a department of the modern

1 Pp. 161, 169, 170, 171, 175, 176, 177.

^ Many years ago, while experimenting on the antidotal inter-relations of
certain vegetable poisons, I pointed out the fallacy of supposing that substances
poisonous to man were equally, or necessarily at all, so to the lower animals j or
of drawing any inferences from the action of a given poison on a certain animal-
genus or species regarding its probable action on any other genus or species —
especially belonging to a different group (' Association Medical Journal,' June 9,
1854).

1868.] Lindsay on the Toot Plant. 471

science of ^'comparative pathology/'^ which is at length beginning
to attract attention from the younger and more intelligent
aspirants for fame in our profession — that I offer no apology for
here transcribing one or two additional instances lately
encountered in my miscellaneous reading.

Speaking of Abyssinian plants, Sir Samuel Baker remarks
as follows: — Of Asclepias gigantea, whose stem and leaves yield
a highly poisonous milk, '^ Although the poisonous qualities of
the plant cause it to be shunned by all other animals, it is never-
theless greedily devoured by goats, which eat it unharmed."^ Of
the fruit of the " Hegleek" tree {Balanites Egyptiaca), which
produces diarrhoea in man [if eaten raw and in quantity] , while
boiled with honey it forms a harmless and pleasant preserve :
" Elephants are particularly fond of the fruit [i. e., berries] of
the 'Hegleek;' they enjoy them beyond any other food, and
they industriously gather them one by one. At the season
when the fruit is ripe, the ' Hegleek' tree is a certain attraction
to elephants, who shake the branches, and pick up the fallen
berries with their trunks ; frequently they overturn the tree
itself as a more direct manner of feeding.'^^ And of the familiar
medicinal " Senna" plant : — it is " rich in a pale green foliage,
which is a strong temptation to the hungry camel. Curiously,
this purgative plant is the animaFs bonne bouche, and is consi-
dered most nourishing as fodder.^^*

Dr. Hector writes me,^ in reference to a statement in my
former paper^ regarding the food of the rare bird, the "Kakapo,""
" On what authority do you state that the ' Kakapo' eats the
Tutu berries? Not that I doubt they would eat them or
anything else almost : but the ' Kakapo' does not abound along
with Tutu as a rule, but in pine and birch forests." My autho-
rity is Dr. Haast, whose experience as a New Zealand explorer
is unrivalled, and whose knowledge of the habits of its native
birds can be inferior to that of no other naturalist. He, how-
ever, again in this instance derives his authority or information
from the Maoris, whose testimony on such a subject I regard as

1 Vide paper by the author on the " Transmission of Diseases between Man and
the Lower Animals." ' Edinburgh "Veterinary Review,' July, 1858.

2 ' Nile Tributaries of Abyssinia,' 1867, p. 31.

3 Ibid., p. 369.

* Ibid., p. 73. Son e Notanda on the varying effects'of certain poisonous plants
on the quality of the fiesh oifish used as human food will be found in a memoir
by M. Auguste Dumeril, on " Venomous Fishes," in the ' Annales de la Soc. Lin-
neenne du Uepartement de Maine-et-Loire' for 1866 ; or, translated, in the 'Annals
of Natural History,' vol. xx (1867), p. 153. The reader may also consult with
advantage the following two papers : — " On the Innocuousness of Belladonna,
Datura, and Myosi^amus to Rabbits," Runge, ' Journal de Pharmacie,' vol. x,
p. 85 ; and " On the Comparative Immunity of Rabbits to the Poisonous Action
of Atropine," by Dr. Wm. Ogle, * Medical Times,' May, 1867, p. 466.

» October, 1865. « P. 170.

472

Original Communications.

[Oct.,

unimpeachable. Speaking more especially of the western and
wild districts of the province of Nelson, he writes in 1860, " The
' Kakapo^ lives in holes burrowed in the ground, where it remains
during the day, coming out in the night. It feeds on berries
and roots. Although able to fly, it rarely or never takes to the
wing, as the natives assured me, who in former years often hunted
it. For this purpose they generally went to the plains, when
the berries of the Tutu {Coriaria sarmentosa) were ripe, which
are a favorite food of that bird, selecting fine moonlight nights.
They ran them down partly with dogs, or even killed them with
long sticks upon the Tutu bushes.''^

Art. III.

Table of Cases, with Weights of the Bodies and Lungs of Live
and Stillborn Children. By Alexander Ogston, M.D.
Aberdeen.

No.

Sex.

Live or still born.

Condition wlien

Weight of body

Weight of lungs

exauiiued.

in grains.

in grains.

1

Male.

Live birth.

Fresh.

58,625

940

2

„

„

„

53,812-5

1421

3

Female.

»

Decomposed.

31,500

420

4

Male.

Still birth.

Fresh.

33,410

494

5

Female.

„

j>

15,968

488

6

jj

Live birth.

»

44,515-6

568

7

Male.

„

Decomposed.

54,031-2

1200

8

jj

Still birth.

Fresh.

14,054-7

300

9

Female.

„

Decomposed.

47,468

410

10

Male.

„

Fresh.

19,250

690

11

»

„

Decomposed.

45,937-5

640

12

„

Live birth.

Fresh.

54,250

1205

13

Female.

Still birth.

Decomposed.

8,750

200

14

,j

Live birth.

Fresh.

45,718-7

730

15

„

„

Decomposed.

35,000

706

16

Male.

„

Fresh.

56,437-5

736

17

Female.

Still birth.

Decomposed.

45,062-5

640

18

Male.

„

Fresh.

20,125

540

19

Female.

Live birth.

„

56,617-5

859

20

,,

Still birth.

„

31,937-5

589

21

Male.

„

„

13,125

120

22

jj

„

j^

57,750

1103

23

Female.

Live birth.

„

37,625

745

24

jj

Still birth.

„

51,843-7

1315

25

jj

jj

jj

15,968-7

507

26

»

Live birth.

»

37,625

726

27

»

Decomposed.

24,937-5

655

28

„

,.

Fresh.

44,187-5

746

1 ' Report of a Topographical and Geological Exploration of the Western Dis-
tricts of the Nelson Province, New Zealand, undertaken for the Provincial Govern-
ment.' Nelson, 1861, p. 138.

1868.1 Ogston 0)1 Bodies and Lungs of Infants.

473

No.
29

Sex.

Live or still born.

Condition when
examined.

Weight of body
in grains.

Wei)iht of lungs
in grains.

Male.

Live birth.

Fresh.

46,932-5

816

30

„

»

„

32,998-5

640

31

Female.

»

37,625

661-5

32

»

„

»

42,875

600

33

»

„

»

44,625

1008

34

Still birth.

Decomposed.

16,734-3

470

35

Male.

Live birth.

Fresh.

51,625

723

36

jj

„

39,648-5

1220

37

Female.

Decomposed.

41,545

890

38

„

Fresh.

47,468-8

761

39

„

„

38,500

709

40

Male.

»

35,000

464

41

Female.

»

49,000

858

42

Male.

Decomposed.

49,546-7

660

43

Female.

Fresh.

48,125

856

44

ti

17

47,507-5

774

45

ty

»»

43,750

643

46

>>

40,796-7

960

47

Male.

»»

45,500

781

48

Female.

,,

47,468-7

1057

49

Male.

Decomposed.

49,000

680

50

»

jj

Fresh.

42,000

1127

51

Female.

„

„

31,500

990

52

jj

jj

jj

32,812-5

810

53

J,

„

»<

57,750

1035

54

Male.

„

»»

53,375

1046

55

jj

Still birth.

>»

15,750

488

56

Female.

Live birth.

42,000

692

57

jj

„

;»

46,593-7

865

58

jj

„

,,

43,750

690

59

Male.

jj

»>

56,000

920

60

Female.

J,

>»

56,000

1029

61

Male.

»

i>

55,562-5

875

Out of a total of eighty-one cases, in which the question as to
the live or still birth of a child had to be answered by the medi-
cal jurist to the law authorities from a post-mortem inspection
of the bodies of the children, and which are recorded in the
medico-legal reports of Professor Ogston, University of Aber-
deen, there are sixty-one in which the particulars as to the
weight of the body and lungs are given, as well as every other
information necessary to be provided with in judging of the
value of these weights as corroborative evidence in the question
of live or still birth. More than corroborative they certainly
cannot be, the condition of the lungs is in competent hands an
unfailing means of answering this important question, and the
variation in the weights of body and lungs, as well as of their
relations to each other, are too great and too general to admit
of such a claim.

474 Original Communications. [Oct.,

The above sixty-one cases, drawn up in the form of a table,
give us, however, some results which it may be well to remem-
ber in judging of such cases. They are given in the order in
which they occurred in practice, with the exception of the
first, which is drawn from the practice of a physician in a
neighbouring county. In deciding as to live or still birth,
the condition of the lungs was the evidence relied on. In the
column relating to freshness or putridity, the condition of the
body was not so much taken into account as the state of the
lungs themselves, for it is well known that the lungs are not
the organs of the body soonest affected by decomposition, and
a commencing decay of the body does not at first affect the
lungs at all. The weights of the bodies were taken in imperial
pounds, ounces, and parts of ounces, which explains the
decimals of grains so often occurring in this column. The
lungs were weighed by apothecaries' weight, excepting Case
31, where imperial weight was used. In the above table the
weights have been reduced to grains for the sake of greater ease
in comparison.

Out of the sixteen cases of still birth, eight are males and
eight females. The aggregate weight of the lungs in the
males is 4375 grains, of the bodies 219,402*2 grains, or a pro-
portion of 1 : 50-103. In the females, lungs = 4628, and bodies
233,7237 grains, or 1 : 50502.

In the live births, where the lungs are fresh, a total of thirty-
eight cases shows fourteen males, with the total weight of the
lungs 12,914, and of the bodies 681,767 grains, or 1 : 52-792,
and twenty-four females with the total weight of the lungs
19,390-5, and of the bodies 1,064,437-2 grains, or 1 : 54847.

In live births, where the lungs were decomposed, out of
seven cases three were males and four were females. The males
have the total weight of the lungs 2540 grains, and of the bodies
143,577-9 grains, or 1 : 56'526 ; the females having the total
weight of the lungs 2671, and of the bodies 132,982-5 grains, or
1 : 49-787.

NoAv, comparing these figures, we find the proportion of the
weight of the lungs to that of the body to be, disregarding
sex —

In still births. In decomposed live births.

In fresh live births.

1 : 50-302 1 : 53-156

1 : 53-819

And in all live births, disregarding the state of freshness or
decomposition, 1 : 53"487.

1868.] Griffiths on Haemodynamics . 475

This leads us to the result that, although common sense indi-
cates an increase of absolute weight in the lungs after inspiration,
and consequently an increased ratio of weight to that of the body,
in the above table of cases the weight of the lungs to that of
the body is greater in still than in lice births — just the reverse
of what might have been expected. Why this should be so is
not to be explained, but the conclusion to which we are driven
is, that in deciding between live and still birth the ratio of the
weight of the lungs to that of the body is quite worthless.

Looking next at the absolute weight of the lungs, great differ-
ences present themselves. In one case of still birth the lungs
weighed 1315 grains, and in one case of live birth they weighed
only 420 grains. But in the general run of live births the
weights of the lungs are greater than in the generality of still
births; and the averages bring this out in a pretty marked
degree, for we have —

Average weight of still-born lungs = 562'6

„ „ live-born decomposed hings = 744'4

„ „ fresh „ = 850-1

„ „ all live-born lungs = 833*6

The average absolute weight of still-born lungs being thus
about five eighths of that of live-born lungs ; whence we con-
clude that, although in any one given case the absolute weight
of the lungs is inadequate to decide the question of live or still
birth, still, as corroborative evidence, it is not without value,
and may be allowed a certain amount of weight along with the
other uncertain signs of live birth in deciding this often very
important question.

Art. IV.
On Hemodynamics. By W. Handsel Griffiths, Ph.D.

In the latter part of the year 1865 I had the honour of read-
ing before the Boyal Irish Academy a paper descriptive of an
instrument which I proposed as a substitute for, and an improve-
ment on, the hsemodromometer of the celebrated Volkmann,
From that date up to the present time I have devoted myself
almost exclusively to the perfection of my instrument, and to
making experiments with it, and I trust that the results, which
I now publish for the first time, will prove an acceptable contri-
bution to physiological literature.

Before proceeding to give an outline of my researcbes, I think

476 Oi'iyinal Communications. [Oct.,

it advisable to state some modifications in the design of my
instrument, which I have latelj'^ adopted.

Dr. Robert Macdonnel, of Dublin, the well-known physiolo-
gist, kindly suggested to me that the method of heating the
support of my apparatus could be more easily and better accom-
plished by means of hot water than by the use of the metallic
heaters. The suggestion was very valuable, for the cost of the
instrument would thus be lessened, and a more equable tempe-
rature would be gained than by my method.

I am not less grateful to Dr. Macdonnel for another sug-
gestion, which however I have not adopted. He recommended
that a circular index tube should be employed instead of the
oblong one which I had designed. Anxious to test the value of
this suggestion, I made repeated experiments with the circular
tube, but was invariably dissatisfied with the result ; the course
of the index-ball was not so free as in the original tube, and the
circulation was in some measure retarded.

In the course of a lengthened correspondence with many emi-
nent physiologists concerning my instrument, a source of failure
was frequently anticipated in the event of the index-ball sticking,
and Dr. Sharpey particularly drew my attention to this point.
After a series of some 300 experiments, I am happy to say that
I have never had to suspend an operation from this cause, nor
have I reason to think that one experiment was thus invalidated.
My objects in describing my instrument previous to detailing
experiments made with it were — first, in the hope that my
brother physiologists would have instruments made on my design,
so that when my own experiments were published, they might
be compared with those of other observers ; and, secondly, I
hoped to draw the attention of physicists to the mechanism of
the instrument, so that I might profit by their criticism, and
eventually produce an accurate and reliable haemodroraometer.
Whether my first object has been fulfilled I am not in a position
confidently to state, but I have reason to believe that several
continental physiologists have studied the subject, and that the
results I have herein mentioned will meet with corroboration at
their hands.

I have forwarded copies of my paper on hsemodromometers to
most of the eminent physicists, and it is a matter of no little
pride to me, that no further strictures have been made on my
instrument other than those I have just alluded to. It has indeed
been objected, that my instrument is somewhat complicated, and
that its use requires delicate manipulation. On seeing the
instrument in work, however, no such objections could be urged,
and it is but right to state that they have been only advanced
theoretically.

1868.] Griffiths on Hemodynamics. 4^77

Before proceeding further, I should remind my readers that
I merely purpose in this paper to give an outline of the general
results I have experimentally obtained, and to describe in gene-
ral a few of the more important of my experiments. Hereafter
I hope to publish a complete register of my researches, so that
future experimentalists may have a standard of comparison.

The first animal subjected to experiment was a healthy dog
about one year old. The animal was securely bound, so that by
its exertions it could not interrupt the course of observation.
The right carotid artery was exposed for about an inch and a
half, and the instrument adapted in the manner I have detailed
in my former paper. The operation was perfectly successful, no
exertions were made by the animal, which had been fed plenti-
fully about half an hour previous to the experiment. The
velocity with which the index-ball was propelled was at the rate
of 425 millimeters per second !

With reference to this experiment I wish it to be particularly
noticed, that the dog was twelve months old, in good health, and
about sixteen inches high; that the time of experiment was
noon, and that the animal had shortly before partaken of a
full meal.

The subject of my second experiment was a bitch which had
been born of the same parents, and at the same time as the dog
previously operated on. Its size was exactly the same, the time
of experiment was noon, and the animal had been fed previously
to operation. The velocity of the circulation in the right
carotid in this instance was at the rate of 448 millimeters per
second.

The same animals were again submitted to experiment two
weeks after the above operations, but the conditions under which
they were now operated on were diflerent. The dog was on this
occasion placed on the operating table in a state of faintness
from hunger ; his left carotid was exposed, and the instrument
adapted. The rate of velocity I estimated at 340 millimeters.
The bitch was on the same day operated upon in the same man-
ner and under the same conditions, and the index-ball showed a
velocity of about 380 millimeters. I should mention here, that
in all these experiments the animals were confined to the hori-
zontal posture. The results of these inquiries would seem to
point to the conclusions, that the velocity in the carotid of a dog
averages about 400 millimeters per second, that the rate of
velocity is greater in the female than in the male, that the
velocity is decreased by hunger, and that the efiect of hunger on
velocity is more apparent in the female than in the male.

I can only say that, after an experience of over 100 experi-
ments similarly performed, I am convinced that these con-

84— XLli. ^1

478 Original Communications. [Oct.,

elusions are correct. Another dog, of same size, weight, and
age, was submitted to experiment about an hour after a full
meal. Instead of placing him in the horizontal posture, he
was operated on while bound to a perpendicular support. On
testing the velocity of the circulation in the right carotid, I
found it to be about 380 millimeters per second.

The conclusion to be drawn from this experiment, and which
is warranted by the results of seven other trials, is that posture
affects velocity, and that it is greater in the carotid while the
animal is in the horizontal position.

The same dog was similarly operated on in about a week
afterwards, the only variation in the experiment being that
the animal was placed head downwards. The left carotid
was experimented on, and showed a velocity of about 470
millimeters.

This experiment was several times repeated, and the con-
clusion to be inferred is that velocity in the carotids was greater
while the animal was in this posture than while in the hori-
zontal or erect position.

My next inquiry was directed to the velocity of circulation
as affected by age. A pup, one month old, was operated on,
the right carotid opened, and the velocity taken ; it proved to
be about 460 millimeters. An animal was next submitted to
experiment whose years numbered twelve. The velocity of the
circulation in the right carotid, in this instance, was measured
at about 300 millimeters per second.

This proves indubitably that age affects velocity to a remark-
able degree. I should mention here that age in the female does
not influence the velocity to the same extent as in the male.
This fact I have gathered from about twelve experiments.

The question next suggested itself, does size affect velocity ?
The following are two of the experiments undertaken to solve
the query.

The right carotid of a dog nearly three feet in height and
two years of age was opened, and showed a velocity of 480 mil-
limeters. A dog of same age, but only eighteen inches high,
was next operated on under similar conditions, and the velocity
was ascertained to be about 420. This result was contrary to
my expectation, for I expected to find a greater variation in
velocity according to size. I am, however, now convinced,
from the result of six experiments, that size does not affect
velocity to any very great extent. It now remained for me to
ascertain whether velocity varied according to the time of day.
A dog, about eighteen months old, was operated on at 6 a.m.,
and the velocity of the current in the right carotid found to be
at the rate of 460 millimeters per second. The left carotid of

1868.] GuiFFiTHs on Hcemodynamics, 479

the same dog was opened at 10 p.m. on the same day, and the
velocity ascertained to be only 380 millimeters. I may mention
that no blood was lost by the animal during the first operation,
and that the dog had been moderately fed about an hour pre-
vious to experiment. Seventeen experiments of this nature
were performed by me, and I invariably found that velocity was
at its maximum about 6 a.m. or 7 a.m., and at its minimum
between 7 p.m. and 10 p.m. I now performed a series of ex-
periments to ascertain the effect of various medicinal agents
on the velocity of the blood's current, a few of the more remark-
able of which I may here detail.

A healthy dog was anaesthetised by inhalation of chloroform
after the velocity of the circulation in the right carotid had been
ascertained to be 420 millimeters per second. While under the
influence of chloroform the left carotid was opened, and I was
not surprised to find that the velocity suffered a considerable
decrease, showing only a rate of 300 millimeters.

Another dog, somewhat similar to the above, with a natural
velocity in the right carotid of 400 millimeters per second, was
found to have that velocity reduced to 330 millimeters, while
the animal was under the influence of narcotism by opium.

A dog of rather large size, with a velocity in the right carotid
of 430 millimeters, was subjected to alcoholic stimulation. The
velocity in the left carotid was taken while in that state, and
the result showed a rate of 550 millimeters nearly. On the
stimulation being carried further, the rate was over 600 milli-
meters ; and, lastly, when the stage of stupefaction had been
induced, the rate decreased rather quickly to 430 millimeters
per second.

Hitherto I have spoken only of the rate of circulation in
the carotids of dogs, inasmuch as most of my experiments were
performed on these animals. I have, however, subjected rabbits
and cats to experiment, in the same manner and under similar
circumstances. As a general result, I may state that the average
velocity in carotids of rabbits of one year old I found to be 350
millimeters in the second, and that in the carotids of cats of the
same age the rate was a,bout 400. From this the question
would naturally arise as to whether velocity varies according to
the nature of animals. I regret to state that I have not worked
out that question sufficiently to warrant my giving an opinion
on it.

I had one and only one opportunity of examining the rate of
velocity in the arteries of a horse. It is a matter of much
regret to me that I have had no other opportunity of experi-
menting on horses, for the one to which 1 now allude was in
such an unhealthy and unnatural state from hard work, bad

480 Original Communications. [Oct.,

feeding, and old age, that I am reluctant to record the results I
obtained, as I believe that they cannot be accepted as affording
a good example of average rate. The velocity of the current in
the right carotid measured only 370 millimeters, that in the
metatarsal artery showed a velocity of 78 millimeters, and in
the maxillary artery 126 millimeters per second.

Of course my experiments were not confined to the carotid
arteries, and I now proceed to state briefly a few of the general
results of experiments on the principal vessels. I should
mention that dogs were the subjects in all the following
cases.

Axillary Artery. — As the result of twelve experiments on the
axillary arteries of dogs, I would state the average velocity in
this artery to be about 430 to 440 millimeters per second.

Brachial Artery. — The brachial artery of seventeen dogs was
opened, and the average velocity found to range between 400
and 430 millimeters.

Radial and Ulnar Arteries. — These arteries were experi-
mented on in eight cases, and the velocity in each was generally
from 360 to 400 millimeters in the second.

Femoral Artery. — The femoral was opened twelve times, and
the velocity found to be very nearly equal to that of the
axillary.

Popliteal Artery. — The popliteal was operated on in only four
cases, and the velocity in each case was 410, 415, 425, and 400
respectively.

Tibial Artery. — This artery, in seven cases, showed an average
velocity of 330 millimeters.

Metatarsal. — Five arteries were opened, and showed a velocity
of between 210 and 250 millimeters.

On one occasion I attempted to take the velocity of the
abdominal aorta, but the experiment was unsuccessful.

From my observations I am enabled to corroborate the
statement of Volkmann respecting the jerking character of the
arterial currents. I was also led on several occasions to put to
the test of experiment Volkmann^s assertion that the velocity is
lessened by loss of blood. On three occasions dogs were sub-
mitted to experiment about an hour after severe depletion. In
one case the velocity of the current in the right carotid showed
a rate of only about 270 millimeters. In the other case the
velocity was about 320, and in the last instance the rate per
second was 345 millimeters.

I have instituted several other original observations, with a
view to determine the effect of the heart's action on the velocity.
I, however, decline to publish the results until I have studied
the subject more extensively.

1868. J Griffiths an Hc^modynarnics. 481

It will be seen, on a reference being made to the writings of
Volkmann, that the results obtained with his instrument differ
considerably from those afforded by mine. I am indebted to
Dr. H. Bence Jones for a very valuable suggestion, whereby I was
enabled to test the exact differences afforded by experiments
with the two instruments. He proposed that I should insert
my hsemodromometer into the artery of one limb, and a Volk-
mann's instrument into the corresponding artery of the other
limb.

Last year I followed this method of experiment : — A dog
about two years and a half old was bound to the operating table.
The left carotid was first opened, and circulation established
through my instrument. The right carotid was then exposed,
Volkmann's instrument adapted, and the results noted. Volk-
mann's instrument showed a velocity of 320 millimeters per
second, whereas the velocity according to my instrument reached
the rate of 430 millimeters ! The instruments were now re-
versed— Volkmann's instrument being inserted into the left
carotid and mine into the right. The velocity, according to
Volkmann's apparatus, was 325 millimeters ; and, according to
mine, it was very nearly 440 in the second. This experiment
was quite sufficient to demonstrate the fact, that a much greater
velocity would be registered by my instrument than by Volk-
mann's, and the result of many subsequent trials on the same
plan were abundantly confirmatory.

The experiments which I have made on the circulation in the
veins have not been nearly so numerous as those performed
on the arteries, inasmuch as I was anxious to study the velocity
of arterial circulation thoroughly, before turning my serious
attention to that of the veins.

The only veins I operated on were the external jugular, the
basilic, and the femoral.

In the external jugular on two occasions I found the velocity
to average 400 millimeters per second. The femoral was five
times operated on, but showed some variation in the velocity; in
one case it was 435, in another 420; in two it reached 440, and
in another case it only reached in a second 400 millimeters.
The basilic showed a velocity in three cases averaging 350 milli-
meters. 1 hope to prosecute my researches on the velocity of
venous circulation when I have completed my study of the
velocity of the current in the arterial vessels.

I shall now briefly recapitulate the general conclusions
which I have arrived at from a consideration of the results of my
experiments.

I. The average velocity in the carotids of dogs is at the

482 Original Communications. [Oct.,

rate of 400 millimeters, or sixteen English inches, per
second.

II. The rate of velocity is always greater in the female than
in the male.

III. Velocity suffers a decrease from hunger.

IV. Velocity is greater after a full meal.

V. The effect of hunger on velocity is more apparent in the
female than in the male.

VI. Velocity in particular arteries is influenced by posture.

VII. Velocity varies with age, but the variation is more
marked in the male than in the female.

VIII. Velocity varies with the time of day.

IX. Velocity varies slightly according to size.

X. Velocity is affected by medicinal agents.

XI. Velocity is greater in the larger arteries, and in those
nearest the heart.

XII. Velocity is decreased by loss of blood.

In concluding this paper I must again remind my readers, that
the experiments herein recorded have merely been selected from
a voluminous series of notes, and that the conclusions at which
I have arrived have not been based on the few leading facts
herein mentioned, but have been justified by the results of some
300 experiments.

When I shall have prosecuted my researches still further
under different conditions, on other animals, and with other
objects in view, I trust that physiologists will then be qualified,
from actual experience of, and experiments with, my instrument,
to correct and assign to my researches whatever value may attach
to them.

I cannot conclude without expressing my thanks to the many
eminent physiologists who have so kindly favoured me with their
opinions of my instrument, and with suggestions for its im-
provement. More than all, my thanks are due to Dr. Macdonnel,
of Dublin, for his valuable advice, for his great kindness in
offering to place his library at my service, and for many other
acts of kindness.

I need not say that it is scarcely likely that a haemodromo-
meter will ever be used on the human subject; and the ques-
tion would now arise — how can we ascertain the average velocity
of the blood-currents in man ? I cannot answer the question,
but I do not despair of being able hereafter to establish some
law, whereby we may be able to calculate with tolerable
certainty the velocity with which the blood circulates in the
human subject.

1868.] Ogle's Fatal Cases of Tetanus, 5fc. 483

Art. V.

Miscellaneous Contributions to the Theory of Pathology. By John
W. Ogle, M.D., F.R.C.P., Physician and Lecturer on Pathology
at St. George's Hospital.

{Continued from vol. xli, p. 234.)

CHAPTER II.

Containing the history of a series of Fatal cases of Idiopathic and
Traumatic Tetanus, and of cases which may be called Tetanoid.

The following cases are intended to illustrate the phenomena of
tetanus, and the appearances presented on post-mortem dissection.

Almost all occurred at St. George's Hospital, but I shall subjoin
additional cases which have, from other sources, come under my
notice.

I have purposely, with a few exceptions, only quoted those cases
of tetanus which proved fatal, and were examined after death.^ One
or two of the cases have been cited already in the periodicals, and
to the citation of these cases I shall refer.

As I have done in respect of the cases of chorea included in
Chapter I., at the conclusion of each case in the present series,
I shall notice any particulars which strike me in its history, and at
the close sum up the general inferences and observations which the
cases collectively suggest.

Case 1. — Tetanus apparently following cold and exposure.

Richard H — , set. 37, was admitted into St. George's Hospital
May 28, 1841, with symptoms of tetanus, but the course of the
disease has not been recorded. It is stated that he had suffered no
accident, but that he had led a very irregular life, and of late had been
exposed to damp and wet, sleeping in the fields, &c. He had been
ill for three days before admission, and died April 5th, about the
twelfth day after the accession of the attacks.

On post-mortem examination, excepting rather more than usual
vascularity of the cranial membranes, all the various parts of the
body appeared to be healthy.

Remarks. — The only points of interest in this case are — 1st, the
absence of any traumatic cause of the disease, according to the

1 Among those which proved fatal and were not examined was an interesting
case of traumatic tetanus, under the care of my colleague Mr. Holmes and
myself, treated by nicotine, and recorded at length iu the ' Medical Times and
Gazette,' 1865, March 12, 1864, p. 277.

484 Original Communications. [Oct.,

history given; InA, the time of death being about twelve days after
the commencement of the symptoms. [106.]

Case 2. — Tetanus following sloughing of a wound.

Frederick B — was brought into St. George's Hospital September
19th, 1841,^ with a sloughing wound at the inner and middle parts
of the foot, and affected by tetanus ; but no history of the attacks or
of their cause has been given. He died on the 22nd of the same
month.

On post-mortem examination, a portion of hard leather was found
embedded in the wound of the foot, the parts around being inflamed
and sloughy; the inner division of the inner plantar nerve was found
to lie directly below the wound of the foot, and to be surrounded by
a thin screen of a yellow colour ; but the nerve was itself healthy,
and so were the nerves of the limb generally. The arachnoid cavity
in the spinal column contained rather more fluid than usual, and the
bloodvessels at the posterior part of the cord were gorged, but
in other respects, excepting some congestion of the lungs, all
the parts of the body appeared healthy.

Remarks. — Though details of the history are wanting, yet it
is worthy of note that the nerve implicated appeared to bs healthy
after death, notwithstanding that the wound was in a sloughy state.
[156.]

Case 3. — Tetanus of traumatic origin, Softening of ike spinal cord, ^c.

Thomas C — was admitted into St. George's Hospital April 8th,
1843. No history was recorded excepting that he had symp-
toms which were very like to those of tetanus. He died on the
18th.

Post-mortem examination. — Bruises of the body and an extensive
sloughy wound exposing the os calcis existed. The peroneal nerve
was exposed, and seen to be of a canary colour and very firm in
the slough. Above and below the injury the nerve was softened and
white.

' During this year, 1841, the following case of convulsive fits of pain, attended
by opisthotonos, occurred in our hospital :

Wm. S — , 83t. 22, was admitted Dec. 1st, 1841. The tongue was clean, the
pulse not full or strong, skin cool, bowels regular, urine natural, appetite good.
He complained of most acute pain in the right temple and cheek-bone — not in the
jaw-bone — in the right ear and round to tlie back of his head, down the neck and
across the loins, not at all in the hands or legs. The pain was not constant, but
came on in fits, during which he was obliged to fall and lie with the head and
hack curved backwards. The pain sometimes lasted an hour, more or less, and
recurred once in two or three days severely, but he felt a little of it continally.
Had been subject to it about a year and a half. His friends attributed it to r fall
on the back of his neck on some stones, but he did not himself do so. He died
very suddenly, but was not examined after death.

1868.]

Ogle's Fatal Cases of Tetanus, ^c. 485

Spinal cord. — This structure was healthy, excepting the dorsal
portion, which was softened throughout its substance.

Aidomen. — Blood was found extravasated behind the peritoneum
at the posterior part of this cavity. The various organs appeared
natural.

Remarks. — Notice the affection of the peroneal nerve ; its softened
state, &c. ; also the softening of the spinal cord. [270.]

Case 4. — Tetanus following a wound and fracture of the foot and

gangrene.

William L — , set. 22, was admitted into St. George's Hospital,
January 20th, 1844, with a contused lacerated wound of the foot and
fractured bones. There was much tension and inflammation requiring
incisions. After separation of the toes by gangrene and the knife
on the 28th day after injury, there was stiffness of the muscles
of the neck and shoulders, and on the day following the jaw was
" locked." Some dyspnsea and dysphagia and general spasms,
with depression and anxiety came on. The spasm became more
frequent and violent, and the urine and motions were passed invo-
luntarily. On the 29th day after injury (January 31st) he died
suddenly in a violent convulsion fifty-eight hours after the commence-
ment of the tetanic symptoms.

Post-mortem examination thirty four hours after death. — The
nerves of the foot were examined, but presented nothing unnatural.
Spine. — Congestion of the spinal veins and of the veins (posterior)
of the spinal marrow was great. Clear fluid existed in the theca
vertebralis. The medulla spinalis was natural.

Cranium. — The brain was natural, but its veins were congested.

The medulla oblongata and pons Varolii showed much vascularity.

Remarks. — Notice the coming on of symptoms on the twenty-
eighth ^^y ^iitx\Xi]\yx^ . Sudden death in a convulsive attack. [26.]

Case 5. — Hydrophobia and tetanus following the bite of a dog.

Mania.

Charles E — , set. 13, was brought into St. George's Hospital June
11th, 1844. He had been bitten by a spaniel in the hand^^fj/days
previously. The dog had been ill for three or four days, and became
worse, being affected by frequent catching and snapping of the jaws,
and died very shortly after inflicting the injury on the patient. The
dog had also bitten a cat, which, after constantly running up and
down the stairs, refusing food, &c., had died after several convulsive
attacks. The wound on the patient's hand healed in three days, and
he remained well until June 11th, when, as he was being washed by
his mother, he refused to let her wash his face, putting his hands to

486 Original Communications. [Oct.,

his face in great fear and saying that he felt as if he was about to be
choked. In the course of the day he was brought to the hospital.
The pulse was frequent, the skin hot and dry, the tongue furred, the
fauces injected, and there was slight difficulty in swallowing. During
the night of the 11th the patient obtained no sleep, and on the
morning of the 12th he w^as greatly distressed, and the countenance
became very anxious on the slightest disturbance. The least breath
of air, the noise made in pouring out water, and the sight even of
water, or the idea of swallowing it, brought on violent spasm of the
muscles of the throat, principally those connected with deglutition.
The patient said he had pain in the throat on any attempt to
swallow, which was attended with much convulsive effort. The
spasms became more frequent, and his mental faculties, which
had been unimpaired, became affected. Thus confusion of thought
and visions of unreal things and persons around him came on, and
in the evening he became quite maniacal, talking incessantly and
foaming at the mouth.

On the 13th, between one and two o'clock a.m., he had several
attacks of general spasms, of which two were very severe and
attended by emprosthotonos. After this he_ became collected
and freer from spasm, and took some beef tea without much
difficulty. He was, however, greatly exhausted, and his expression in-
dicative of great anxiety. At 10 a.m. he again became violent, talking
incessantly, and refusing to take anything, shouting and singing,
and vomiting a black matter, which he brought up with hiccough ;
the respiration was greatly hurried but not difficult. At one p.m.
the delirium continued, but the patient was evidently very much
weaker. The pupils were dilated, the eye wild and prominent, and
the mouth constantly filling with dark-coloured foam, which he
snatched with his fingers and threw at the bystanders. The
extremities were cold and the hands blue. The pulse and action of
the heart became more and more enfeebled, and the patient quietly
and gradually sank, and died at two p.m.

Post-mo7iem examination 24 Jiours after death, and the weather
being extremely hot. The brain was found to be very dark and
congested generally, the grey matter being very pink. It was also
softer than natural throughout. The cerebral membranes and ven-
tricles presented nothing unusual, and no unusual sub-arachnoid
or ventricular fluid existed. The cerebellum, pons Varolii and
medulla oblongata congested and pink, like the other parts of the
brain. The substance of the medulla oblongata was carefully ex-
amined, by the microscope, by Mr. Toynbee and Dr. B. Jones, and,
as I learn from the latter gentleman, showed nothing unnatural. The
spinal cord and membranes were natural. The pharynx and fauces
were very vascular as well as the upper part of the larynx. The
lower part of the larynx and the bronchi were somewhat vascular ;

1868.J

Ogle's Fatal Cases of Tetanus, ^c. 487

and the lungs, which contained some small deposits of scrofulous
matter, were much congested posteriorly. The pneumogastric
nerves on both sides were examined, and found to be healthy. The
heart was natural, the contained blood being dark and thick, and
mixed with a small amount of dark coagulum. The mucous mem-
brane of the oesophageal end of the stomach was rather congested ;
also the spleen and kidneys. The other parts of the body were in a
natural condition.

Remarks. — ^This case is one of a most interesting nature, as
showing the complication of hydrophobia and tetanus.' Thus
we have the intense spasm, the snapping, the emprosthotonos
and the dysphagia of tetanus, accompanied by the choking feeling
and distress consequent on the stimulus of the cold water to the
face or even the very thought of water (emotional), the peculiar
form of spasm observed in hydrophobia. The foaming also is
remarkable, being such as occurs commonly in epilepsy, though
by no means distinctive of that affection. The case is one which
seems to a certain degree to link together all the three forms
of disease — hydrophobia, tetanus, and epilepsy — under one common
pathological classification. Given, excessive irritability of the
common spinal centre arising from agents acting either cen-
trally or peripherally through the centripetal nerves, we have
resulting from the application of any suitable exciting stimulus
or irritation, motor action or spasm, which may either be of
the general muscular system as in epilepsy ; or of particular
regions as those of the jaw, neck, throat, or back, &c., as
in tetanus ; or more especially of the throat and pharynx, as in the
present case of hydrophobia, the spinal derangement being attended

^ This is the only case of hydrophobia, I believe, that we have ever had in our
hospital. For the following case of chorea, in which symptoms were presented
simulating hydrophobia, I have to thank Dr. Benee Jones :

Sarah Williams, aet. 17, was admitted into St. George's Hospital, May 22ud,
1839, with chorea of a fortnight's duration, and with a general cachectic appear-
ance, the twitching being confined to the right arm and leg. Pulse very weak
and quick. Bowels open. Tr. Ferri Amm., 5ij, Ammoniac Sesquicarb., gr. vj.
Mist. Camph., 5x, Syrupi, jj ; bis die. Pil. Aloes c. Myrrh., gr. vj omni noct. Bal.
Imbrif. omni mane. Ordinary diet, without vegetables.

27. Bandage to the ankle.

29. Omitr. Bal. Imbrif. Want of power over the right arm. Irregular action
of the muscles much diminished. Einp. Canth. nucha), rep. alia.

31. Some increased power over the right arm since the blister.

June 3. Tr. Assafcet., 3j ; Liq. Cal., 5j ; Aquae Cinnam., §ss ; Syrupi, 3j ; ter
die.

5. More movement of the leg and arm on the right side. Bal. Imbrif. orani
mane. 76.

10. Perstat. Great improvement in power over the lower limbs.

22. Mist. J^tberis Co. 5iss, statim ; Enema aper. hac vesp.

23. Calomel, gr. V, statim. ; Ht. Senna;, post horas iv; Cue. ad ^^ij nnchaej
Ht. Salin. 4ti9 horis ; Bal. tepidum hora somui.

24. Was attacked the night before last with violent spasms, principally of the

488 Original Communications. [Oct.,

by cerebral disturbance, as in the present instance, with mental
delusions, and even mania. The detailed points worthy of remark
in the case are — 1st, the length of time which elapsed between the
time of the seizure and the commencement of the symptoms, viz.,
Ji/li/ days, during which period no uneasiness either about the injured
part or in the body generally was complained of ; 2nd, the existence
of emprosthotonos, a much rarer form of spasm than its counter-
part, opisthotonos; 3rd, death by exhaustion; 4th, the presence
after death merely of a congested state of the brain ; the spinal
cord and the cerebral and spinal membranes being healthy, and no
increased serous effusion existing either within the cranium or
spinal column. The generally softened state of the brain may be
fairly attributed to approaching decomposition, owing to the great
heat of the weather and the long time which had elapsed between
death and the post-mortem examination. (136).

Case 6. — A second attack of tetanus, apparently not traumatic.

James G — , set. 26, was admitted into St. George's Hospital De-
cember 31st, 1845, quite unable to open his mouth and with some
dysphagia. There was also stiffness of the muscles at the back parts
of the neck, and pain at the sides of the face in the temporal and
masseteric regions. The attack had begun the day before, and very
much in the same manner as did a previous and similar one which
he suffered from about a year previously. At that time he was
attacked with stiffness about the jaws and pain, which first began
in the right and afterwards in the left side of the face, and was
attended by pain in the eyes and ears. All his symptoms were
at that time worse during the night. He was brought into the
hospital, and went out quite well in a week's time.

On this, his second admission, he was freely cupped and blistered
at the back of the neck.

On the 1st of January the pain was so bad at the side of the

muscles of deglutition simulating hydrophobia. She used the warm hath last
night, and was cupped with great advantage. At present the involuntary-
motions of the muscles of the arm are greater than they have been during
the last few weeks. Is at present working herself into an hysterical lit. Ht.
^theris Co. statim ; Bal. tepidum vespere ; postea emp. Canth. spinae.

27. The blister-sore well. The involuntary action of the muscles continues very
violent. Deglutition is again difficult. Her senses remain entire. Enema
Terebinth. Bal. tepid, vespere ; Acetatis Morphlae, gr. i ; Aceti, gr. vj ; Aquae
fort., 3x ; Syrupi, 5,] ; hora somni.

28. Rep. enema Terebinth, cal., gr. v, in pulv. hac noct. ; Ht. Sennse mane.

29. Quieter night; involuntary motion much less to-day. She appears to have
been relieved by the shower-bath. Bowels open freely. Swallows with difficulty.
Rep. Ht. Morphiaj hora somni ; Bal, Imbrif. eras. mane.

July 1. Passed a restless night. Has been relieved by the shower-bath. Bowels
not open. Ht. Sennse.

Went out at her own request.

1868.] Ogle's Fatal Cases of Tetanus, S^c. 489

face that leeches were applied^ and with relief. The bowels were
open. The pulse small and weak, but regular. Abdomen tense and.
hard. Turpentine injections were given.

On the 2nd no relief had resulted from the injections, but the
face was better owing to fomentations. Poultices to the sides of the
face were ordered, also beef tea was freely given, and calomel and
opium every four hours.

On the 5th the pills were omitted as ptyalism had come on. The
patient was much the same.

On the 6th there was less pain in the jaw, and much less tight-
ness about the throat. The abdomen was less tense and hard, and
the patient said he was much better, but the mouth was still quite
closed. Alum gargle ordered to be freely used.

7th. — The pain and stiffness had more abated, but a pain was
complained of under both axillse. The abdomen was natural, and
the bowels open.

8th. — The abdomen was very painful, and the muscles in a state
of tonic tension. There was no tympanitis. There was dyspnoea
and slight dysphagia and pain with a diffused redness of the integu-
ments at the upper parts of the back. The muscles of the neck or
back were, however, not contracted. All pain in the sides of the
face had gone, but the countenance was haggard. The bowels were
confined, and the pulse quick. No sleep could be obtained.
Morphia was given and a blister applied to the chest. As the pain
proved excessive, tincture of opium (20 drops) and again 40 drops
were given before the next morning.

On the 9th the jaw could be slightly opened, and the pain in the
abdomen and side was less. There was, however, pain on respira-
tion, and the muscles of respiration seemed rather fixed. Some
dysuria was complained of. Cough with expectoration existed, and
some dullness on percussion at the lower parts of the left side of
the chest, both in front and behind. The tongue was white; the
skin cool ; pulse weak. A third of a grain of tartar emetic was
given every six hours and a blister applied to the chest. In the
evening, as more pain existed in the chest, tincture of opium was
given.

On the lOlli he was very restless, and the pain at the side was
increased, but that in the abdomen had left him. Pulse 95.

On the 11th great pain in the abdomen was coraj)lained of,
whilst that in the chest was less. No pain existed in the face.
Great prostration of strength existed. The pulse was weak, and the
skin hot. Leeches were applied to the abdomen, and brandy given.

On the 12th, early in the morning, as the pain was intense at the
abdomen, tincture of opium was given. During the day collapse
and dyspncea came on, and the patient sank and died.

Post-inortem examination, 19 hours after death. The masseter

490 Original Communications. [Oct.,

muscles were found to be very contracted. The brain was itself
natural, excepting the existence of many and large bloody puncta
or section of it. Much sub-arachnoid fluid and adhesion of the dura
mater to the cranium existed. The spinal cord was natural. Both
pleural cavities contained pus and recently-exuded fibrine, and
the left lung was highly hepatized. Pus and recent fibrine also
existed in the pericardial sac and in the peritoneal cavity.

Remarks. — The points of interest worthy of notice in the above
case are — 1st, the absence of any known traumatic cause of the
attack ; 2ud, the repetition of the attack, a similar one having
previously existed, and being recovered from quickly; 3rd, the
affection beginning by rigidity of the jaws ; 4th, partial remission of
the symptoms ; 5th, the supervention of extensive inflammatory
disease in the thoracic and abdominal cavities, the symptoms of
which it became necessary to distinguish from those strictly tetanic
in character ; 6th, death apparently from exhaustion. [15.]

Case 7. — Tetanus following fracture of the hones of the hand.

George M — , set. 42, was admitted into St. George's Hospital
January 31st, 184<5, with a compound comminuted fracture of
some of the matacarpal bones of the hand. Portions of the
fractured bones were removed. The wound suppurated foully, but
improved under the green dressing (sulphate of copper) .

February 8th. — Sickness was complained of, and uneasiness in
one of the axiUse ; and on the 9th febrile symptoms set in, and the
absorbents of the arm became inflamed. Decoction of bark with
Liq. Ammon. Acetatis was given.

13th. — The redness .was less, but when the tongue was protruded
rigidity of its muscles was complained of. Wine was ordered in
addition to the medicine.

14th. — An erysipelatous state of the arm came on, and an abscess
formed, which was opened on the 18th, when also, in addition to the
rigidity of the tongue, rigidity of the jaw came on, so that he could
only slightly open the mouth.

On the 19 th there was a very anxious expression, and the muscles
of the forehead were very rigid. The muscles of the neck were not
affected.

On the 21st the muscles about the throat were rigid, and the
mouth was quite closed. Morphia was given, and turpentine
injections.

22nd. — Muscles of neck more rigid. The oil of turpentine in
drachm doses given.

24th. — Muscles of neck less rigid, and powers of speech greater.

25 th. — Some uneasiness about the epigastrium, and slight

1868.] Ogle's Fatal Cases of Tetanus, ^c. 491

opisthotonos came on. Sanious purulent fluid was discharged from
the abscess. The turpentine injections have been repeated.

26th. — Muscles of neck more rigid. Pulse 128.

27th. — Several tremors of the lower limbs took place. Dysphagia
and fits of sneezing caine on. Perspiration profuse.

28th. — Muscles rather more relaxed. Injection repeated.

March 1st. — Universal trembling of tlie limbs came on, and also
pain at the epigastrium. Extreme depression supervened, and
finally death.

On post-mortem, examination, 35 hours after death, the muscles of
the jaw were very rigid, but not so the other muscles of the body.
The brain was very wet and congested, as was also the pons Varolii
and medulla oblongata. The spinal cord was natural. Both lungs
were hepatized in patches. The heart's cavities contained large
fibrinous coagula, and its walls were softer than natural. The
spleen was very soft and congested.

Remarks. — 1st. The history of this case shows very clearly the
course which the symptoms took ; for instance, on the thirteenth day
of the month we have noticed the stiffness of the muscles of the tongue ;
on the eighteenth, the affection of the muscles of the jaw ; on the
twenty-first, the affection of the muscles of the throat ; on the
twenty-fourth, slight remission in tlie rigidity of the muscles; on
the twenty-fifth, opisthotonos and epigastric uneasiness; on the
twenty-seventh, dysphagia and tremors of the lower limbs; March
1st, universal trembling. The early date of the affection of
the lingual muscles, and the late period of the opisthotonos are
specially interesting ; as also the " partial remission " of the
symptoms. 2nd. The presence of disease of the lungsis worthy
of note. 3rd. The mode of death, by depression, must be ob-
served ; and also, 4th, the rigidity of muscles after death, confined
to those of the jaw. [54.]

Case 8. — Tetanus following a hum.
Sarah W — , set. 19, was brought into St. George's Hospital
December 28th, 1846, with an extensive burn of the upper ex-
tremities and back, chiefly superficial, owing to a hot cinder falling
on her dress. She was warm, and her general condition was hopeful
on her admission. She went on favourably, the sloughs separating
well, until January 5th, when she became weaker daily, and the
discharge from the burns became fcetid. Her respiration also
became much hurried, and on the 6th and 7th of January was very
laborious. The pulse also became weak and frequent, and the
countenance was expressive of much suffering. The tongue was
inclined to be dry, but was clean. On the 8th of January, slight
stifliiess in the jaws was complained of, accompanied by pain, and
these symptoms increased until decided trismus was established.

493 Original Communications. [Oct.,

On the morning of the 9th, the jaws were firmly fixed, and their
muscles very rigid, and throughout the day occasional attacks of
dyspnoea catne on, but no general spasms. The perspiration was
very profuse, and the patient became weaker, and died on the 10th.

Post-mortem examination. — All the viscera were found to be
healthy.

Remarks. — The points of interest in this case are — Istly, the
occurrence of untoward symptoms first on the eighth day after the
injury, but it is difficult to say whether the dyspusea wliich at that
time came on should be attributed to a tetanic condition of certain
muscles engaged in respiration, or to some congestion of the bron-
chial or pulmonary vessels such as is not uncommon in cases where
destruction of any extensive part of the. skin from any cause has
taken place; the dyspnoea being paroxysmal, and the lungs and
bronchi being found natural after death leaves one at liberty to sup-
pose these symptoms to have been of a tetanic nature. 2ndly, the
accession of stiffness about the jaws on the eleventh day after the
burn. 3rdly, the absence of any more general spasm, emprosthotonos,
&c. 4thly, the uniform persistence of the spasmodic state of the jaw-
muscles, no remission being observed. And, 5thly, the method of
death, being that by exhaustion, aided possibly to some extent,
although not very materially, by that of apnoea, consequent on the
rigid state of the respiratory muscles. [17.]

Case 9. — Tetanus following a wound of the cornea of the left eye.

Tiiomas S — , set. 33, was admitted into St. George's Hospital
January lOtli, 1847, into the hospital, with a wound of the left
cornea; an opening being made by a whip lash, through which
the aqueous humour had escaped. On admission, much redness
and tension of the eyelid existed, preventing free opening of the
eye. On the 12th of January, inflammatory fever set in with
pain in the globe of the left eye and in the forehead, and on the
16th suppuration of the eyeball, giving much relief to the pain.
The mouth became drawn to the right side, and the whole counte-
nance expressive of great distress and agitation. The patient also
complained of slight pain, with stifi'ness about the jaws. On the
1 7th decided symptoms of tetanus had come on ; there was great pain
in the jaws and neck, and the jaws were firmly closed. On the 18th
much purulent fluid escaped from the affected eyeball, an incision
having been freely made into it ; and throughout the day all the
peculiar symptoms became aggravated, the patient sitting for hours
holding the jaws in his hand, in great suffering. Besides rigidity
and hardness of the masseter and buccinator muscles, there was
rigidity of both sterno-cleido-mastoid muscles, especially of the
left one. The muscles at the back of the neck were not affected.

1868.] Ogle^s Fatal Cases of Tetanus, ^c. 493

During the paroxysms of spasm of the affected muscles which
occurred at longer or shorter intervals, the respiration was inter-
fered with, becoming hurried and interrupted, and performed with
convulsive energy for a few seconds at a time. These attacks be-
came more and more frequent, and the patient gradually weaker.
During the night of the 19th, violent spasm of tlie muscles in front
of and at the back of the body came on, and during most of the
night alternate attacks of emprosthotonos and opisthotonos took place,
the respiration being greatly interrupted. The patient died early
on the morning of the 20th.

Post-mortem examination. The muscles of the body generally
were found to be very rigid. The left eyeball was somewhat shrunk,
tlie lids being closed by purulent fluid. The brain presented, on
section, numerous bloody puncta, and the vessels of the dura mater
as well as the surface of the brain were greatly engorged, the cor-
tical parts being very pink. The mucous membrane of the fauces,
specially the upper part, was very congested, as was that of the
trachsea. The lungs were congested, but otherwise natural. The
heart was natural, with its cavities contracted, the blood contained
being unusually fluid. The contents of the abdomen presented no-
thing unusual. On examining the orbit, the eyeball was found to
be almost entirely occupied by purulent fluid, and recently effused
fibrine existed amongst the muscles. The optic nerve presented
nothing unnatural.

Remarks. — The case is interesting. Istly, from the unusual
form of injury giving rise to the symptoms, the cornea of the eye
being the affected part. 2ndly, from the sixth day after injury
being that on which the symptoms set in. 3rdly, from the occur-
rence, first of the rigidity of the jaw-muscles and of those at the
anterior part of the neck, the muscles at the back of the neck being
free. 4thly, from the accession of alternating emprosthotonos and
opisthotonos, showing that the existence of those forms of spasm
was not owing simply to over action of one set of muscles, the
other and antagonistic ones being overcome by reason of their com-
parative weakness, but was due to the pecuhar capricious character
of the affection, different series of muscles being affected. And
5thly, it is interesting as much as there was no remission of the
severe symptoms. [34.]

Case 10. — Tetanus following extensive laceration of the thigh.

C. E. K — , set. 10, was brought into St. George's Hospital May
15th, 1849, having an hour previously extensively lacerated the fore
part of the thigh by falling on an iron spike. On the next day
sphacelus of part of the integument had come on, and much febrile

84— XLii. 32

494 Original Communications. [Oct.,

action speedily assuming a typhoid character came on with delirium.
The slough separated, and after a time the pulse gained in power,
and general action was much less depressed, the wound going on
well. On the thirteenth day after the accident, the jaws were
noticed to be slightly stiff, and there was pain and distress at the epi-
gastrium, and in a few hours decided trismus had set in. Turpen-
tine lit XX. was given every four hours. On the following day, slight
opisthotonos and great tenderness and tension of the abdomen came
on. There was great prsecordial distress, and the slightest pressure
at the epigastrium brought on strong spasm. The jaws became quite
closed, and the arms involved in the general tetanic action; degluti-
tion became difficult, and at last almost impossible. The alvine
evacuations were dark and offensive, the skin moist. Pulse from 120
— 140, and feeble. At first the spasms were shght, and occurred at
intervals of about half an hour, but they daily increased in strength
and frequency, and during night of June 1st he had two violent
attacks, in the last of which he died.

Post-mortem examination. — Two sloughing wounds were found,
one occupying the front and outer part of the left thigh and another
of the size of half-crown on the outer side of the left hip.

The blood-vessels inside the spinal canal were very congested, and a
small amount of extravasated blood was found on the posterior sur-
face of the dura mater, corresponding to the lower part of the cervical
and the upper of the dorsal part of the cord. The dura mater of the
cord was slightly thickened and opaque. The other membranes
were healthy, the spinal cord itself quite healthy, as also the brain and
its membrane. Excepting slight congestion, the thoracic and abdomi-
nal organs were natural.

As regards the wound of the thigh, &c., some of the branches of
the anterior crural nerve in the situation of the wound appeared
more vascular than natural. Nothing more was found.

Remarks. — Notice 1, The traumatic origin of the disease ; 2,
The fact of the tetanic spasm commencing, and that in the jaw-
muscles, on the thirteenth day after the injury ; 3, The congestion,
even to extravasation of blood within the spinal canal, and the vas-
cularity of the nerve in the neighbourhood of the wound. [118.]

Case 11. — Tetanus following a comminuted compound fracture of

the leg.

George P — , set. 27, was admitted February 22nd, 1850, into
St. George's Hospital, having an hour or two previously suffered
a compound and comminuted fracture of both bones of one leg.
lie went on well until the 25th, when much swelling and tension of
the limb requiring incisions came on. On the 27th there was much
foul suppuration, the pulse, however, being quick and the tongue clean.

1868.] Ogle's Fatal Cases of Tetanus, ^c. 495

On the 28th the leg was very painful and more swelled, and he had
passed a sleepless night. There was slight stiffness of the jaws,
but there were no general convulsions and no dysphagia, etc. The
skin was hot and dry, the tongue coated, and the pulse 120, and
rather full. Incisions into the leg were made, letting out much pus.
A calomel and scammony powder was given, and at night a morphia
draught given. On the 1st of March very decidedly tetanic symp-
toms came on. The countenance was much altered, the mouth was
firmly closed, and there was violent spasm of the muscles of the
back, the chest, arms, and legs, slight opisthotonos existing. The
injured leg was more swelled, and the wound gangrenous. The
pulse was 120, but not weak. The skin was dry and the bowels
confined. A turpentine injection was administered and half-drachm
doses of turpentine given internally every six hours. The injection
brought away no fsecal matter, and the patient became worse, and the
spasms more frequent. The patient sank gradually, and died at six
a.m. on the 2nd.

Post-mortem examination jifty-five hours after death. — It was
found that the posterior tibial nerves passing through the sloughy
mass were covered by a coating of recent fibrine, on the removal
of which the neurilemma of the nerve was discovered to be in a
highly vascular condition. A portion of the peroneal nerve included
within the slough presented also a very vascular and almost a sloughy
condition. The other parts of the body were examined, but nothing
unnatural was found.

Remarks. — The points of interest about this case are — Istly, the
accession of tetanic symptoms on the sixth day. 2ndly, the stiffness
of the jaws, without any dysphagia, showing itself first of all the
symptoms. And 3rdly, followed on the seventh day by general tetanic
convulsions, the extremities being affected as well as the back and
thorax. 4thly, the absence of any remission in the symptoms.
5thly, the mode of death being by exhaustion. 6thly, the extensive
implication of large nerves in the sloughy wound. [41.]

Case 12. — Tetanus, apparently caused by an ulcer of the leg.

Henry M — , set. 63, was admitted into the hospital June 10th,
1851. It was said by his friends that he had been suffering for
some days previously from slight fever, but no cause for the attack
of tetanus was known. On the morning of the day of admission he
had been suddenly seized with difficulty in moving the lower jaw,
and very shortly afterwards became affected with general tetanus.
When admitted the whole body was in a state of spasm, opistho-
tonos existing. Turpentine was given in half-drachm doses every
four hours, and a turpentine injection administered, which produced
a copious discharge of fsecal matter. During its administration the

496 Original Communications. [Oct.,

nurse detected a small ulcer under the right knee, whicli turned out
to have been produced by the tying of a bandage round the knee
very tightly for support to the part. It was found that the patient
could only swallow a little of the turpentine, and the general spasm
continued until coma set in, of which he died. A second turpentine
injection was given ; but the patient died shortly afterwards, on the
day following his admission.

Post-mortem examination thirteen hours after death. — The body
was found to be in good condition and well made, with a small ulcer,
having livid margins and surrounded by redness of the skin, behind
the right knee, below and to the outer side of the flexure of the joint.

The spinal cord, excepting being generally rather softened, was
healthy.

The brain was natural, excepting slight general softening.

The lungs were healthy ; the heart was enlarged, with thinning
of the walls of the right ventricle. The abdominal viscera were
natural.

On examining the ulcer the surrounding parts were found to be
.callous, having the peroneal nerve imbedded within, but not appa-
rently much compressed by them, just as it turns round the fibula.
There was no redness or injury of the nerve itself.

RemarJcs. — The points of interest in this case are — 1st, its sup-
posed idiopathic character until the ulcer was accidentally found ;
2nd, the pre-existence of febrile symptoms before the spasm set in ;
3rd, the muscles of the jaw being the first to be afi'ected ; 4th, the
short duration of trismus before the general spasm set in; 5th, the
mode of death being that by coma.

The general softening of both the brain and spinal cord was most
probably dependent on the approach of decomposition. (3.)^

The two following cases may be termed tetanoid, exhibiting
spasms arising from affections of the nervous centres, and may be
well compared with true tetanus.

Case 12 a. — Tetanus with twitching s following a fall in a patient
affected by scrofulous deposits within the brain.

James S — , set. 15, who was admitted into St. George's Hospital
April 1st, 1851, having fallen from a horse and struck the back of
the head seven days previously. Tor two days after the accident he

' In the same year (1851) the following case was brought into the hospital,
illustrating a disposition to tetanic spasm, and it may here be timely quoted. It
was that of James P— , set. 40, who had fallen from a height and sustained
fracture, with depression of the left parietal base and correspondent laceration of
the dura mater, and also laceration of the surface of the brain. Trephining was
resorted to, and the patient went on well for four days. After this he lost all
power of speech, though he retained his mental powers. On the least exertion,

1868.] Ogle's Fatal Cases of Tetanus, S^c. 497

was insensible, but subsequently became partly conscious tliougli
drowsy. After this, inflammatory symptoms were set up, and
great struggling, with twitchings of the arms and legs, which first
began in the legs.

On the 5th of April, strabismus came on, and the jaws became
firmly closed, and so remained for two or three days.

Post-mortem examination twenty-nine hours after death. — Extensive
serous effusion in the cerebral ventricles and beneath the arachnoid
membrane were found ; and scrofulous deposits in the substance of
the brain. Excepting congestion of the blood-vessels nothing un-
usual M'as noticed about the membranes of the brain or spinal
cord. The other organs of the body were natural. [76.]

Case 13. — Opisthotonos connected with diffuse Inflammation of the
Spinal Membranes following puncture of a Spina Bifida.

Lewis M — , set. 20, was admitted into St, George's Hospital June
25, 1852, with a large tumour, of the size of a man^s head, attached
to the lower part of the back, which fluctuated, and had one or two
ulcerations on its surface. It appeared that the tumour, which
had existed since birth, had burst once or twice previously, and had
discharged clear fluid ; and at these times some twitchings had been
observed, and the bowels had acted involuntarily. A trocar was
passed, and much albuminous liquid let out. This was folloM^ed by
pain in the head and belly and retraction of the head, whilst, how-
ever, the superficial muscles of the neck were quite flaccid. The
evacuations w^ere passed unconsciously. The head gradually became
drawn back, and fixed so as hardly to form a right angle with the
spine ; and pain at the sternum, with dysphagia, came on. Inflam-
mation of the surface and bursting of the tumour took place, the
pulse gradually failed, and the patient became unconscious and died,
the deep muscles of the neck becoming more tense, and the head
more dragged back until death.

Post-mortem examination. — The cyst which communicated with
the spinal canal was found lined by recently formed fibrine, and the
arachnoid and pia mater of the lower part of the chord showed
decided evidence of inflammation, being coated by recent fibrine.
The chord itself was also softened at the lower part of the dorsal
region.

The details of this case are not here given, ^ as it is only adduced

and when he was touched or spolcen to, convulsive action came on, and the muscles
of the lower jaw were especially affected, the face being drawn to the left side.
The patient died comatose. (' P, M. Book,' 1851, fol. 175 ; also ' Hospital Cata-
logue,' series viii, No. 66.)

^ The case has been related at length by my colleague Mr. Holmes, in the
• Transactions of the Pathological Society of London,' vol. iii, p. 10.

498 Original Communications. [Oct.,

witli reference to the tetanic symptoms whicli carae on, and which
were obviously connected with the inflammation of the spinal chord
and its membranes, for which he was treated.

Remarks. — The points worthy of attention in the case are —
1. The absence of any remission in the tetanic symptoms. 2. The
spasm of the deep muscles of the neck, whilst the superficial ones
remained relaxed. 3. The order of the symptoms, the pains in the
belly and head following the spasm of the neck, and being followed
in their turn by the dysphagia and pain at the lower parts of the
«5ternum ; and 4. The death apparently from exhaustion. [141.]

Case 13a. — Tetanus following ulceration of the integuments about

the knee-joint.

Martha K — , set. 44, was admitted into St. George's Hospital April
11,1852, having been thrown down by a bull, and thus incurred a lace-
ration of the integuments of the right knee just above the patella. The
accident occurred March 28th. The wound had gone on fairly well
until April 9th, when the lower jaw became fixed, and so remained. On
admission she could just move the jaw, so as to separate the teeth a
very short distance, and the muscles closing the jaw were very rigid
and contracted. She could speak plainly, and could drink small quan-
tities provided she swallowed slowly ; but if she tried to swallow
quickly, choking sensations came on. The wound was very large, and
healthy in appearance, having a free discharge, but it was very tender ;
the patella was not exposed. No pain was complained of, except when
the wound was touched. After admission the bowels were freely
opened with a calomel purge, and she was put on calomel and opium
every four hours.

On the 12th she seemed comfortable. The expression of the face
was natural. The pulse was 104, and rather weak. Porter was
given to her, and the calomel and opium continued.

On the ]3th the jaws were more firmly fixed, and a peculiar
grinning expression of the face existed; moreover, the powers of
speaking were interfered with. Much pain was complained of about
the jaw and occasional attacks of spasmodic dyspnoea. The pulse
was regular and 100. The bowels were not open. The gums were
distinctly affected by the calomel. She was purged, the calomel and
opium were discontinued, and the hydrocyanic acid given, six minims
every three hours.

On the 14th the patient was very weak ; the pulse was very feeble
and quick. She could with difficulty swallow anything owing to
choking sensations, and the muscles about the back of the neck were
very rigid, the head being slightly drawn back. Occasional pain
was felt near the lower end of the sternum. The bowels were not
open. The wound of the leg was deeper, and rather sloughy.

1888.] Ogle's Fatal Cases of Tetanus, ^c. 499

Oil the 15th the rigidity of the muscles of the neck and jaw was
diminished^ but she had been unable to swallow since the noon ot
the previous day. The bowels being confined, two aperient enemata
were given without any result.

On the 16th she had become greatly exhausted, and the pulse
imperceptible. The pain at the end of the sternum had increased,
and the skin was covered by cold perspiration. The patient was
quite sensible ; slie gradually sank and died in the evening.

Fost-mortem examination. — The body was emaciated and the
patella was found deprived of its periosteum. The knee-joint itself
was natural.

Within the cranmm the subarachnoid fluid was slightly increased,
and the brain generally rather more vascular than natural.

Within the spinal column the veins at the posterior part were full,
and the whole of the cord was slightly softened from decomposition.

The contents of the thoracic and alsdominal cavities were natural.

Remarks. — The points of interest in this case are — 1st, the order
of succession of the symptoms, the lower jaw becoming fixed on the
twelfth day after the injury, on the sixteenth day the spasmodic
dyspnoea coming on, and on the seventeenth day the muscles of the
neck becoming rigid and the head drawn back ; 2nd, the occasional
pain near the end of the sternum ; 3rd, the sensibility and conscious-
ness remaining until the last ; 4th, the partial remission of the
symptoms ; 5th, the method of death being apparently that by ex-
haustion. (93.)

Case 14. — Tetanus following a lacerated wound of a hand and fracture
of the hones of a finger.

Isaac B — , set. 26, was brought into St. George's Hospital August
25th, 1852, having attended for about one week as an out-patient,
owing to a lacerated wound of the right hand and fracture of the bones
of a finger. One of the joints of the finger was also torn open, and
much inflammation with sloughing of the wounds resulted. After
admission he was treated by wine and good diet, and considerably
recovered ; but on the morning of the 29th the patient complained
of " sore throat" and pain about the middle of the abdomen, and in
the course of the day decided symptoms of tetanus set in, the jaws
being fixed and the head being forcibly drawn back at times with
much pain.

On the 30th the jaws were so fixed that they could not be sepa-
rated beyond a quarter of an inch, and the face assumed a peculiar
grinning expression, the masseter muscles being very rigid. Any
attempts to swallow usually brought on attacks of opisthotonos, but
he could swallow fluids. There was also pain in the back and ab-
domen, and some difiiculty in moving all the limbs. No sleep had

500 Original Communications. [Oct.,

been obtained. The pulse was quiet and natural and the bowels
open. A turpentine injection was administered and calomel and
opium given every six hours. In the evening a moxa was applied
to the back.

On the 31st the patient said he thought he was better. The
muscles of the jaws were less rigid; the spasms, though frequent,
were less severe; and the limbs could be moved with greater ease.
No sleep could be obtained. The pulse was very weak, and about
134 in the minute; and perspiration was profuse. During the
afternoon the spasms became more intense, and the patient was ob-
viously sinking. The urine was noticed to be turbid and of a
greenish hue, and was also found highly albuminous and containing
blood-globules.

At about 5 a.m. on the 1st of September the patient died in an
attack of spasm.

Post-mortem examination, thirty -three hotirs after death. The
integuments generally were found to be much congested. Great
rigidity of the muscles of the lower limbs existed, but only slight
rigidity of the upper ones.

The spinal cord generally and the central white parts in the brain
were much softened, and the veins within the cranium and spinal
column were highly congested.

Nothing more of note was observable about the nervous centres.
The kidneys were very fatty, and slight extravasation of blood was
found beneath the mucous membrane of the pelvis of one of them.
The other abdominal viscera presented nothing unnatural. The
heart and lungs were healthy. Some old pleuritic adhesions
existed within the chest.

Remarks. — The points of interest in the above case are — 1st,
the appearance of symptoms on the tenth day after the injury, the
first symptoms being fixedness of the jaws and pain in the abdomen,
being preceded for a few hours by a feeling about the throat described
by the patient as a " sore throat ;" 2nd, the production of opistho-
tonos on attempts to swallow ; 3rd, difficulty in moving " all the
limbs;" 4th, the partial remission of symptoms not long before
death; 5th, the sloughy state of the wound and the co-existence of
disease of the kidneys.

The pains continued in the back and abdomen may have been
simply the result of the spasmodic action of the muscles of those
parts. [174.]

Case 15. — Tetanus following wounds of the scalp and thumb.

Eobert H — , set. 43, of good general health and temperate, was
admitted into St. George's Hospital June 20th, 1854, having been
thrown from a restive horse on the same day. He had a scalp wound

1868.] Ogle's Fatal Cases of Tetanus, ^c. 501

on the left side of the forehead, not exposing the bone, and also a
superficial wound of the right thumb. The wound of the thumb
was painful on the first day, the pulse was quiet, the tongue clean,
and the bowels open.

On the fifth day after the injury the patient left his bed, as all
had been going on well.

On the sixth day difficulty in opening the mouth came on, so that
the patient could only just protrude the tongue, which was then
greatly furred, and there was much difficulty in swallowing, but no
pain was complained of. The wound of the thumb appeared to be
going on favorably, but that of the scalp was in a sloughy state.
The pulse was 72 and soft, the bowels confined. Calomel and
opium, followed by a senna draught, were given. There was great
difficulty in swallowing the draught; but no spasm was produced
by the act of swallowing, and the patients had a good night.

On the morning of the 27th, at 6 o^clock, a distinct attack of
opisthotonos came on, and the jaws were more firmly closed, so that
the patient could not protrude the tongue at all. The masseters
and abdominal muscles were observed to be rigidly contracted, but
the muscles of the extremities were unaffected. The attack of
opisthotonos passed off" in a few minutes, but the contraction of the
other muscles continued. Attempts to swallow produced spasm
about the muscles of the throat. The patient was quite sensible,
and complained of pain in the back and shoulders, but in no other
part. A purgative enema brought away much dark fsecal matter.
About noon an attempt to swallow induced another attack of
spasm of the muscles of the neck and back, and the expression
became rapidly more distressed, the features becoming pinched and
"sardonic.^' The pulse was 96, ^and very weak. Large doses of
calomel and opium were given, and turpentine injections at intervals.
The spasms continuing, chloroform was inhaled at 7 p.m. After
five or six inspirations of the chloroform, air being properly admitted
along with it, spasmodic closure of the glottis came on, and for
about one minute respiration was quite suspended. He was relieved
by ammoniacal vapour applied to the nostrils, and cold water
affusion to the face ; but the spasms persisted at intervals during
the evening. The pulse became quick but weak. An injection was
given, bringing away copious dark stools, but a second injection was
immediately followed by an attack of spasm. After another such
attack, about 9 p.m., he died ; and immediately after the cessation
of the breathing the lower jaw dropped, and the muscles, which had
been contracted, were observed to be perfectly relaxed and flaccid.

Post-mortem examination twenty-four hours after death. — The
scalp wound was seen to be sloughy, but that on the thumb was
granulating healthily. The contents of the cranial and spinal cavities
were quite natural. The lungs were quite natural ; the heart vA^as

502 Original Communications. [Oct.,

also natural, the ventricles being firmly contracted. The liver and the
kidneys were congested, the latter being large and coarse. The left
frontal nerve in the neighbourhood of the scalp-wound was quite
healthy, and not implicated ; nor were the branches of the median
nerve, which were found passing through the wound of the thumb,
at all affected.

Remarks. — The points deserving attention in the case are — 1st,
the accession of symptoms on the sixth day ; 2nd, the rigidity of the
jaw-muscles and of those connected with the act of swallowing
coming on first, at the same time no pain being complained of, and
good sleep being obtained ; 3rd, opisthotonos coming on upon the
seventh day, the extremities being unaffected; 4th, spasm of the
muscles of the back and shoulders being set up by attempts at
swallowing, and of the muscles of the glottis during the inhalation
of chloroform, as also the general spasm by the act of the adminis-
tration of the enema; 5th, the absence of any remission.

It may be worthy of remark that one of the wounds was sloughy
to the end of the patient's life. It is also of interest to notice the
contraction of the heart's walls found after death, and the very
rapid relaxation of the spasmodically affected muscles which took
place. [164.]

Case 16. — Tetanus from injury to the surface of the fingers (/).

Ebenezer D — , set. 38, a watchmaker, was admitted into St.
George's Hospital March 19th, 1855. He was pale and sickly,
in look, but said that he had always enjoyed good health, except a
slight cough and bronchitic symptoms of two months' duration.
He acknowledged that he often ran small pieces of glass and wire
into his fingers, an evil incident to his calling, but had not done so
of late, and knew of nothing to cause his present attack. On the
evening of the 15th he had been much exposed to wet and cold,
and on the morning of the 16th, when at breakfast, he felt a "tight-
ness" about his jaws, and had to cut his bread rather thinner than
usual in order to get it into his mouth. This difficulty in moving
the jaw increased until the evening of the 17th, when he could only
open his mouth to half the natural extent, and was obhged to place a
j)iece of gutta percha between the teeth ; with this in his mouth he was
admitted into the hospital. When seen his face was flushed, his skin
warm, and his pulse 86 and soft. He complained of an aching pain
between the shoulders, and he had a cough with frothy expectora-
tion, which was only got rid of with difficulty. The jaws were so
closed that the tongue could not be seen, and the muscles of the
neck and abdomen were very rigid, but no opisthotonos existed. His
mental powers were intact. He stated that he had lately slept quite
comfortably as far as the cough would permit him, and that his

1868.] Ogle's Fatal Cases of Tetanus, ^c, 503

bowels were freely open. A blister was applied to the nape of the
neck, and he was galvanized.

On the morning of the 20th the mouth could be opened more
freely, and the muscles of the neck were less rigid. He had had a
good night's rest. The pulse was 72, and rather feeble. The ex-
pectoration was the same. Stimulants were given, and sinapisms
applied to the chest.

March 21*^. — During the night the cough was unusually
troublesome, and this morning, although again galvanized, the jaws
were more closely fixed. He complained of pain in the abdomen and
rigidity of its walls, but there was neither rigidity nor pain about the
extremities. The pulse was feeble, and the skin cold and damp.
But little food could be taken. His mental functions were unaifected,
and he was himself quite conscious of his extreme danger. The
bowels were confined. Two purgative enemata were administered,
and the bowels opened by them, and when I saw him at 10 p.m.,
the jaws had become almost quite closed. Opiates were given, and
galvanism repeated.

March ^^nd. — Cough was somewhat easier, and there was less
distress owing to difficult respiration, but he had passed a very
restless night. His aspect was dejected, and he complained much of
pain above the body, specially at the abdomen, striking up thence to
the chest. There were slight startings of the muscles of the leg. No
dysphagia'existed, and nourishing fluids were poured into his mouth,
which he swallowed. Hewas quite sensible,but somewhat drowsy from
the opiates, and said that he " wished to choke rather than be tor-
tured any longer by the phlegm." The pupils were quite natural,
and also the general sensibility of the skin, which was freely per-
spiring. Quinine was ordered to be given in small and frequent
doses. I saw him again at 10 p.m., when he was suffering more
from pain, specially at the abdomen, which was, as before, very
rigid, and in the head. The abdominal pain was somewhat relieved
by hot epithems applied. No twitchings of the muscles w^ere
perceived, and the cough was less, the urine was passed freely and
naturally, but the bowels were confined. The pulse was weak and
the skin moist.

23rf/. — It was reported by the nurse that he had slept much
in the night, that at 3 a.m. there had been considerable starting of
the right arm and thigh, and that at 7 a.m. the patient had seemed
brighter and more cheerful, and had passed urine naturally and plen-
tifully. At 8.45 a.m. there was much starting in both arms and
legs, but no spasm in the face, and no dysphagia and no dyspnoea.
The vacuations were passed voluntarily and naturally. The pupils
were natural, but the pulse much weaker. The patient gradually
sank, the lips becoming dark purple, and he died at 9 p.m. without
suffering any pain. The nurse spontaneously remarked that she

504 Original Communications. [Oct.,

" never witnessed a quieter death," and that there was " not even
that long-drawn breath of death^' which is so common. She stated
that when he slept there was no relaxation of the muscles of the
jaw, which remained quite fixed, but that directly after death the
jaw fell, and had twice to be tied up.

Post-mortem exammation made twenty- seven hours after death. —
The body was in good condition and well made. There was rather
a large amount of clear fluid beneath, both the cerebral and spinal
arachnoid membranes and the brain being watery, showing numbers
of bloody puncta on section, and rather softened generally. The
lungs were highly congested, and the lower part of the left one was
partially hepatized. The heart was healthy, and the blood con-
tained fluid. There was much blood under the fascia lining the
posterior surface of the abdominal muscles as high as the umbiHcus,
and the right rectus abdominis muscle was found to he ruptured
almost entirely across at a point about two and a half inches above its
origin. Tiie ruptured muscle was exhibited to the members of the
Pathological Society by the late Mr. Gray, and is described at page
381 of the sixth volume of their ' Transactions,' but the history of
the case is not there given in extenso.

Remarks. — The points of history connected with this case appear
to be — Istly, the primary symptom being the " stiffness^' of the jaw,
and the pains about the shoulders and neck on the following day
resembling rheumatic pains; 2ndly, the occurrence on i\\e,ffth day
of pain and rigidity of the abdomen, whilst the extremities were free,
and on the sixth day of headache and startings of the legs, and on
the seventh day of startings in the right arm and thigh ; 3rdly, the
freedom from any extreme pain, the good sleep obtained, and the
partial remission of symptoms ; 4thly, the rupture of the muscle
during life ; 5thly, the complication of symptoms by previous lung
disease ; and, 6thly, the absence throughout of opisthotonos, or of
dysphagia, or dyspnoea. [92.]

Case ] 7. — Tetanus following a gun-shot wound of the thigh and
hip-joint : softening of the spinal cord.

Timothy C — , set. 28, was admitted into St. George's Hospital
January 8th, ] 858, having sustained a gun-shot wound of the thigh
a hand's breadth below the groin and into the hip-joint. On ad-
mission collapse existed, and the pulse was small, and 108 per
minute. Diffusible stimulants were given, but he became worse,
and much pain was experienced. The paiu increased in paroxysms,
and a sloughy state of the wound came on. Castor oil and an
enema of turpentine were exhibited, and subsequently port wine and
full diet were given. In the evening of the 13th, he complained of

1868.] Ogle's Fatal Cases of Tetanus, i^c. 505

stiffness about the neck and jaws, and on the following morning
had slight convulsive action of the muscles of the back, which
somewhat subsided in the course of the day. In the night tetanic
convulsion increased, and also strong opisthotonos had set in. He
died at 1 o^clock p.m.

Post-mortem examination. — The limbs generally Ave re very rigid.

The heart weighed fourteen ounces ; the left ventricle was very
contracted.

The bones and the cerebral membranes were natural. A slightly
increased amount of fluid existed in the ventricles, and beneath
the arachnoid membrane, which was a little thickened. The brain
was pale.

The bones of the vertebrae and spinal membranes were natural.
The spinal cord was firm, excepting about the level of the eleventh
dorsal vertebra, where it was so softened as to be diffluent.

Remarks. — Notice, 1st, the traumatic origin of the affection;
2nd, the early symptoms being rigidity of the muscles of the jaw
and neck coming on at the 6 th day. [14.]

Case 18. — Tetanus following compound fracture of a leg.

E.W — , a quiet and dull child, set. 8, was admitted into St. George's
Hospital, January 27th, 1 858, with compound fracture of the leg. On
the day after admission he was restless and feverish, and a calomel
purge was given. On the 30th the pulse was small and rapid, the
tongue furred, and he had pain and rigidity about the face and neck.
Wine and ammoniated salines were given. During the next few days
the pain and tetanic symptoms of the face were more marked, and
he soon lost power of mastication.

On the 6th of February he was attacked by paroxysmal tetanic
stiffness of the jaw and muscles of the back, and five minims of
tincture of opium were given every four hours, to which tincture of
cinchona bark was subsequently added, and wine given ad libitum.
Beef-tea enemata were administered. The tetanus increased, and
belladonna was subsequently given every six hours, but in vam, and
he died on the 18th.

Post-mortem e^camination. — A considerable sized nerve was traced
into the large granulating surface of the leg, but it appeared to be
quite healthy. The tibia was found fractured.

Prain and spinal column. — The contents appeared to be quite
natural.

The other organs of the body were natural.

Remarks. — Notice the supervention of tetanic symptoms on the
third day after injury, and the freedom of the nervous centres from
congestion. [44.]

506 Original Communications. [Oct.,

Case 19. — Tetanus following injury of the thigh; a portion of iron
being retained in the wound.

William D — , set. 61, was admitted into St. George's Hospital Nov.
5th, 1858, having received on the same day a gunshot wound of the
thigh. Suppuration resulted, and the pus was evacuated. On the
13th he became feverish, and great pain in the thigh came on, and
at night trismus supervened, followed by delirium. On the day
afterward the tetanic spasms increased, attended by difficulty in arti-
culation and dysphagia, and the muscles of the neck and abdomen
became rigid and hard. Attacks of opisthotonos came on, and the
spasmodic paroxysms continued constantly with intervals of only
about five minutes. The wound sloughed, and a piece of iron (two
inches by one) was found imbedded beneath the fascia lata. Stimu-
lants were freely given, and turpentine injections every three hours.
The tetanus continued until death, no pain except at the wound
being experienced, and this was excessive just before the tetanic
attacks came on. Three quarters of a grain of morphia were injected
subcutaneously, but no good result followed. Death occurred No-
vember 16 th,

Post-mortem examination. — The rigor mortis was very strong.
No nerves were found involved in the wound. Cranium and Spinal
column. Much subarachnoid fluid in the cranium existed, and the
dura mater was very adherent to the bone. Otherwise the brain
Mas natural.

The spinal cord was natural.

Thorax. — Excepting pleural adhesions the thoracic organs were
natural.

Remarks. — Notice the trismus as the earliest symptom, as occur-
ring on the eighth day after the injury. [272.]

Case 20. — Tetanus following the wound of an artery.

Alfred B — , set. 6 years, was admitted into St. George's Hospital
June 8th, 1859, with a punctured wound of the ulnar artery, which
sloughed. Much blood was lost. On the 11th he became very
sick, and convulsions came on, followed by loss of consciousness
and dilatation of the pupils. The entire body was thrown into a
condition of tonic spasm, and in spite of treatment he died on that
day.

Post-mortem examination. — ^Excepting that the brain was wet and
rather pale, nothing observable was found which might account for
the tetanic spasm.

Remarks. — Notice, 1st, the advent of the convulsion ; 2nd, tonic
spasm on the third day after the injury. [135.]

1868.] Ogle's Fatal Cases of Tetanus, ^c. 507

Case 21. — Tetanus following a burn, incurred hy a fall during an
epileptic attack.

John D. R — , set. 24, was admitted into St. George's Hospital
October 19th^ 1859. When aged 7 he had a blow on the left ear
followed by a tit, and since then had had a fit every year. In one
of them he fell into the fire a few days before admission, and burnt
the left arm, side of chest, and hip. Opium was given to allay
pain, and subsequently bark and wine.

On the 22nd he became slightly delirious, and passed his motions
in bed. Four ounces of brandy were given in the twenty-four hours,
and he improved until the 27th, when he became restless, and slept
badly. After eating dinner on this day he observed some stift'ness of
his jaws, and on the next day could only open his mouth slightly, the
pulse being 112 and weak. The soft parts about the shoulder
sloughed much. Ammoniated salines with excess of ammonia and
laudanum were given. He slept shghtly during the night, but on
the 29th had frequent pain in the affected arm, running up to the
face. The jaws were quite rigid and firmly closed, the abdomen
hard and tense, the pulse 126, and feeble, and the skin profusely
sweating. The bowels were confined, and an enema of turpentine
was administered. An increase of laudanum was ordered, but in
the evening opisthotonos came on, and attacks of this continued
during the night, and on the next morning (the 30th). During
one of the attacks the jaw became relaxed, but in several he was
almost suffocated owing to spasm of the glottis. In spite of stimu-
lants, &c., he sank, and became quite unable to swallow, and died
shortly after one of the paroxysms.

Post-mortem examination. — Thorax. — The heart was natural, and
its cavities firmly contracted ; the lungs were natural.

Abdomen. — One or two patches of congestion existed on the inner
surface of the duodenum, and the kidneys also were congested ; the
other organs were natural.

Cranium and spinal column. — The brain and spinal cord and
respective membranes were natural. The nerves of the brachial
plexus were traced into the affected arm, and found to be natural,
excepting the sheath of the median nerve, which was a little more
vascular than usual ; but this was doubtful.

Remarks. — The earliest symptom being rigidity of the jaw-muscles
and the traumatic origin of the affection are to be noticed. It may
be asked how far did the epileptic tendency render tetanus the more
likely to occur ? [238.]

508 Original Communications. [Oct.,

Case 22. — Tetanus following a wound of the hand.

William K — , set. 32, was admitted into St. George's Hospital Aug.
25 J 1860, with a lacerated wound of the left hand. He was going on
well, when on the 27 th, he had some stiffness of the neck and pain in
the back, and violent cramps in the legs. The bowels were confined,
and he had calomel and senna given, which gave much relief to
symptoms. On the 31st, the forefinger looked very dark, and a small
gangrenous spot was apparent near its extremity. On the follow-
ing day all the fingers became gangrenous and sloughy, and on
the next day (September 2nd) he was found in a cold sweat,
with spasm in the muscles of the neck and back, and with
a coated and brown tongue. Late in the evening the muscles
of the abdomen were hard, and the jaws fixed. Spasms came on
every quarter of an hour. Turpentine enemata were given and
brandy, but the spasms increased in severity and intensity, and dur-
ing the night opisthotonos came on. On the 3rd he had no rest
from continuous spasms which occurred every five minutes. He was
unable to swallow without severe convulsion occurring, and often
after an attempt to swallow, spasm of the glottis came on. Of this
spasm of the glottis he eventually died.

Post-mortem examination. — The wound was found to have been
granulating well. The radial nerve was traced into the hand, and
its branches were found to be natural. The median nerve was
healthy. The brain and spinal cord and all the organs of the body
were found to be natural.

Remarks. — Notice the occurrence and subsidence of suspicious
symptoms on the second day after the injury; their recurrence in an
aggravated form on the eighth day. [240.]

Case 23. Tetanus following lacerated wound of the hand.

James P — , set. 60,was admitted into St. George's Hospital Oct. 8th,
1860, with a lacerated wound of the hand, which he had received six
days before, but stating that on the morning of admission he had been
seized with pain extending along the back to the occiput, and in the
jaws, which he had an inability to open. In the afternoon he was found
lying on his side with his head and shoulders drawn forcibly back,
and unable to open his mouth more than half an inch. The pulse
was weak, and 84 per minute. Three grains of calomel were given
every four hours. On the 9th it appeared he had had but little sleep.
He was in constant spasm, and the opisthotonos was more marked,
the jaws being nearly closed. The pulse was 104, and very feeble.
Dysphagia existed, and each attempt to swallow produced spasm.
Three-quarters of a grain of morphia were injected subcutaueously

1868.] Ogle's Fatal Cases of Tetanus, ^c. 509

into the arm, and some hours afterwards repeated with some appa-
rent relief. He gradually sank and died without any spasm at the
last on the same day, the 9th.

Post-mortem examination. — The branches of the nerves leading to
the wound were found healthy. The brain and spinal cord and all
the organs were found in quite a natural state, excepting the kidneys,
of which the capsules were adherent.

RemarJcs. — Notice, 1st, that the early symptoms were pain in the
jaws and occiput, and rigidity of the jaw-muscles ; and, 2nd, that
the sixth day after the injury was the day on which they began.
[277.]

Case 24 — Tetanus immediately following cold and {at some distance)
a graze on the hand. Rupture of the psoas muscle.

Eichard N — , carman, set. 43, was admitted into St.George's Hospital
April 9th, 1862. He had two months previously grazed his right elbow,
and the back of the right thumb, but the M'ound had healed in a week.
One month after this he caught cold owing to exposure to weather,
and on the 6th of April, shivering, with sore tliroat, and some dyspha-
gia occurred, and increased until his admission, when he could not
open his mouth more than a quarter of an inch. Rigidity of the
limbs, with pain over the abdomen generally, came on, the tongue
was white, perspiration excessive, the pulse weak, and 96 ])er
minute. A rhubarb draught, and subsequently stimulants and bark
and hyoscyamus were given. He had turpentine stupes applied to the
abdomen. He became much relieved, but two days after admission
an attack of general spasm set in, followed by a second one, which
immediately followed the exhibition of a dose of medicine.

On the 12th the abdomen was very tense, a slight " sardonic
grin'' existed on the countenance, and there was much hardness of
the temporal and masseter muscles, but he could open his mouth
half an inch. Dysphagia was great, and when he swallowed great con-
tortion of the face was produced.

Very decided opisthotonos existed on the 13th. iEther and lauda-
num were given, and subsequently ice in bladders applied from the
nape of the neck to the sacrum, and kept carefully in contact with the
spine for three hours "without any good effect. Subsequently a blister
dressed with morphia was applied, and after that it was dressed with
six grains of quinine every four hours. Two days later a third of a
grain of extract of belladonna was added to each draught. On the
day afterwards (the 16th) he was easier, the belly was softer, and the
belladonna was increased until he took a grain at a time.

On the 18th he became speechless, and in all ways worse, the
opisthotonos being greater. Six drops of the tincture of aconite
were given every three hours. Delirium and delusions supervened,
84~XLii. 33

510 Original Communications. [Oct.,

He drank largely of wine and porter notwithstanding the choking.
At last he died rather suddenly on the 20th.

Post-mortem examination. — Thorax. — The lungs were congested
posteriorly.

Abdomen. — Much blood existed in the peritoneum owing to a rent
in the psoas muscle two and a half inches in length.

Cranium. — The brain was healthy.

Spinal column. — The bones were natural. The spinal cord was
natural excepting slight softening at the lower part ; but this was
thought to be probably owing to violence in the removal.^

Remarks. — Notice the approach of the attack by rigidity of the
muscles of and about the jaw. [93,]

Case 25. Tetanus following swelling and inflammation of the

cheek.

George W — , set. 6, was admitted into St. George's Hospital July
12th, 1862, with trismus, rigidity of the limbs and hurried, noisy,
and forcible breathing, through the nearly-closed teeth. It appeared
that a few days previously, the cheek had been red and swollen, but
the swelling had gone down. At intervals of from one to twelve
hours tetanic convulsions affected the whole body, and after each
attack he drank water, and often fell asleep. Extract of Belladonna
was given in doses of one sixteenth of a grain, and a purge of
calomel and scammony. Two days later a blister was applied to the
nape of the neck, and the purging was continued. On the 16th he
died in a violent tetanic convulsion.

Post-mortem examination. — Thorax. — The lower lobes of both
lungs were solidified.

Cranium and spinal colu7nn. — The bones were natural. The
cerebral dura mater was found adherent to the skull, and some old
arachnoid adhesions existed between the hemispheres. The brain
and spinal cord were much congested, and especially the surface of
the spinal cord.

Remarks. — Notice the great congestion of the nervous centres.
[193.]

Case 26. — Tetanus following a fall and bruise.

William B — , set. 88, was admitted into St. George's Hospital May
i2th, 1863, having April 30th fallen a long distance to the ground,
bruising the skin of the right leg. On the 11th of May he complained
of stiffness of the neck, and some dysphagia. In the night the mouth
became quite closed, and he had several " fits " of severe dyspnoea,
accompanied by contraction of the muscles of the back. Whenadmitted
on the 12th the surface of the body was cold and clammy, and the
' This case has been related in the ' Lancet,' for Sept. 6th, 1862. See p. 256.

1868.] Ogle's Fatal Cases of Tetanus, ^c. 511

back was so curved that the arm could be passed between it and the
bed. The risus sardonicus was decided. Pulse 100, regular. Every
ten or fifteen minutes a momentary contraction of the muscles of the
face and spine took place, brought on by attempts to swallow, or take
deep inspiration. The breathing was almost quite abdominal. There
was a deep sloughing wound of the surface of the right leg. Under
the influence of chloroform, the actual cautery was applied along the
back from the occiput to the middle of the dorsal region. The spas-
modic attacks increased, and he died in one of them on the morning of
admission. During the last four hours he could move his jaw freely.

Posi-mortem examination. — Only the spinal cord could be ex-
amined; and this was done by Dr. Dickinson according to Dr.
Lockhart darkens method of examination. Congestion of the
vessels of the dura mater and of the spinal cord itself existed but
nothing more.

Remarks. — Notice the stiffness of the neck and the dysphagia as
the earliest symptoms, and their occurrence on the eleventh day
after the injury; also the congestion of the spinal cord. [123.]

Case 27. — Tetanus following a fall.

Thomas S — , fet. 40, having been exposed much to cold and draughts,
was admitted into St. George's Hospital June 5, 1864, with trismus
of three days' standing. He received some injury in the back from
a fall, but no wound or discoloration existed. He had much pain in
the neck and chest, and slight dysphagia. The skin and pulse were
natural. He was treated by belladonna and chloroform inhahations,
and subsequently by turpentine injection, and extract of belladonna,
gr. \ every four hours. His sleep was disturbed by twitchings,
and the next day, though he had much pain from the clavicles to the
spine and numbness of throat, yet he felt himself better. Opisthotonos,
however, came on, and inability to flex the knees. Tobacco injec-
tions were given, and 1 gr. of extract of belladonna every three hours,
and brandy freely administered. The pupils were not dilated. The
pulse and respiration became very quickened. Later on chloroform
inhalations were resorted to, but alarming lividity of the face and
neck were produced by it. He died after two more severe spasms
than usual, June 10th.

Post-mortem examination. — Cranium. — Thevessels of the brain and
its membranes were very congested. The arachnoid was rather opaque.

The spinal cord and its membranes were very unusually vascular.

Thorax. — Old pericardial adhesions existed.

Abdomen. — The kidneys were granular. The liver fatty.

Remarks. — The cause of the affection in this case is doubtful.
Most probably it was unconnected with the fall which the patient
sustained. [190.]

(To he concluded^

513 [Oct.,

PART POUETH.

(tti)ronicU of JHetiical Science.

(chiefly foreign and contemporary.)

REPORT ON MATERIA MEBICA AND THERAPEUTICS.
By Robert Hunter Semple, M.D.,

Member of the Royal College of Physicians, Physician to the Eastern Dispejwary, London.

On the Use of Iodide of Potassiv/m in the Treatment of Cachexia;
and other Diseased Conditions. By Sir Hewet Cooper, M.D., of
Hull. — After some general remarks upon the eifects of iodine oo
glandular tumours and thickened structural deposits, and upon the
almost specific action exerted by the iodide of potassium over
periostitis, Sir Henry Cooper refers more particularly to the efficacy
of the iodide in syphilis and chronic rheumatism. In these last-
named diseases the iodide, although often successfully employed,
sometimes fails ; and Sir H. Cooper attributes the failure to the fact,
that the drug is given only in moderate doses. He, therefore, fol-
lowing the plan formerly recommended b}' Dr. Elliotson, gives very
large doses of the iodide, namely, from ten to thirty grains three
times a day. It is a remarkable fact that, although a drachm of
iodide of potassium represents a poisonous dose of iodine, yet thirty-
grain doses may undoubtedly be given three times a day with per-
fect impunity ; and it is still more remarkable that the occurrence of
physiological symptoms, such as coryza, is almost unknown where the
large doses are given. Sir H. Cooper then relates nine cases of
syphilitic cachexia, in which the iodide of potassium was prescribed
in large doses with irsarked benefit. With respect to the rheumatic
cachexia the results were not so decisive, but still great amendment
of the general symptoms usually followed, and sometimes also much
relief of the local symptoms, from the same kind of treatment. In
cases also of inflammation of mucous membranes, as in bronchitis,
Sir H. Cooper thinks that relief is afforded more rapidly by com-
bining the use of iodide of potassium with that of tartarised anti-
mony than when either remedy is used alone, and he adduces
two cases in support of this view. — British Medical Journal, Septem-
ber 28, 1S67.

1868.1 Report on Materia Medica and Therapeutics. 513

On the different kinds of Cod-liver Oil, and on those which are hest
adapted for Medical Use. By Dr. Ca.zik, of Boulogne- sur-Mer.^ —
Dr. Cazin describes three kinds of oil, namely, the white, the brown,
and the black, and there are intermediate varieties ; and the white
oil presents very different qualities, as superior white, ordinary
white, and steamed white, the last being obtained by the aid of
steam. The white oil is slightly acid to litmus paper ; the taste is
mild, like that of the fresh fish, and the smell is similar, and has
nothing disagreeable. The brown oil has a reddish-brown colour,
like Malaga wine or old rum, the smell of salt herring, a strong fishy
taste, and a decidedly rough after-taste, and is more acid than the
white. The black oil is of a greenish black-brown colour, analogous
to that of tar, of a thicker consistence than the other two oils, not
transparent, and very acid ; the taste is very acrid, and the smell is
empyreumatic and nauseous. The white oil is proved by chemical
analysis to be rich in inorganic principles, especially iodine, phos-
phorus, and phosphoric acid, but the biliary principles and volatile
acids occur only in small proportion. The brown oil may be consi-
dered as intermediate between the white and the black, as to its
richness in active principles. The black contains the least iodine and
inorganic principles ; but the volatile acids, and the biliary prin-
ciples left by the disintegrated parenchyma of the liver, predominate
in a marked degree. Dr. Cazin, after considering the different con-
stituents of the three kinds of oil, arrives at the conclusion that the
white is the best adapted for medical practice ; for although its
action is certainly more slow, yet it is better borne by the stomach,
and is taken without difiiculty. It contains more iodine than the
black, but rather less than the brown. The disgusting smell and the
disagreeable taste of the black, and even of the brown oil, prevent
their being regularly administered. — Bulletin General de Thera-
feutique, November 30, 1867,

On the Action of Belladonna. By Dr. D. de Savignac, — Although
belladonna is a stupefying agent when it acts fatally, it is also an
excitant ; and this latter property, according to Dr. de Savignac,
constitutes the fundamental character of its mode of operation. Its
excitant properties are directed especially to the great sympathetic
nerve, as is proved by the therapeutical applications of belladonna.
The drug excites the contractility of the muscular fibres of the intes-
tine, and thus promotes the alvine discharges. It acts besides on
the biliary tubes and on the common bile-duct, rendering the stools
bilious, and hence its beneficial influence in cases of hepatic colic
due to the presence of biliary calculi. Its action on the sphincters
appears to be of a nature to place their powers in harmony and equi-
librium, for as these structures both dilate and contract, it is neces-
sary that neither function should preponderate over the other.
Thus belladonna in small doses excites the motive power both of the
hollow viscera and of their sphincters, acting both on the dilators
and contractors, and giving to the viscera the power of moving
onwards the excrementitious matters nntil they are out of the

514 Chronicle of Medical Science. [Oct.,

system. Thus retention of urine may be due to paralysis or to spasm
of the neck of the bladder ; in the first case, belladonna excites the
expulsive contractions, and in the second it removes the spasm.
Dr. de Savignac also alludes to the advantages obtained from the
local use of blisters spread with belladonna ointment in rheumatic
pericarditis and endocarditis, and in organic diseases of the heart ;
and he atti-ibutes this effect to the use of belladonna in checking the
disorder, the irregularity, and the morbid energy of the beats of the
heart, and in restoring their normal rhythm. This property, which
is analogous to that possessed by digitalis, may probably be referred
to an exciting action of the vagus nerve, after what has been taught
by M. Germain S6e on the functions of this nerve as a regulator of
the movements of the heart. In its action as an external appli-
cation, belladonna is at once a sedative and resolvent ; and thus,
when applied in the form of ointment to joints affected with rheuma-
tism, it relieves the pain and dissipates the swelling, and its resolvent
powers are further proved by its efficacy in the treatment of glan-
dular swellings ; and oculists daily make use of it for the purpose of
promoting, after the operation for cataract, the absorption of the
fragments of the capsiile of the crystalline lens, or of the products of
consecutive iritis. Where there is resolution there is necessarily
excitation, both nervous and vascular, of the parts affected. Dr. de
Savignac then refers to the employment of belladonna in cases of
asthma, which is caused by spasm or paralysis of the muscular fibres
of the bronchial tubes, most probably the latter : but in whichever
way the phenomena of asthma are. explained, the action of belladonna
is intelligible, for it will act as a sedative in case of spasm, and as an
excitant in case of paralysis. But although Dr. de Savignac has
proved that, in many cases, the therapeutical action of belladonna
depends upon a common excitation of the dilating and constricting
muscles, he does not wish to deny that its excito-motory properties
have an elective tendency to act upon the dilators, as is well seen in
the case of the iris, the dilators of which are excited by the smallest
doses of belladonna or atropine. The anaesthetic and sedative
powers of belladonna, although well known, are not easily explained
upon physiological principles ; and all that is certain is, that the drug,
like opium, relieves pain, but the modus operandi is still to be sought
for. — Bulletin General de Therapeutique, November 30, 1867.

On tTie Treatment of Malarial Fevers hy the Subcutaneous Use of
the Sulphate of Qitinia. By Dr. E. C. Segtjin, of New Tork. —
After giving a brief sketch of the recent history of the subcutaneous
injection of quinia in malarial fever. Dr. Seguin states that this
method was first tried in the New York Hospital by Dr. Gr. M. Smith
in 1866. Since then it has been applied to all cases of that fever,
and is now a part of the regular practice of the institution. The
solution used is composed of sixty grains of subsulphate of quinia,
forty minims of dilute sulphuric acid, and a fluid ounce of water, and
thirty-five minims of this solution are equal to four grains of quinia.
The solution may be varied by the addition of four or six grains of

1868.] Report on Materia Medica and Therapeutics. 515

sulphate of morphia, by which the injection is rendered less painful.
It was found that the abscesses sometimes caused by the injection
were due to the presence of undissolved crystals of quinia, or the
occasional accidental introduction of particles of dust ; and it was
also found that an excess of acid generally removed the most fertile
source of danger, while it only slightly increased the pain of admi-
nistration. The cases of fever received were very severe, and it was
therefore necessary to use much larger doses of anti-periodic medi-
cines than are usual in northern practice. One'grain of quinia under
the skin was equivalent to five or six by the mouth, but in the treat-
ment mouth-doses of quinia and iron were employed at the same
time. In the intermittent cases the most satisfactory results were
obtained, but in the remittent ones the experience was small and not
satisfactory. By the contemporaneous use of the hypodermic
method and giving doses by the mouth, an immense saving was
effected in the use of the medicine, not more being used in the entire
course of many cases than was formerly required to avert a single
paroxysm. — New York Medical Journal, December, 1867,

On the Treatment of Cancer hy Acetic Acid Injections. By Dr. F.
D. Lbnte, of New Tork. — Dr. Lente has tried the acetic acid treat-
ment in two cases of cancer ; and as he does not intend, at least for
the present, to repeat the trial, he gives the results in detail. One
case was that of a scirrhous tumour of the left mammary gland in an
unmarried lady about sixty years old. It did not involve the nipple,
and the axillary glands were perfectly free from disease. Dr. Lente
punctured the tumour; and having passed a needle into its substance,
he injected upwards a quarter of a drachm of a solution of acetic
acid in water, one part to three, and the same quantity downwards.
The injection caused intense pain, which was relieved only by
anaesthetics. A drachm more was subsequently injected while the
patient was under ether, and afterwards half a drachm more. An
abscess was formed, which however soon healed ; but the patient was
so worn out by the pain and the confinement, that an operation was
at length resorted to, and the tumour having been removed the
patient recovered. The other case was one of epithelioma of the
prepuce and glans penis, and the disease had lasted about eight years.
The diseased mass was nearly as large as a duck's egg; and when it
was ulcerated, it had the appearance of a cauliflower excrescence.
Bromine was employed at first, after the excrescences had been
removed by a bistoury and the application of the actual cautery, the
bromine being applied to the raw surfaces, but acetic acid was sub-
sequently injected. The progress of the disease, however, was not
arrested, and the glans was becoming still further involved, and
amputation was therefore advised. — New YorTc Medical Journal,
December, 1867.

On tlie Use of Powdered Alum in a case of extensive Burns. By
Dr. "W. M. Ttjbner, of Philadelphia. — The case mentioned was that
of a man who, when in a state of intoxication, was scalded by a large

516 Chronicle of Medical Science. [Oct.,

quantity of boiling coffee ; and when he was seen by Dr. Turner, a
week after the accident, the exterior portion of the right thigh and
hip was burned to the length of fifteen inches, with an average
breadth of eight inches and a half. The left thigh was also scalded,
the injury extending from the scrotum to the patella. There was an
open wound on both legs, and there was profuse and offensire suppu-
ration. The usual treatment was employed for some days, consisting
of poultices, rags wrung out of carron oil, tonics, opium, and mode-
rate stimulation, but without much benefit, and the application of
nitrate of silver to the edges of the wounds caused such intense pain,
that it was discontinued. To add to the gravity of the case,
haemorrhage supervened one day with such violence, that Dr. Turner
was obliged to have recourse to the first styptic he could find ; and as
there was some burnt alum in the house, he applied it in powder to
the bleeding surface. On examining the wounds next day, be was
surprised to find that not only the haemorrhage was arrested, but
the surface of the wounds to which the alum had been applied pre-
sented a healthy appearance, and seemed inclined to heal. Dr. Turner
therefore employed the alum regularly as a dressing ; and from the
time that he did so, each wound continued to improve till it entirely
closed ; and what is still more extraordinary, it left no drawing
cicatrix. Dr. Turner ascribes the successful termination of the case
entirely to this accidental employment of alum, and he thinks it
worth a trial in other similar cases. — Kew YorJc Medical Journal^
January, 1868.

On the Therapeutical Action of Medicines in dilated conditions
of the Blood-vessels. By Dr. A. Reith, of Aberdeen. — In this paper,
which is altogether theoretical, Dr. Reith offers an explanation of
the action of medicines, founded upon recent views connected with
the pathology of the nervous system. The origin of almost all
diseases is supposed to exist in the nervous centres, consisting of
the joint cerebro- spinal and vaso-motor systems. Irritation of the
vaso-motor nerves, as has been shown by Bernard and Brown-
Sequard, causes contraction of the blood-vessels, while division of the
same nerves causes dilatation, and in the latter case inflammation is
set up. Now Dr. Eeith assumes that the action of all medicines is
primarily on the vaso-motor system, and he considers that this action
is analogous to the production of inflammation. In other words,
medicines, whatever may be their operation, possess the double pro-
perty of stimulating and paralysing the sympathetic system, that is
to say, of contracting and dilating the blood-vessels. As a practical
application of this theory, it is stated that, if inflammation is a
paralysis of the vaso-motor system, and if medicinal agents also
paralyse the same system, inflammation ought to be aggravated by
medicines in their usual doses, and experience confirms this suppo-
sition. But if, continues Dr. Eeith, medicines be given in less than
their usual doses, so as to produce only one of the two effects first
mentioned, namely, so as to induce only contraction, then inflam-
mation is antagonised. But the doses which ought to be used are

1868.] Report on Materia Medica and Therapeutics. 5] 7

not yet determined, and must be fixed by experience, whicb
Dr. Eeith is preparing to supply. He goes on to state that the
theory of the action of medicines being analogous to the process of
inflammation, and of medicines in small doses being antagonistic to
disease, seems to lend some countenance to the doctrines of homoeo-
pathy ; and he admits that it does so, but not in the sense in which
the followers of Hahnemann carry out these doctrines, the extra-
vagances of that sect being such as to obscure whatever is good in
the theory. — Edinburgh Medical Journal, February, 1868.

On the Medicinal Properties of the Cherry Laurel. By J. Broker.
— Mr. Broker, a Dutch pharmacologist, has instituted a series of
investigations to show the influence exercised on the proportion of
prussic acid in the leaves of the cherry laurel {prunus lauro-cerasus),
by the mode of preparation, and the season of the year in which the
leaves are gathered. After giving the details of the chemical pro-
cesses by which the relative amount of hydrocyanic acid in the leaves
is estimated, he states that the proportion of this acid varies very
considerably ; and he gives a table showing that leaves gathered in
difierent months of the year contain very difierent amounts of the
acid. Thus he finds that the leaves gathered in July contain
the greatest proportion of prussic acid, and those gathered in Feb-
ruary contain the least ; and he states, besides, that the nature of
the soil, the character of the weather, and the constitution of the
leaves themselves, and their age, whether one or two years, influence
the proportion of prussic acid which they contain. He is, therefore,
inclined to think that the cherry-laurel water might be safely ex-
cluded from the pharmacopoeias, inasmuch as the bitter almond
contains a more definite and constant proportion of prussic acid, and
is, moreover, more readily to be obtained than the cherry-laurel
leaves. This view is confirmed by the results of the investigations
made by two Dutch pharmaceutists in the laboratory of the Uni-
versity of Utrecht, who found that out of twenty- seven specimens of
cherry-laurel water, obtained from difi'erent shops, only nine con-
tained more or less exactly the amount of prussic acid prescribed in
the codex, and that the highest proportion of prussic acid compared
with the lowest was as 9 to 1. — Nederl. Tijdschr., qiwtedin Schmidt'' s
Jahrhucher der Gesammten Medicin., April 2nd, 1868.

On two novel AjjpUcafions of the Iodide of Potassium. By Dr. A.
De Beatjfort. — The treatment of the chronic inflammations of the
mucous membranes is most simple and efficacious whenever topical
remedies are employed on the diseased structures ; but it is often
difficult, or even impossible, to apply these remedies in this direct
manner. Among the mucous surfaces which it is difficult to reach
directly are those of the lacrymal canals and the uterine canal ; and
practitioners are well aware of the unsatisfactory results of the
treatment of the morbid conditions of those passages. Dr. Beaufort
has, therefore, been induced to try the introduction, through the
channel of the circulation, of a medicinal agent which might produce

518 Chronicle of Medical Science, [Oct.,

similar results to those obtained by balsamic and terebinthinate
remedies in the vesical and urethral mucous membranes. He turned
his attention to the iodide of potassium, which, when taken internally,
is eliminated in such great abundance by the secretion of the tears,
and which may also be detected, though in less quantity, in the mucous
secretion of the uterus ; and clinical observations confirmed his thera-
peutical hypothesis. His first attempt was in the case of a young
woman of a scofulous temperament, affected for three months with
an engorgement of the lacrymal sac, with incomplete obstruction of
the nasal canal. He instituted an exclusive treatment by the iodide
in the progressive dose of twenty-five centigrammes to a gramme
(a gramme is about fifteen English grains). At the end of a fort-
night the symptoms had ceased, and the tears had resumed their
normal course. Dr. Beaufort thinks that the iodide could not have
acted in so short a time upon the constitutional malady under which
the patient suffered ; and he, therefore, infers that the salt must
have been carried by the circulation to the diseased membrane, and
fresh observations confirmed him in this view, for he subsequently
treated patients of a good constitution attacked with chronic in-
flammation of the lacrymal passages, and the results were equally
favorable. He expresses his conviction that in many cases this
treatment will supersede other painful and tedious methods of me-
dication. In cases of chronic inflammation of the uterine mucous
membrane the success of the treatment by the iodide was less rapid,
and the instances were less numerous ; but they seem to Dr. Beau-
fort to be sufficiently remarkable to deserve the attention of the pro-
fession. In several instances of internal metritis, with abundant
leucorrhoea and the train of symptoms which torment so many
females, he has seen remarkable benefit follow from the use of
the iodide, after other treatment had been tried in vain. It is
necessary te increase the dose to a greater extent than in the other
cases mentioned, namely, from one to two grammes, and to insist on
its employment for a longer period. The engorgement of the organ
is relieved in the most striking manner, and when this has disap-
peared, the symptoms due to the affection of the mucous membrane
cease more easily. Dr. Beaufort has also found the iodide service-
able in cases of granular and ulcerative affections of the neck of the
womb. He conceives that the remedial action is owing to the
alterative properties of the salt in devascularizing the inflamed
mucous membrane, and in restoring its capillary texture to its
normal type. Even if it is insufficient by itself to effect a perfect
cure, it is a useful auxiliary to other methods of treatment. —
Bulletin GenSral de TMrapeutique, January 30, 1868.

On the Treatment of Phagedenic Chancre hy the Internal Employ-
ment of Calomel. By Dr. Belhomme. — Dr. Belhomme remarks
that only two medicines employed internally have been considered
efficacious in the treatment of phagedenic chancre, namely, opium
and arsenious acid, and that although Eicord has sometimes suc-
ceeded by the mercurial treatment in curing the disease, yet the

1868.] Report on Mateina Medica and Therapeutics. 519

preparations of mercury have been regarded as injurious by most
authors. The local applications recommended, however, are nume-
rous, including the actual cautery, nitric, sulphuric, and hydrochloric
acids, chloride of zinc, nitrate of mercury, &c. But although mer-
cury has been supposed by most authors to promote the appearance
and the spread of phagedena, and even, as it would appear, by Dr.
Belhomme's admission, by himself in a former memoir, yet he now
believes that calomel, employed internally, may be used with advan-
tage in this affection. He was induced to try its effects by recol-
lecting that one of his former instructors. Dr. Gibert, of the
Hopital St. Louis, occasionally administered calomel in non-syphilitic
phagedena, and hence Dr. Belhomme used it also in syphilitic cases.
But he has always given the mineral in small doses, repeated at
regular intervals, the patient taking from five to seven centigrammes
(a centigramme is the one hundredth of a gramme, equivalent to
about fifteen grains) every day in packets of one centigramme each,
two in the morning, two in the afternoon, and two or three in the
evening. Only four cases are related, and in them the treatment
appears to have been successful ; the duration of the cure is said
to be from three weeks to a month in the simple cases, but much
longer in the severe cases of ulceration. — Ibid., June 30, 1868.

On the Indications and Gontra-indications of tlie Employment of
Alcohol in the Treatment of Pneumonia. By Dr. Pecholier, of
Montpellier. — The treatment of pneumonia by alcohol has lately
found considerable favour among French physicians ; but they by
no means advocate the indiscriminate use of this agent in all cases
of pneumonia. M. Pecholier has lately endeavoured to determine
the question as to the indications and contra-indications of the alco-
holic treatment, by a series of clinical observations made on a certain
number of cases which seemed favorable to the attempt, and the
summary of the results in five cases is recorded, a cure having been
accomplished in each instance. Prom the facts observed, and the
theories advanced as to the properties of alcohol, especially the
property it possesses of awakening the dormant remedial powers of
the constitution, and that of arresting the waste of the tissues, M.
Pecholier concludes that alcohol is suitable for the treatment of
cases of adynamic pneumonia, such as are comprised in the following
categories : — 1. In habitual drunkards, in whom the disease assumes
an entirely special character, and in whom the beneficial effects of
the alcoholic treatment have long been recognised. 2. In cases
where the pneumonia presents itself under special characters, whether
dependent on the etiology, as the adynamic medical constitution, the
spring or autumn season, old age and weakness, enfeebled constitu-
tion, &c., or in relation to local symptoms, as in latent pneumonia,
where the rational signs are wanting, or even the physical signs are
slow in manifesting themselves, or in cases marked by general symp-
toms, as prostration, dorsal decubitus, coma, delirium, pale face,
pulse rather slow or too frequent but very compressible, weak
action of the heart, &c. 3. Where the disease, although sthenic at

520 Chronicle of Medical Science. [Oct.,

the beginning, has changed ita character, and presents symptoms
of adynamia, whatever may be the cause of the change, the peculiar
nature of the affection, the abuse of bleeding, and other depleting
measures, &c. 4. In many cases of double pneumonia, especially
when the second lung is attacked a certain number of days after the
first, and when the patient has been weakened by the treatment of
the primitive lesion. 5. In the pneumonia of the aged. 6. In
secondary cases of pneumonia, which supervene in the course of
other febrile diseases. 7, and lastly. In all cases, whatever may be
the age of the patient, or the season, or the climate, when an atten-
tive analysis of the symptoms, the state of the pulse, or that of the
functions of innervation, shows that the pneumonia is really asthenic.
The contra-indications of alcoholic remedies in pneumonia are easily
deduced from the above considerations. The principal of them are
the winter season and dry cold, the youth and vigour of the patient,
a full and hard pulse, a red and injected face, or, in a word, when
the symptoms are characteristic of the condition known as inflam'
matory fever. A very red and dry tongue, and a painful condition
of the epigastrium, may also be regarded as contra-indications, even
in adynamic cases. The editors of the ' Bulletin,' in quoting M.
Pecholier's views, agree with him that the doses of the alcoholic
fluid should be proportionate to the severity of the case and the
peculiarities of the constitution ; and they further observe that the
doses should be so divided as never to produce too great an excite-
ment, which may be followed by depression ; and that the remedy
should never be too quickly stopped when it has produced its effects,
but should be given for some days longer in decreasing doses. —
Montpellier Medical, reviewed in the Bulletin OenSral de Therapeti-
tique, May 15, 1868.

On the Employment of Phosphorus in Medicine, and especially in
Progressive Locomotor Ataxy. By Dr. Du jaedin-Beaumetz, of the
Hopital de la Pitie. — In the first part of the series of papers on the
above subject. Dr. Dujardin-Beaumetz gives a sketch of the different
preparations employed by the earlier physicians who prescribed
phosphorus for the cure of disease, the medical applications of this
substance having followed close upon its discovery in 1GG7 by
Brandt, an alchemist of Hamburgh. The solution of phosphorus in
oil is the preparation most usually employed, for the solution in sul-
phuret of carbon is dangerous, owing to the poisonous character of
the latter menstruum. Dr. Dujardin-Beaumetz then proceeds to
describe the most suitable doses of phosphorus, those employed in
early times having been manifestly too large, and even dangerous.
Thus a Jew was poisoned by three grains of phosphorus given as a
medicine for an attack of apoplexy. Dr. Dujardin-Beaumetz recom-
mends that the phosphorus should be given at first in doses of a
milligramme (one thousandth of a gramme, which is equivalent to
about fifteen grains), and to increase the dose gradually until some
marked effect is produced, either on the digestive system, or on some
other system or organ. It must be recollected that phosphorus is

1868.] Report on Materia Medica and Therapeutics. 521

an accumulative medicine, and that great care must be taken in the
progressive increase of the doses.

Dr. Dujardin-Beaumetz has been led to employ phosphorus in
progressive locomotor ataxy for two reasons, first, because this dis-
ease has hitherto resisted all kinds of treatment; and, secondly,
because in this disease two symptoms are found, in which the cura-
tive action of phosphorus has long been recognised, namely, amau-
rosis and impotence. He then gives the details of four cases of pro-
gressive locomotor ataxy, in which the phosphorus was administered
with considerable benefit. Three were males, and one was a female.
In two cases the phosphuretted oil was employed, and in the other
two capsules of phosphuretted chloroform (ten decigrammes of
chloroform to one milligramme of phosphorus). In all the cases
there was decided improvement of the symptoms, the gait became
less uncertain, and the incoordination less marked ; there was more
firmness in walking, and this was proved by the power of walking to
considerable distances, and of going up and down stairs. The general
sensibility was but little altered by the treatment except in one case.
The eyes, which were more or less afiiected in all the cases, were
not at all improved by the use of the phosphorus. The genital
organs were strongly affected only in one case, in which the patient
had numerous erections. A curious effect of phosphorus was ob-
served, in addition to the other results, namely, a general feeling of
satisfaction or contentment, which made the patients who were
subjected to the treatment ask for its continuance. The patients all
bore the phosphorus well, and their general health was never dis-
turbed for a moment. Some symptoms, referable to the digestive
organs, such as diarrhoea and sickness, were sometimes developed
during the treatment ; and they are of great importance in deter-
mining the graduation of the doses. As soon as these symp-
toms appear, the doses must be suspended for a time, and resumed
after a day or two have elapsed. Dr. Dujardin-Beaumetz has
reached from one milligramme of phosphorus to eight milligrammes
without producing any disturbance of the digestive organs ; but in
general this effect is produced when five milligrammes have been
reached. He admits that the cases recorded are too few to afford
definite results at present; but he recommends a further trial of
phosphorus in the affection described. — Bulletin General de TMra-
peutique, Jan. 15, Feb. 29, March 18, 1868.

On the Assimilation of Phosphate of Lime and its Therapeutical
Employment. By Messrs. Dusaet and Blache, of Paris. — The
authors of this paper have endeavoured to determine the question
whether the phosphate of lime enters into the system by the trans-
formations it undergoes in the stomach, or whether it is necessary,
for the purpose of assimilation, that it should undergo a previous
elaboration in a living organism. The experiments they have in-
stituted appear to show that the solution of the phosphate in the
juices of the stomach is influenced by the form which the phosphate
assumes, for while the hydrated phosphate is rapidly dissolved, cal-

522 Chronicle of Medical Science. [Oct.,

cined bones and hartshorn are not sensibly dissolved ; and speci-
mens containing carbonate of lime are dissolved only imperfectly.
Messrs. Dusart and Blache, therefore, propose, as the best prepara-
tion for assimilation, the hydrated phosphate vsrhich has already
been subjected to the action of the gastric acids, and which they
call lacto-phospTiate of lime. This substance has an agreeably acidu-
lous taste, and is readily digested. Experiments were made upon
some of the lower animals, with a view of determining whether the
repair of fractured bones was accelerated by the internal use of the
phosphate, and it was found that such was really the result. Under
the use of the lacto-pJiosphate of lime, Messrs. Dusart and Blache
found that the increase in weight of the bones of the animals ex-
ceeded by more than 33 per cent, the weight of the animals sub -
j ected to ordinary treatment. The'animals chosen for the experiment
were guinea-pigs. — Ibid., July 30, 1868.

On the Treatment of Aneurism hy Iodide of Potassiu/m. By Dr.
G-. W. Balfoub, of the Hoyal Infirmary, Edinburgh. — Dr. Balfour
commences this very interesting paper by relating the particulars
of three cases, treated under his own direction, in which the re-
sults were very satisfactory. In one of the cases there was appa-
rently an inveterate aneurismal diathesis, as there were several
aneurisms ; but still, under the use of the iodide of potassium, given
in thirty-grain doses twice a day for a considerable period, the im-
provement was well marked, and the symptoms of aneurism dis-
appeared in certain arteries, although they persisted in others. Dr.
Balfour, after remarking upon the serious character of the disease,
and the hazardous remedies sometimes proposed for its relief, ex-
presses his belief that the success achieved in his cases has been
sufiiciently well marked to justify him in recommending a further
trial of the iodide in the treatment of aneurism. The use of the
iodide for this purpose has been adopted, not from speculative ideas,
but from empirical observations, which have been made almost acci-
dentally, for the first case so treated seems to have been one under
the care of M. Nelaton, who administered the iodide only because
the patient stated that he had derived benefit from its use under
other surgeons. To the surprise of M. Nelaton all the symptoms
were improved, and the tumour almost entirely disappeared. M.
Bouillaud next followed out this plan of treatment in four cases, in
one of which the improvement was well marked ; and in the East
Indies Dr. Chuckerbutty, of Calcutta, found out, almost accidentally,
that an aneurism of the innominata became gradually solidified
under the use of the iodide given to relieve a bronchial complaint,
from which a patient was at the same time suffering. Hence Dr.
Chuckerbutty was induced to treat several other cases of aneurism
in the same manner, and he has recorded the particulars of three.
In two of them the result was fatal ; but still, even in these, con-
siderable relief was obtained, and in one the sac was found after
death filled with dense, solid coagula. Dr. Chuckerbutty points out
that the consolidation of the contents of the aneurismal sac is the

1868.] Report on Materia Medica and Therapeutics. 523

important fact in the history of these cases, and he thinks that this
result depends upon some property of the iodide in reference to the
coagulation of the blood. Dr. Eoberts, of Manchester, has also em-
ployed the iodide in the treatment of aneurism with very consider-
able success. Dr. Balfour remarks that out of fifteen cases of
aneurism treated by the iodide of potassium, of which the particu-
lars have hitherto been published, there has been relief in a marked
degree to the sufierings of the patient in all but one, and in twelve
there was undoubted diminution in the size of the sac ; while in a
few there has been apparently a perfect cure. In order to effect
the desired end, several circumstances must be carefully attended to,
and especially the dose, which, in the cases related, varied from five
grains to thirty, three times a day. Coryza, salivation, and diarrhoea,
occasionally follow the use of the iodide ; but in such cases the in-
conveniences may be obviated by the temporary discontinuance of
the drug. The iodide must also be continued for a very consider-
able time in most instances, some cases requiring at least twelve
months. Eest in the recumbent posture is also a matter of para-
mount necessity, and the diet should be carefully regulated, avoiding
the evils of starvation on the one hand, and of plethora on the other.
Dr. Balfour does not agree with Dr. Chuckerbutty, that the efiicacy
of the iodide depends upon its power of increasing the coagulability of
the blood ; but he attributes to it a sedative action on the nervous
system analogous to that exercised by the bromide of potassium. —
Edinhurgh Medical Journal, July, 1868.

On the Action of the Hyposulphite of Soda in Inter mittents. By
Dr. CnuBB, of Cambridge, U.S. — Dr. Chubb made trial of the
hyposulphite of soda in several cases of malarial disease, and the
results were very satisfactory. Out of twenty-seven cases in which
it was administered, the paroxysms were arrested in twenty-five, and
in eleven of them the arrest was immediate. In five cases, however,
relapses occurred ; but in three of these the disease was again
arrested by the use of the hyposulphite, and did not return ; in the
other two of the relapsing cases, sulphate of quinine was resorted to
in order to complete the cure. In one case the patient, a female,
had been the victim of ague for twelve months, during which she
had been drugged to excess with quinia, iron, &c., but had never
passed more than two weeks without a recurrence of the chills, and
her general health was much impaired. She took the hyposulphite
in doses of fifteen grains every two hours, and had but one paroxysm
after the treatment was instituted. She had no relapse since her
recovery. Out of the twenty-seven cases two are recorded as
failures ; but in one the failure was not complete, for the paroxysms
were mitigated in severity. In the other case the failure was de-
cided, for although the patient persevered in taking from fifteen to
twenty grains of the hyposulphite every two hours for a week, no
real improvement was obtained ; but the disease was at once cut
short by the adoption of ordinary treatment. Dr. Chubb considers
that the hyposulphites constitute a valuable addition to the reme-

521 Chronicle of Medical Science. [Oct.,

dies used in the treatment of malarial disease, but that in the
majority of cases they are less prompt in their action than the
preparations of cinchona. — American Journal of the Medical Sciences,
April, 1868.

REPORT ON MIDWIFERY

By RoBEET Baenes, M.D. Lond., F.R.C.P.,

Obstetric Physician to St. Thomas's Hospital, &c. &c.

I. — The NoN-PEEaNANT State.

1. Spontaneous Hupture of the Uterus with Intra-uterine Polypus.
By Dr. La.echee.

2. On Sounding the Fallopian Tubes. By Dr. Hildebeandt.

1. A woman was admitted into the Hotel-Dieu with pain in the
abdomen. After four days profuse bleeding set in. She refused
examination. Two days later meteorism and peritonitis appeared
and she died. Section revealed diffuse peritonitis and adhesion of
all the organs of the small pelvis. A polypus was found in the
uterus seated in the anterior wall near the isthmus. The posterior
surface of the cervix was ulcerated, and at one spot torn through,
communicating with the cavity of the abdomen. — Arch. Qen. de
Med., Nov., 1867.

2. Dr. Hildebrandt relates two cases in which he was satisfied
that he passed the uterine sound several inches along the Fallopian
tube. In one case, the patient had worn an intra-uterine pessary,
and immediately after removing this, passing the sound he found its
point went freely along the tube, and was felt through the abdomi-
nal walls. The end of the pessary he conjectured had distended the
uterine orifice of the tube, and thus facilitated the entry of the
sound, for after discontinuing the use of the pessary the entry of the
sound was no longer easy. He refers to analogous cases by Veit
(' Virchow's Handbuch der Speciellen Pathologic,' 1867), and by
Matthews Duncan ('Edin. Med. Joum.,' 1856). He calls attention
to this patency of the tubes as explanatory of those cases in which
air or fluids penetrate from the uterus into the abdominal cavity. —
Monatsschr.f. Oeburtsk., June, 1868.

II. — Gestation.

1. A Case of Polypous Hyperplasia of the Decidua. By Prof. Dohen".

2. Pibrous Myxoma of the Placenta : gestation in a tivo -horned uterus.

By Dr. Hildebbandt.

3. A Case of Primary Abdominal gestation. By Dr. Matecki of

Posen.

4. A Case of Tubo-ovarian Gestation. By Dr. Baaet de la Faille.
1. Professor Dohrn describes and figures with great care a case

1868.]

Report OH Midivifery. 525

of hyperplasia of the decidua. The condition has been described by
Virchow, Strassmann, and G-usserow, as consisting in the knotty out-
growths on the free surface of the decidua. Dohru's specimen came
from a young woman who aborted in her first pregnancy at the end
of two months. The decidua reflexa was covered on its free surface
with small, long-stalked growths resembling polypi. No glandular
openings, such as existed, everywhere else on the decidua, were seen
on these growths. • Microscopic examination showed distinctly the
hyperplasia described by Yirchow. The decidua contained many
vessels and little fat, as is usual in aborted ova of this data. The
polypus excrescences were especially vascular, and their tissues
interspersed with small blood-extravasations. The decidual cells were
larger than normal, larger than the cells taken from the parts of the
decidua not affected by the polypus excrescences, and having much
larger nuclei. The chorion was surrounded by villi, which were in
many places undergoing cystic change. Dohrn considers the deci-
dual disease to have been the cause of the abortion, by its disturbing
the vascular development of the ovum. — Monats.f. Gel., May, 1866.

2. Professor Hildebrandt relates the following case : — A woman
pregnant for the third time. There was an excessive collection of
liquor amnii. Labour set in spontaneously at about six months.
The foetus was living, but soon died. The placenta was very remark-
able. It weighed one pound. The membranes were very thick, but
normal. The rent was central. The cord was inserted in the mar-
gin ; from this point there ran a venous branch diametrically across
the placenta : in the same direction ran an arterial branch, but cross-
ing the vein at an acute angle. Both vessels traversed the mem-
branes, and formed a swelling the size of a fist supported on a stalk
about an inch long. This tumour was embedded in the completely
normal placental tissue. It had no connection with the placental
tissues, except through the vessels described as its stalk. The
mass of the tumour consisted of fibrous tissue, containing small round
and oblong nuclei. In other places the tissue had the characters of
mucous membrane. The cause of this tumour H. considers to be
the abnormal condition of the vein and artery connected with it ;
the tumour itself being a degenerated cotyledon.

3. A woman about thirty years old, who had borne five living chil-
dren, came under care in October with signs of marked hectic fever.
She had menstruated in February. A quantity of foul-smelling
purulent matter had been escaping from the vagina. Below the navel
and on the left side the child's head was felt, and foetal movements
were also felt. She complained of extreme pain in the left side,
which continued until she died next day. During life no os uteri
could be felt. The omentum was closely adherent to the peritoneum
everywhere. The uterus was about seven inches long and five wide,
and directed to the right ; the tubes were enormously hypertrophied,
so that they formed with the uterus a kind of fork : the upper
margin of the tubes was free, the others adhered to the neighbouring
structures. On lifting up this fork, the embryo was seen in its
membranes, lying transversely, not at all decomposed, and of full

84— XLii, 34

526 Chronicle of Medical Science. [Oct.,

growth. The placenta was very large, and was in no way attached
either to the uterus or tubes. The uterus was removed : it showed
no sign of scar ; the cavity showed no trace of decidua. The transi-
tion of the cavity into the tube was free, and the canal so large that
the little finger would pass some way into it. The condition of the
fimbriae could not be ascertained. The ovaries were quite normal.
The author dilates upon the difficulty of diagnosis in these cases. —
Hid., June, 1868.

4. B. B — had had three children normally. On the 5th June,
1866, she suffered acute abdominal pains. There was no fever.
Two days before this she had sat out in the garden, and believed she
had caught cold. The pain subsided, but on the 9th a sudden and
severe pain set in : she shrieked and fainted, collapse followed. The
appearances indicated internal haemorrhage. She was estimated to
be three months pregnant. Eupture of an extra-uterine foetal sac was
diagnosed. Dr. de la Faille's father believed the gestation was
interstitial, basing his opinion upon the facts that he found the pain
very acute in the uterus itself, when it was lightly touched, and that
no circumscribed tumour could be felt in the flaccid abdomen.
Much bloody mucus flowed from the vagina. The woman died in
forty-two hours. On section a three-months' foetus was found in
the abdomen. On the right side of the uterus was a projecting
place in the shape of a large tumour, and in it an opening with torn
edges. The uterus was of the size found in the fourth month of
pregnancy. The cervix was filled with a mucous plug ; the cavity
was lined with a very thick decidua. The placenta was seated in
the forepart of the tumour, and behind it was the cavity which had
contained the foetus. There was a slight trace of a wall between
the uterine cavity and the foetal sac. Both tubes were closed.

Dr. de la Faille analyses briefly the other cases of interstitial gesta-
tion recorded by other authors. Ibid., June, 1868.

III. — Laboue.

1. On Tardy Labour. By Dr. Rigler.

2. A red line round the Funis as a sign of Retarded Birth. By Dr.

J. B. BOKD.

3. On Turning in Narrow Pelvis. By Dr. Stbassman.

4. 0)1 the 3fechanism of Turning, and on Turning in Narrow Pelvis.
By Dr. Schaelau.

1. Dr. Rigler relates the following case : — A woman, aet. 28,
menstruated on the 7th December, and expected labour in the
middle of the following September. This, however, did not occur
till the middle (14th) of October, that is, at the period of the eleventh
menstruation. Menstruation had always recurred regularly every
four weeks when not pregnant. She quickened in the middle of
May. The labour was natural ; the child very large ; there was
nearly complete absence of liquor amnii. The placenta weighing
three pounds was expelled • it was covered with calcareous concre-
tions. The child died during labour. Dr. Eigler, who seems to have

1868.]

Report on Midwifery. 527

taken pains to eliminate all sources of fallacy, concludes that gesta-
tion lasted 308 daya.—Ifonats.f. Oeh., May, 1868.

2. Dr. Bond gives cases to support the opinion that when labour
has been retarded beyond the normal period, a bright red ring is
found encircling the umbilicus just where the funis joins it. Dr.
Parish contributes a case in confirmation. — Med. Ti?nes and Oaz.,
August, 1868.

3. Dr. Strassmann shows by cases that turning in narrow pelvis
may give successful results even when the greatest or bi-parietal
diameter of the child's head is caught in the narrowed conjugate,
and that it is therefore not essential in performing the operation to
take care that the occiput shall fall into the wider half of the pelvis.
He says it is difficult or impossible to secure that the occiput shall
so fall. In one case he delivered with great difficulty a child which
died soon after birth, by the forceps through a pelvis, the conjugate
of which measured 2 75", although the occiput came through the
wider half of the pelvis ; in the second labour he delivered the
same woman of a live child which survived by turning, although the
occiput came through the smaller half of the pelvis. Three other
cases illustrate the same point. In all four cases the conjugate gave
at the utmost 3". Three children were born alive, one having died
from prolapsus of the funis before turning. Strassmann insists
much upon the importance of aiding the extraction of the head, by
pressing upon the head through the abdomen externally. — Monats.
f. Gel., June, 1868.

4. Dr. Scharlau gives a summary of 64 cases in which he turned ;
50 of the children were alive before the operation, of these 43 were
delivered alive. Five mothers died ; 2 of metro-phlebitis, 1 of peri-
tonitis, 2 of ruptured uterus. Dr. Scharlau prefers the decubitus on
the side, and seizing one foot rather than both, selecting that
foot which belongs to the presenting side of the child. In placing
the woman he lays her on that side to which, in transverse presen-
tations, the breech of the child is directed ; and in head presenta-
tions, on that side to which the child's abdomen is directed. In
discussing which foot ought to be seized, he cites the dogma of
Kristeller, who enjoins to seize the foot which corresponds to the
presenting side when the child's back is directed forwards, and the
opposite foot when the belly is directed forwards. In this Scharlau
does not concur. He says that he turned in 22 cases in which the
belly was directed forwards ; in 20 of these he seized the lowermost
foot, in 2 the upper. In the 20 cases turning took place easily ; in
the 2 it was difficult, in one of them impossible until he seized the
lower foot. He further says that in other cases in which colleagues
had seized the opposite foot and could not turn, he succeeded with-
out difficulty by seizing the foot corresponding to the presenting
side. Twelve of Scharlau's cases were complicated with narrowing
of the pelvis. Referring to the statement of Martin that the de-
pression in the foetal skull caused by the projecting promontory is
always considerably in front of the bi-parietal or larger transverse
diameter, Scharlau exhibits four casts of heads in which the depres-

528 Chronicle of Medical Science. [Oct.,

sion appeared near the bi-parietal diameter. He says two questions
must be considered before deciding on the indications for turning in
contracted pelvis:—!. In what way do children perish when the
head presents in a narrow pelvis ? 2. "What advantage is offered by
bringing the head last through a narrow pelvis ? In answer to the
first he says the child dies through a premature formation of a caput
Buccedaneum, which in protracted labour becomes very large, and
the child dies of brain-hyperaemia and oedema before the forceps can
be applied. In other cases the forceps may just extract a child in a
deeply soporous condition from which it cannot be restored. The
advantage of bringing the head last consists in the turning to
account the elasticity of the head- bones. He says it is not alone
the smaller or bi-temporal diameter that can be reduced, but also
the bi-parietal. In some eases the elasticity was so great that the
bones yielded readily during extraction, and recovered their normal
form very quickly afterwards. Of the 12 children, 11 were alive
before turning ; 1 died during the operation from laceration of the
cervical vertebrae ; 10 were born alive, but 2 of these died soon after
birth. Dr. Scliarlau concludes that the conjugate diameter may be
narrowed to 7i centim. (a little under 3 inches), and the operation
give a good result, even with a full-grown child ; that in a conjugate
diameter of 7\ centim. not only the bi-temporal, but also the bi-
parietal diameter of the head may be safely compressed to pass ; that
it is desirable but not essential for the transverse diameter of the
pelvis to be wide enough to admit the occiput by the side of the
promontory. — Ibid., May, 1868.

IV. — Childbed.

1. Researches on the Involution of the Uterus during the first eight

days of Childbed. By Dr. JSchneideb.

2. A Case of Qonorrhoeal Mheumatism occurring after Parturition.

By Mr. Hablet.

1. Dr. Schneider, referring to the recorded observations upon the
progressive diminution of the uterus after labour, instancing those
of Hecker and Scanzoni, objects that the measurements were made
on pathological specimens, that is, of uteri after death. He has
repeated the inquiry by taking measurements during life. In 111
women during the first eight days following labour he measured
twice daily the height of the fundus uteri above the symphysis, as
well as the greatest breadth of the organ. To measure the height,
he pressed the fingers perpendicularly to the abdomen over the
fundus, so that the palmar surface of the hand marked the level.
The distance of this level from the upper edge of the symphysis was
then measured. The measurement so obtained was generally trust-
worthy for the first six or seven days ; but after that there is gene-
rally some degree of anteflexion, and the os uteri is tilted backwards,
so that the upper point of the line of measurement is taken from
behind rather than from the fundus. The measurements of every
case are given in detail. The height of the fundus diminishes con-

1868.] Report on Midwifery. 529

stantly, with the exception of a slight increase on the fourth day.
The extent of diminution from the first to the fifth day amounts to
5'1 centim. It proceeds much more quickly during the first four
than during the succeeding four days. The breadth of the uterus
loses about 3 centim. in the eight days. Comparing thirty-seven
primiparse with seventy-four primiparae, it was found that the invo-
lution of the uterus proceeded with much greater irregularity in the
first — a result certainly not expected, the increase noticed on the
fourth day being chiefly observed in the primiparse. Schneider explains
this more imperfect involution in primiparse as being not probably the
rule in normal puerpery, but as the result of causes acting more
especially on primiparse. Forceps deliveries are much more com-
mon. Severe labour more frequently called for chloroform. They
more frequently did not suckle. They were in greater proportion
subject to puerperal processes. All these conditions Schneider
proved by his observations to have a marked influence, the last one
especially, in retarding involution. — Monats.f. Oeh., May, 1868.

2. Mr. Harley's patient had in all probability contracted gonor-
rhoea at the end of gestation. The child had obstinate gonorrhceal
ophthalmia. The mother had severe acute rheumatism two days
after labour, attacking the left ankle, left wrist, hand, shoulder, and
neck of the same side. She slowly recovered, some stifiness of the
joints remaining. — Duh. Quart. Journ. of Med. Science, Aug., 1868.

V. — The New-born Infant.

1. On Sot BatJis as a cause of Trismus in New-born Infants. By
Dr. Kebek.

1. It was observed that a large number of cases of tetanus had
occurred in new-born infants in the town of Elbing. It was further
found that almost all these cases had arisen in the practice of one
midwife. Inquiry was instituted. It appeared that during 1864
and 1865 this midwife had attended 380 labours with a result of
09 cases of tetanus in the children ! It further appeared that hardly
any cases occurred in the practice of the eleven other midwives in
the town. Dr. Busch, a physician in the town, who was called in to
several of the cases, thus describes the symptoms :- — The first was the
child's refusing the breast. This never occurred before the third
day from the birth, most frequently on the fifth or sixth day, and once
on the tenth. If the finger is at this time inserted between the
jaws, stiffness is felt. The child cries, and the features contract
spasmodically. In twelve or fourteen hours these symptoms are
more marked. After a warm camomile bath, the cramp subsides ;
the child sleeps quietly, but its breathing is scarcely visible. Pre-
sently the jaws cannot be separated. The slightest touch evokes
spasms in the face and limbs. The fingers are held fast in the
palm, the thighs are bent upon the abdomen, the muscles of the
abdomen are hard. Warm baths bring no more relief. Later, it is
not necessary to move the child to cause spasm. It is enough to
touch the bed or to clap one's hands. The child becomes, in the

530 Chronicle of Medical Science. [Oct.,

fit, blue in the face, cries plaintively, and foams at the mouth.
Death usually ensued on the third or fourth day. Shortly before
death the convulsions ceased, the respiration, which had always been
regular, became shorter and at length ceased without signs of
dyspnoea. The rigor mortis was very strong, but did not last long.
Dr. Busch never observed inilammation of the navel or of its
vessels.

The practice of the midwife in the conduct of the labour and the
management of the child was minutely observed. The conclusion
formed was that she washed the child in water that was unusually
hot. She was cautioned to use a thermometer, and not to exceed a
temperature of 28° C.

"Whether this was followed by the disappearance of tetanus is not
reported. — Monats.f. Geb., June, 1868.

The following memoirs, for want of space, are referred to by title
only, or very briefly :

On the Postural Treatment of Prolapse of the Funis. By Dr. C.
H. KiDD. Dr. Kidd narrates a successful case in illustration. —
Dublin Quart. Journ., August, 1868.

Case of Enormous Fihro-cellular Tumour of the Vagina. By Dr.
Beattt. The tumour was successfully removed by ligature. —
Dublin Quart. Journ., August, 1868.

On Recurrent Typhus in Pregnant Women. By Dr. Zuelzeb.
Dr. Zuelzer cites the observations of various authors upon the rela-
tions of fevers to pregnancy. — Mon. f. Oeburtsk, June, 1868.

Two Cases of Anterior Encephalocele. By Drs. Heckeb and Buhl.
— Mon.f. Geburtsh., June, 1868.

A Case of Quintuple Birth. By Dr. Galopin. (The children
were all male, of about five and a half months' development. Eive
umbilical cords were inserted into two placentas.) — Journ. de
Bruxelles, 1867.

Eighty-four Observations on the Bodies of New-horn Infants in
reference to Breslau's Pespiration-test. By Dr. Liman. — Vier-
teljahrschr.f. Oerichtl. Med., 1868,

Version in Contracted Pelvis. Dr. Ringland relates an interesting
case illustrating the value of this operation. — Dublin Quart. Journ.,
August, 1868.

A Pelvimeter for Internal and External Measurement and Simul-
taneous Estimation of the Inclination of the Pelvis. By Dr. Lazabe-
wiTSCH. — Monats.f. Geb., May, 1868.

A Fibrous Tumou/r of the Uterus eliminated by Softening in a Female
who had Disease of the Heart. By F. Oppeet, M.D. — Med. Times
and Gaz., August, 1868.

Labour Obstructed by Enlarged Kidneys. By Dr. Wolff. Berlin
Klin. Wchnschr., 1867.

A Case of Vesico-Vaqinal Fistula following the Passage of a Vesical
Calculus. By Dr. MendiQl.— Monats.f. Geb., June, 1868.

1868,] Report on Pathology and Medicine. 531

REPORT ON PATHOLOGY AND PRINCIPLES AND

PRACTICE OP MEDICINE.

By Feakcis C. Webb, M.D., F.L.S.,

Member of the Royal College of Physicians, Physician to the Great Northern Hospital.

The Diagnosis of Diseases of the Nervous System ly Means of the
Ophthalmoscope. — lu a memoir presented to the Academy of Sciences,
Mr. E. Bouchut draws the following conclusions : — 1. The ophthal-
moscope enables iis often to discover in the interior of the eye lesions
of circulation, secretion, and nutrition which indicate organic disease
of the cerebro-spinal system. 2. Optic neuritis, neuro-retinitis,
choroiditis and papillary atrophy accompany the greater part of
acute and chronic diseases of the brain and of the cord. 3. By the
anatomical and physiological relations of the eye with the brain and
cord we can explain the law of coincidence of optical neuritis with
organic lesions of the nervous system. 4. When a chronic or acute
inflammation has its seat in the brain, that inflammation, through
the medium of the optic nerve, may be propagated to the eye.
5. Diseases of the anterior pillars of the cord may, through the
medium of the sympathetic, produce in the eye the phenomena of
papillary hypertemia which will later give rise to atrophy of the optic
nerve. 6. Optic neuritis and neuro-retinitis produced by acute or
chronic diseases of the nervous system are generally observed in
both eyes. 7. In lesions of the encephalon or its meninges optic neu-
ritis is in general more marked in the eye corresponding to the
hemisphere which is most gravely affected. 8. Alterations of the
optic nerve and of the retina complicated by nervous troubles of
sensation, intelligence or movement, always indicate an organic
disease of the brain. 9. Alterations of the optic nerve and of the
retina must not be isolated from other morbid symptoms, whilst
their establishment adds to diagnosis an element of incontestable
certitude. The diseases of the nervous system in which optic neu-
ritis and neuro-retinitis may be observed are — Phlebitis of the
sinuses, acute and chronic meningitis, chronic encephalitis, cerebral
hsemorrhage, tumours of the brain, cerebral contusion and compres-
sion, chronic hydrocephalus, abscess of the brain, acute myelitis,
locomotive ataxia, the contraction known as essential, and certain
forms of epilepsy, paralysis or neurosis connected with organic
lesion of the nervous substance.

Tumours of the Brain. — Dr. R. Bartholow relates three cases in
which tumour of the brain was diagnosed. In one only, however,
did circumstances permit the verification of the diagnosis after death.
After a resume of the observations of previous writers, he thus sums
up the combinations of symptoms which, he thinks, may indicate the
situation of the morbid growth. " In cases of tumour of the eere-
Irwn, the following symptoms are observed : — Headache, not, how-

532 Chronicle of Medical Science. [Oct.,

ever, confined to the seat of the morbid growth, and thus indicating
its position, but limited to one side of the head, or deep-seated and
diffused ; epileptiform convulsions and mental derangement. Altera-
tions of sensibility and of the special senses do not usually occur.
Paralysis is not generally present in tumours of the posterior lobes,
but is common in tumours of the middle and anterior lobes. Altera-
tions in the special senses occur more frequently in tumour of the
middle lobe, except the sense of smell, which is more usually affected
by tumour in the anterior lobe. Tumours of the corpus striatum
and optic tJmlamus are accompanied by the following symptoms : —
Hemiplegia, partial or complete, on the side opposite "the tumour,
and convulsions ; common sensation and the special senses are not
frequently affected, and the mind is not often impaired. In tumour
involving the crura cerebri, lesions of sensation and paralysis of the
face and of the limbs on the opposite side, giddiness and paralysis
of the motor oculi have been observed. In tumour of the pituitari/
gland the symptoms are frontal headache, amavirosis, first in one
eye, then extending to the other. The mental powers are generally
unimpaired, and there are no alterations of speech, sensation, or
motion. In a case which has been brought to my notice, non-
saccharine diuresis and epileptic convulsions were prominent symp-
toms. The symptoms are more complex in tumour of the ^ons. We
find here crossed paralysis ; face paralysed on the same and limbs
on the opposite side ; pain or anaesthesia in the paralysed parts, dis-
orders of the special senses ; dysphagia and mental derangement.
Convulsions are so uncommon in tumours of the pons that Ladame
lays down the following rule : — 'If a tumour has attained sufficient
size to allow of its presence being diagnosed, and if convulsions
be present, the probability is that the seat of the tumour is not in
the pons Varolii.' He also considers, and no doubt justly, that the
simultaneous affection of several of the organs of sense is indicative
of tumour of the pons. In tumours of the medulla oblongata,
pains in the limbs, anaesthesia, convulsions, and sometimes partial or
complete paraplegia, giddiness, vomiting, staggering gait, pains in
lower extremities, amaurosis, dulness of intellect, hallucination, deli-
rium, &c., have been observed. The following symptoms have been
observed in tumour of the cerebellum : occipital headache, convulsive
attacks, defect in the power of co-ordination, whence walking or
standing are difficult or impossible, convergent strabismus, amau-
rosis ; usually no disturbance of sensation except headache ; no
paralysis ; no lesions of speech ; no mental derangement. Mental
derangement, however, does occur sometimes in cases of tumour of
the cerebellum, as a result of the changes in the circulation of the
brain produced by the new growth." — Dr. M. Bartholow, American
Journal Medical Sciences, April, 1868.

Fatal general Emphysema supervening on Chronic Pleurisy and
Hydrothorax. — Dr. J. E. Thomson relates the case of a bricklayer's
labourer, aet. 34, who having apparently been in good health (except
that he had complained of palpitation and dyspnoea on exertion), and

1868.] Report on Pathology and Medicine. 533

engaged in his work, became suddenly sick, and, whilst vomiting felt
something give way in his chest. Shortly afterwards he brought up
a little blood ; great difficulty of breathing followed. Emphysema
showed itself in the cellular tissue of the neck, and rapidly spread,
especially on the right side. On percussion there was hyper-reso-
nance over the right apex, and as low as the level of the third rib.
Below that there was relative dulness. On the left side percussion
was natural. On auscultation over the right apex the respiratory
murmur was harsb, but there were no moist sounds or friction
murmur. On the left side the breathing was slightly harsh. A
systolic bruit was audible at the ensiform cartilage. The emphysema
rapidly increased, the respirations rose to sixty, the pulse could not
be counted, and he sank rapidly.

Postmortem twenty -jive hours after death. — One of the cusps of
the mitral valve was converted into a small hard nodule. The right
pleural cavity contained several quarts of a brown fluid. The lung
was compressed against the vertebral column and bound down by
adhesions which were most dense at the apex. The pleura over the
lower part of the lung and diaphragm was covered with lymph.
There were no traces of emphysema beneath the costal pleura.
The lower and middle lobes of the right lung were solidified and
friable. The apex contained cretaceous tubercle. The left lung and
pleura were healthy except some interlobular emphysema over the
anterior aspect of the former. The right bronchi contained a little
blood. The posterior mediastrum contained no air, but air was pre-
sent in large quantity in the anterior. The author supposes that
rupture took place in the anterior part of the right lung. — Dr.
J. Boherts Thomson, Edin. Med. Jov/rn., June, 1868.

Thoracic Aneurysm and Dementia. — Dr. W. Moore relates three
cases of thoracic aneurism in which dementia was a prominent
symptom. In the first there was aneurysm of the transverse
portion of the aorta probably interfering with the carotid supply ;
in the second there was a large aneurysm springing from the upper
part of the transverse portion of the aorta, with the left carotid
impervious from its origin to its bifurcation and atrophy of the left
hemisphere of the brain ; in the third there was an enormous
aneurysm springing from the front of the ascending portion of the
arch, the carotids and large arteries of the brain were found after
death well-nigh empty, and there was general atrophy of the brain.
The author's object in adducing these cases is, he writes, to show
that " mental diseases," so called, may be entailed by comparatively
remote physical conditions, and hence arises the importance of
taking the widest range in the consideration of these affections. If
in a case of dementia we can detect a latent aneurysm or intra-
thoracic tumour which from its situation, it is to be presumed, would
cause obstruction of the cerebral supply and consequent atrophy of
the brain, it is clear that the prognosis and treatment of the case
would be materially affected. — Dr. TV. Moore, Dub. Quart. Jov/rn.,
May, 1868.

534 Chronicle of Medical Science. [Oct.,

Ascending and Descending Breathing : its Value as a Symptom
and its Mechanism. — The peculiar irregularity of breathing referred
to in this paper was first described by Dr. Cheyne. The early
cases in which the symptom was observed were all cases of fatty
degeneration of the heart, and it was supposed to be a symptom
pathognomonic of that disease. It was thus described by Dr.
Stokes. Among the indications of the malady he says there some-
times occurs " a form of respiratory distress peculiar to this affection,
consisting of a period of apparently perfect apnoea, succeeded by
feeble and short inspirations, which gradually increase in strength
and depth until the respiratory act is carried to the highest pitch of
which it seems capable, when the inspirations, pursuing a descend-
ing scale, regularly diminish until the commencement of another
apnoeal period." Other cases where this symptom was observed,
however, occurred in which the heart was found to be free from
fatty degeneration, but the left ventricle was found hypertrophied
in consequence of valvular or arterial disease. This condition has
hitherto generally been associated by writers with a weak state of the
right ventricle, or attributed to some perverted action of the nervous
centres. Dr. Little offers a new explanation : — " In health the right
and left ventricles, though differing so much in the thickness of their
walls, are equally competent for their duties ; the right ventricle is
able to fill the pulmonary capillaries as thoroughly as the left one,
with the aid of the other forces which contribute to the circulation,
fills the systemic. But if an abnormal burden is imposed on the left,
if rigid valves narrow its outlet, or permit the blood it discharges at
each systole to fall back into its cavity, or if the arterial coats, their
elasticity destroyed by disease, no longer help the heart ; if the aorta,
instead of taking charge of each wave of blood as it leaves the ven-
tricle, and propelling it onward by the steady recoil of its walls, is
permanently dilated, and allows each portion of blood to remain in
its ascending trunk, and so to impede the entrance of that which
follows — under any of these conditions the left heart, however hyper-
trophied, may be quite unable to rid itself of the blood as rapidly as
it is supplied to it by the right ventricle. Blood would, therefore,
accumulate in the left auricle, in the pulmonary veins, and in the
capillaries of the lungs. That blood having already absorbed as
much oxygen as it required, would fail to produce that impression
on the ultimate filaments of the pneumogastric which black blood
does, and wbich impression is converted by the nervous centres into
the motor impulse which produces breathing. Breathing would,
therefore, cease ; and inasmuch as the respiratory act seems to assist
in carrying the blood to the left side of the heart, it would no
longer be so over-stimulated by fresh supplies, and its contractions
would become less frequent and more regular. After a few systoles,
however, it would succeed in discharging the red blood collected in
its cavities to such an extent that they could receive some of that
which lay in the pulmonary veins and lungs. Space being thus
gained, the black blood which the pulmonary artery contained would
reach the capillaries of the lung in amount proportionate to that of

1868.] Report on Pathology and Medicine. 535

the arterial which had gone forward, and sufficient air would be
drawn into the cheat to aerate so much blood. That very act would
carry forward a still larger charge of arterial blood to the left side,
and make room for the reception, by the lungs, of a still further
increase of venous blood, and, as a consequence, a still deeper inspi-
ration would follow, and the deepest would occur when the largest
quantity of venous and the smallest quantity of arterial lay in the
lungs. The red blood, reaching the left heart, would excite it to
those frequent and irregular contractions which accompany the
respiratory distress, but, frequent and irregular, they would be also
ineflfectual, red blood would begin again to accumulate in the left
heart, the pulmonary veins, and the lungs, till at last these capillaries
would contain little else, and the exciting cause of inspiration, the
venous blood, being no longer present, the act itself would again
cease. Precisely similar conditions might, it seems to me, be sup-
plied by fatty degeneration, for if it were — as I believe is often the
case — somewhat more advanced in the left than in the right ven-
tricle, or if, in addition to fatty degeneration, disease of the valves
or atheromatous deposit in the aorta were present, the balance
between the two sides of the heart would be destroyed. In Dr,
Cheyne's original case, indeed, it is mentioned that the aorta was
studded with steabomatous and earthy concretions." — Dr. James
Little, Duh. Quart. Joxirn. of Med. Science, August, 1868.

HypertropJiy of the Lymphatic Glands (L'Adenie). — MM. August
Ollivier and Louis Eanvier have published an interesting case of a
woman, set. 59, who died asphyxiated from pressure of the bronchial
glands. In the commencement of her illness in October, 1866, she
perceived two or three hypertrophied lymphatic glands on the sides
of the neck. Her health, however, did not appear at first to suffer,
but some months after she began to experience pain in the hypo-
chondria and dyspnoea. The disease extended ; the axillary, the in-
guinal and pelvic glands enlarged ; afterwards debility and true
cachexia set in, and she ultimately died asphyxiated after eight
months' illness. The post-mortem revealed great enlargement of the
thyroid body, the glandular vesicles of which had undergone an
hypertrophy allied to a colloid transformation, large masses of
glands in which the pneumogastric and recurrent nerves were im-
bedded, and by which these nerves must have been compressed ; the
bronchial glands were enormously enlarged ; the heart was atrophied ;
all the vessels at the base of the heart were compressed and flattened,
especially the brachio- cephalic trunk. In the abdomen was found
an enormous tumour, weighing 640 grammes, and composed of a
mass of lymphatic glands. The authors distinguish between the
hypertrophy of the lymphatic glands (I'adenie) and the various forms
of cancer, by the fact that in the former the tumours are composed
entirely of lymphatic tissue — the adenoid tissue of His, Clinically,
they distinguish between adenie and adenitis by the absence of pain
and all trace of inflammatory action ; pathologically, by the fact that
in adenitis the histological process tends to the formation of pus,

536 Chronicle of Medical Science. [Oct.,

cheesy matter, or fibrous tissue. In adenie the ganglia keep their
essential structure ; the follicles are enlarged, but they are always
formed of characteristic tissue, lymphatic tissue, the adenoid tissue
of His. The reticulated stroma remains sound, or frequently the
fibrillse are better marked and more voluminous ; at some of their
points of junction collections of nuclei may be observed. This
latter fact differentiates the condition from the normal, the presence
of nuclei indicating a certain degree of irritation, and being common
to adenie and inflammatory neoplasy. — Drs. Auguste Ollivier and
Louis Banvier, Gaz. Med. de Paris, Juillet 4, 1848.

Sodghin^s Disease. — Dr. J. J. Black relates a case of progressive
enlargement of the lymphatic glands, " Hodgkin's disease." J. S — ,
large, well-developed mulatto, entered the Philadelphia Hospital,
Blockley, in the early part of August, 1865, suffering from enlarge-
ment of the lymphatic glands and dropsical symptoms. Eight
weeks before had got wet, when the swellings began and increased
rapidly. No syphilitic or hereditary taint to be discovered. There
appeared to be an enlargement of every discernible lymphatic gland
in the body — the chains along the lower jaw, sub-occipital, axillary,
those in the groins, abdomen, and other parts. The glands on the
left side were decidedly and correspondingly larger than those on
the right. The left thigh and leg were very much enlarged and
cedematous, the right limb slightly so. There was much fluid in the
abdomen ; left side of the chest was full of fluid, and a considerable
quantity on the right side. Urine normal in quantity ; contained
no albumen ; chlorides abundant ; bowels regular ; pulse 100 ; respi-
rations 24, with all the evidence of effusion into the cavity of the
chest. Under treatment by iodide of potassium and iron, cod-liver
oil, &c., he improved, but afterwards relapsed and died eight weeks
after admission. Post-mortem, twelve hours after death. — Lymphatics
of left groin enormously enlarged above and below Poupart's liga-
ment. Pemoral vein obliterated by a semi-organised clot; right
inguinal glands two thirds as large as the left. Chains of lymphatics
on each side of lower jaw much enlarged ; left internal jugular vein
very much dilated; external jugular vein of left side very much
dilated. The left side of thorax was full of a thin serous fluid ; the
lung compressed and carnified. Effusion also in right cavity to less
amount ; azygos and hemi-azygos veins nearly or quite obliterated
by semi-organized clots. The lymphatics of the neck imder the
sternum running deep down, enormously enlarged, and pressing on
all the neighbouring parts. Along the trachea was a mass of
lymphatics enormously enlarged. Two of them contained tuber-
culous masses. Spleen enlarged, and full of waxy-looking bodies.
A mass consisting of one half the mesenteric glands weighed two
pounds five ounces. In the whole mass was only one very small and
hard tuberculous spot. There was a large mass of glands pressing
on the primitive internal and external iliac veins. In the primitive
iliac veins were large pouch-like dilatations which would admit a
hen's egg. The author calculates that all the lymphatic glands of
the body together weighed thirteen pounds fourteen ounces. The

1868.] Report on Pathology and Medicine. 537

blood appeared deficient in red corpuscles. The microscope showed
the enlarged glands to consist of numerous nucleated cells and a
large amount of fibrous matter, in fact difiering little from the
healthy gland. Sulphuric acid, and afterwards iodine, applied to
the spleen and lymphatic glands, gave a characteristic blue. Owing
to accident, the kidneys and liver were not carefully examined. The
author states that he has met with two other cases of the disease,
one that of a soldier, set. 65, the other that of a mulatto boy, set.
16. Both cases proved fatal. A somewhat similar case is recorded
by Dr. W. Carson, ' Western Journal of Medicine,' Feb., 1860 ; but
the patient was a woman, set. 28. The duration of her illness was ten
or twelve weeks. — Dr. J. J. Black, American Journal of Medical
Sciences, April, 1868.

Acute Leucocythceniia in Diphtheritic Resorption. — M. E. Bouchut
relates the case of a child, set. 5, who was brought into the Hospital
for Sick Children, suffering from croup. Tracheotomy was per-
forraed ; albuminuria, with leucocythsemia, as proved by the large
number of white globules seen in the blood by the microscope, was
developed, and the child died. M. Bouchut believes that diphtheritic
resorption took place, and that acute leucocytha^mia accompanied it.
He writes, " That which is most curious in this observation is the
acute leucocythsemia accompanying diphtheritic resorption, a pheno-
menon of which cliniciens have hitherto made no mention. I have
heretofore spoken of the acute leucocythsemia of puerperal fever as a
pathological state, distinct from hepatic, splenic, or ganglionic leuco-
cythsemia ; and I have asserted that, without study of this variety of
leuksemia, the history of this alteration of the blood must be incom-
plete. AVithout wishing to create a new kind, I have stated that
in certain severe cases of puerperal metritis and in purulent re-
sorptioa an acute leucocythsemia terminating rapidly in death is
present. For some years I have shown in my clinique cases of grave
diphtheritis equally accompanied by acute leucocythsemia, and I
again call the attention of observers to this variety of alteration of
the blood."— Jf. E. Bouchut, Gaz. M6d. de Paris, Juin 20, 1868.

Intermittent or Paroxysmal Jlcematuria.— Dr. E. Headlam Green-
how states that withiu the last ten years he has had under his care
seven cases of this disease. In all the immediate exciting cause of
the attack was some definite exposure to cold or wot. The paroxysms
come on suddenly, almost immediately after the chill has been expe-
rienced, and pass off rapidly after the effects of the chill have been
counteracted, and the patient has become warm. In every instance
the paroxysms have begun with coldness of the extremities, followed
by general chilliness, amounting in the severe attacks to rigors. In
every case, also, the chilliness or shivering has been attended by
a feeling of weight and pain in the loins, and by pain or a sense of
weakness or stiffness in the lower limbs. The chilliness is usually
followed by an imperfectly marked febrile hot stage. During the
paroxysms urine, which looks as if it were mixed with blood, is
passed, and in each case observed the paroxysms have run the same

538 Chronicle of Medical Science. [Oct.,

course. " Erom half an hour to two hours after the chilliness or
rigors the patient has never failed to pass the first dark-coloured
urine, -which has always been highly albuminous, and has contained
numerous crystals of oxalate of lime, with more or less of brownish-
or yellowish-red amorphous granular matter, and a few hyaline
casts, but only occasionally some stray blood-corpuscles. At each
succeeding micturition after the chilliness the urine has invariably
shown more or less diminution of colour, of albumen, of oxalate of
lime, and of its other abnormal contents, resuming its natural cha-
racter and appearance by the second or third micturition after slight
attacks, and usually by the fourth or fifth after severer paroxysms."
By the second day after an attack the patients have usually recovered,
and continue well until some fresh exposure. The patients all had
a pale, sallow, cachectic aspect. Two were jaundiced, and the others
had at times an icteroid tint of skin. From the history of these
cases Dr. Grreenhow concludes that there is no cause of hsemorrhage
in the kidneys themselves, but rather that the disintegrated blood
transudes through the walls of the blood-vessels in the Malpighian
bodies. The kidneys, he thinks, are rather the organs of elimination
than the seat of the disease; and he suggests that possibly "the
paroxysms may consist in the sudden disintegration of an unusually
large quantity of blood-corpuscles, setting free so considerable an
amount of hsemato-globulin that it cannot undergo the normal
changes, but is eliminated through the kidneys in a comparatively
unaltered state." In the disease as he has observed it there has
been no malarious influence to produce it ; and whilst it resembles
ague in its paroxysmal form, it differs from it in not being periodical,
and in requiring a fresh exposure to cold and damp to excite each
paroxysm. He infers the existence of some form of dysci'asia upon
which the external chill acts as the exciting cause of the paroxysm.
He considers the presence of oxalate of lime crystals in the urine
during the paroxysms significant. In four cases which he relates
so-called rheumatic pains were also experienced during the attack. —
Dr. JE. Headlmn Oreenhow, JEdin. Med. Journ., May, 1868.

On Hippuric Acid, and on the relation existing hetween its Deposit
and Vomiting in Organic Diseases of the Stomach. — Dr. J. J. da
Silva Amado records the case of a man, set. 37, who sufiered from
tumour in the epigastrium, and in whose urine there was a large
proportion of hippuric acid, which deposited spontaneously. The
details of the case seemed to support the belief that there was a
correlation between the vomiting and the abnormal urinary deposit.
On those days on which there was no vomiting there was no deposit.
When the vomiting was excessive the deposit of hippuric acid was
abundant. The following are the conclusions the author appends : —
1. In a normal state man excretes, by urine, about two grammes
of hippuric acid in twenty-four hours, 2, This quantity augments
(a) under a purely vegetable diet, (i) by the ingestion of benzoic
acid or one of its derivatives, (c) by exaggerated exercise, {d) in
pyrexias, (e) in diabetes. 3. The proportion of hippuric acid ex-
creted diminishes or disappears more or less completely (a) under

1868.] Report on Pathology and Medicine. 539

the influence of an exclusively animal diet, (J) by prolonged repose,
(c) by abstinence, (d) by icterus, 4. Exaggerated production of
hippuric acid following ingestion of benzoic acid, or one of its de-
rivatives, seems to result from the reaction of these substances on
the glucose of the liver. 5. "When an exaggerated production of
hippuric acid is not due to the ingestion of benzoic acid it seems to be
due to the oxidation of tyrosine. 6. It is not proved that there is
any malady characterised by an exaggerated and continued excretion
of hippuric acid. 7. Hippuric acid may appear in the urine as a
sediment. 8. In organic aifections of the stomach a relation may
exist between vomiting and an exaggerated excretion of hippuric
acid. — Dr. J. J. da Silva Amado, Qaz. Med. de Paris, Juillet 11
and 18.

Microscopic Examination of the Lymph of Variola Vaccina and
Variola Ovina. — Professor Hallier and Decent A. Zuern have found
in the lymph of sheep-pox very fine threads and small bodies, the
latter moving actively. Examination of the pustules of sheep-pox
in the process of development showed a large number of small
nucleated cells. The elements of the epidermis contained nuclei
and threads in large quantity. By cultivating with the lymph ob-
tained from vaccine and ovine pocks, they have always been able to
reproduce the same organisms. In the lymph of smallpox M. Hallier
found numerous micrococcus cells in larger quantities than in vaccine
or in ovine lymph. Magnified 800 times, these vegetable organisms
appeared to be distinct rounded bodies, moving about, and here and
there they were seen to be attached to lymph-corpuscles. Fine
threads were also present in abundance. Dr. E. Keber, of Dantzic,
states that both in vaccine and variolous lymph, and in the lymph of
varicella, he has observed peculiar organic bodies. He has not
satisfied himself of their occurrence in the blood of the affected, or
in the air surrounding them. The bodies are granular cells i^^o^^
to -j^Tjth of a line in diameter, innumerable free nuclei from -g-^Tyth
to ^-fj^^jsth, and numerous minute molecules. The cells have a fine
membrane, which swells with water, and they differ entirely from
mucus- or pus-corpuscles. — Virchoio^s Archiv, November, 1867;
February, 1868; and Edin. Med. Journ., June, 1868.

Infusoria in the Air expired in Whooping -Cough. — M. Poulet has
communicated to the French Academy of Sciences some observations
made during an epidemic of whooping-cough. He collected the
breath of the patients, and on examining the vapour microscopically
he states that he found a large number of minute infusoria, which
were in all the cases examined identical. The species of infusoria
observed were the Monas or Bacterium termo, Monas punctu/m,
and Bacterium bacillus. — Gaz. Held, de Med. et de Chir., August 16,
1867 ; American Journal Med. Sci., April, 1868.

Parasitic Forms i7ifccting the Epithelial Cells of the Urinary and
Generative Organs. — Dr. J. H. Salisbury figures and describes a
number of cryptogamic forms and also of animal organisms which
he says he has found in the parent epithelial cells lining the genital

540 Chronicle of Medical Science. [Oct.,

and urinary organs. These parasites all produce more or less irrita-
tion, and as a consequence the physiological function of the cell is
deranged. Hence arrive excessive cell activity and secretion, with
resulting pathological products, and frequently cell death and dis-
integration. The discharges irritate, and the parts become inflamed
and often thicliened and indurated. Indurations of the womb thus
produced may be mistaken for scirrhus. Fourteen kinds of crypto-
gamic parasites are described, belonging to the groups Penicillium,
Torulus, Botrytis, Zymotosis, Sarcina, Spharrotheca, and Grypta ; and
five kinds of animal parasites : — I. Trichina cystica (Salisbury), a small
species of Trichina found in the human bladder. The author has
met with it three times ; the ova may be found in the urine ; in one
case ten to fifteen ova were found in a single drop. II. A species
of Vibrio resembling that occurring in vinegar, to be found in freshly
voided urine. III. Trichomanas vagince. IV. GiUaris hicaudalis
(Salisbury) consists of a single cell, slightly oval, having two hair-
like caudal prolongations. The cell is covered with short, thickly
set cilia. It is found in the secretion of the womb, vagina, and
bladder. V. Trichomanas irregularis {^•^i\.i^\)•avJ) . The body smaller
and more variable in size than T. vagince. — J. H. Salisbury, M.D.,
American Journal of Medical Sciences, April, 1868.

The Pathology of Eczema Marginatum. — Dr. M'Call Anderson
describes this disease as commencing on the inside of the thigh,
where it is in contact with the scrotum, in the shape of a small
round patch, which is red, elevated, itching, and which may, as the
disease extends, become the seat of papules, vesicles, excoriations or
crusts. The eruption heals in the centre, leaving the skin dis-
coloured, owing to pigmentary deposit, while it extends at the
edges in the shape of a circle, until it may reach the size of the
palm or more. Similar patches often form in the neighbourhood,
which coalesce with the circle first formed in such a way that a huge
circle of eruption may result, which extends nearly to the umbilicus
above, the knee below, and the sacrum behind. Inside this circle
new circles often form, and similar patches may be detected in other
parts of the body. Tiie disease is most common to shoemakers and
dragoons, owing to the moisture and friction entailed by their occu-
pations. In India it is common and is known by the name of
Burmese ringworm. Dr. M'Call Anderson differs from llebra and
E. Wilson as to the character and origin of this disease. He does
not think it eczema, and he maintains with Kobner of Breslau that
it is due to the same vegetable parasite that is found in tinea cir-
cinata, of which indeed he considers the disease a variety. He relates
two cases, in which microscopic examination of the scales from the
eruption discovered " spores, some of them isolated, some in chains
andtubes of a fungous growth." Solution of bichloride (gr.ij to the 3J)
seems to cure the disease. The author notices, incidentally, that the
use of bichloride lotion, followed by the use of solution of hyposul-
phite of soda, has the effect of dying the hair of a jet black colour. —
Dr. M'Call Anderson, Edinburgh Medical Journal, May, 1868.

1868.] Report on Toxicology, Forensic Medicine, ^c. 541

REPORT ON TOXICOLOGY, PORENSIC MEDICINE,

AND HYGIENE.

By Benjamin W. Richaedson, M.D., F.R.S.,

Senior Pliysician to the Royal Infirmary for Diseases of tlie Chest.

I. — ToxicoLoaY.

Chemical Constitution and the Physiological Action of Poisons. —
We give precedence with sincere pleasure, in this report, to the
researches of Drs. Crum-Brown and Eraser on the connection
between chemical constitution and physiological action, and on the
changes produced by direct chemical addition on the physiological
action of certain poisons. The aiithors begin by stating that, as the
chemical constitution of the majority of physiologically active sub-
stances is known, they investigate the subject by examining the
physiological action of a substance before and after the performance
upon it of a definite chemical operation introducing a known change
into its constitution. There are two kinds of operation to choose
between — replacement and addition. In their first inquiries the
authors chose to select the effect of addition, their reason for
such selection being that replacement does not produce nearly sa
great a change of physiological action as addition does. The fol-
lowing is a full abstract of their further argument and of their
experiments :

" Comparing the action of carbonic oxide and carbonic acid,
hydrocyanic acid and methylamine, arsenious and kakodylic acids,
strychnia and brucia, and the salts of the ammonium bases derived
from them, it may be seen that addition, in many cases at least,
diminishes or removes physiological activity. This comparison leads
to a suspicion that physiological activity is in some way connected
with chemical condensation, by which term the authors mean sus-
ceptibility of addition, whether the addition takes place by the
increase of the atomicity of an atom, or of a group of atoms. Thig
suspicion receives some confirmation from the fact that such of
the stable combinations of pentatomic arsenic and antimony as
have been examined physiologically are stated to be inert, while
all the soluble compounds of triatomic arsenic and antimony are
active ; similarly, the aromatic bodies are, as a rule, more active
than the corresponding fatty bodies. The occurrence, however, of
such poisons as alcohol, oxalic acid, and corrosive sublimate among
saturated substances, and of comparatively inert condensed com-
pounds, such as benzoic acid and salicine, shows that condensation
is not the only condition of physiological activity.

" The statements of Stahlscbmidt and Schroff", in reference to the
action of the salts of methyl-strychnia, induced the authors to turn
their attention, in the first place, to the eff'ect of the addition of

84— XLii. 35

543 Chronicle of Medical Science. [Oct.,

iodide of methyl to the natural alkaloids. As the iodides of the
complex ammoniums thus produced are, in most cases, sparingly
soluble in water, they have also examined the action of the corre-
sponding sulphates.

" The poisonous alkaloids thus examined, and included in this
paper, are strychnia, brucia, thebaia, codeia, morphia, and nicotia.
The authors give details of the processes followed in obtaining the
iodide and the sulphate of the methyl- derivatives of these bases,
and they describe their physiological effects.

" Twelve grains of iodide of methyl-strychnium,i subcutaneously
administered, produced no effect on a rabbit weighing three pounds.
Fifteen grains were recovered from after symptoms, and twenty
grains was a fatal dose. When exhibited by the stomach, twenty
grains of this compound did not cause any symptom ; while the
same rabbit was rapidly killed by one tenth of a grain of strychnia,
given in exactly the same way. Twenty grains of iodide of methyl-
strychnium contain about fourteen grains of strychnia,

" The sulphate of methyl-strychnium, being a much more soluble
salt than the iodide, was found to have a much smaller poisonous
dose. One grain was fatal to a rabbit by subcutaneous exhibition.
Eight tenths of a grain were recovered from, while five tenths did
not cause any symptom. The rabbit that recovered after the
administration of eight tenths of a grain of sulphate of methyl-
strychnium, died shortly after one twentieth of a grain of strychnia
was injected under the skin.

" Both the iodide and the sulphate of methyl-strychnium pro-
duced symptoms altogether different from those of strychnia. There
were no convulsions, nor was there the slightest exaggeration of
the reflex function ; the symptoms were those of paralysis, and death
was produced by the asphyxia that this occasioned. The authors
further investigated this action by localised poisoning in frogs ;
and they have demonstrated that iodide and sulphate of methyl-
strychnium paralyse the peripheral terminations (end-organs) of the
motor nerves, and, therefore, possess exactly the same action as
curare (wourali).

" Brucia and thebaia act in the same way as strychnia, and it was
found that iodide and sulphate of methyl-bruciura and methyl-
thebaium have the same action as the analogous strychnia compounds.
The fatal dose of iodide of methyl-brucium was found to be very
much the same as that of the corresponding compound of strychnia ;
a larger dose was, however, necessary to produce death with sulphate
of methyl-brucium than with sulphate of methyl-strychnium.
Iodide of raethyl-thebaium, being more soluble in warm water, has
a smaller fatal dose than the iodides of methyl-strychnium and
methyl-brucium. Six grains produced no effect when injected under
the skin of a rabbit; eight grains caused symptoms, which were
recovered from ; and death occurred eleven minutes after the injec-
tion of ten grains. Eight grains of iodide of methyl-thebaium

1 " The action of iodide of etbyl-stryclmium was .also examined, and found to
be the same as that of iodide of methyl-strychnium."

1868.] Report on Toxicology, Forensic Medicine, ^c, 543

contained about five grains and a half of thebaia, and, for a rabbit,
the fatal dose of this alkaloid is one fifth of a grain.

"Among the opium alkaloids, codeia ranks next to thebaia in
activity. It vs^as found by the authors that six grains of iodide of
methyl-codeium dissolved in warm water, and injected under the
skin of a rabbit, caused no eficct. Ten grains, however, was an
almost fatal dose, and this contains about twelve times as much
codeia as would kill a rabbit. It was also found that the fatal dose
of sulphate of methyl-codeium is not very different from that of the
iodide. Neither of these compounds possess the usual convulsant
action of codeia ; and as this alkaloid has but a feeble soporific action,
it was difiicult to determine how far this was modified by the direct
chemical addition of methyl compounds. The authors also found
that iodide and sulphate of methyl-codeium paralyse the motor nerve
end-organs, an effect that is not produced by codeia itself.

" Iodide of methyl-morphium is a very insoluble substance. The
largest dose that could, therefore, be administered subcutaneously
to a rabbit was twenty grains, and this large quantity produced no
effect. Eight grains of morphia were, some days afterwards, ex-
hibited in the same way to this rabbit ; the result was a decided
soporific effect, followed by epileptiform convulsions and death.

" No effect was produced when iodide of methyl-morphium was
administered to rabbits by the stomach, even in so large a dose as
thirty grains.

" Eecoguising the possible fallacies connected with experiments
with such a substance on rabbits, the authors determined to observe
the effect on man. One of themselves accordingly took, on one
occasion, half a grain of iodide of methyl-morphium as a powder,
and on another one grain (containing about three fourths of a grain
of morphia) ; but on neither occasion was there observed the slightest
soporific or other effect.

" Four grains of sulphate of methyl-morphium produced decided
narcotism on a rabbit, but no convulsive effect. Indeed, with this
dose, and with various others that were given, paralysis appeared,
and the authors have demonstrated that this symptom is due to an
effect on the motor nerve end-organs.

" Iodide of methyl-nicotium was obtained in the form of crystals
extremely soluble in cold water. When given to rabbits by sub-
cutaneous injection, a dose of five grains was perfectly inert ; one of
fifteen grains produced serious symptoms, followed by recovery; and
a dose of twenty grains was fatal. The symptoms were principally
distinguished from those of nicotia by the absence of convulsions ;
but no paralytic action on motor nerve end-organs was caused.

"The authors have also investigated the action of iodide of
methyl, and they obtained no evidence in support of the extremely
improbable hypothesis, that some of the changes produced in the
action of the substances they had examined might have been due
to the addition of the physiological action of the methyl compounds.
They conclude by discussing the possible causes of these modifica-
tions, by pointing out some of the practical applications of their

.544 Chronicle of Medical Science. [Oct.,

results, and by promising to examine how far iodide of methyl may
prove an antidote to the poisonous effects of these vegetable alka-
loids, whose fatal dose it increases." — Transactions of the Moyal
Society of Edinburgh, January 6th, 1868.

On the Neutralisation of some Poisons hy bodies of the Methyl and
Ethyl series. — We have ourselves been following a line of research
physiological in character and running somewhat parallel, in its way,
with the researches of Drs. Crum- Brown and Eraser. In 1860 we
observed and recorded (in Brown-Sequard's ' Journal ') the fact that
in frogs the synthesis of cataract could be produced by injecting
solutions of chloride of potassium and sodium, but that the iodides of
the same metals would not give the synthesis. This led us to
believe that the iodides, even in organisms of frogs, were changed in
composition in the body. This same view was further confirmed by
the known curative effects of iodide salts in some forms of disease in
the human subject. The question, therefore, came to us whether the
iodides within the organism would neutralize the action of some of the
alkaloidal poisons. To test this the following research was made ; it
dated from the 24th of October last year. We made three solutions : —
1. Consisted of two minims of iodide of ethyl and thirty of alco-
hol and water. 2. Consisted of the thirtieth of a grain of strychnia
in thirty minims of alcohol and water. 3. Consisted of the thirtieth
of a grain of strychnia with two minims of the iodide of ethyl and
thirty of alcohol and water. A frog was injected with the solu-
tion No. 2. It became tetanic in one minute and a half. Another
frog was injected with the solution No, 3, i.e. the solution of
strychnia and iodide of ethyl. This frog also became tetanic in one
minute and a half. The frog No. 1 was now injected with a solution
containing five minims of the iodide of ethyl. Within ten minutes
the spontaneous tetanus had ceased, and spasm, under the influence
of irritation, was very much less. In twenty minutes there was
entire relaxation, but with faint twitches when the skin was touched.
The frog No, 2 was next injected with a solution containing one
grain of iodide of ethyl. There was immediate relaxation of all the
tetanic action, and irritation brought on no spasm. One hour after
this the frog No. 1 still twitched when touched ; while frog No. 2
remained relaxed and living, but paralysed. Both frogs died on the
following day, retaining their symptoms to the end. It was clear in
these two cases that the iodide of ethyl exerted an antidotal action
to the poison, but as the animals died with different classes of
symptoms a further research was made. A large frog was injected
Avith ten minims of the iodide only. It seemed quite unaffected
for some hours, but on the following day it died, presenting symptoms
of general paralysis similar to the frog that had received the larger
injection after the strychnia. Thus, the question had to be solved
whether any precise formula of neutralization could be arrived at.
In one experiment, it was clear, we had not used enough iodide to
overcome the spasm, in another we had thrown in so much as to
more than neutralize, in fact to kill b}'^ the iodide itself. Can,

1868.] Report on Toxicology, Forensic McMcine, &;c. 545

then, any known quantities for exact neutralization be introduced into
a living body ? TJp to this time we have failed after the most careful
study to find such quantity ; we can certainly prolong life twenty -four
and even twenty-eight hours after a terribly intense dose of strych-
nia, but ultimately there is death. Iodide of methyl acts in precisely
a similar way as the iodide of ethyl, as do also the bromides of methyl
or ethyl. Another series of experiments were about the same time
made with nicotin. On October 26th (1867) two minims of nicotin
were injected subcutaneousiy into a large rabbit. The animal died
in twenty-five seconds. Another rabbit was injected with one minim
of nicotin and ten of the iodide of methyl ; it died in one minute
and fifty-one seconds. A guinea-pig and a rabbit were treated with
ten minims of the iodide only. It remained well for several hours,
but both died the next day. Again, varied experiments were carried
out to get at the neutralizing proportions of these two agents, and
guinea-pigs were made to replace rabbits. But the point was never
reached. Death from an intense dose of nicotin was frequently kept
back for hours and the convulsive action was prevented, but the end
"was death. A point of inquiry still remained — to determine, namely,
whether these neutralizing effects of the iodides were chemical or
physiological in character. To approach a conclusion on this point
we tested the action of the nitrites of the methyl, ethyl, and amyl
series in a similar manner, and obtained results showing that the
nitrites are also antidotal, but that the symptoms of strychnine poison
returned when the antidote was allowed to escape from the body.
We are bound, therefore, to afiirm, in relation to the nitrites, that
their neutralizing action is purely physiological, but we are not pre-
pared to draw the inference from this that the iodides and bromides
are to be placed, as antidotes, in the same position. — Abstract of
Heport to the British Association for the Advancement of Science, 1868.

Immediate Action of Hydrocyanic Acid. — Mr. Clay Hall reports
to Professor Alfred StUle the case of a gentleman who destroyed
himself by taking about 100 drops of the diluted hydrocyanic
acid prepared by Squibbs, of Brooklyn, of the strength of 2 per
cent, of the pure anhydrous acid. The facts are of interest,
from the circumstance that Mr. Hall was with the deceased within
five minutes after the poison was taken, found him alive, and
remained with him unto his death, which occurred twenty minutes
after taking the acid. From the evidence at the inquest it was
elicited that the deceased, a Mr. Pomeroy, went into a barn, poured
into a goblet the poison (about 100 drops), recorked the bottle
holding the poison, placed it on a shelf, and then going to the steps
of the barn, placed his hat carefully on them ; he now went back to
the goblet, drank the fatal draught, placed the glass upon a ledge
eight feet from the floor, laid himself upon the floor, placed his
hands across his breast, and passed into unconsciousness. Mr.
Clay Hall was the first person who got to Mr. Pomeroy, who had
not then been in the barn five minutes. He (Pomeroy), says Mr.
Hall, was lying extended upon the floor, unconscious. His muscles

546 Chronicle of Medical Science. [Oct.^

were relaxed and flaccid, with the exception of the muscles of the jaw,
the jaw being firmly closed; hia hands were folded across his chest,
as in repose ; the eyes were fixed, but lifelike, the pupils were in their
normal condition; respiration was slow, but not laboured, although,
deep drawn ; his pulse was about 50, becoming slower and less strong
to the moment of his death. During the most forcible expirations
not the slightest odour of the acid could be perceived in the breath.
His respiration became slower and slower until intervals of one
minute intervened, and in twelve minutes he breathed his last. At
the moment of dissolution the pupil dilated, but there was not the
movement of a muscle to indicate death; he simply ceased to
breathe. The veins of his neck were strongly congested. Shortly
after death the lifelike appearance of the corpse was surprising, and
thirty-six hours afterwards the eye retained its brightness. — Amer.
Journ. of the Medical Sciences, January, 1868.

Case of Poisoning with Rhus Toxicodendron.. — Dr. W. R. Sanders
records the following very rare instance of poisoning by the Ehus toxi-
codendron (poison ivy). Peter Doig, set. 26, a gardener, was admitted
into the Rojal Infirmary, under Dr. Sanders's care, on July 25th, 1867.
He was a strongly built man, of middle stature, and had evidently been
in the enjoyment of robust health. He stated that after the diseases of
childhood he had never suffered from any illness, with the exception
of an attack of gastric fever, at the age of twenty, from which he perfectly
recovered. The symptoms, on account of which he now sought medi-
cal treatment, consisted chiefly of an erysipelatous eruption on certain
parts of the skin, of which he gave the following history : — About
three weeks before admission, viz. on July 6th, he had, in company
with other gardeners in Mr. Lawson's nursery, been employed in gather-
ing the shoots of the Rhus toxicodendron for the purpose of supplying a
homoeopathic druggist in town. Doig continued at this occupation for
about two and a half hours on that afternoon. Instead of pulling up
the whole plant, as other workmen did, Doig plucked off the young
shoots, and in so doing his hand came into frequent contact with the
juice of the plant. This juice, which was white and milky when fresh,
became dark on exposure, and concreted on the palms and wrists,
forming dark scales, which adhered so closely that they were removed
with difficulty by rubbing ofi" the superficial layer of cuticle. At this
time no inconvenience whatever was felt ; but, four days afterwards,
Doig noticed two blisters, each about the size of a threepenny piece, on
the flexor surface of the right wrist. On the top of each blister there
remained adherent a portion of the black concreted juice, and there was
some redness around the vesications, but no pain. Four or five days
subsequently the other wrist became similarly affected, and about
the same time the redness began to spread slowly up both forearms.
Nothing farther was noticed until the 23rd, when he was obliged to give
up work in consequence of the swelling and stiffness of the forearms,
accompanied by severe numbing and stinging pain, to relieve which he
had rolled his arms in cold moist cloths. This was seventeen days after
exposure to the poisonous juice. On the 24th, being now greatly

1868.] Report on Toxicology, Forensic Medicine, ^c. ^4:7

alarmed at the progress of the eruption, he applied to the infirmary,
where he was first admitted into the surgical wards, under Dr. G-U-
lespie, who next transferred him to Dr. Sanders. On examining the
patient, Dr. Sanders found the skin on the flexor surface of both
forearms swollen, and of a florid red colour, like that of erysipelas, and
the red surface was covered with small transparent vesicles, each
about the size of a pin's head, closely set together. The vesicles resem-
bled those of eczema, or the minute inflammatory vesications produced
by the application of turpentine. Both forearms were considerably swollen,
and felt stiff to the patient. Some of the black spots formed by the
dried acrid juice were still seen on the palms of the hands and on the
adjoining parts of the wrists. The skin of the (upper) arms was natu-
ral. The face, though less affected than the forearms and not vesicated,
was swollen and erythematous, the eyelids being puffy and partially
closed. The trunk of the body was untouched, but the skin of the
penis and the scrotum was red, oedematous, and painful, and there were
scattered spots of inflamed and slightly elevated skin on the inner
surface of both thighs. The inflamed portion of skin was the
seat of pain, sometimes of a numbing character, sometimes stinging
like the irritation of nettles. The pain was worse at night, owing
to the heat, but it was not severe anywhere except in the forearms.
It was remarkable that these symptoms were unaccompanied by
constitutional disturbances ; the pulse was quiet and the appetite good.
The tongue was somewhat furred and dry, but this was owing to con-
stipation, which was easily relieved. During the course of the follow-
ing day (26th) the red patches extended up the arms, and also down
the sides as far as the knees, while some scattered spots appeared over
the pubes. Next day (27th), the swelling and redness of both face
and arms were diminishing, and the vesicles on the forearms were dry-
ing up into scabs, but the erythematous eruption on the thighs con-
tinued to spread downwards to the legs and upwards on the trunk of
the body. On the 29th, at noon, the abdomen was found covered with
irregularly shaped patches of inflamed skin, which had extended from
the pubes upwards as far as the hypochondria. At the margin of the
large patches there were numerous detached, small, reddish spots, like
the eruption at the outset of measles, the larger patches resembling the
continuous rash of scarlet fever. On the 31st the redness had extended
to the back, while anteriorly the skin, from the pubes to the clavicles,
was marked with inflamed patches and spots, the region of the sternum
being alone unaffected. The legs were almost entirely covered with erup-
tion. There was no vesication on any of these parts. But while the erup-
tion was thus spreading on the lower half of the body, the upper half
was recovering. Thus, the forearms were now nearly well, the redness
and swelling were gone, only a few small vesicles remaining on the backs
of the hands and between the fingers. The face had nearly the natu-
ral appearance, very slight desquamation being observable. At even-
ing visit Doig complained of stiffness and rheumatic pains on the knees
and elbows, but no swelling of the joints was present. These pains
were ascribed by the patient to sitting up in a cold side room, and
they were quite gone next day. Doig still presented no constitutional

548 Chronicle of Medical Science, [Oct.,

disturbance ; with the exception of a tendency to constipation, all the;
functions were normal. On the 1st of August the eruption ceased to
spread on the trunk, and soon began to fade. It had now completely
disappeared on the face, arms, scrotum, and other parts first affected.
There was very slight desquamation, the skin returning to its natu-
ral state. On the 2nd of August Doig left to go to the country, hav-
ing been eight days in the infirmary. Dr. Sanders saw him again
about three months afterwards, when he said that after going to the
country from the infirmary the eruption, which had almost entirely
subsided, reappeared on the trunk of the body, but it lasted only for a
few days, and then completely and finally disappeared. The case
required only ordinary care, never presenting at any time an appear-
ance of danger. The patient, indeed, was at first in a state of extreme
alarm ; the fact of being poisoned and the persistent progress of the
symptoms filled his mind with undefined terror. But on being confi-
dently assured that his symptoms were free from danger he had the
good sense to believe the statement, and the relief of his fears was per-
haps the most important part of the treatment. Death has been caused
by the poison in experiments on animals, but Dr. Sanders is not aware of
any fatal cases in man. One circumstance deserving of notice in Doig's
case is, that he alone was affected out of a number of persons employed
in gathering the poison ivy. This might be ascribed to a special sus-
ceptibility of skin above referred to, but his own account suggested a
more obvious cause in the fact that, while others gathered the entire
plant, he alone plucked the young shoots, and in breaking off the young
twigs set free the juice, which came in abundant contact with his
arms and forearms. In Doig the irritant was long in taking effect, for
on the wrists, which were most acted upon by the juice, the inflammatory
action did not occur until after a considerable interval ; and the face,
which had received a small dose of the irritant principle, was only sub-
sequentlj' and less severely affected. The only circumstance requiring
special explanation is the spreading of the eruption over the trunk of
the body at a later period of the case, after all sources of irritation were
removed. This, it appears, can only be explained on the supposition
that some of the poison had at length been absorbed into the blood —
or at least into the tissues of the skin — and this agrees with the obser-
vations of toxicologists, which have shown that the cutaneous symp-
toms may arise from the internal administration of the poison, or what
is the same, from its absorption in the blood, as well as from its exter-
nal local application. — Edinhurgh Medical Journal, February, 1868.

Hygiene.

Defects of Biulding Materials in relation to Health — Saline Damp.
— The author of this communication writes a separate essay without
giving his name. He is " a metropolitan ratepayer," — that is all he
allows us to know of him. In a somewhat crude manner he presents
us with a new subject belonging to public health, for which reason of
novelty we notice him. He urges that the question of building upon
an extensive scale for the accommodation of pauper lunatics and pauper
patients afilicted with smallpox or fever is assuming very prominent

1868.] Report on Toxicology, Forensic Medicine, &^c. 549

proportions, and is becoming important in the social arrangements of
the metropolis under the provisions of the Poor Law Act of 1867. In
the construction of two of these extensive buildings (asylums) near to
London, viz. at Leavesdon and Caterham, the author estimates that if
bricks be used some twenty or thirty millions will be required for each,
and that in bricks and mortar the third of the whole expenditure will
be incurred. The legislature has assumed, says the writer, the respon-
sibility of regulating the construction of buildings by the Metropolitan
Building Act of 1855, and two amendment acts, modifying and extend-
ing the provisions of the original statute, have since received the
sanction of Parliament. These acts contain provisions relating to the
lines of walls, recesses, and openings, parapets and breast-summers,
chimneys and flues, fireplaces and conveyance pipes for heated air,
steam and other products of combustion, but they make no reference
whatever to the character and quality of the materials commonly used
in the erection of such huildings. There are no regulations enforceable
to ensure the structure being perfectly dry in all seasons of the year.
This matter of dryness of the building, as a necessity for the health of
the occupants, is the point dwelt on by the author, who confines him-
self to an exposure of the error of using building materials charged with
saline matters. Many of our public buildings give evidence of this
error — ocular demonstration of inherent defects. The Hanwell viaduct
of the Great Western Railway is adduced in proof of this fact. This,
with its mildewed walls, indicates a process of absorption of water and
giving up of water, according to the condition of the air, which means
that in every part there is damp. If saline matter exist in bricks or
in mortar, they act like sponge ; they absorb moisture from the air, and
they give it up again under the influence of heat. The new boundary-
walls of the Coldbath Fields' Prison, near to Mount Pleasant, is an
instance in further illustration ; and, adds the writer, " we should not
be surprised if the costly erection of St. Thomas's Hospital, now in
progress, should, in after years, awaken posterity to the fact that
materials containing saline matter were used in the building." As to
the source of this evil, the author traces it to the employment of sea
sand, from which the saline matters have not been removed. " While
the building acts, as before said, abound in rules applying to form of
construction, they absolutely ignore the quality of building materials ;
hence, we have private dwellings, public schools, infirmaries, hospitals,
workhouses, and prisons, built of bricks containing saline matter, kept
together by means of mortar which has been mixed up with sea sand,
or with Thames sand containing salt. Buildings so constructed never
fail to show the tests of dampness. The walls mildewed on the out-
side frequently present a similar appearance inside through three or four
coats of paint. The observant eye may notice on a flatted wall
blisters of paint, which, if cut, will let moisture exude and trickle
down. The board-room of the mansion in Spring Gardens, where
the Metropolitan Board of Works holds its weekly meetings, and
which is at present temporarily occupied by the Asylum District
Board, affords striking proof of the correctness of these remarks." In
many cases, the author believes, builders err in selecting materials from

550 Chronicle of Medical Science. [Oct.,

sheer ignorance, and that architects, highly educated professional men,
from want of practical attention, have failed to detect the hidden causes
which are silently operating in producing the most disastrous results.
Sand is often dragged from the bed of the river too near to the sea or
brought as ballast in ships from foreign ports, and being saturated
with salt is unloaded into barges and sold to builders, who have every
inducement to use seaborne sand, inasmuch as it makes beautiful
white mortar, and may be mixed with lime in larger quantities than
sand obtained inland. The soft Thames sand used in making bricks
gives them a fine pale yellow surface ; this kind of brick is pleasing to
the eye, but if it be not " weathered " it renders the structure built of
it open to all the defects which have already been stated. Owing to
the fineness of the work it yields, architects often specify that all the
outside work is to be done with Thames sand. The author points out
further that the woodwork of buildings as well as the brickwork is
constantly charged with saline matter when brought across the sea.
Wood absorbs moisture rapidly. It first absorbs water in the course
of its transit from its place of growth to its place of shipment ; then it
is exposed upon its sea-voyage to a further absorption of saline par-
ticles, and the author has often found timber unloaded from ships in
the Commercial Docks and elsewhere nearly as wet before it was
put into the water of the timber-basin as it would be after lying there
in rafts. The timber thus brought over the sea is " well-pickled," and
lying in fresh water does not abstract (we suppose in the time allowed)
the whole of the saline matter it may have taken up. The author, we
think, up to this point proves his case ; he has shown that building
materials charged with saline matter are in daily use, and he has
further shown that buildings so constructed are of necessity damp
buildings. But when he proceeds, as he afterwards does, to dwell on
the " consequences," he proceeds beyond his knowledge. He opines
that the " chronic rheumatism, ague, and intermittent fever " of our
workhouses and many of our large hospitals originate from pervading
damp ; that the like obtains in the crowded dwellings of the poor ;
that the rich, whose residences wear a degree of splendour on their
exterior, have " the same canker-worm of saline damp ;" and that
diseases are thus generated and matured when neither " medical men,
family nurses, anxious parents, nor disconsolate children," ever dreamed
of the agent that was creating the evil. In order to prevent the
errors that he has pointed out, the author says it would be desirable,
in so far as it can be done, to take all materials from the estate upon
which the proposed buildings are to be erected. The bricks ought to
be either slop made, or the mould sanded with the best quality of
soft inland sand. The mortar should be made of lime mixed with
inland sand, and to save sand a portion of burnt earth ground in a
mortar-mill may be mixed with an equal quantity of sand. The
mortar in all cases should be ground. If suitable stone can be obtained
within a practicable distance, at an expense less than, or not exceeding
that, of brick, it is preferable. We have given a faithful resume of this
short essay, and while we do not think the author has proved anything
in. respect to the production of disease, we admit he has given to our

1868.] Report on Toxicology, Forensic Medicine, ^c. 551

profession a good practical hint. We are becoming, especially through
the labours of Dr. George Buchanan, keenly alive as to the influence
of damp in the production of phthisis pulmonalis, and we are glad to
know any important fact in respect to the cause of permanent damp in
our dwellings. Saline damp comes to us, therefore, as an idea charged
with interest and deserving our closest observation. It is our busi-
ness to ascertain if a statement so positively made be really true.

SUMMAET.

The Antagonistic Action of Opium and Belladonna. By J, T. Newman,
M.D. (* Chicago Medical Journal,' November, 1867.)
Dr. Newman relates a case in which a woman who was an opium-
eater, and who could take sixteen grains of morphia at once without
injury, took a dose sufficiently excessive to produce coma, stertor, small
pulse, contracted pupils, fixture of the jaws, and coldness of the extre-
mities. She recovered after subcutaneous injection of nearly two
grains of sulphate of atropia.

On the Melting and Subliming Temperatures of the principal Poisons,
Organic and Inorganic. By William A. Gut, M.B., F.E.S.
(Reprint from the ' Pharmaceutical Journal,' February, 1868.)
A brief but very useful extract of the varied and most interesting
communications of Dr. Guy on sublimation of poisons. Deserves pub-
lication as a distinct essay.

Case of Mental Derangement limited to a single Moral Sentiment,

occurring periodically, that sentiment heing in a perfectly normal

condition during the intervals. By Professor Samuel Jacksok,

M.D. (' American Journal of the Medical Sciences,' April, 1868.)

The case recorded by Professor Jackson establishes, he thinks, two

facts : — the first the independence of the moral sentiments in a manner

similar to that of the mental faculties, as demonstrated by the fact of

a single moral sentiment being diseased for nearly four years ; the

second that in monomania there may be intermissions.

Researches on the Nature and Action of Indian and African Arrow-
Poisons. By Heemann Beigel, M.D. (From the ' Journal of
Anatomy and Physiology,' vol. ii.)
A very able paper, full of laborious experimental facts, and eminently

suggestive.

On Adulteration of Suh-nitrate of Bismuth. By Prof. E.. Redwood.
(' Pharmaceutical Journal,' August, 1868.)
Dr. Eedwood in this communication shows that sub-nitrate of
bismuth is adulterated with phosphate of lime. The fact had pre-
viously been pointed out by M. Eoussin, who found in one case as
much as twenty-eight per cent, in a sample which presented the usual
appearance, and answered to the ordinary tests of sub-nitrate of
bismuth. Eoussin's process is as follows for the detection : — Dissolve
equal quantities of the sub-nitrate and of tartaric acid slightly diluted
with water, and add to this a strong solution of carbonate of potash
until all effervescence has ceased and the liquid is rendered strongly

552 Chronicle of Medical Science. [Oct.,

alkaline. If the sub-nitrate of bismuth be pure, the liquid will be
clear and will remain so even after it has been boiled ; but if the
sample of sub-nitrate submitted to the test should contain phosphate
of lime, even to the extent of but one or two per cent., this will form a
white precipitate, which will not dissolve with long-continued boiling.
To these remarks Dr. Redwood adds that the phosphate of lime, even
when present in large quantity, is not precipitated in the first instance
after the addition of the carbonate of potash, but its precipitation is
immediately effected by boiling the solution. From one sample he
obtained eleven per cent, and from another forty per cent, of this adul>
terant. He thinks both specimens were of foreign manufacture.

Indian Sanitation. (In the ' Public Health,' Nos. 5 and 6.)
An able article, doing credit to the new and useful publication in
which it appears.

On Sewerage, with ItemarTcs on the Sest Means of House Drainage.
By C. B. Nankivell, M.D.
In this address, published at the request of the Torquay Medical
Society, Dr. Nankivell maintains the health side of the sewage ques-
tion in preference to the mere question of utilisation.

Change of Molecular Structure during Cadaveric Decomposition. By
C. EoBiN. (* La France Medicale,' October, 1867.)
M. Robin has conducted a series of researches on the change which
takes place in the anatomic elements of the tissues after death. He
has traced the changes from the first or progressive step to complete
putrefaction, and states that when putrefaction is accomplished the
tissues are reduced to a condition of molecular granulation, the
granules being very minute, numerous, grey in colour, and having very
active movement. The phenomenon of granular change does not
appear until, by the smell, the substance is distinctly proved to have
undergone putrefaction. Any partially solidified elementary homo-
geneous substances, fibres, or cells, if they do not present granulations
at first, are ultimately resolved into the granular form, the change
being complete throughout the whole of the structure.

Labour during Sleep. By Wendell Case, M.D, (' The American
Journal of the Medical Sciences,' January, 1868.)
The question whether labour can occur during ordinary sleep with-
out disturbing the mother has been answered affirmatively by Dr.
Case. He relates that in the evening of December 16th, 1860, he
was summoned to visit Mrs. B — , a lady from France, residing in the
town of Hopedale, six miles from his residence. She was twenty-one
years old, and was near the period of her confinement, but attributed
her symptoms to over-fatigue on the previous day. Dr. Case found
there had been severe pains in the lumbar region and slight nausea.
The OS uteri was dilated to three fourths the size of a half-dollar. At
ten o'clock Dr. Case, having waited an hour for return of pains, sug-
gested that they should all retire to rest, and that he should be called,
if required. About 4 a.m. the husband of the lady, in great fright,
summoned him, exclaiming, " Monsieur le Medecin, il y a quelquechose

,1868.]

Report on Surgery. 553

entre les jambes de ma femme ;" and to his (Dr. Case's) great surprise,
.he found the head of the child had been wholly expelled during the
profound sleep of the mother. In a moment the lady was delivered,
and in less than twenty minutes the secundines were expelled. The
patient said she had dreamed something was the matter with her, and
awoke with a fright, probably the instant the head was expelled. She
.has since been confined, and with the usual amount of labour-pains.

REPORT ON SURGERY.

Br JoHif CiiATTO, M.R.C.S.E.

Treatment of Secondary Syphilis hy the Hypodermic Injection of
Corrosive Sublimate. — Dr. Lewin, after disposing of the non-mer-
curial treatment of syphilis as little better than a crotchet, proceeds
to show that, of all means of employing mercury, that illustrated in
this paper is the best. He has employed it for more than two years
at the Berlin Charite ; and both he, his colleagues, and his patients,
are satisfied with the results. The cases here referred to amount to
500, viz. 356 women and 144 men, the symptoms in all being tho-
roughly well characterised. The details are minutely tabulated, so
that the various facts, such as prior treatment and its nature, the
absence of this, the occurrence of relapse, &c., are duly set forth and
easily referred to. Dr. Lewin employs Luer's syringe, or in some
cases a larger one, and, owing to the corrosive nature of the fluid,
insists upon its being constantly washed out, and its point frequently
sharpened. In private practice he keeps a marked canula for
each patient. He prefers the back, lateral thoracic region, or
buttock, as the place of puncture, because less irritative inflamma-
tion ensues ; but in iritis the temporal region is preferable. In the
great bulk of the cases a solution of 4 grains to the ounce was em-
ployed, which, supposing the syringe to hold 15 grains, would give
■i grain each time. In the very sensitive, from ^ to -^^ grain of
morphia may be added with glycerine. The injections are best per-
formed in the forenoon and afternoon, and, if a very rapid cure is
sought, again in the evening. The patient need not be confined to
his bed, or in warm weather even to the bouse, care being taken
that he is not exposed to chills. Even when this precaution has
been neglected ill results have seldom followed. The diet need not
be much restricted, beyond being somewhat diminished in quantity ;
but alcoholic drinks should only be taken exceptionally. Great care
should be taken in keeping the mouth clean, but moderate smoking
may be allowed. The pain caused by the injection is sometimes
considerable, especially if it be not performed adroitly, or the patient
is very sensitive. In general, he soon becomes accustomed to it.
The subsequent irritation, which usually soon subsides, sometimes
goes on to inflammation, induration, or suppuration, especially if the
injection be too strong or too freely used, some patients being far

554 Chronicle of Medical Science. [Oct.,

more susceptible than others. Dr. Lewin, in cases of slight venous
haemorrhage that have occurred among his many hundred injections,
has never met with an instance of ill consequences supposed to be
due to the introduction of the injected substances into the circu-
lation. He found in his 144 male cases that the average quantity
of 2f grains of sublimate were required to effect a cure, while in
those of the cases which had previously undergone no other treat-
ment 3 grs, were required. In the 356 women 2\ grains sufficed,
i. e. "I less than in the men.

Summing up his opinions, Dr. Lewin states that preference should
be given to this mode, because (1) of the rapidity with which the
symptoms disappear, this holding an exact proportion to the quantity
of sublimate daily injected. Thus, two or three injections per diem of
^ to f grain cured numerous cases of iritis in from five to seven days.
In these cases of very rapid cure the patient must keep indoors,
and avoid all bodily or mental excitement. (2) The results, also,
are certain and precise. In and out the hospital, the author during
two years and a half has treated 900 cases, exhibiting every variety
of symptom and group of symptoms ; and in almost all of these, even
in desperate cases, many of which had been fruitlessly treated by
other modes, he has met with the most gratifying results. Syphilitic
disease of the bones has offered the greatest resistance, for, although
the nocturnal pains have been relieved, and the subperiosteal deposits
removed, yet the bones themselves did not recover their normal
volume. (3) The relapses are small in number and slight in cha-
racter. The statistical comparison of the results obtained by this and
by other means shows that while the relapses after the latter
amounted to 81 per cent., those following the injection method were
only 31 per cent. (4) Finally, the great convenience of the method,
both for the patient and the surgeon. — Annalen des Gharitc'
KranTcenhauses, Band xiv.

Injuries of the Elbow. — Professor Bigelow observes that there is
no class of injuries which so frequently gives rise to discontent and
litigation, and these cases often turn out much less satisfactorily
than they would have done had certain simple rules of treatment
been adhered to. " The rule I would enjoin upon you is the follow-
ing : — Ascertain first if the olecranon is broken, as this injury requires
a special treatment. In all the other injuries, whether you are able
to make an exact diagnosis, or are wholly unable to do so on account
of the swelling, treat them as though the forearm had been dislocated
haclcwards, and secure the arm at right angles to an inside angular
splint. The propriety of this measure will not be doubted with
regard to the more common dislocations of the arm. The very rare
instances of the radius dislocated forwards, or the all but impossible
dislocation of the ulna forwards alone, would doubtless declare
themselves, and the boues would be replaced during the manipula-
tion. Practically speaking, they are so rare that they need not be
taken into account. But among the fractures, the transverse
fracture of the lower end of the humerus, the T fracture into the

1868.]

Report on Surgery. 55 J

joint, the fracture of the inner or outer condyle separately, the com-
paratively rare fracture of the coronoid process of the ulna, or of the
radius or ulna near the joint, are all properly treated by the ex-
pedient above described ; while the common injuries of the lower
end of the humerus, including the fracture of the internal condyle
into the joint, in most cases peremptorily demand it. In these
cases it is sometimes difficult or impossible to make an accurate
diagnosis ; but the above treatment covers the whole of them, and
does harm to none, while it is the omission of it, as I believe, that
directly leads to deformity in a large proportion of them. . . . The
patient being now etherized, the character of the injury is deter-
mined as far as may be without unnecessary harm from manipulation
of the parts, and the elbow being placed at right angles, the wrist is
drawn forwards, while the humerus is pushed backwards at the
elbow. In this position it is forcibly maintained while the frag-
ments are adjusted as far as may be, and an internal angular splint,
padded by a folded towel, is applied by an assistant. To this the
arm and forearm are now secured, the friction of the bandage of the
forearm being relied on to prevent any backward displacement of
the elbow. An outside straight splint may also be secured to the
forearm if thought necessary. A few inches above and below the
elbow may be left uncovered for cooling applications, and especially
leeches if the swelling or superficial congestion make them advisable."
Professor Bigelow also insists upon another point, viz. the injurious
effect of the passive motion usually directed to be employed when the
joint has become somewhat stiff from the above plan of treatment
having been neglected or from the severe character of the injury.
Such motion he believes does much harm by inducing pain and in-
flammatory action, the removal of which causes great delay. When
the olecranon has been injured or the fragments of the humerus not
properly replaced such motion may do especial harm. When the
case has been properly treated and " the splint has been removed at
the proper interval for repair (from four to six weeks), the arm can
be flexed or extended through even a very small arc, not with that
deceptive springiness and elasticity of the ligaments, but in a way
to satisfy the surgeon that the cartilages are sliding one upon the
other, however little. My rule is to leave the rest to nature with
entire confidence in the result — allowing the patient to take off" his
splint daily, and as he pleases to flex and extend his arm as the
pain and tenderness may allow him, encouraging him in his attempts
to reach his forehead with his hand. I have also often advised a
patient to bore holes in a soft board with a small gimlet, to increase
the power of rotation. But if the cartilages do not slide through
even in a small arc, and motion is restricted, elastic, and springy,
owing to bony deformity, so much the worse for the patient, and
so much the longer and less perfect the recovery, I do not believe
you can accelerate it by passive motion, as the term is usually un-
derstood. . . . Exactly how far these remarks on passive motion
apply to the knee and other joints and injuries, I will not attempt
here to define, but can only say that I have seen more harm than

556 Chronicle of Medical Science. [Oct.,

good arise from forcible flexion of the knee after rheumatism and
aft^r fracture of the shaft of the femur. In simple fractures of the
elbow, except of the olecranon, these remarks may be summed up as
follows : — Always etherize the patient ; go through the motions of
reducing a backward dislocation of the forearm, and apply an
internal angular splint. When there is bony deformity or project-
ing callus, passive motion does harm ; and when the bones [are in
place and under supervision it is unnecessary." — Boston Medical and
Sv/rgical Journal, May 7.

Suture of Divided Nerves. — M. Blum, after a careful analysis of
the numerous facts which have been published in France upon this
interesting subject, arrives at these conclusions: — 1. Experiments
made upon animals do not suffice for the solution of this problem.
Although upon them we can, up to a certain point, demonstrate
sensibility to pain, it is impossible to pursue the ditferent variations
which the sensibility to touch may undergo. It is upon clinical
observation we can alone rely. 2. The statements made by Eulenberg
and Landois, that the suture has led to disastrous consequences, are
ill-founded ; but it must be admitted that in some cases these may be
so violent as to oblige the surgeon to forego all attempts at bringing
the ends together. 3, There is no well-authenticated instance of
immediate union after suture of nerves. 4. The anatomical union
produced by the suture of a nerve seems, however, to expedite the
re -establishment of its functions ; and in this point of view it is a
good operation, worthy of being preserved. — Archives Gen., July.

Pelikari's Modification of PirogoJTs Tibio-tarsal Operation. — Pro-
fessor Heyfelder states that he has had ample opportunity of con-
firming the good opinion he had formed of this operation in his own
cases in Finland and St. Petersburg, by the experience derived from
the Prusso- Austrian war of 1866. The procedure consists in making
a curved incision, which, commencing above the posterior edge of the
internal or external malleolus, passes along the dorsal surface of the
foot and terminates at the other malleolus. After this incision,
which divides only the skin, and the preliminary separation of the
incised parts, the subjacent tissues are completely cut through down
to the bone, and the epiphyses of the two bones of the leg are
removed by the saw. The soft parts covering the os calcis are next
divided, and the bone sawn in the same direction. The sawn surfaces
ofthe bones of the leg and of the os calcis are easily brought in
contact, which is impossible by the unmodified procedure, even after
section of" the tendo Achillis. — Gazette Medicale, August 29.

deduction of Dislocations (f'tcr the Subcutaneous Injection of Ace-
tate of Morphia. — Dr. Thierfelder relates four cases iu which reduc-
tion of dislocations, which had resisted the efforts made, speedily
yielded after narcosis had been induced by tlie injection of from one
half to one fifth of a grain of morphia. The cases he tried the plan
in were examples of luxations of the humerus, the elbow, and the
femur, and their narration bears out his statement of its effica<;y. He
says — " 1. That the necespary degree of narcosis, producing muscular

1808.] Report on Surgery. 557

relaxation is mucli more certainly and readily obtained by the
morphia than by the inhalation of chloroform. 2. This amount of
narcosis produced by morphia, contrariwise to what is observed in
the use of chloroform, is attended with little or no loss of con-
sciousness— a circumstance of great consequence when we con-
sider how disturbing the loss of sensibility is to the operator. In
drinkers, too, chloroform gives rise to excitement rather than to
anaesthesia, while in such persons (who are especially liable to this
class of accidents) morphia thus employed forms a very certain
means of treatment, 3. In luxations occurring in subjects suffering
from organic disease in which chloroform is contra-indicated, the
morphia is admissible. 4. The simplicity of the apparatus required
enables the practitioner to always have it at hand. 5. The special
assistance required in the administration of chloroform is no longer
necessary." — Ploss* ZeitscTirift fur Med. und Chir., No. 4.

On Accumulation of fluid in the Hernial Sac as an ohstacle to re-
duction and on Petifs operation in relation to the Taxis. — Dr. Ea-
voth relates two cases as illustrative of the fact that accumulation
of fluid in the sac not unfrequently prevents a reduction of a hernia,
which may be easily effected after that has been discharged by
puncture. He is a great advocate for Petit's operation, which he
would rather have regarded as adjuvatory to the taxis than as
herniotomy properly so-called. He thinks that this might lead to
a much needed revision of the treatment of incarcerated hernia. In
the great majority of cases it is with a simple mechanical obstacle
we have to do, and it is surprising that the prognosis of incarceration
should continue so unfavourable. The author believes, however,
that the treatment of hernia is capable of as great improvement as
that which has been brought about in the operation for cataract.
In this last old prejudices have been cast away, and technical pro-
cedures have been vastly improved. Among the prejudices which
still beset the management of incarcerated hernia is the abuse of the
taxis and delay in the operation. Hours and days are lost in resort-
ing to various means which an exacter diagnosis ought to have
taught from the first would be fruitless. The fear of the operation
has often delayed resorting to it, and Petit's procedure has had to
contend with prejudices. Of course there are exceptional cases in
which it cannot be resorted to ; but in spite of these, Dr. Eavoth
believes a valuable rule to be that after the taxis and its adjuvants
have been tried in vain, Petit's operation should be resorted to
without delay. Discharging the fluid the sac may contain is, as
already stated, of great utility. Another point to be observed is
the ease and safety with which the omentum even of large hernias
which have existed for years may be returned, omental adhesions
and degenerations being of far rarer occurrence than usually sup-
posed. Por this reason the separation and removal of the omentum
must be avoided as much as possible, leading as it does to much
delay in healing the wound. The external wound is also often made
too large, and left unclean. The smaller and cleaner it is the greater
will be the likelihood of primary union. There is great advantage

84— XIII. 36

558 Chronicle of Medical Science. [Oct.,

in making the incision in part subcutaneously, and at all events at
first it should be only small, enlarging it afterwards if necessary.
An attempt should be made to unite the wound by first intention,
or at all events to render the suppurative process as slight as pos-
sible. The chief danger of the operation is dependent upon the
condition of the hernia and its treatment prior to this being under-
taken. The less the patient has suffered from the duration of the
strangulation and the consequent interruption to the normal activity
of the intestinal canal, and the less the hernia and surrounding parts
have been subjected to excessive injury from the taxis, the more
favourable the prognosis and the more simple the after-treatment of
the operation. — Berlin Klin. Woeh., No. 22.

Treatment of Bronchocele. — Professor Liicke, of Bern, observes that
bronchocele in all its forms abounds in that canton, and that inflam-
mation and suppuration in the cystic and parenchymatous forms are
of common occurrence, as is the danger of suffocation from the
growth of the bronchocele. In the ordinary parenchymatous form
iodine has become the common popular remedy, which in many cases
arrests the progress of the disease, confining it to the ordinary " thick
neck," which from time to time, and especially in women after con-
finement, requires resort to be had again to the iodine. In the
aneurysmatic form, when from the amount of pulsation present the
ligature seemed the only remedy, small doses of the iodide of potas-
sium in some cases have exerted a remarkable effect in causing a
subsidence of the pulsation, and a diminution of the tumour itself.
The cystic bronchocele is curable in all its forms. Frequently, punc-
ture with subsequent iodine injection suffices ; but we may have
to resort to incision with suture of the sac. This in Dr. Liicke' s
cases has never been followed by bad consequences, although he
has employed it in cysts which have attained the size of a child's
head, with rigid, calcified walls. The only objection to it is the
hideous cicatrix left behind. The seton recommended lately by Ham-
burger is correctly characterised by Patruban as a bad and dangerous
procedure. When the soft parenchymatous bronchocele assumes a
certain degree of consistency, which arises either from colloid dege-
neration, or, more frequently, from the formation of hard nodules
within the substance of the glandular mass, the disease completely
resists the external and internal use of iodine. Extirpation has been
hitherto the only remedy, and this has been only applicable in small,
movable, median bronchoceles, and quite exceptionally in those
of large size. Alarming haemorrhage and purulent infection have
occurred so often as to leave the operation few defenders. Cauteri-
zation is also a dangerous procedure, and leads only to an imper-
fect recovery. The author relates an interesting case, in which,
after persevering with the injection of tincture of iodine into the
substance of the tumour, he succeeded in procuring its absorption.
He has had other cases, but they are of too recent occurrence to
report upon. In chronic enlargement of the lymphatic glands,
which have resisted all other means, and have been on account of
their number or position unsuitable for extirpation, he has also in-
jected the iodine with success. — Ibid., No. 25.

1868.] Report on Surgeri/. 559

SUMMAEY.

Amputation. — MacCormac. Amputation of theThigh compared with
Excision of the Knee. (Dublin Joum., August. "With an Illustration.)

Aneurism. — Servier. On Gluteal Aneurism. (Gaz. Hebd., Nos. 21
and 22 . Relates a fatal case, in which digital compression of the
aorta and afterwards injection of the perchloride of iron were tried.)

Carotid Artery. — Lefort. On the Therapeutical Value of Ligature
of the Common Carotid. (Gaz. Hebd., Nos. 28, 30, and 35. Bhmne
of a memoir communicated to the Academy of Medicine founded on
435 cases, all of which the author states he has verified by the
original accounts.)

Dislocation. — Tillaux. Mechanism of Dislocation of the Femur
backwards. (Union Med., No. 82, With a Discussion at the
Society of Surgery.) — Mathieu. Mechanism of Dislocation of the
Lower Jaw. (Archives Gen., August.)

Ear. — Zaufal. Condition of the Vena Mastoidea in Caries of
the Temporal Bone, with Otitis. (Wien "Woch., Nos. 40 and
41.) — Politzer. On the Employment of the Tuning Fork in the
Diagnosis of Diseases of the Ear. (Ibid., Nos, 42, 43, and 44.)
— Schwartze. Mode of Perforating the Membrana Tympani.
(Archiv fiir Ohrenheil, B. 3, H. 4.) — Schwartze. On the Caustic
Treatment of Suppurative Otorrhea. (Ibid., B. 4, H. 1.) — "Wreden.
On Myringomykosis Aspergillina. (St. Petersb. Med. Zeit., 1867,
No. 9. Under this name is described a parasitic growth of ^ the
membrana tympani. Fourteen cases given, and plates of the
aspergillinae.)

Enchondrosis. — Parisot. Treatment of Enchondrosis of the Pha-
langes and Metacarpus. (Gaz. Hebd., No. 31. Instead of ampu-
tating the part on which the enchondrosis is placed, Parisot re-
moves the latter by gouging \6videment].)

Erectile Tumours. — Valette. Treatment of Erectile Tumours.
(Gaz. Med. de Lyon, No. 27. Employs a ligature in combination
with chloride of zinc. Discussion at the Society of Medicine.) —
Santesson. On the Danger of Injecting Nsevi with the Perchloride
of Iron. (Journal fiir Kinderkr., Mars. Death produced in a child
apparently from some of the injection entering the facial vein.)

Excision. — Podrazki. Successful Case of Excision of the Wrist.
(Wien. Med. Woch., No. 39. The author believes that this is the
only recorded case after gunshot wound.) — Croly. Cases of Excision.
(Dublin Journal, May and August. With Illustrations.) — Thomp-
son. Excision of the Knee after Gunshot Wound. (Ibid., August.)
— Maas. Excision of the Knee. (Berlin Klin. Woch., Nos. 26 and
27. Two cases occurring in Middeldorpf s Clinic.)

Exostosis. — Boekel. Case of Multiple Exostoses. (Gazette des
Hop., No. 88. These occurred in a girl seven years of age, impli-
cating the bones of the extremities and the ribs on both sides. One
on the forearm preventing pronation was successfully removed.)

Eye. — Galezowski. On Affections of the Cornea and their Treat-
ment. (Union Med., Nos. 89 and 90.) — Jeffries. Three Cases of
Retinitis Pigmentosa. (Boston Med. Journ., April 30. ALso gives
a ready method of recording the field of vision.) — Kiigel. On

560 Chronicle of Medical Science. [Oct.,

Nystagmus, (Annales d'Oculistique, Mai.) — Sichel. Ou the Opera-
tion of Strabismus. (Ibid.) — Von Graefe. On Conical Cornea.
(Berlin Klin. Wocb., Nos. 23 and 24. Describes a new mode of
treatment by producing interstitial infiltration.) — Zehender. Retro-
spect of the Results of Ligature of the Carotid in Pulsating Orbital
Tumours. (Klin. Monat. fiir Augenh. Relates to thirty-one cases
already published.) — Taylor. Reports on Cases of Extraction by
Linear Flap. (Edinburgh Medical Journal, July and August.) —
Berlin. Foreign Bodies in the Vitreous llumour. (Archiv fiir
Ophthal., xiv, A. 2.) — Leber. On Optio Neuritis. (Ibid.)

Fracture. — Berenger-Feraud. Ligature of Bones in Compound
Fractures. (Bull, de Therap., August 15 and 30. Adds a case to
nine others already published. The treatment consists in connect-
ing the fragments by means of metallic or other ligatures wound
around them.) — Sonrier, Fracture of the Os Calcis by Compression.
(Recueil de Med. Militaire, June. The case is rare, as almost all
others have been induced by the traction of the tendo Achillis.
Autopsy and Woodcuts.)

Gunshot Wounds. — Butcher. Remarkable Cases of Gunshot
Wounds. (Dublin Journal, May. With Illustrations.) Eve.
Three Cases of Gunshot Wound of the Spine. (American Journal
of Medical Science, July. With observations on division of the
spinal cord without immediate death.)

Hare-lip. — ColHs. jJEsthetic Treatment of Hare-lip. (Dublin
Journal, May. Illustrations.)

Hernia. — Rose.- Observations on Hernia. (Annalen der Charite,
B. xiv. Concerning forty-seven cases occurring during four years
at the Bethanien, Berlin.) — Kiittner. On Internal Incarceration.
(Virchovv's Archiv, xliii, H. 4. Several Cases. With practical re-
marks and Illustrations.)

Hip-joint. — Packard. Notes on the Diagnosis of Injuries to the
Hip. (New York Medical Journal, July.)

Laryngoscope, — Merkel. Report on recent Progress in Laryn-
goscopy. (Schmidt's Jahrb., No. 5.) — Ziemssen. Laryngoscopic
Observations. (Deutsche Arch., B. iv, H. 2 and 4.)

Ovariotomy. — Koeberle. Statistical Results. (Gaz. Hebd., No.
32. Relates to 69 operations performed between 1862-68, 45 or
two thirds recovering. The particulars are given in detailed tables.)
—Greene. Eight Cases. (Boston Joum., April 30 and May 7.
Six recoveries. Greene attaches great importance to the employ-
ment of artificial serum [recommended by Dr. Peaslee], the parts
being kept constantly moistened in it. It should be used at blood-
heat ; and the author believes that in any operation where a large
surface is exposed, hot water causes much less shock than cold.) —
Decristoforis. Fatal Case. (Gaz. Med. Ital. Lombard., Nos. 25
and 26.)— Schroeder. Two Cases. (Berlin Klin. Woch., No. 21.
One fatal from intestinal perforation twenty-two days after opera-
tion.)—StilKng. Case. (Deutsche Klin., No. 20. Fatal on the
eighth day from peritonitis and trismus.)

Pericardium. — Baizeau. Puncture of th6 Pericardium in a sur-
gical point of view. (Gaz. Hebd., Nos. 33 and 36.)

1868.] Books, ^c, received for Review. 561

Plastic Operations. — Pean. Successful Case of Autoplastic Opera-
tion of the Neck by means of a large flap derived from the thoracic
region. (Union Med., Nos. 93 and 94.)— Nelaton. Case of
Rhinoplasty by a new method based on adherent cicatrices. (Gaz.
des Hop., No. 70. Illustrations.) — Stokes. Plastic Operation after
G-un-shot Wound of the Orbit. (Dublin Journ., May. Illustra-
tions.) — "Whitehead. Muco-periosteal Uranoplasty. (American
Journ. Med. Sci., July. Illustrations.)

^ Spine. — Schildbach. On the Mode of Examination and Mensura-
tion in Scoliosis. (Jahrb. f. Kinderheil., H. 3.)

SypJiilis. — Pournier. On Indurated Pseudo-chancre in Syphilitic
Subjects. (Arch. Gen., June and July.)

Testis. — Liegey. Neuralgic Orchitis. (Journ. de Med. de Brux-
elles, May. Four cases given.)

Transfiision. — Belina-Swiontkowski. Description of a New
Transfusion Apparatus. ( Wien. Woch., No. 44.)

Urinary Organs. — Buchanan. Eeasons for preferring Lithotrity
to Lithotomy in the Adult Male. (Ed. Med. Journ., July.) —
Richardson. The Instantaneous Method of Treating Stricture.
(Dublin Journ., August. Illustrations.) — Amussat's Lithotome.
(Rev. Med., August 15. Figures and Descriptions.) — Plett. Im-
paction of a Calculus in the Urethra. (Journ. f. Kind., April.
Occurred in a boy six years old. Puncture of the bladder and ure-
throtomy were performed. Recovered.) — Chauvel. Impaction of a
Calculus in the Urethra. (Rec. de Med. Mil., June. A Calculus
arrested without any prior symptom. Removed by the " button-
hole" operation.)

BOOKS, PAMPHLETS, &c., RECEIVED FOR REVIEW.

Pharmacopoeia of India. Prepared under Medical Education and Medical, In te-

the authority of Her Majesty's Secretary rests. By J. Ashe. Essay to which the

of State for India in Council. By E. J. Carmichael Prize was awarded. Dublin,

Waring, M.D. IndiaOffice. 1868. London, Fannin and Co. 1868. pp. 164.

Allen and Co. pp. 502. First Carmichael Prize. — The Medical

Dr. Watter's Doctrines of Life. Letter Profession, and its Educational and Li-

from Dr. Carpenter of London to the censing Bodies. By E. D. Mapother, M.D.

Editors of the ' St. Louis' Medical and Dublin, Fannin and Co. 1868. pp. 227.

Surgical Journal.' Lectures on the Diagnosis and Treat-

An Improved Method of Extraction of ment of Functional Nervous Affections.

Cataract, with Results of 107 Operations. By C. E. Brown-Sequard, M.D., F.R.S.

Bv J. R. Wolfe, M.D., &c. London, Part I. Physiological Pathology and

Churchill and Sons. 1868. pp. 71. General Therapeutics of Functional Ner-

Electro- Physiology and Therapeutics, vous Affections. Williams and Norgate.

&c., including the Phenomena of Elec- The Practitioner : a Monthly Journal of

trical Fishes. By C. E. Morgan, M.D. Therapeutics. Edited by F. E. Anstie,

New York, Wood and Co. 1868. pp. 714. M.D., F.R.C.P.,. and H. Lawson, M.D.

Treatise on the Diseases of the Eye, in- London, Macmillan and Co. No. I, July,

eluding the Anatomy of the Organ. By Who Discovered Anaesthesia .'' By S.

C. S. von Carion, M.D., Professor of Parsons Shaw. Manchester and London.

Ophthalmology, Vienna. Translated and Pamphlet.)

edited by C. E. Hackley, M.D., and D. Bathing : its Uses and Advantages,

B. St. John Roosa, M.D., of New York. showing When and How to Bathe. By

London, Hardwicke. 1868. pp. 774. G. Worthington. London, Churchill and

On the Treatment of Aneurysm by Sons. (Pamphlet.)

Iodide of Potassiuni. By G. W. Balfour, On Asthma: its Pathology and Treat-

M.D., &c. (Reprint from 'Edinburgh ment. By H. H. Salter, M.D., F.R.S,,

Medical Journal,' 1868. Pamphlet.) Physician to Charing Cross Hospital, &c.

562

Books, ^c, received for Revieiv. [Oct., 1868.

Se<;oad Edition. London, Churchill and
Sons. 1868. pp. 464.

Observations on the Treatment of Zymo-
tic Diseases by the Administration of Sul-
phites. By J. Polli, M.D. Eead before the
British Medical Association, Dublin, 1867.
(Pamphlet.)

Diseases of the Womb. — Uterine Catarrh
frequently the Cause of Sterility, &c. By
H. E. Gautillon, M.D. pp. 88.

On Treatment of Paralysis by Hypo-
dermic Injections of Strychnine, with Ee-
marks on Infantile Paralysis. By M. G.
Echeverria, M.D. (From ' Proceedings
of Connecticut Medical Society,' 1868.)

On Digitalis : with some Observations
on the Urine. By T. L. Brunton, M.B.
London, Churchill and Sons, and Mach-
lachlan and Stewart. 1868. pp. 132.

Some of the Educational Aspects of
State Medicine. By H. W. Rumsey, M.D.,
E.K.C.S. London, Eidgway. (Pamphlet.)

On the Immediate Treatment of Stric-
ture of the Urethra by the employment of
the "Stricture Dilator." By B. Holt,
F.E.C.S., Senior Surgeon to Westminster
Hospital. London, Churchill and Sons.
1868. Pp. 136.

Principles of Organic Life. London,
Hardwicke. 1868. Pp. 464.

The Institutes of Medicine. By Mar-
tyn Paine, M.D., LL.D, Eighth Edition.
New York and London. 1867. pp.
1145.

On Varicose Disease of the Lower Ex-
tremities and its Allied Disorders, &c. ;
being the Lettsomian Lectures before the
Medical Society of London in 1867. By
John Gay, F.E.G.S., Surgeon to the Great
Northern Hospital, &c. London, Church-
hill and Sons. 1868. pp. 171.

Holden's Manual of the Dissection of
the Human Body. Edited by Luther
Holden and John Langton. Third Edi-
tion. London, Churchill and Sons. 1868.
pp. 604.

Injuries and Diseases of the Jaws. The
Jacksonian Prize Essay of the Eoyal Col-
lege of Surgeons of England, 1867. By
Christopher Heath, F.R.C.S., Assistant-
Surgeon to University College Hospital,
London, Churchill and Sons. 1868. pp.416.

Greenho w on Intermittent or Paroxysmal
Haematuria. (Eeprint from ' Edinburgh
Medical Journal,' May, 1868. Pamphlet.)

On Famine Fever and some of the other
Cognate Forms of Typhus. A Lecture by
Eudolf Virchow. Berlin. Williams and
Norgate. 1868. pp. 48.

St. Andrew's Medical Graduates' Asso-
ciation Transactions, 1867. Edited by L.
W. Sedgwick, M.D. London, Churchill
and Sons. 1868. pp. 252.

Observations on Amputation of the
Thigh, and on the Merits of that Opera-
tion as compared with Excision of the

Knee. By W. MacCormac, M.D., &c,
(Eeprint from 'Dublin Quarterly Journal.'
Pamphlet.)

Clinical Lectures on the Diseases of the
Liver, Jaundice, and Abdominal Dropsy.
By C. Murchison, M.D. London, Long-
mans, Green, and Co. 1868. pp. 556.

A Treatise on Physiology and Hygiene
for Schools, Families, and Colleges. By
J. C. Dalton, M.D., Professor of Physiology
in the College of Physicians and Surgeons,
New York. London, Sampson Low and
Marston. 1868. pp. 399.

Designs for a Convalescent Hospital.
By John Dale, Architect. London, Brown.
1868. (Pamphlet.)

Eevista Medico-Quirurgica y.Dentistica.
De los Sres. Wilson y Yonzalez. Nos I y
II. 1868. Nueua-York.

Des Grandes Epidemies, et de leur Pro-
phylaxie Internationale, &c. Par Leon
Depautaine, M.D. Bailliere. 1868.

Le Cholera Etiologie et Prophylaxie
Origine, &c. &c. Expose des Travaux de
la Conference Sanitaire Internationale de
Constantinople. Par A. Fauvel. Bail-
liere. 1868. pp. 673.

Essai sur les Families Pathologiques.
Par L. Gaillard. Paris, BailUere. 1868.
(Pamphlet.)

Des Hajmorrhoides. Par le Dr. F.
Fredault. Extrait de 'L'Art Medical.'
Bailliere. 1868. pp. 270.

Azione degll Astre e delle Meteore sulla
Mente Umanse saua ed alienata. Del
Prof.C.Lombroso. Milano. 1868. pp.107.

Reports, Journals, Reviews, Sec

Edinburgh Medical Journal. July,
August, September, 1868.

Dublin Quarterly Journal of Medical
Science. August, 1868.

Tenth Annual Eeport of the Lunacy
Commissioners for Scotland. 1868.

Medical Eeport of the Aberdeen Eoyal
Lunatic Asylum. 1868.

Twenty-second Eeport of the Commis-
sioners in Lunacy.

Fourth, Fifth, Sixth, and Seventh
Annual Eeports of the Board of Managers
of the Women's Hospital of Philadelphia,
for 1865, 1866, 1867, 1868.

Eeport of the City of Glasgow Fever
Hospital for year ending April, 1868.
By Dr. J. B. Eussell.

Statistical Eeport of the Health of the
Navy for 1865.

American Journal of the Medical Sci-
ences. Jul}', 1868.

New York Medical Journal. July,
August, September, 1868.

The Indian Annals of Medical Science.
No, XXIV. Calcutta.

INDEX TO VOL. XLII

BRITISH AND FOREIGN MEDICO-OHIRURGICAL REVIEW.

PAGE

Abdominal gestation, on . . 252

Accolas on biliary ducts . . 260

Acetic acid injections, on . . 515

Ainser and Lobe on the blood . 264

Air-baths, compressed, on . . 439

Allbutt on skin diseases . . 53
Alum in burns .... 515

American military surgery . . 170

surgical works . , 397

Andrew on mitral valve disease . 319

Aneurysm, traumatic, on . . 329

Angina and diphtheria, on . . 417

Anstie on the sphygmograph . 1

Anthrax, Richet on . . . 246

Aphasia, Ogle (W.) on . . .51
Artery, external iliac, ligature of . 322

Artisans, diseases of . . .50

Atlas and axis, on disease of the . 326

Baart de la Faille on tubo-ova-

rian gestation .... 524
Baker (M.) on life . . .317
Balfour on iodide of potassium . 522
Barnes's midwifery reports . 252, 524
Bartholew on brain tumours . .531
Barwell on spinal curvature . . 443
Beaufort on iodide of potassium . 517
Beigel on arrow poisons . . 551
Belhomme on chancre . . 518
Belladonna, on ... . 513
Bidder on the sympathetic . . 260
Bigelow on elbow injuries . . 554
Biliary ducts, on ... 260
Bizzozero on tubercle . . .26
Blandford on insanity . . .49
Blasius on spondylolisthesis . . 255
Blood circulation, works on the . 264
Blood, Heaton on the . . . 198
Bloxam on fractures . . . 327
Blum on suture of nerves . . 556
Bottcher on pus .... 272
Boucbut on lcucocytha;mia . , 537
on the ophthalmoscope . 531

Brain disease. Fish on .
Brain, tumours of

' shocks on .

Brinton on amputation
Brodhurst on loose cartilages
Broker on cherry laurel
Bronchocele, on .
Brown-Sequard on arrest of
vulsions .

Callender on brain shocks
Cancer, Pemberton on .
Rasmussen on .

W. H. Moore on

Canniff on surgery
Cartilages, loose, on
Caryier on cod-liver oil
Ciisati on osteomalacia, &c.
Cerebro-spinal meningitis
Chancre, Venning (E.) on

calomel in

Cbatto's surgical reports
Chemistry, Galloway's .

Kay-Shuttleworth's . 207

Cherry laurel, on the . . . 517
Childbed, on .... 526

Children's diseases, on . . . 389

Child's physiological essays . . 175

Cholera, Milrov on . . . 209

Church on . . . 320

Chubb on hyposulphite of soda . 523
Church on cholera . . . 320
Clarke (E. H.) on ear-polypus . 422
Club-foot, on . . . .416
Cod-liver oil, on . . . . 513
Cohnstein on the foetus . . 252
Collins on cerebro-spinal fever . 328
Condie on children's diseases . 389
Convulsions, Gee on . . . 316
Cooper (Sir H.) on iodide of potas-
sium 512

Coote on traumatic aneurysm . 329
Corneal tumours .... 281

PAQB
. 328
. 531
, 328
. 244
. 52
. 517
. 558
3on-
. 269

. 328
. 448
. 277

317,447
. 397
. 52
. 513

255, 258
. 328
. 52
. 518

244, 553
. 430

564

INDEX TO VOL. XLII.

PAGE
Coronary artery, aneurysm of . 55
Corrosive sublimate, injections of,

in syphilis .... 553

Cretinism, Saint-Lager on . .17
Croup and diphtheria, Haward on 53

Da Costa's medical diagnosis . 199
Dalton's physiology . . .57
Darwin on variation under domes-
tication 143

Davis on surgery .... 397
Deafness, Smith (T.) on . . 318
Delagarde's surgical cases . . 324
Delirium, H. Jones on . . .49
Desgrange's surgical lectures . 181
Demarquay on medical pneumato-

logy 183

Diabetes, Heusley on . . . 321
Dislocation, reduction of . . 556
Dohrn on the " decidua" . . 524
Donders on food and work . . 196
Drachmann on club foot . . 416
Dreessen on abdominal gestation . 252
Duchenne on muscular paralysis . 276
Duckworth on the urine . .321
Dujardin-Beaumetz on the action

of phosphorus .... 520
Durand's philosophical physiology 58
Dusart and Blacke on phosphate

of lime 521

Dutch archives of medicine . . 425

Ear diseases, on . . . . 167

Eczema marginatum, on . . 540

Elbow injuries, on . . . 554

Emphysema, pulmonary, on . . 326
Engelmann on the gustatory nerve 188

Entacoustics, Jago on . . . 225

Epilepsy, Fox (W.) on . . .50

Evans on injuries of head . . 322

Factory certificates, on . . 449

Fallopian gestation ' . . . 252
Fish on brain disease . . . 328
Flint's physiology . . .57

Food and work, on . . 196,198
Foster (B.W.) on the sphygmograph 1
Fox (W.) on tubercle . . .26

(E.) on epilepsy . . .50

Friedreich on the blood . . 264
Fungi in kidneys .... 281
Funke's physiology . . .57

Galloway's chemistry . . . 430

Gee on convulsions . . .316

Germinal matter, Morris on . . 195

Gestation, works on . . . 524

Giraldes on surgery of children . 389

Goitre, Saint-Tiager on . . 17

Gonorrhoeal rheumatism, on , 246

PAGE

Greaves on factory certificates . 449

Greenhow on hajmaturia . . 537

Griffiths on ha;modynamics . . 475

Grimshaw on sphygmograph . 1

Gustatory nerve, on the . . 189
Guy on poisons .... 531

Guyon on the blood . . . 264

HaBmodynamics, on . .
Hsematuria, paroxysmal, on .
Hair-containing tumour
Hall on artisans' diseases
Hall (C.) on hydrocyanic acid
Haward on croup and diphtheria
Head on intestinal obstruction
Head, on injuries of the
Heaton on the blood
Hecker on rupture of uterus
on asphyxia

475
537
281

50
545

53
315
322
198
255
260
255
260
260

on fatty degeneration

on the umbilicus

Heidenhain on saliva .

Hensley on pulmonary emphysema 326

on diabetes . . .321

Hernia, Ravoth on . . . 557

Holmes on . . .56

Hildebrandt on Fallopian tubes . 524

Hip-joint amputation . . . 170

Hoarseness, on . . . . 444

Hodgkin's disease, on . . . 536

Hodgson on retained testicle , 50

Hollis on thermometer in disease . 323

Holmes on hernia . . .56

on the surgei'y of children 389

Holt on the stricture dilator . 436

Hillier on children's diseases . 389

Huxley's physiology . . .57

Hydatids in chest, on . . . 327

Hydrocyanic acid, on action of . 545

Hygiene, works on . . . 548

Hygroma and hydrarthrosis, on . 247

Hyposulphite of soda, on . . 523

Infusoria in the air, on . . 539

Insanity, Blandford on . . 49

International sanitary conference . 106
Intestinal obstruction, on . . 315
Iodide of potassium in aneurysm . 522

^ — in cachexias . 512

De Beaufort on 517

Iris-movements, Lee (R. J.) on . 187
Irritability, Morris on . . . 196

Jackson on mental derangement . 551
Jago on entacoustics . . . 225
Jones (H.) on delirium . . .49

Kay-Shuttleworth's chemistry . 207
Keber on trismus . . . 529

INDEX TO VOL. XLII.

565

PAGE

Kirke's physiology . . .57

Klebs on meningitis . . . 328

Knee-joint amputation . . 244

Kuhne's physiological chemistry . 58

Labour, works on . . 255, 526

Lannelongue on the blood . . 264
Larcher on rupture of uterus . 524
Lebert on tubercle . . .26
Lee (R. J.) on iris . . . 187

Leg, fractures of, on . . . 327
Legros on the blood . . . 264
Lente on cancer . . . .515
Leucocythsemia, on . . . 537
Lewin on syphilis and mercurial

injections ..... 553
Life, Baker (M.) on . . . 317
Ligamentum petellse, rupture of . 248
Lindsay on the toot plant . . 465
Lithotrity, Marjolin on . . 245

Little on spinal curvature . . 204
LiJcke on bronchocele . . . 558
Lymphatic gland disease, on . 535

M'Call Anderson on eczema . . 540

Mackenzie on hoarseness, &c. . 444

Marjolin on lithotrity . . . 245

Marshall's physiology . . .57

Marsh on tracheotomy . . 325

Martin on Fallopian gestation . 252

Matecki on abdominal gestation . 524

Medical diagnosis, Da Costa's . 199
Memoirs of the Imperial Academy

of Medicine . . . .130

Metschnikow on the blood . . 264

Micrology, report on . . . 271
Midwifery reports, Barnes's . 252, 524

: works on . . . 524

Miller on temperature . . . 450

Milroy on cholera . . . 209

Mitchell on rattlesnake venom . 303

Mitral valve disease, on . . 319

Montgomery on cells . . . 198

Moore (W.) on dementia . . 533

(C. H.) on cancer . 317, 447

Morris (J.) on germinal matter . 195
on irritability . . 196

Nankivell on sewerage
Nerves, works on the .
suture of .

. 552

. 269

. 556

Newman on opium poisoning . 551

(Esophagus, inflammation of, on . 279
Ogle (John W.) on aneurysm of
coronary arterj' . • .55

on cases of tetanus 483

Ogle (W.) on aphasia . . .51
Ogston on stillborn children . 472

PAGE

Ophthalmoscope, on the, in disease
of nervous system . . . 531

Opium and belladonna, antagon-
ism between, on . . . 551

Osteomalacia, on . . . . 255

Packard on inflammation . . 412

Paget on senile scrofula . . 328

Paralysis, Duchenne on . . 276

Parasites in cells, on , . . 539

Paris hospitals, statistics of . . 428
Parker on the shoulder-girdle, &c. 432

Parkes on nitrogen elimination . 58

Pecholier on alcohol . . . 519

Pemberton on cancer . . . 447

Perrond on tuberculosis . . 273

Pfeiffer on the placenta . . 252

Phosphate of lime, on . . . 521

Phosphorus-poisoning . . . 278

in paralysis, on . . 520

Physiology, works on . . 57, 260

Piso-Borme on muscle . . . 271

Pneumonia, alcohol in . . . 519

Pneumatology, on . , . 183

Pneumonia, Sturges on . .54

Poisons, chemistry of, &c. . .541

neutralisation of, on . . 544

Polypus of the ear, on . . . 422
Poppel on tubo-uterine gestation . 252

Poulet on infusoria in air . . 539

Power's physiological report . . 260

Pregnancy, works on . . . 252

Prichard on ligature of arteries . 322

Prince on plastics . . . 397

Prostatic disease, on . . . 193

Puerperal state, works on . . 258

Pus formation, Bottcher on . . 272

Pyaemia, Savory on . . . 314

Quain's anatomy .
Quinine, subcutaneous use of

. 58
. 514

Radcliffe (J. N.) on meningitis . 328
Ranvier on phosphorus poisoning 278
Rasmussen on cancer . . . 277
Rattlesnake venom, on . . 303

Ravoth on hernia . . . 557

Rectum, Smith (H.) on . . 203

Redwood on bismuth adulterations 551
Reflex paralysis, Echeverria on . 207
Reith on action of medicines . 516

Retina, on the . . . . 329
Reynolds's system of medicine . 285
Rhus toxicodendron, poisoning by 546
Richardson's report on toxicology 541
Richet on anthrax . . . 246

on gonorrheal rheumatism . 246

Rigler on labour .... 526
Robin on cadaveric change . . 552

566

INDEX TO VOL XLII.

PAGE

Saint-Lager on goitre, &c. . . 17

Salisbury on skin diseases . . 282

on parasites , . . 539

Saliva, Heidenhain on the . . 260

Sanderson on the sphygmograph . 1

Sandahl on compressed air-baths . 439

Sanitary conference reports . . 106

Sappey on the optic nerve . . 272

Savignac on belladonna . . 513

Savory on pyasmia . . . 314

Scharlan on turning . . . 526

Schneider on involution of uterus 528

Semple's materia medical report . 512

Senile scrofula, on . . . 328

Sphygmograph, works on the . 1
St. Bartholomew's Hospital Re-
ports ....
St. George's Hospital reports
Stricture dilator, Holt on the
Shoulder-girdle and sternum, on
Skin diseases, new

Smith (T.) on deafness .
Smith (H.) on the rectum
Sound, Tyndall on
Southam on urinary calculi
Southey on tubercle
Southey's case of hydatid in
Spender on ulcers, &c.
Spinal curvature, Little on

on

Spiritual wives
Spondylolisthesis, on .
Stille on epidemic meningitis
Stone on typhoid fever
Strassman on turning .
Streatfeild's micrological report
Sturges on pneumonia .
Subcutaneous use of quinine
Sympathetic, Bidder on the

Temperature in fever, on
Testicle, retained, on .

314
48
436
432
282
. 53
. 318
. 203
. 419
. 423
. 26
chest 327
. 409
. 204
. 443
. 358
. 255
328
237
526
271
54
514
260

PAGE

Tetanus, Ogle's (John W.) cases of 483
Thermometer, on, in disease . . 323
in disease, Thomp-

son (R.) on
Thierfelder on dislocations
Thompson (Sir H.) on prostatic

(R.) on thermometer in

disease ....

450
50

51

556

193

51

(J. R.) on emphysema . 533

Tonge on fungi in kidneys . . 281
Toot plant, on the . . . 465

Toynbee on ear diseases . . 167
Tracheotomy, on, in children . 325
Trideau on angina, &c. . , 417

Tuberculosis, Perrond on . . 273
Tubercle, works on . , .26
Tubo-uterine gestation . . . 252
Turner on burns .... 515

— on disease of atlas and axis 326

Tyndall on sound . . . .419
Typhoid fever. Stone on . . 237

Ulcers, &c.. Spender on . . 409
Urine, on substances passing by

the

Uterus, rupture of . , .

Variola, on the lymph of . . 539

Venning (E.) on chancres . . 52

Villemin on tuberculosis . . 26

Virchow on tubercle . . .26

Volkmann on hygroma, &c. . . 247

Wagner on inflammation of oeso-
phagus 279

Wales on surgical apparatus, &c. . 397
Webb's report on pathology . . 531
Wittich on the nerves . . . 269
Wyss on tubercle . . .26

Wy wodzofF on the healing process 273

Ziemssen and Hess on meningitis . 328

321
255

END OF VOL. XLII.

rr\llililM>iiii